Jejunal Diverticulitis

A case of perforated jejunal diverticulitis in a 44-yr-old man is described and the literature is reviewed. Jejunal diverticulosis occurs in 0.07% to 2% of the population. Enteroclysis is the best diagnostic test. Diverticulitis with perforation is rare and is associated with high mortality. Treatment is surgical resection of the involved segment. Other complications are bacterial overgrowth, obstruction, and acute hemorrhage. Several theories to explain the physiopathogenesis of the diverticula formation may relate to manometric or histological abnormalities of the small bowel.     

Intestinal motility in small bowel diverticulosis: a case report and review of the literature

Small bowel diverticulosis is a rare disease that is usually associated with recurrent pseudo-obstruction, bacterial overgrowth, and malabsorption. The more severe complications include hemorrhage and perforation. There is evidence to suggest that this entity is a result of small bowel motor dysfunction. For this reason, it has been associated with disorders in which a myopathic or neuropathic process is involved, such as scleroderma. The majority of patients with jejunal diverticulosis do not require surgery and can be managed medically. We report a case of jejunal diverticulosis in a 63-year-old gentleman who presented with symptoms of pseudo-obstruction. Ambulatory duodenojejunal manometry revealed several abnormalities suggestive of small bowel motor dysfunction. Enteroclysis, however, did not find evidence of mechanical obstruction, and the patient had marked improvement with cisapride and antibiotics.     

Extensive jejunal diverticulosis in a family, a matter of inheritance?

Diverticulosis of the jejunum is a rare finding (0.06 to 1.3%). Possible complications are bacterial overgrowth, malabsorption, bleeding, mechanical obstruction, volvulus and perforation. At present only one case report on familial jejunal diverticulosis has been published. We describe three patients with jejunal diverticulosis within one family, which might suggest inheritance.     

Causes of malabsorption in the elderly

The pathogenesis of malabsorption has been studied in 70 patients who presented over the age of 65 years and who were referred to a special investigative unit. Often more than one cause was apparent. Fourteen patients had pancreatic insufficiency, most of whom had no history of pain, alcoholism or gallstones. Twenty-three patients had the postgastrectomy syndrome or small-bowel diverticulosis or both. There were eight coeliacs aged 65-72 years at diagnosis. Fifteen patients had an anatomically normal small bowel; eight of these were over 80 years old, and 10 had vitamin B12 deficiency of whom five had confirmed pernicious anaemia. Enterobacterial overgrowth was a feature of all diagnostic groups except pancreatic and coeliac disease. Vitamin B12 deficiency may be an effect of malabsorption, but can also be a cause through impairment of enterocyte function. The association of pernicious anaemia and B12 deficiency with otherwise unexplained malabsorption and bacterial overgrowth suggests that gastric atrophy is a major causal factor in this syndrome, combined in some cases with a 'vicious circle' of B12 malabsorption and deficiency.     

Small intestinal bacterial overgrowth in patients with cirrhosis: prevalence and relation with spontaneous bacterial peritonitis

OBJECTIVES: The significance of small intestinal bacterial overgrowth in patients with cirrhosis is not fully understood and its diagnostic criteria are not uniform. We examined the association of small intestinal bacterial overgrowth with spontaneous bacterial peritonitis and compared various microbiological criteria. METHODS: Jejunal secretions from 70 patients with cirrhosis were cultivated quantitatively and classified according to various definitions. Clinical characteristics of patients were evaluated and the incidence of spontaneous bacterial peritonitis was monitored during a 1-yr follow-up. RESULTS: Small intestinal bacterial overgrowth, defined as > or = 10(5) total colony-forming units/ml jejunal secretions, was present in 61% of patients. Small intestinal bacterial overgrowth was associated with acid-suppressive therapy (p = 0.01) and hypochlorhydria (p < 0.001). Twenty-nine patients with persistent ascites were observed. Six episodes of spontaneous bacterial peritonitis occurred after an average 12.8 wk. Occurence of spontaneous bacterial peritonitis correlated with ascitic fluid protein concentration (p = 0.01) and serum bilirubin (p = 0.04) but not with small intestinal bacterial overgrowth (p = 0.39). Its association with acid-suppressive therapy was of borderline significance (hazard ratio = 7.0, p = 0.08). CONCLUSIONS: Small intestinal bacterial overgrowth in cirrhotic patients is associated with acid-suppressive therapy and hypochlorhydria, but not with spontaneous bacterial peritonitis. The potential role of acid-suppressive therapy in the pathogenesis of spontaneous bacterial peritonitis merits further studies.     

Intestinal lymphangiectasia secondary to radiotherapy and chemotherapy

Summary We report a case of intestinal lymphangiectasia secondary to radiotherapy and chemotherapy. The patient also had small bowel bacterial overgrowth and pancreatic insufficiency. Lymphatic ectasia as a histological feature has been described previously in association with postradiotherapy malabsorption, but radiation-induced lymphangiectasia producing clinical manifestations has hitherto not been reported.Replacement of dietary long-chain fats with medium-chain triglycerides, pancreatic enzyme supplements, and a short course of oxytetracycline, resulted in dramatic clinical improvement.The possibility of intestinal lymphangiectasia should be borne in mind in patients with postradiotherapy malabsorption. A low serum albumin and lymphocyte count should draw attention to this possibility.     

Small intestinal bacterial overgrowth in human cirrhosis is associated with systemic endotoxemia

OBJECTIVES: Systemic endotoxemia has been implicated in various pathophysiological sequelae of chronic liver disease. One of its potential causes is increased intestinal absorption of endotoxin. We therefore examined the association of small intestinal bacterial overgrowth with systemic endotoxemia in patients with cirrhosis. METHODS: Fifty-three consecutive patients with cirrhosis (Child-Pugh group A, 23; group B, 18; group C, 12) were included. Jejunal secretions were cultivated quantitatively and systemic endotoxemia determined by the chromogenic Limulus amoebocyte assay. Patients were followed up for 1 yr. RESULTS: Small intestinal bacterial overgrowth, defined as > or = 10(5) total colony forming units per milliliter of jejunal secretions, was present in 59% of patients and strongly associated with acid suppressive therapy. The mean plasma endotoxin level was 0.86 +/- 0.48 endotoxin units/ml (range = 0.03-1.44) and was significantly associated with small intestinal bacterial overgrowth (0.99 vs 0.60 endotoxin units/ml, p = 0.03). During the 1-yr follow-up, seven patients were lost to follow up or underwent liver transplantation and 12 patients died. Multivariate Cox regression showed Child-Pugh group to be the only predictor for survival. CONCLUSIONS: Small intestinal bacterial overgrowth in cirrhotic patients is common and associated with systemic endotoxemia. The clinical relevance of this association remains to be defined.     

Diagnosis of small intestinal bacterial overgrowth in patients with cirrhosis of the liver: poor performance of the glucose breath hydrogen test

BACKGROUND/AIMS: Small intestinal bacterial overgrowth is known to occur in association with cirrhosis of the liver and studies are needed to assess its pathophysiological role. The glucose breath hydrogen test as an indirect test for small intestinal bacterial overgrowth has been applied to patients with cirrhosis but has not yet been validated against quantitative culture of jejunal secretion in this particular patient population. METHODS: Forty patients with cirrhosis underwent glucose breath hydrogen test and jejunoscopy. Jejunal secretions were cultivated quantitatively for aerobe and anaerobe microorganisms. RESULTS: Small intestinal bacterial overgrowth was detected by culture of jejunal aspirates in 73% of patients, being associated with age and the administration of acid-suppressive therapy. The glucose breath hydrogen test correlated poorly with culture results, sensitivity and specificity ranging from 27%-52% and 36%-80%, respectively. CONCLUSIONS: In patients with cirrhosis, the glucose breath hydrogen test correlates poorly with the diagnostic gold standard for small intestinal bacterial overgrowth. Until other non-invasive tests have been validated, studies addressing the role of small intestinal bacterial overgrowth in patients with cirrhosis should resort to microbiological culture of jejunal secretions.     

Steatorrhea and weight loss in a 72-year-old man

Unintentional weight loss is an ominous sign, particularly when it occurs in the elderly; concern for malignancy is especially worrisome. In this report, we describe a 72-yr-old man who presented with weight loss and was found to have massive steatorrhea. An extensive evaluation revealed evidence of primary biliary cirrhosis (PBC), celiac disease, and small intestinal bacterial overgrowth. No malignancy was identified. The weight loss was attributed to severe steatorrhea due, in part, to intraluminal bile salt deficiency, small bowel mucosal disease, and bacterial overgrowth. Several points are discussed regarding gastrointestinal function in elderly patients with chronic liver disease secondary to PBC. The rare association between PBC and celiac disease in adults is also discussed. Finally, we suggest that bacterial overgrowth plays a significant role in the development of steatorrhea in some persons with PBC and that an assessment for bacterial overgrowth should be performed on persons with steatorrhea and PBC.     

Etiology of portal hypertension may influence gastrointestinal transit

Background: Gastrointestinal transit studies have shown contradictory results in patients with portal hypertension. We have studied gastric emptying, small‐bowel transit and colonic transit in patients with portal hypertension. The association between small‐bowel bacterial overgrowth and gastrointestinal transit was assessed. Methods: Sixteen patients (6 females) with portal hypertension and esophageal varices were included. A newly developed radiological procedure was used to measure gastrointestinal transit during one visit. Variceal pressure was measured and culture of small‐bowel aspirate was used to diagnose small‐bowel bacterial overgrowth. The results were compared to results obtained in 83 healthy subjects. Results: Half gastric emptying time in male patients was 3.8 (0.9–5.8)?h versus 2.5 (0.4–4.0)?h in healthy males (median and percentile 10–90; P?P?Conclusion: Etiology of liver disease and gender may influence transit in patients with portal hypertension. Small‐bowel bacterial overgrowth was associated with delayed small‐bowel transit.     

Intestinal motility in patients with small bowel diverticulosis

It has been demonstrated that motility disorders may be responsible for esophageal and colon diverticulosis. Recently anatomic alterations of both small bowel muscular layers and myenteric plexus have been described in patients with small bowel diverticulosis. Such pathological features could be responsible for motility disorders and small bowel diverticulosis formation. The aim of this work was to study the small bowel motility in patients with small bowel diverticulosis. Ten patients (mean age: 69.2 +/- 6 years mean +/- SEM) with more than 3 diverticula in the jejunum or the ileum (excepting duodenal diverticulum) were studied. After an overnight fast, a 4 lumen probe (side holes 10 cm apart) was used to record duodeno-jejunal motility for 4 hours. Esophageal manometry was also performed in 8 patients. The mean number of phase 3 of the migrating motor complex (mean +/- SEM) during 4 hours was significantly lower in patients with small bowel diverticulosis (0.15 +/- 0.05/hours; mean +/- SEM) than in 10 normal volunteers (0.52 +/- 0.07/hours; mean +/- SEM) (P less than 0.01); 5 patients had zero phase 3 during the 4 hours of recording; one patient displayed intestinal hypomotility associated with aberrant phase 3 like activity; 4 patients showed simultaneous minute-rhythm during more than 80 percent of the phase 2 of the migrating motor complex. Esophageal manometry was also disturbed in 6 patients (low amplitude contractions less than 30 cm H2O in the distal esophagus). Bacterial overgrowth was investigated in 8 patients by means of a glucose breath-test and was found in 6 cases. In conclusion, duodeno jejunal motility is altered in patients with small bowel diverticulosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Association between colonic diverticulosis and prevalence of colorectal polyps

Introduction

Diverticulosis and colorectal polyps increase in frequency as the population ages. Proposed common mechanisms for both include lack of dietary fiber, increased saturated fats, and slow colonic transit time. The association of diverticulosis and colorectal polyps has been previously reported with conflicting results. Despite sharing common epidemiologic predisposing factors, the association between diverticulosis and colon polyps remains unclear and needs better clarification.

Aim

The primary aim of our study is to evaluate if there is any association between diverticular disease and colorectal polyps.

Materials and methods

This is a retrospective cohort study. All consecutive patients who underwent colonoscopy between January 2009 and December 2011 were included, except those with history of inflammatory bowel disease, polyposis syndrome, and poor bowel preparation. Univariate and multivariate logistic regression analysis was conducted to analyze the association between colon polyps and diverticulosis. Hyperplastic polyps were excluded from the statistical analysis, and only pre-cancerous adenomas were included.

Results

A total of 2,223 patients met the inclusion criteria. The prevalence of colorectal polyps in patients with diverticulosis was significantly higher than those without diverticulosis (odds ratio (OR) 1.54; 95 % confidence interval (CI) 1.27–1.80, p?=?0.001). This association was found significant for all locations of polyps and all histological subtypes. There was also a statistically significant association between age, presence of diverticulosis, and colorectal polyps (OR 1.03; 95 % CI 1.02–1.04). The incidence of colorectal polyps increases as age advances in patients with diverticulosis, with the highest association in patients >70 years of age (OR 3.55; 95 % CI 2.50–5.04). There was no significant association between indication for colonoscopy and presence of colorectal polyps in patients with diverticulosis (OR 0.98; 95 % CI 0.95–1.01). The incidence of diverticulitis was low (<1 %), and there was no association between diverticulitis and colon polyps.

Conclusion

There is a significant association between diverticulosis and synchronous pre-cancerous colorectal polyps (adenomas). Patients with diverticulosis have a higher risk of colorectal polyps as compared to those without. This observation needs further validation by a large prospective cohort study.     

Small bowel bacterial overgrowth in subjects living in residential care homes.

OBJECTIVES: in elderly people, bacterial overgrowth of the small bowel may be occult. The significance of positive breath tests are uncertain: many fit elderly subjects with positive tests show no evidence of malabsorption. We assessed the prevalence and significance of bacterial overgrowth in the small bowel in a relatively unselected elderly population. METHODS: residents of seven elderly people's homes had a glucose hydrogen breath test. A medical history and anthropomorphic measurements were recorded. Volunteers with positive breath tests were given doxycycline. After 4 months all volunteers were reassessed. RESULTS: of 140 residents, 62 were tested. Nine (14.5%) had a positive breath test. There was no difference in anthropomorphic and bowel habit data between those with positive and those with negative breath tests. After 4 months of antibiotic treatment, volunteers with a positive breath test had increased weight and body mass index, while those with a negative test had decreased weight and body mass index. CONCLUSIONS: the percentage of volunteers with a positive breath test was much lower than in previous studies. This may be due to the relatively unselected nature of the volunteers. Treatment of bacterial overgrowth resulted in a small but significant improvement in anthropometric indices. The lack of association of positive breath tests with baseline anthropomorphic measurements or bowel habit highlights the occult nature of the bacterial overgrowth and questions its clinical importance.     

Serum Pepsinogen and Gastrin Levels: Reliable Markers to Predict Small Intestinal Bacterial Overgrowth

BackgroundSerum pepsinogen, a useful indicator of gastric acidity, could reflect small intestinal bacterial overgrowth. The aim of this study is to evaluate the relationship between small intestinal bacterial overgrowth and profiles including pepsinogen or gastrin.MethodsWe conducted a prospective study with 62 patients with a functional gastrointestinal disorder. All patients underwent glucose breath test for small intestinal bacterial overgrowth, immediately followed by upper endoscopy to survey gastric injury and Campylobacter-like organism test for Helicobacter pylori and serum laboratory tests including gastrin, pepsinogen I and II.ResultsThe positivity to small intestinal bacterial overgrowth was 17.7%. Significantly, low total hydrogen concentration during a glucose breath test, low prevalence for gastric injury, and high H. pylori positivity rate were shown in groups with pepsinogen I/II ratio ≤ 3.5 compared to those with pepsinogen I/II ratio > 3.5 or in groups with serum gastrin > 35.4 pg/mL comparing to those with serum ≤ 35.4 pg/mL, respectively. A high gastrin level was independently associated with H. pylori infection. A proportionally correlated tendency between pepsinogen I/II ratio and total hydrogen concentration was shown, whereas that of inverse proportion between H₂ and gastrin was observed. Old age was solely independent predicting factor for small intestinal bacterial overgrowth (P = .03) in the multivariate analysis.ConclusionOld age was significantly related to the presence of small intestinal bacterial overgrowth in functional gastrointestinal disorder patients. Although pepsinogen and small intestinal bacterial overgrowth seem irrelevant, elevated gastrin level may cautiously indicate a decreased breath hydrogen concentration. Further studies should consider the function of intestinal motility and gastric acidity in patients with hydrogen-producing small intestinal bacterial overgrowth.     

Evaluation of the rice breath hydrogen test for small intestinal bacterial overgrowth

OBJECTIVES: The aims of this study were 1) to document the sensitivity, specificity, and predictive values of the rice breath hydrogen test for small intestinal bacterial overgrowth; 2) to determine the possible influence of concurrent gastric bacterial overgrowth and gastroduodenal pH on the efficacy of this test; and 3) to investigate whether reliability is limited by an inability of small intestinal luminal flora to ferment rice or its product of hydrolysis, maltose. METHODS: Twenty adult subjects were investigated with microbiological culture of proximal small intestinal aspirate and a 3-g/kg rice breath hydrogen test. Gastroduodenal pH, the presence or absence of gastric bacterial overgrowth, and the in vitro capability of small intestinal luminal flora to ferment rice and maltose, its product of hydrolysis, were determined. RESULTS: Sensitivity of the rice breath hydrogen test for small intestinal bacterial overgrowth was 33% and remained low even when subjects with small intestinal overgrowth with oropharyngeal-type (38%) and colonic-type flora (20%) and those with concurrent small intestinal and gastric bacterial overgrowth (40%) were considered separately. Sensitivity remained suboptimal despite favorable gastroduodenal luminal pH and documented ability of bacterial isolates to ferment rice and maltose in vitro. Specificity of the rice breath hydrogen test for small intestinal bacterial overgrowth was 91%. Positive predictive value, negative predictive value, and predictive accuracy were 75%, 63%, and 65%, respectively. CONCLUSIONS: Clinical value of the rice breath hydrogen test for detecting small intestinal bacterial overgrowth is limited. The rice breath hydrogen test is not a suitable alternative to small intestinal intubation and culture of secretions for the detection of small intestinal bacterial overgrowth.     

Association between hypothyroidism and small intestinal bacterial overgrowth

OBJECTIVES: Small intestinal bacterial overgrowth is defined as an abnormally high bacterial population level in the small intestine. Intestinal motor dysfunction associated with hypothyroidism could predispose to bacterial overgrowth. Luminal bacteria could modulate gastrointestinal symptoms and interfere with levothyroxine absorption. The aims of the present study were to assess the prevalence and clinical pattern of bacterial overgrowth in patients with a history of overt hypothyroidism and the effects of bacterial overgrowth decontamination on thyroid hormone levels. METHODS: A total of 50 consecutive patients with a history of overt hypothyroidism due to autoimmune thyroiditis was enrolled. Diagnosis of bacterial overgrowth was based on positivity to a hydrogen glucose breath test. Bacterial overgrowth positive patients were treated with 1,200 mg rifaximin each day for a week. A glucose breath test, gastrointestinal symptoms, and thyroid hormone plasma levels were reassessed 1 month after treatment. RESULTS: A total of 27 patients with a history of hypothyroidism demonstrated a positive result to the breath test (27 of 50, 54%), compared with two in the control group (two of 40, 5%). The difference was statistically significant (P < 0.001). Abdominal discomfort, flatulence, and bloating were significantly more prevalent in the bacterial overgrowth positive group. These symptoms significantly improved after antibiotic decontamination. Thyroid hormone plasma levels were not significantly affected by successful bacterial overgrowth decontamination. CONCLUSIONS: The history of overt hypothyroidism is associated with bacterial overgrowth development. Excess bacteria could influence clinical gastrointestinal manifestations. Bacterial overgrowth decontamination is associated with improved gastrointestinal symptoms. However, fermenting carbohydrate luminal bacteria do not interfere with thyroid hormone levels.     

Intestinal permeability and bacterial growth of the small bowel in patients with primary sclerosing cholangitis

OBJECTIVE: Animal studies show that small intestinal bacterial overgrowth and infusion of bacterial antigens into portal blood cause hepatic histological changes similar to those seen in primary sclerosing cholangitis in man. It has been suggested that aa similar mechanism involving bacterial overgrowth with increased small-bowel permeability may play a pathogenic role in patients with primary sclerosing cholangitis (13 M, 9 F, median age 37 years, range 21-74 years), 19 of whom (83%) had quiescent inflammatory bowel disease, were included in the study along with 18 healthy volunteers (9 F, ( M, median age 36 years, range 23-80 years). Small-bowel bacterial overgrowth was defined as the presence of colonic flora>10(5) colony-forming units (cfu)/ml from duodenal aspirations. Small-bowel intestinal permeability was assessed as the differential urinary excretion of lactulose/L-rhamnose. RESULTS: Bacterial overgrowth was evident in one patient with primary sclerosing cholangitis (4.5%) (Enterobacter) and in none of the controls. Intestinal permeability in patients with primary sclerosing cholangitis (0.034 (0.026-0.041) (median, interquartile range (IQR)) did not differ significantly from that of the controls (0.033 (0.025-0.041). CONCLUSIONS: Small intestinal bacterial overgrowth and increased intestinal permeability does not seem to play an important pathogenic role in patients with primary sclerosing cholangitis.     

COBALAMIN DEFICIENCY and SMALL BOWEL BACTERIAL OVERGROWTH: A COMMON ASSOCIATION

Background  Bacterial overgrowth may cause cobalamin deficiency through competition for dietary cobalamin in the small intestine. The objective of this study was to prospectively determine the prevalence of small bowel bacterial overgrowth in patients with documented cobalamin deficiency in a tertiary referral centre.
Methods  Patients identified with cobalamin deficiency underwent diagnostic investigations including: Endoscopy (with gastric antrum, gastric body and duodenal biopsies and duodenal aspirate), ¹⁴C-D-Xylose breath test, intrinsic factor antibody, anti-endomysial antibody and red cell folate level. 'Definite' small bowel bacterial overgrowth was defined as either a positive ¹⁴C-D-Xylose breath test or > 100 000 CFU/mL of culture of duodenal aspirate. 'Suspected' small bowel bacterial overgrowth was defined as an elevated red cell folate in the absence of supplemental folate therapy.
Results  Over a 2-year period, 62 patients with cobalamin deficiency were identified, of whom, 26 (42%) had 'definite' small bowel bacterial overgrowth, whilst a further nine (15%) had 'suspected' small bowel bacterial overgrowth. Nineteen (31%) had pernicious anaemia, and no cause for cobalamin deficiency could be found in eight (13%) patients. The diagnosis found in the remaining patients included coeliac disease (4), Crohn's Disease (1), gastric resection (2), vegan (2), homozygotes of the MTHFR gene (C677T) mutation (2), and one had enteropathy associated with common variable immunodeficiency (CVID). 'Definite' small bowel bacterial overgrowth was found to coexist with nine of the 19 cases of pernicious anaemia, two coeliac subjects, one CVID enteropathy and one patient with the MTHFR gene mutation.
Conclusion  Small bowel bacterial overgrowth is commonly associated with cobalamin deficiency.     

Evaluation of small bowel bacterial overgrowth

Small bowel bacterial overgrowth historically has been associated with malabsorption syndrome attributed to deconjugation of bile acids in the upper small intestine. Recent reports raise the possibility that bacterial overgrowth may be a cause of watery diarrhea or irritable bowel syndrome. Quantitative culture of jejunal contents has been the gold standard for diagnosis, but a variety of indirect tests have been developed (and mostly discarded) over the years in an attempt to facilitate the diagnosis of small bowel bacterial overgrowth. These include breath tests and biochemical tests based on bacterial metabolism of various substrates. Problems with these indirect tests include rapid transit, which may cause substrate to reach the luxuriant bacterial flora in the colon, producing false positives and vagaries of the tests themselves, which may produce falsely negative results. The perfect test for small bowel bacterial overgrowth is yet to be devised.     

Diverticulosis of the small intestine

Seven patients with small-intestinal diverticulosis were studied by means of intestinal absorptive tests, biopsies, and bacterial cultures of small-intestinal aspirates. Aerobic bacterial cultures were obtained in all patients, while anaerobic cultures with a modified Hungate roll-tube technic were performed in 3. Three of the patients manifested steatorrhea and were studied over prolonged periods of time. The bacterial flora varied over a wide quantitative range, with highest total counts in excess of 10⁹ colony-forming units per milliliter found in the 2 patients with the most severe malabsorption. Despite multiple diverticulosis, 1 patient without steatorrhea had no recoverable aerobic or anaerobic bacterial flora. E. coli predominated among the recovered aerobic organisms in this series, but A. aerogenes and various streptococci also were encountered repeatedly. Patients treated with antibiotics directed at the aerobic flora showed prompt improvement in absorption, and reduction in bacterial counts. Repeated short courses of antibiotics were needed to treat early bacteriologic and clinical relapses. After several such courses, all 3 patients treated maintained their clinical and metabolic improvement for periods of close observation ranging from 2 to 15 months without additional antibiotic treatment, and the clinical remissions were accompanied by gradual reductions in total bacterial counts to “borderline normal” limits. Of the 3 patients, 1 has now been followed for 5 years without relapse. It is apparent that the mere presence of diverticulosis does not lead necessarily to malabsorption. Malabsorption of fat, Vitamin B₁₂, and other nutrients was found only in patients with excessive bacterial flora, emphasizing the crucial role bacteria play in the pathogenesis of malabsorption in diverticulosis of the small intestine.