Small-bowel colonization alone is a cause of diarrhea

Bacterial overgrowth in the small bowel is known to occur in patients with persistent diarrhea, but it has been unclear if colonization alone causes fluid secretion. We studied isogenic, nontoxigenic Escherichia coli strains with colonizing factor antigen II (CFA/II) (1392+) and without CFA/II (1392-) in 18-h rabbit ileal loops. Neither strain produced fluid, but quantitative cultures of rabbit ileal loops with the CFA/II-positive strain had a mean of 10(3) more CFU of bacteria per cm2 than did cultures of rabbit ileal loops with the CFA/II-negative strain or a negative control (P less than 0.05). Of 11 rabbits given strain 1392+ via the small bowel in the reversible ileal tie model, 7 became colonized (mean, 10(10.4) +/- 1.6 CFU/cm2) over 72 h, and all 7 developed diarrhea and had gross gut fluid accumulation, versus none of 10 rabbits given strain 1392- (mean, 10(3.6) +/- 1.9 CFU/cm2) (P less than 0.05). Both strains grew equivalently in vitro. The mechanism by which this E. coli strain which colonizes small-bowel mucosa but produces no recognized toxins causes fluid accumulation and diarrhea in a rabbit model at 72 h remains to be elucidated.