Can cause gas-bloat syndrome and dysphagia post antireflux surgery.

–       Inability to belch, postprandial bloating, flatulence

Symptoms: Diarrhoea, postprandial bloating and flatulence (increased gas production in the small bowel, bacterial fermentation)

Cause: PPI use changes gut microbiota towards the oral microbiome and by reducing acid levels, allows the colonisation of microorganisms in the proximal gut.

Diagnosis: Presence of bacteria in SB >10³ CFU/ml. Duodenal aspirates is difficult.  Hydrogen and Methane brath testing (HMBT) is widely accepted.

Treatment: wide spectrum antibiotics to cover aerobes and anaerobes (Augmentin, Metronidazole, Co-trimoxazole, Ciprofloxacin) for 1-2 weeks. Check levels of B12, iron, niacin, thiamine.