This is a guest post written by Amy Nett, MD.
The normal small bowel, which connects the stomach to the large bowel, is approximately 20 feet long. Gut microbiome bacteria are normally present throughout the entire gastrointestinal tract, but in varied amounts. Relatively few bacteria normally live in the small bowel (less than 10,000 bacteria per milliliter of fluid) when compared with the large bowel, or colon (at least 1,000,000,000 bacteria per milliliter of fluid). And, the types of bacteria normally present in the small bowel are different from those in the colon.
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Why You Should Thank Your Small Bowel and the Beneficial Bacteria That Live There
The small bowel plays an important role in digesting food and absorbing nutrients. It is also an important part of the immune system, containing an impressive network of lymphoid cells (cells of the immune system that help fight infections and regulate the immune system).
Are you at risk for small intestinal bacterial overgrowth? Find out what the most common risk factors and symptoms are.#SIBO #SIBOsymptomps
The normal (beneficial) bacteria that are an essential part of the healthy small bowel also perform important functions. These beneficial microorganisms help protect against bad (i.e. pathogenic) bacteria and yeast that are ingested. They help the body absorb nutrients, and also produce several nutrients (such as short chain fatty acids) and vitamins like folate and vitamin K. These bacteria help maintain the normal muscular activity of the small bowel, which creates waves that move the contents of the intestine, like food, through the gut.
What Is SIBO?
SIBO, small intestinal bacterial overgrowth, is defined as an increase in the number of bacteria, and/or changes in the types of bacteria present in the small bowel. In most patients, SIBO is not caused by a single type of bacteria, but is an overgrowth of the various types of bacteria that should normally be found in the colon (1). Less commonly, SIBO results from an increase in the otherwise normal bacteria of the small bowel.
SIBO has been shown to negatively affect both the structure and function of the small bowel. It may significantly interfere with digestion of food and absorption of nutrients, primarily by damaging the cells lining the small bowel (the mucosa). Additionally, this damage to the small bowel mucosa can lead to leaky gut (when the intestinal barrier becomes permeable, allowing large protein molecules to escape into the bloodstream), which is known to have a number of potential complications including immune reactions that cause food allergies or sensitivities, generalized inflammation, and autoimmune diseases (2).
These pathogenic bacteria, whether too many or the wrong types, can lead to nutritional deficiencies on top of those due to poor digestion or malabsorption. In particular, the bacteria will take up certain B vitamins, such as vitamin B12, before our own cells have a chance to absorb these important nutrients. They may also consume some of the amino acids, or protein, that we’ve ingested, which can lead to both mild protein deficiency and an increase in ammonia production by certain bacteria. (We normally produce some ammonia daily from normal metabolism, but ammonia requires detoxification, so this may add to an already burdened detoxification system.) The bacteria may also decrease fat absorption through their effect on bile acids, leading to deficiencies in fat soluble vitamins like A and D.
What Causes SIBO?
The body has several different ways of preventing SIBO. These include gastric acid secretion (maintaining an acidic environment), waves of bowel wall muscular activity, immunoglobulins in the intestinal fluid, and a valve that normally allows the flow of contents into the large bowel but prevents them from refluxing back into the small bowel. (This is called the ileocecal valve because it’s located between the ileum, or terminal end of the small intestine, and the cecum, a pouch forming the first part of the large bowel.)
The cause of SIBO is usually complex, and likely affects more than one of the protective mechanisms listed above. A number of risk factors for SIBO have been identified, with some of the more common risk factors listed below. For a more complete discussion of associated diseases and risk factors check out this study and this study.
Risk Factors for SIBO
- Low stomach acid
- Irritable bowel syndrome
- Celiac disease (long-standing)
- Crohn’s disease
- Prior bowel surgery
- Diabetes mellitus (type I and type II)
- Multiple courses of antibiotics
- Organ system dysfunction, such as liver cirrhosis, chronic pancreatitis, or renal failure
Moderate Alcohol Consumption and Oral Contraceptive Pills (OCPs) Also Increase the Risk for SIBO
Heavy alcohol use has long been recognized in association with SIBO (3). This study also found an association between SIBO and moderate alcohol consumption, defined as up to one drink per day for women and two drinks per day for men. Alcohol appears to have effects on several of the normal protective mechanisms, including causing injury to the small bowel mucosal cells, contributing to leaky gut, and decreasing the muscular contractions. Additionally, alcohol may “feed” a few specific types of bacteria contributing to overgrowth (4).
Overall there appears to be a moderate association between OCPs and inflammatory bowel disease (IBD) such as Crohn’s disease (5). Though no studies to date specifically correlate the use of OCPs with SIBO, given the known relationship between IBD and SIBO, it is likely that this association holds true for SIBO as well. However, once patients stop taking OCPs, this risk appears to reverse.
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How Do You Know If You Have SIBO?
The number of people with SIBO in the general population remains unknown. Some studies suggest that between 6 to 15% of healthy, asymptomatic people have SIBO, while up to 80% of people with irritable bowel syndrome (IBS) have SIBO (6).
Complicating this, the most commonly used tests (breath tests measuring levels of hydrogen and methane gas) still have fairly high rates of false negatives (meaning the test results come back as negative but you actually do have the disease) (7).
The most common symptoms of SIBO include:
- Abdominal pain/discomfort
- Bloating and abdominal distention
- Diarrhea
- Constipation (generally associated with methanogens as Chris discussed in his recent podcast)
- Gas and belching
- In more severe cases, there may be weight loss and symptoms related to vitamin deficiencies.
Is SIBO Contagious?
Unlike many other bacterial infections of the gastrointestinal tract, SIBO is not contagious, and there is no evidence that exposure to any single microorganism increases the risk for developing SIBO. SIBO occurs due to a complex interplay of many different factors and is not passed on between individuals. However, some evidence suggests that there is an association between Helicobacter pylori and methane production, suggesting that H. pylori plays a role in gut dysbiosis. (8)
Why SIBO Can Be Difficult to Treat
Antibiotics are often used to treat SIBO. However, studies show that despite treatment with antibiotics, recurrence develops in almost half of all patients within one year. One study comparing treatment with rifaximin (the most commonly used antibiotic for SIBO) and botanical antimicrobials showed slightly better outcomes with the botanical protocol, but still with successful treatment in close to only half of all patients after one course of treatment.
These finding suggests that treatment of the overgrowth alone is not enough for most people. An additional piece of successful treatment must include addressing the underlying cause, or predisposing factor.
Though there are many identified associations between SIBO and other diseases as described above, abnormalities in gut motility are recognized as one of the most common associations. One study published this month demonstrated that patients with SIBO do have significant delays in small bowel transit time (the amount of time it takes something to move through the small bowel). This finding suggests that patients with SIBO, who do not recover after a standard course of antibiotics, or botanical antimicrobial protocol (which we prefer), may benefit from the addition of a prokinetic agent, which increases the muscular contractions of the small bowel. Octreotide and low dose naltrexone are two such options that are being investigated, and may help treat some cases of SIBO that don’t respond to antimicrobials alone. Other options may include prucalopride and low-dose erythromycin, as well as lubiprostone. (9)
As research into SIBO continues, we are increasingly understanding the complexity of this disease, and how treatment must be tailored to each individual to maximize success.
If you need support in dealing with SIBO, consider working with the California Center for Functional Medicine. CCFM offers a membership-based health transformation service that excels at helping people with chronic conditions make the changes necessary to reclaim their health. Find out more about what CCFM has to offer.
About Amy: Amy Nett, MD, graduated from Georgetown University School of Medicine in 2007. She subsequently completed a year of internal medicine training at Santa Barbara Cottage Hospital, followed by five years of specialty training in radiology at Stanford University Hospital, with additional subspecialty training in pediatric radiology.
Along the course of her medical training and working through her own personal health issues, she found her passion for Functional Medicine. She works with patients through a Functional Medicine approach, working to identify and treat the root causes of illness. She uses nutritional therapy, herbal medicine, supplements, stress management, detoxification and lifestyle changes to restore proper function and improve health.
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I had what I later found out to be SIBO for years. Several GI docs thought it was my pancreas even though I told them that I had no signs of pancreatitis. I finally had the definitive pancreatitis test which proved my pancreas was fine.
I tried ever crazy thing out there that I could find. I initially steered clear of antibiotics because of all of the Candida hoopla. I eventually found out antibiotics would help but then symptoms would recur after months and sometimes days… I barely managed the symptoms for years with antibiotics, Betaine HCL and found raw milk helped but then developed a milk allergy.
I previously tried Align and it didn’t help at all. I knew my microbiome was still out of wack because my symptoms would reoccur so I finally decided to buy the expensive refrigerated probiotics from my local heath food store and took the maximum dosage for months. The first couple of weeks I couldn’t believe the amount of matter leaving my body but it was more well formed and more complete(I used to get off the toilet then 2 minutes later feel that I needed to get back on it) and no longer had steatorrhea (the bacteria was destroying my bile acids) after the first few days. I felt normal after a couple of weeks. Weeks later I started eating raw fermented foods and that made my breath much better. I also had bone broth since then.
I’ve been off the pro-biotics for a year now and have put on some muscle and feel great still. I hope this helps you!
I feel nauseous after eating for 5 months. Get some bloat & fatigue & nausea from water, too. Had endoscopy and found nothing. I can handle with nausea if I take digestive enzymes with each meal but water still gives me bloat & nausea. Two different docs said me that it’s just simply indigestion but I’m doubt about SIBO.
Please give me a suggestion.
I got tan appointment via telephone with a group in Idaho. I think that’s where they are. Digestive experts for sure! http://redmountainclinic.com and guess what, there’s no 2 year waiting list like there is for Chris with a $1000 starting price. I paid $180 for a 40 minute appt. They have various YouTube videos, so you can see how much they understand the gut. It’s called Beyond MTHFR on YouTube. I ordered all the recommended supplements at Vitacost, and I will follow up here if I feel better. The Biocidin, Biofilm, and Oliverex protocol didn’t work, and I used 2 bottles of it. I’ll let you know. I’m trying to treat bacteria imbalance, SIBO, and yeast overgrowth.
Cheryl,
Drink Keifer daily and take a probiotic with 10 different strains of bacteria. Wal-Mart has one that only cost 12.00. I also take a Tofranil 50mg at night to block signals from stomach to the brain per the Mayo Clinic in Arizona. Dr. Steven Dubois recommend it and I went 7 years ago.
I was diagnosed by a dr with SIBO and was put on antibiotics (very harmful for the body) for 2 weeks and then told to do 2 weeks of probiotics. Since that didnt work for me and i do not like using antibiotics, I bought some probiotics (Florell @ Vitacost.com) and started eating probiotic or greek yogurt with fruit (blueberries, strawberries). This will help regulate the pH of the digestive system which will help promote healthy bacteria growth in the intestines. A good part of your diet you will need to limit or eliminate are refined sugars, sweets, breads, pastries, sugar drinks, carbohydrates, starchy foods, etc. The bacteria in your intestines flourishes in sugars and carbohydrates so by limiting these, it will limit continued overgrowth. If you change your diet to mainly green veggies (not the starchy kind like corn/potatoes) and protein (meats, cheeses, dairy), some fruits and very little carbohydrates/breads then you will probably see some progress! hopefully this helps you 🙂
Bilgin,
You will know if it is SIBO or not. do you belch all the time? Do you sound like you have had 24 beers when you belch. SIBO causes severe gas and belching that hurts in your chest. You think your having a heart attach but, after someone pats your back (like when you were a baby) and you belch the chest pain goes away. I have had SIBO for 7 years. I have taken several rounds of Xifian. You need to take 550 mg 2x daily for a month to get any hope of getting better. It never goes away just goes dormant as long as your good bacteria out ways your bad. I also take a probiotic daily and drink 8oz of Keifer to help add good bacteria into my system. I went from lying in the bed for 2 years to flying to the Mayo clinic in Arizona for help to taking Tofranil every night to block the signals from my stomach to the brain. this combo has helped me go back to work. I still have flair ups but at least I only suffer every once in a while. Stay away from other antibiotics as much as you can and load up on probiotics if you have to take something other than xifian.
I bloat just from water. You’re the first other I’ve seen say that as well! I’ve been in tx for SIBO for 2 yrs & it got better, but just recurred when my primary hyperparatyroidism (PHPT) got worse. I read that PHPT is a systemic cause, so waiting til after surgery to restart Xifaxan. I eat a crazy strict diet of very low-fodmap, in combo with all the other recommended diets. :/
I believe Bartonella, Lyme, or some infection of the brain may be a significant cause of SIBO disease, cause the stomach to stop working.
That makes sense. I’ve had Lyme and now have been diagnosed with SIBO
Any one have information on Narcotic Bowel Syndrome? Any info on opoids as they affect a hydrogen/methane breath test?
I’ve had gastrointestinal issues my whole life…finally I know what the problem is! Now, to fix it.
Hi ,
I’ve read your information on treating SIBO. I’m seeing a naturopath but she is not helping much. I have been diagnosed with chronic pancreatitis from my GI, and had a positive SIBO test from naturopath. I was put on a low FodMap diet also told to eat no grains.
I agree so much with your strategy. I can’t eat dairy because of food allergy, I can’t have soy. My diet is super low fat due to CP. Now with SIBO I can’t eat a lot of other things as well .
The challenge is I do not want to lose weight. I am also hungry all the time. I need someone to work with me who can truly help me. My GI says I will never get rid of it to take antibiotics and then it will eventually come back then take another round and continue the process. I don’t think that sounds like much of a plan., but the diet I’m on now I do take some drops with oil of oregano etc., some formula as well but the diet is too limiting. Do you have suggestions as to who I should see or what approach sounds reasonable.
Try to get a Skype appointment with someone in Allison Siebecker’s office in Portland, Oregon.
Bactestat is a product you can order online. It helped me a lot to keep bacteria down. Pure digestive enzymes without sweeteners or maltodextrin – any corn derived sweetener. Stevia is the only sweetener to use. Once in a while I do a course of nano silver 10 ppm. I take courses of strong probiotics / acidophilus / that ilk every so often. Buy greens in bulk (collards, kale, turnip greens, bok choi) and have a ay of cooking and freezing your blended green soup once a week, so you can pull out two frozen bags any day to have with you in case your stomach growls. Putting green puree in at this point is very helpful, alkalizing, energizing, and balances the body, plus fills your stomach with something harmless and healthy. Do the same with solid food like green beans, broccoli, turnips, whatever your non-offending foods are. It’s important to have these on hand so you don’t grab something stupid at a fast food and throw your system off for a few days because you didn’t plan.
Bactestat is a product you can order online. It helped me a lot to keep bacteria down. Pure digestive enzymes without sweeteners or maltodextrin – any corn derived sweetener. Stevia is the only sweetener to use. Once in a while I do a course of nano silver 10 ppm. I take courses of strong probiotics / acidophilus / that ilk every so often. Buy greens in bulk (collards, kale, turnip greens, bok choi) and have a day of cooking and freezing your blended green soup once a week, so you can pull out two frozen bags any day to have with you in case your stomach growls. Putting green puree in at this point is very helpful, alkalizing, energizing, and balances the body, plus fills your stomach with something harmless and healthy. Do the same with solid food like green beans, broccoli, turnips, whatever your non-offending foods are. It’s important to have these on hand so you don’t grab something stupid at a fast food and throw your system off for a few days because you didn’t plan.
Tina,
I have had SIBO for 7 years and went to the Mayo Clinic in Arizona because of it. I take a probiotic with 10 different strains from Walmart everyday, drink 8oz of Keifer (if you can) and take 1 50 mg tablet of TOfrainl to block the signals from my stomach to my brain. I have had several rounds of Xifian and it works but, you have to take it for at least a month for it to really help a 2 week course is not going to help. Hope you GI is studing SIBO.
Hi Amy,
Great information! SIBO has played a huge role in my life both personally and professionally- After meeting Dr. Pimentel author of “A New IBS Solution” in 2001 there was no question that his understanding and thinking “outside the box” of GI Health/Medicine was very unique. Of the 10 GI I visited, only Dr. Pimentel mentioned that sometimes bacteria in colon can make it’s way up north and set up shop in the small bowel creating havoc.
After many rounds of experimenting, what helped me the most was taking Garlic, Enzymes and Probiotic Supplements along with major dietary changes. These changes corrected my motility issues and improved my health dramatically.
I was wondering if anyone with SIBO has belching smelling like selfur or something horrible. I work in close proximity to people and it is so embarrassing! Help!
sulfur belches sound like giardia – a parasitic infection.
you might want to look into that possibility 🙂
Had 3 fundoplications and gastroparesis and recurrent sibo. No teeth so can’t chew. Stomach addicted to ppi forever as heave worse without but still heave daily with intolerable nausea bowels loud gas dizzy bedridden. Antibiotics don’t work. I sustain life via Ensure shakes. Am alone and have depression and anxiety. Tryin to stay alive til son leaves. What do I try next? Email [email protected]
So sorry Nancy. I have gastroparesis, illium valve, chronic fatigue and post op pain from botched surgery. I lose hope some days. I don’t have a life, like I had hoped. I’m in bed a lot but here’s what has helped. Finding a kind and competent Naturalpathic MD. Ask for their experience with your problems, get some exercise, (I walk around my house), really find a nutritionist or the naturalpath for absorption issues.Also food allergies are very intrusive. I juice veggies, just a little, and drink raw kefir but you have to ask a medical person what is right for you. Lastly, support. Those Meet-up groups for spiritual help, or online pain groups. Pain is exhausting. Know that your not alone. We’re here for you.
Enteric coated peppermint pills before every meal have taken away a lot of my symptoms. I have a form of SIBO that causes constipation and gas. Also juicing in the in morning, fruits and kale or spinach blended to start my day have all helped alleviate a lot of my uncomfortable symptoms. I was initially prescribed Xifaxin, 10 day course and it worked great, problem is 2 months later the symptoms came back. I dont want to be on a cycle of expensive antibiotics and honestly the peppermint has worked great
I’m “case managing” my husband’s SIBO, and he can’t take any kind of juices, and about half of fruits and veges are off his FODMAP list; mint really bothers him. Not sure what the common denominator of this thing is. The expensive antibiotics didn’t help, and now we’re trying botanicals, but there are hundreds of possibilities, not sure which ones and for how long, then when to restart probiotics, and which ones…
I couldn’t afford the antibiotics so I have been doing Candibactin, Oreganol, Biocydin, Berberine and garlic. I pulse them. 3 weeks on each one. I also do the SCD diet but when I cheat and eat any grains or sugar I go right back to symptoms.
I also have something (as yet undiagnosed) which I think may be SIBO. I have continual nagging lower abdominal pain, constipation, gas but also bloating. I look 6 months pregnant but I know I’m not. I am awaiting an ultrasound scan and an appointment with a gastroenteritis. I feel very depressed after reading the e-mail for if it is SIBO, it seems hard to get an accurate diagnosis and even harder to get rid of it. I will try your recommendations though, as I feel so desperate.
There are SIBO breath tests out there to see if you are positive or negative. I would call around and find a GI doc that provides this testing. Good luck!
Hello, My Mom had gas and bloating in her stomach, and she looked like 6 months pregnant too. Then the doctor told her to stop eating AT ALL for 4 days, only depending on infusion + antibiotics + other medicines. Right now she’s still in hospital, but now she can eat liquid without feel pain, because previously before she was hospitalized, even mineral water caused her pain. I hope this will help you as well!
Hi Amy
Ive been suffering from IBS for the past 2 years, but my symptoms have been going away as i have been changing and adjusting my diet, and managing stress at work. For about a couple of months now ive noticed that ive been getting really bad smelling and excessive gas, usually at night time, also really bad bloating and cramps. Its worth to point out that i live in Colombia and tests for SIBO do not exist here yet. I was prescribed Rifaximin and took it for 10 days, 2 times a day and felt instant relief from ALL my symptoms. 4 weeks later bad smelling gas came back along with the other symptoms. Im desperate now realising that in Colombia there is no proper testing for SIBO and im afraid ill be destined to suffer from this until the day i die. Is there any way i can contact a doctor via Skype? or another way to get tested for SIBO in order to get the right treatment? please help!
Try bactestat. You can order it online. Keeps bacteria down – it’s an alternative formula – whether it’s homeopathic or not I don’t know but it helped me plus the FODMAP diet (esp. no grains-too carby) and avoiding high sugar foods.
Why don’t you try saukrawt. it helps get rid of the bacteria in the gut.
I have Ehlers Danlos Syndrome and was diagnosed w SIBO via hydrogen breath test (very high). Does anyone else here have EDS or a similar genetic connective tissue disorder? Doc said EDS poor functioning of my intestinal muscles and more fragile permeable tissues in gut are cause, not diet, and dietary changes won’t help much. I’m in so CAl and still need a good GP who knows EDS. My SINO symptoms are getting full very fast, food sitting in upper abdomen, pain and bloating, and then when a severe attack results horrible cramping and feeling I can’t go, just doubled over, followed by loose movements. After one of these it’s like I’m punched in the stomach for 2 days. I didn’t do Rifaximin due to cost, and it was presented as a temporary fix. I’ve mostly done otc cleanse, Omneprazole, Pepto/GasX, and fasting. I just don’t eat after this. The only thing I’ve ever noticed helps move my system a little is eating an apple or oatmeal. The severity of attacks fluctuates, but I’ve had them since childhood. They worsened after ovarian cancer abdominal surgery. My gastro doc is very respected at UCI, but I hoped for more solutions. He told me to go to ER next severe attack for a bunch of tests, but I’ve never been able to do this as I’m immobilized by pain when having one. I’ve tried probiotics and they don’t do much. I appreciate any advice.
Lisa, please look into treating sibo with Dr. Allison Siebeckers SIBO herbal treatment (google sibo herbal treatment) and you will find her website (siboinfo) in which she lists success amongst treating people with botanical herbs I.e. oregano oil, goldenseal, neem, cinnamon. Along with this, I highly recommend trying a low FODMAP diet to keep symptoms at bay until you can wash away the extra microbes with the herbs.
I made a word document of Dr. Siebecker’s protocol. And I included the website address. She has a whole lot more information, but all at once it can be overwhelming. Please read thoroughly. I haven’t followed it precisely, but at some point I intend to see if I can make a Skype appointment with her associate. Personally, I would urge anyone who can, to make a Skype appointment. I surely do not think I could do this on my own. I took a few Herbals via Naturapathic Docs, follow the SCD/FODMAPS and six months after losing 26 pounds due to SIBO after pneumonia antibiotics I started to gain weight. I felt that was a turning point. I still, though, have lots of gas, constipation (that magnesium citrate mostly takes care of), and I have to be super careful with diet. Hope this helps.
Dr. Siebecker Diet and Supplement Treatment
http://ndnr.com/gastrointestinal/sibo/
Dietary Treatment
Diets used to treat SIBO reduce bacterial load and fermentation of carbohydrates, as well as aid tissue healing. They do this by decreasing polysaccharides, oligosaccharides and disaccharides via the elimination of all grains, starchy vegetables, lactose, and sweeteners other than honey. Legumes are eliminated initially. We have found that using the Specific Carbohydrate Diet™ (SCD) or its variant, the Gut and Psychology Syndrome™ diet (GAPS) as the core diet, with the incorporation of the fruit and vegetable recommendations from the Low FODMAP™ diet (Table 1) is an effective approach. (See Table 2 for SIBO Diet Resources.) The Low FODMAP diet is an IBS treatment diet that is a result of investigating the levels of fermentable carbohydrates in foods; it has a success rate of 76% for IBS.12 The FODMAP diet is not specifically designed for SIBO and therefore does not eliminate polysaccharide and disaccharide sources such as grains, starch, starchy vegetables, and sucrose. Eliminating these poly- and disaccharides is essential in SIBO. In SIBO, well-absorbed carbohydrates, foods that usually go to feed the host, feed instead the increased small intestine bacteria, creating symptoms and fueling more bacterial growth1 (Figure 8).
Any diet will need to be individualized by trial and error over time. Providing a food chart or particular diet prescription merely offers a place to start.
Low-carbohydrate diets are weight loss diets. Particular attention must be paid to those who are borderline or underweight. If a SIBO diet leads to excessive weight loss, this dietary strategy will need to be altered to allow for more carbohydrates. In these circumstances one or more of the other 3 treatment options described in our previous article should be considered, along with white rice, glucose and other carbohydrate sources.
Probiotics
Probiotics are a controversial intervention in SIBO because lactobacilli have been cultured in SIBO13 and there is concern about adding to the bacterial overload. This is particularly the case when there is decreased motility due to a dysfunctional migrating motor complex (MMC). Despite this concern, the few probiotic studies that have focused directly on SIBO have shown good results, with an eradication rate of 47% from Bacillus clausii as the only treatment,14 64% success rate from Lactobacillus casei Shirota as the only treatment,15 and a clinical improvement of 82% from Lactobacillus casei and L. plantarum, Streptococcus faecalis, and Bifidobacter brevis as the only treatment.16 Probiotic yogurt containing Lactobacillus johnsonii normalized cytokine responses, reducing the low-grade, chronic inflammation found in SIBO, after 4 weeks of supplementation.17 We have seen good results in our SIBO patients using various multi-strain and single probiotics, as well as homemade lactose-free yogurt and cultured vegetables.
A key point for the use of probiotic supplements in SIBO is to avoid prebiotics as main ingredients. Prebiotics are fermentable food for bacteria which can exacerbate symptoms during active SIBO and encourage bacterial growth post-SIBO. Common prebiotics found in probiotic supplements include: FOS (fructo-oligosaccharide), MOS (mannan-oligosaccharide), GOS (galacto-oligosaccharide), inulin, and arabinogalactan. Prebiotics may be individually tolerated in the small amounts used as base ingredients.
Intestinal Permeability
Studies examining the rate of mucosal healing post-SIBO found that intestinal permeability normalized in 75%-100% of SIBO patients within four weeks following successful antibiotic treatment.18,19 For those whose permeability does not normalize, supplements may aid in the process of healing.
Mucilaginous herbs are traditionally employed for mucosal healing, including Glycyrrhiza glabra (licorice), Ulmus fulva (slippery elm), Aloe vera, and Althea officinalis (marshmallow); however, their use post-SIBO is controversial due to their mucopolysaccharide content which could encourage bacterial regrowth. Specific nutrients we have used include colostrum (2-6 g QD), L-glutamine (375-1500+ mg QD), zinc carnosine (75-150 mg QD), vitamins A and D, often given as cod liver oil (1 tbsp QD), curcumin (400 mg to 3 g QD), resveratrol (250 mg to 2 g QD), glutathione, as oral liposomal (50-425 mg QD) or the glutathione precursor N-acetylcysteine (200-600 mg QD. Supplements are given for 1 to 3 months, or may be continued long term. Higher dosages of curcumin and resveratrol are given for 2 weeks for the purpose of down-regulating NF-Κβ, a mediator of increased intestinal permeability, followed by more moderate maintenance levels.20, 21,22
Prevention
Supplements
Betaine hydrochloric acid or herbal bitter supplements, which encourage hydrochloric acid (HCl) secretion23 may be used to decrease the load of ingested bacteria. When considering HCl supplementation, Heidelberg pH testing is the gold standard.
Meal Spacing
In addition to prokinetic agents (discussed in our January 2013 article), spacing meals 4 to 5 hours apart, ingesting nothing other than water, allows the migrating motor complex (MMC) to sweep the small intestine clean of bacteria at night and between meals.24 We have found this to be very helpful clinically. If a low-carb SIBO diet does not correct hypoglycemia, this strategy will need to be altered to allow for more frequent meals.
Current perspectives on test interpretation and treatment strategies will be discussed at the 2014 SIBO Symposium, January 18-19th in Portland OR, and will also be available via live and recorded webinar (www.sibosymposium.com).
Allison Siebecker, ND, MSOM, LAc is a graduate of National College of Natural Medicine (Portland, Oregon), where she specializes in treating small intestinal bacterial overgrowth (SIBO) and is adjunct professor of advanced gastroenterology. She is currently writing a book on SIBO. Visit her educational SIBO website at http://www.siboinfo.com.
Steven Sandberg-Lewis, ND, DHANP is a graduate of NCNM where he practices, supervises student shifts, and has been professor of gastroenterology since 1996. His book, Functional Gastroenterology, is available at http://www.ncnm.edu/bookstore.
References
1. Lin HC. Small intestinal bacterial overgrowth: a framework for understanding irritable bowel syndrome. JAMA. 2004;292(7):852-858.
2. Shah ED, Basseri RJ, Chong K, Pimentel M. Abnormal breath testing in IBS: a meta-analysis. Dig Dis Sci. 2010;55(9):2441-2449.
3. Khoshini R, Dai SC, Lezcano S, Pimentel M. A systematic review of diagnostic tests for small intestinal bacterial overgrowth. Dig Dis Sci. 2008;53(6):1443-1454.
4. Lord RS, Bralley JA. Clinical applications of urinary organic acids. Part 2. Dysbiosis markers. Altern Med Rev. 2008;13(4):292-306.
5. Riordan SM, Kim R. Bacterial overgrowth as a cause of irritable bowel syndrome. Curr Opin Gastroenterol. 2006;22(6):669-673.
6. Koide A, Yamaguchi T, Odaka T, et al. Quantitative analysis of bowel gas using plain abdominal radiograph in patients with irritable bowel syndrome. Am J Gastroenterol. 2000;95(7):1735-1741.
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I don’t know that I have SIBO. I do know in early may I had Kefir for the first time ever over a period of 2 days I have not been able to digest raw vegetables, heavy fibers, moderate fried foods ever since. I was worried I contracted h. pylori. But now I wonder if the yeast in the Kefir caused an imbalance. I am sure I must have had the imbalance of the other yeast from too many sugars for a few years. April 1st I started a no sugar, low dairy except plain yogurt and no gluten diet. I was doing great eating my veggies until the Kefir. So maybe it skewed that yeast overgrowth since the Candida yeast was not being fed by sugars, yeast breads and cheese. This is really messed up because the pain is so bad sometimes I am in tears. This helps me. Coconut oil mixed in Cranberry apple tea sipped through the day along with drinking water. Coconut in my homemade granola (oats, pecans, almond sliced, small amount of organic raw honey, cinnamon, blueberries cooked in I keep it in the frig and have it with organic plain yogurt (not super probiotic yogurt just the normal kind). I can eat chicken & wild rice soup, salmon (also make a chowder myself take it into work and add water) I can only eat small portions of cooked veggies ( I made homemade lightly cheesy mashed potatoes and broccoli I ate in small portions or mixed with my chicken and rice soup.) problem is it hasn’t gotten better yet when I think I can start eating like I used to the bad pains (gas or inflammation in the upper stomach going down yo my belly just double me over. I will be stricter and stay on this diet for 3 weeks solid eating only what I know will do no harm. For me I am thankful for coconut oil and Wolfgang’s organic chicken and wild rice soup or I might starve. Oh I also take a sublingual b-12 every other day in case this bacteria is stopping absorption. Had taco seasoned organic beef about a 1/4 cup yesterday with tomato, yogurt, non gmo corn taco shell yesterday amounted to one small taco did fine, also can eat a very small portion of mild tika chicken curry with cumin rice with only a little funny I’m the gut feeling ate the rest the next day and no worries. I eat a tiny bit of a new food and wait 45 minutes if no pain then have the rest of what would be a half portion for most people. Cinnamon regulates your blood sugar and so being concerned the other yeast was out of balance every other evening About 3 hours before bedtime I will eat a piece of Udi’s gluen free toast with a scraping of butter and a tiny bit of cinnamon honey I make up. The honey is a natural sleep aid so I haven’t cut it out but I always have it with cinnamon now. Cranberry tea helps balance me too, I think I was getting a urinary tract problem, now I am fine. Just moderation a small amounts and try to supplement if you think you are nutrient deficient. I really want to try the oil of oregano and maybe licorice extract but I will wait til I am over this particular bout. I can’t believe how screwed up my system got after the kefir. I only wanted to be healthy now I am worse off – and everyone praises that stuff to the skies there are only a few people who are beginning to talk about the fact that it may not be for everyone
It seems the more I hear about SIBO and with my own clients too, I’m noticing that high stress and anxiety play a large role in how well SIBO is managed and reversed.
If it seems like everything is going well but SIBO is still not managed, then it’s time to look at stress and self-care (or lack of self-care). This of course could be said for almost any illness but it does seem to be part of the puzzle here with SIBO.
I’m wondering, are other SIBO sufferers finding they’re chronically stressed out or that they need to do more self-care?
Well again I don’t know that I have SIBO but the only thing stressing me out right now is the pain when I eat something hard to digest. When I have my Coconut oil infused tea and granola and easy foods and get my sleep. I can take the same amount of stress as always without stomach pain. It’s the food digestive issues that make me unable to cope with even sitting and reading on a lazy Sunday. I was never the one in my family to have stomach issues, and until I gained too much wait I didn’t have GERD or any complaint. Now I went on the diet and am happy to be mostly sugar free but some thing set me back a month into my diet and whether it was kefir, contracting h. pylori from raw produce or some other imbalance, the affliction is stressing me out not the stress exacerbating the affliction. My good days are lovely and I feel so much empathy now for people who have had a lifetime of this sort of thing. I do not doubt there are some people whose stress level is a direct link to a stomach affliction, but I would also ask these people to keep a meticulous food diary and find out what they ate 45 minutes before the “big meeting” or on the afternoon of the “deal closing” did they go out for coffee, eat a meal on the run, have a celebratory donut? That could have been the trigger and not the stress.
Weight not wait. Sorry I am in pain right now. I had a short mocha at 3:30 and like clock work 45 minutes later, severe pain. I am home now 7:01 and the pain is just now subsiding. It was a test, a test my body failed. I used to drink Grande mocha frappes in March without pain. I don’t want to go back to sugary coffees, but I do want my veggies again. I long for my salad days to return. Come on little intestine be a pal!
Well I’m almost back to normal. Still drinking my daily coconut oil in the cran-apple tea. Did that help? Or heal. Don’t know had a small bit of salad and I am fine. So I was 4 weeks in terrible pain with stomach distention, yellow stools, etc. Then two weeks ago I started taking coconut oil in tea and making granola with it in. I also became less strict with yeast breads and cheese starting slowly adding honey and cinnamon honey toast to regulate blood sugar in case my pancreas was over taxed. I stress again I did not have the sibo test. The doctor I saw would not do it but sent me to a GI spec which I couldn’t get into see. The fb group for sibo has an excellent video about sibo, very encouraging. I think for me nothing radical was necessary. Just giving my stomach the time to heal. I really want to hear from others who may have tried coconut oil and/or honey/cinnamon for 2 weeks and eating only food that they can handled with little or no pain. I am curious to know if coconut oil is just okay or if it is really a healer
Yes, having what I suspect is severe SIBO with Candida, constipation, massive food intolerance, leaky gut, and the resultant depression, chronic and ongoing stress has been a MAJOR factor! Every time I experience another episode, my condition gets worse. I am very debilitated. And I can’t seem to find a practitioner who takes me seriously.
Hello everybody,
Can any of you add me to the SIBO Facebook group?
I’m guys sin that we have to be fb friends first:)
Please sent a request, as someone who is suffering for over a year I’m sure that the fb group could be of great help.
Many Thanks!
Uri Perelman
just go to the FB group and submit a request to join….
http://www.facebook.com/groups/470628319710443/
Thank you for the link to the support group! Please add me. Symptoms for 2 years and finally a diagnosis of SIBO… took Abx, and 7 weeks later it is back.
I was diagnosed with SIBO early this year using a hydrogen breath test. I’ve been on the SCD diet since then (following it strictly) and have taken both a course of Rifaximin and then the herbal protocol. My symptoms have improved (very little gut pain in the past few months), which is pretty amazing. But my subsequent breath tests have gotten worse — the hydrogen and methane production has only gone up. Has anyone run into this? Or does anyone know what might be happening? I’m just so confused.
Hello,
This may interest you.
“When yeast cells are rapidly killed, a die-off (or Herxheimer reaction) occurs and metabolic by-products are released into the body. The Candida yeast cells actually release 79 different toxins when they die, including ethanol and acetaldehyde.
Acetaldehyde in particular has a whole host of detrimental effects on your health and wellbeing.”
Well here’s a thought, eating a healthy diet is important. But balance is all important and listening to you body. I don’t know everyone’s beginning – when sibo hit, after food poisoning is what many doctors suspect. But what if it isn’t just food poisoning. I wonder in my case of terrible gastroenteritis so easy to pinpoint the date when I took that “healthy” kefir and nearly went into the fetal position at work from pain. A bad batch of kefir or just the kefir causing die off of Candida or parasites in huge amounts that a. my liver, gall bladder, and pancreas couldn’t handle b. caused the living Candida colonies to migrate up to the small intestine and c. the crowning indignity of allowing my food to ferment because nothing was working right with the bacteria in the wrong place. I would like to at least put the question to the group. How have been on a cleanse, or high prebiotic or probiotic diet before getting the sibo? I think that many people have a pre-disposition for imbalance of some sort but I a fairly certain my recent issues are connected to the day I took the kefir and tried to “step up” my diet which I was doing fine on for a month.
I got Sibo after eating fermented foods! I have Non-Celiac Gluten Sensitivity and eat paleo. Was fine till I added fermented foods. Two rounds of antibiotics over the course of the year and following a low fodmap diet didn’t cure me, but It is under control as long as I am very careful.
There are 1350 biowarfare labs in just North America. They can issue upgrades to the bugs they are creating biofilm in our guts faster than you can get a revision to your I-pad Aps. Until people talk about this problem at this level then it will be simply trying a new fad for palliation of casualties of warfare. You can’t win attrition. All of the symptoms posted by all of the people on all of the messageboards have no commonality therefore no set way of addressing. It is like the Borg rotating their shield frequencies so that they cannot be attacked. The use of antibiotics just serves to mutate the bugs further. It is clear from the Lyme nonsense that high-powered antibiotics force the organisms into L-forms, which are more destructive and completely invisible to the immune system. So, while the symptoms might disappear for 5-7 years they come back when the cell wall is re-acquired by the organism that never went away. People have to research and think and act intelligently in the face of this onslaught or they will never succeed. The first thing that has to happen is that the weapons makers have to be stopped.
While I believe our government has used populations to experiment on. (Quaker Oats allowing the government experiments) and they will again. I think there may be commonality for some digestive ailments. A man on another board did make a brilliant point in defense of bacteria and parasites or at least ran on the idea that when we try to obliterate these things that have “evolved” with our human bodies we wreak havoc on our delicate systems. Yes we are all bombarded by pollution in air and water, genetic modification, antimicrobials, antibiotics, radiated foods, nanotechnology, and pesticides designed to burst the stomachs of insects. The best we can do is gently and deliberately make food and lifestyle changes that aren’t radical. The precancerous growths in my mothers stomach were unusually cut down the last time she was tested, the only thing she did different was buy organic. In the last year her feet have stopped swelling up. For a year and a half she has been gluten free. The idea the government is unleashing biowarfare on most of us would seem to suggest there is nothing we can do about it. Again I have no doubt the polluting industries badly regulated by our government are causing misery for many – fracking and crop dusting come to mind. But I don’t believe it’s in every area of the US. I would think if there are some evil Nazi like scientists who want to experiment on us most of them are intelligent enough to know they will not be spared in a mass release of biowarfare agents. It’s the greedy gmo pesticide and oil industries causing our slow agonizing break down coupled with the Western notion of supersizing, ultimate detoxifying, sanitizing, mega diet trending. This is not a knock at people born with immune issues but it is a knock at those sites that tell you to step up the detox regime and buy their herbal supplements. They tell you to ignore the stress your body is going through and keep fighting the good fight. I have never been convinced by people who ignore their own body’s protest to stop and take it slower. I am hopeful that some sibo suffers may have a common start to this autoimmune disease and some sibo suffers may also find a common cure.
As someone recently diagnosed with SIBO after 40 years of gut problems and weight loss, I’m struggling to find some answers. Following diagnosis almost by accident when doing a hospital breath test for lactose intolerance, I then self-treated for 6 weeks with herbal antimicrobials that have been mentioned in this conversation before the prescription for Rifaximin was forthcoming. I experienced severe diarrhoea & vomiting 5 days into the Rifaximin course, and following the drug advice sheet, I stopped taking it. When tested again 2 weeks later, however, I tested negative for SIBO. Then, after a further two weeks, I had a further breath test for fructose intolerance, and immediately spiked for hydrogen at over 70ppm within 40 minutes, suggesting the SIBO had returned with a vengeance and was backed up almost to my stomach. No formal treatment has been prescribed since then, as getting a gastroenterology appointment on the UK’s National Health Service takes ages. I am puzzled how SIBO can apparently return so quickly in such a short time span. I’m back trying to self-medicate with a herbal protocol & Betaine HCl, but am confused about the following issues, for which I would be grateful for any advice or suggestions.
[1] Some sufferers and practitioners advise that probiotics are beneficial in treating SIBO. Others say that the probiotics are killed off if you are concurrently taking antimicrobials like Oregano Oil. Is it a case of either/or, or can it be both/and??
[2] I have also read that Oregano Oil is too powerful to take for more than about 2-3 weeks max. Is that the case, as it seems to be one of the more effective non-drug options?
[3] Is kefir helpful in cases of SIBO? I’m unsure if fermented products help or hinder bacterial overgrowth.
[4] Various people on this thread have recommended Prescript-Assist, which is a prebiotic as well as a probiotic. I had problems with prebiotics last year that contained inulin – which I believe is a fructose. I am on low FODMAPs diet and it had been suggested that low FODMAPs is not compatible with prebiotics.
[5] Has anyone any helpful suggestions to reverse weight loss? All my nutrition efforts seems to be malabsorbed because of the intransigent SIBO. Even consuming Calogen supplements is not stopping the slide this time. I’m grateful for any suggestions, and if anyone knows a UK-based functional practitioner knowledgeable on SIBO that would be really helpful. Not even the hospital gastroenterology dietician here seemed to have heard of SIBO, let alone have good treatment plans. Many thanks all, and prayerful good wishes for speedy recovery from a fellow-sufferer.
Hi Tony, I feel your pain. I have been suffering from what I now think to be a bad case of SIBO. The only time I’m not bloated is on a no carb diet which is not realistic to stay on forever! Doctors have sent me in circles so at my wits end I had a Skype consultation with Kate Arnold nutrition (eastbourn based) and immediately is sending me for blood tests, stool test, SIBO and lactose test. I am yet to be fully diagnosed (watch this space) but she has treated a number of people with this and has amazing reviews. Please do look her up on the Internet. Good luck. Rachel 🙂
Thanks Rachel, I will do. Best wishes for a good recovery yourself.
Also digestive enzymes help, but they say that letting your stomach have the rumble from being hungry is good, but being I’m thin as well it’s important to eat
Tony – I blame kefir for at least part of my current trouble – I would say it’s like healthy plain yogurt on steroids. I am great with yogurt. But one of the best mild things for me is simple cranberry or cranberry apple tea made weak with a half teaspoon of coconut oil mixed in drink slowly through the day and change to spring water in between to help flush fluids. It doesn’t stop a bad attach right away. But it helps a mild food indiscretion and more importantly if you do have something like h pylori it is proved in lab tests to kill off even antibiotic resistant h pylori strains. And it at least does no harm as long as you have no nut allergies. If you doctor puts you on antibiotics you may want to consider a probiotic course of mild plain yogurt, but nothing that will cause die off that creates toxins you liver, pancreas, etc will have to try yo fight. I think babying yourself with healthy foods you know won’t harm you is more important than cleansing diets. Organic raw honey, a tiny bit is known to heal, mixed with cinnamon to regulate your blood sugar level might help once a day over a period of time. It helps me. I don’t know if it helps everyone. I hope you feel better soon
Dr elena Stirling Scotland can do Skype supporting me
Tony
I have also experienced the same side effects of SIBO and had beat this beast three months ago but after going out this weekend I have been infected with a new bacteria or virus that is munching all my food and giving unbelievable gass at dinner time (from lunch food)
But to answer your question yes take probiotics in between your oil of oregano. I will be taking 2 ADP oil of oregano every 3 hours on an empty stomach ( total of 6) as well as colloidal silver and iodine. And when taking these make sure you take a biofilm disrupter from klare labs (interface plus) as well as eating a low carb diet. SCD, LOW FODMAP. But I believe this issue is caused my a heavy metal over load in the gut (mercury). Something to just think about. I wouldn’t take the oregano longer than 3 weeks tho with a two week break. I’d avoid all fermented foods but prescription assist is a great probiotic. If your in despair look into fecal matter transplants. Not something iv done but a last resort if I ever had one. Besides the prescript assist I would also avoid prebiotics but check out perfect pass probiotic, and colema boards to flush out bacteria. Kind of lost where we were but I feel like I’m starting over after a bad decision, but a chance to see if my protocol works. I’ll keep you up to date as I started the ADP yesturday and am having real bad gas still but it takes a little to kill em
Chris had mentioned that lactic acid forming probiotics can contribute to the SIBO issue as there maybe an overgrowth of them. So, would that mean to avoid lacto-fermented foods then if you have SIBO?
I think what he meant was “prebiotics”, not probiotics. Prebiotics are the chemicals that create the good balance for the good bacteria to grow. Unfortunately, most of them contain some kinds of sugars like oligosaccarides or polyols, so should be delayed until about a year after the SIBO resolves. It may be useless to take probiotics during antibiotic treatment if the antimicrobials kill them off (and expensive), but should be taken again right after completing the antimicrobials.
How do you get an in-person appointment? My husband’s SIBO is so entrenched, that everything he tries seems to make it worse, or at least not better. He was diagnosed by the only gastroenterologist in Washington State, and treated with low-FODMAP and antibiotics, then botanicals, and is now in full-blown relapse. Don’t think the GI Doc has any more answers.
I didn’t intend for this email to go into the comments; I thought it was going directly to the doctor, so I could get an appointment.
Looking to collect long term SIBO success stories from real people at this FB group. Please join and post your story if you have had success…
https://www.facebook.com/groups/836770986360031/
can we join the group if we’re just suffering at this point and have yet to find success in treating it?
Yes. That is the purpose of the site. For those of us starting this journey or struggling, to learn from those that have had success. The trick is trying to get those that are successful to post their success story…
I have been recently diagnosed with SIBO and am taking herbal antibiotics and following a strict SCD diet. As many of you can relate to, SIBO is complex and often very difficult to cure (all these tools – e.g. diet, antibiotics seem only to manage the symptoms).
Once finished with my herbal antibiotics, I am going to give my digestion a complete rest by fasting in order to allow my body to heal itself. This idea came after reading a very informative eBook on water fasting (see below):
http://www.soilandhealth.org/02/0201hyglibcat/020127shelton.III/020127.toc.htm
In nature, animals when they are sick or diseased instinctively stop eating to allow their bodies to heal themselves (only drinking water). I believe this may be the cure that would help all of us to restore balance in our bodies. While I believe a 1-3 day fast is beneficial, the author mentions that longer fasts are needed (7-30 days) in order to fully restore health. The book does mention that the length of time for a fast should not be predetermined and that you only start eating again when hunger comes back (nature’s way of telling you it’s time!).
I’m naturally a lean person, so my biggest apprehension with this approach was about losing weight. But actually, gaining weight back once the fast is done is supposed to be rapid and you will be able to keep a healthy weight since your digestion allows you to assimilate nutrients much better!
Does anyone else have any experience with water fasting? I will start mine in June and will document the results for anyone interested.
Take care all, and good luck with your healing!
Clinton