Small Intestinal Motility Disturbances and Bacterial Overgrowth in Patients With Liver Cirrhosis and Portal Hypertension Steingerdur Anna Gunnarsdottir, M.D., Riadh Sadik, M.D., Steven Shev, M.D., Ph.D., Magnus Simre ´n, M.D., Ph.D., Henrik Sjo ¨vall, M.D., Ph.D., Per-Ove Stotzer, M.D., Ph.D., Hasse Abrahamsson, M.D., Ph.D., Rolf Olsson, M.D., Ph.D., and Einar S. Bjo ¨rnsson, M.D., Ph.D. Department of Internal Medicine, Section of Gastroenterology and Hepatology, Sahlgrenska University Hospital, Go ¨teborg, Sweden OBJECTIVES: Altered small bowel motility and a high prev- alence of small intestinal bacterial overgrowth (SIBO) has been observed in patients with liver cirrhosis. Our aim was to explore the relationship between motility abnormalities, portal hypertension, and SIBO. METHODS: Twenty-four patients with liver cirrhosis were included. Twelve had portal hypertension (PH) and 12 had liver cirrhosis (LC) alone. Child-Pugh score was the same in the groups. Antroduodenojejunal pressure recordings were performed, and noninvasive variceal pressure measurements were undertaken. Thirty-two healthy volunteers served as a reference group. Bacterial cultures were obtained from je- junal aspirates. RESULTS: The PH group had a higher proportion of indi- vidual pressure waves that were retrograde in the proximal duodenum during phase II (52% vs 13% vs 8% of propa- gated contractions; p  0.001) as well as postprandially (49% vs 18% vs 13%; p  0.01) compared with LC and controls, respectively. Long clusters were more common in PH than in controls (9.1  2.1 vs 4.9  0.8; p  0.05), and a higher motility index in phase III in the proximal and distal duodenum was seen in the PH as compared with the other groups. The mean variceal pressure was 21  1 mm Hg. Motor abnormalities were not correlated to the level of variceal pressure. Thirty-three percent of the patients in the PH group but none in the LC group had SIBO. CONCLUSIONS: Abnormal small bowel motility and SIBO is common in patients with liver cirrhosis with concomitant portal hypertension. Portal hypertension per se might be significantly related to small bowel abnormalities observed in patients with liver cirrhosis. (Am J Gastroenterol 2003; 98:1362–1370. © 2003 by Am. Coll. of Gastroenterology) INTRODUCTION GI symptoms such as nausea, vomiting, abdominal pain, and diarrhea are common in patients with advanced liver disease (1). However, the etiopathogenesis of GI symptoms in pa- tients with liver disease is obscure. Changes in GI function can be due to malabsorption (2), GI motility disturbances (3, 4), small intestinal bacterial overgrowth (SIBO) (5), or various effects of metabolic derangement caused by liver cirrhosis. However, the importance of portal hypertension per se as related to small intestinal motility and bacterial overgrowth of the upper gut is poorly understood. Altered small intestinal motility has been described in patients with liver cirrhosis, but no correlation was observed between small bowel motor abnormalities and the etiology of the liver disease or with the occurrence of SIBO (6). A relationship has been reported between the severity of liver failure and the intensity of small intestinal motility distur- bances (3, 4). These studies have demonstrated a prolonged duration of the migrating motor complex (MMC) and an increased frequency of clustered contractions in patients with liver cirrhosis (3, 4). Such disturbances could play a role in the pathogenesis of SIBO and even lead to compli- cations of chronic liver disease, such as malabsorption, spontaneous bacterial peritonitis, and encephalopathy. A correlation has been reported between the absence of phase III of the MMC and SIBO (7, 8). The propagation pattern of individual contractions has been well characterized in healthy subjects (9, 10, 11). Patients with SIBO have been shown to have fewer propagated contractions in the proxi- mal duodenum in phase II when compared with healthy subjects (8), but the characteristics of the individual con- tractions in the upper gut in cirrhotic patients are unex- plored. A high prevalence of SIBO has been observed in patients with liver cirrhosis with spontaneous bacterial peri- tonitis (5, 12), but other investigators did not find any evidence of SIBO in patients with advanced liver cirrhosis (13). Slowing of orocecal transit has been observed in pa- tients with cirrhosis (14) and in portal hypertensive rats (15). Antibiotic therapy improves the orocecal transit time, which makes it likely that bacterial overgrowth alters the small bowel motility in patients with liver cirrhosis (14). Treat- ment with cisapride or antibiotics can reverse altered small bowel motility, orocecal transit time, and SIBO in patients THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 98, No. 6, 2003 © 2003 by Am. Coll. of Gastroenterology ISSN 0002-9270/03/$30.00 Published by Elsevier Inc. doi:10.1016/S0002-9270(03)00250-8