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Notes: Background:  Insulin resistance and oxidative stress induced by products of small intestinal bacterial activity are putative factors in the pathogenesis of non-alcoholic steatohepatitis. Acylated ghrelin is the biologically active form of an orexigenic gastric hormone that modifies insulin sensitivity and body composition.Aim:  To investigate the effect of ciprofloxacin on small intestinal bacterial activity, ethanol, ghrelin and insulin in non-alcoholic steatohepatitis patients.Methods:  Twelve non-alcoholic steatohepatitis patients and 11 controls were studied before and after ciprofloxacin 500 mg b.d. for 5 days. After an overnight fast, 75 g glucose was ingested and blood was sampled every 20 min for 120 min. Acylated and total ghrelin, ethanol and insulin were measured. Small intestinal bacterial activity was detected by glucose hydrogen breath test.Results:  Mean (range) integrated plasma acylated ghrelin which was 102 (21–241) and 202 (88–366) pg/mL · 2 h in non-alcoholic steatohepatitis and controls respectively (P = 0.015). This difference persisted after correction for body mass index and was unaffected by ciprofloxacin treatment. One of six non-alcoholic steatohepatitis patients positive for small intestinal bacterial activity remained positive after ciprofloxacin. In contrast, the one healthy control positive for small intestinal bacterial activity remained positive after ciprofloxacin (P = 0.025). Ethanol was detected in two subjects in each group, becoming immeasurable after ciprofloxacin. In non-alcoholic steatohepatitis patients median (range) fasting insulin increased from 113 (10–223) to 152 (32–396) pmol/L (P 〈 0.02), after ciprofloxacin. This was accompanied by similar changes in insulin resistance.Conclusions:  Small intestinal bacterial activity is common in non-alcoholic steatohepatitis. Low acylated ghrelin in non-alcoholic steatohepatitis cannot be attributed to small intestinal bacterial activity. Changes in fasting insulin and ethanol following ciprofloxacin suggest that these parameters may be influenced by small intestinal bacterial activity.