What is SIBO?

SIBO occurs when the bacteria that normally live in the colon move backwards, up into the small intestine (where they are not supposed to be in high numbers) and an overgrowth develops.

When the bacteria are in the small intestine, THEY start digesting and fermenting your food, instead of YOU, creating gas, bloating, and malabsorption for the host.

What are the symptoms?

  • Extreme bloating (many people say they look 6 months pregnant)
  • Constipation, diarrhea, or both
  • Abdominal pain, tenderness, or discomfort
  • Burping and/or farting
  • Nausea
  • Acid reflux
  • Gastroparesis (like food is just sitting in stomach, won’t go down- feels like a brick in the stomach)
  • Food sensitivities or intolerances
  • Leaky gut
  • Anxiety & depression (very common for SIBO – the LPS in the bacterial cell wall (endotoxins) increase inflammatory cytokines, which affect mood)
  • Brain fog

Common comorbidities:

  • IBS
  • Hypothyroidism

How is it diagnosed?

With a breath test, done either at the hospital/clinic, or at home with a mail-order kit.

The patient consumes a lactulose beverage (a carbohydrate that is indigestible to humans, but readily consumed by gut bacteria), and breathes into a bag every 20 minutes or so.

The breath samples are analyzed for the presence of hydrogen (H2) and methane (CH4) gases. These gases are created when the gut bacteria ferment the lactulose. Then they travel through the blood stream & are exhaled on the breath.

It important to check for BOTH hydrogen & methane, since the bacteria that produce the various gases are different, and may require different types of antibiotics/treatments to eradicate.

High levels of either one of these gases too soon after drinking the lactulose beverage can indicate SIBO. (If SIBO is present, there should be 2 peaks on the graph, one when the bacteria in the small intestine are fermenting the carbohydrate, and a second, probably larger peak, when the carbs hit the colon).

Pimentel suggests that an increase in breath hydrogen of 20 ppm above basal levels within 90 minutes of drinking the lactulose, or a rise in breath methane of more than 12ppm above basal levels within 120 minutes should be considered as diagnostic of SIBO.

But, there are issues with false positives (if the person has increased transit time, sometimes the lactulose reaches the colon very quickly & can be mistaken as a reaction in the small intestine) AND false negatives (if the person has slow transit time). Average transit time is 2 hours for the lactulose to get through the small intestine.

There is also a more invasive way of testing- via a bacterial counts of duodenal or jejunal aspirates w. endoscopy, with the diagnosis of SIBO occurring when there are >100,000 cfu/mL.

Other conditions that can cause bloating, like ovarian cancer, bowel cancer, etc. should be ruled out.

Can do a guaiac stool test to check for invisible blood in stool. Helps rule out colon cancer.

How is it treated?

3 ways:

  • Prescription antibiotics (Xifaxin / Rifaximin) for 2 weeks
  • Herbal antibiotics (Candibactin AR & BR) for 4 weeks
  • Elemental diet (Physicians Elemental Diet by Integrative Therapeutics) for 2 to 4 weeks

It is a tough condition though that often comes back and requires multiple rounds of treatment.

Supplement options:

  • Atrantil
    • An herbal product that can knock out Archaea bacteria (methane producing) that are not killed easily by the antibiotics.
    • Helpful for constipation-dominant SIBO
    • Practitioners can get 4 free samples to let people try
  • Prokinetics to help stimulate the MMC
    • Ginger (100-300 mg, three times per day)
    • 5-HTP (50-150 mg, three times per day)
    • Artichoke extract (320 mg, three times per day)

Diet-related advice:

  • It is generally advised to space meals out, 4 to 5 hours between each meal, to allow the MMC to properly clear out the bowels (so that you are not constantly supplying the bacteria with a food source). This could be an issue if someone has hypoglycemia though, so you may have to increase meal frequency in that case.
  • The most custom diet that can help reduce inflammation (& perhaps better allow the immune system to focus on clearing the bacteria out of the small intestine) is MRT + LEAP
  • Other practitioners employ the Specific Carbohydrate Diet or the low-FODMAP diet while the patient is also undergoing antibiotic or herbal therapies.
  • You can also attempt to treat SIBO entirely with diet by using a 2-week elemental diet designed to starve off the bacteria.

Nutrient Deficiencies Associated w. SIBO:

  • Vitamin B-12
  • All other B-vitamins
  • Fat soluble vitamins A,D,E,K (due to deconjugation of bile salts by excess bacteria)
  • Folate
  • Iron
  • Calcium
  • Selenium
  • Zinc
  • Hypoalbuminemia

Related Concerns:

  • Microcytic anemia due to iron deficiency
  • Macrocytic anemia due to vitamin B-12/folate deficiency
  • Polyneuropathy due to B-12 deficiency
  • Steatorrhea (fatty stools) due to lipid malabsorption caused by the excess bacteria
  • Tetany due to hypocalcemia
  • Night blindness due to vitamin A deficiency
  • Dermatitis due to selenium deficiency
  • Linked to rosacea (exact mechanism unclear)
  • Cachexia due to protein-energy malnutrition
  • Increased gut permeability (normalizes in at least 75% of SIBO patients after antibiotic treatment. For those who it does not, can use various supplements to help heal. See Leaky Gut note for more info.)

Factors that increase risk of developing SIBO:

  1. Low stomach acid

Can be related to stress, PPI overuse…

Low stomach acid is a risk factor because one of its functions is to kill any pathogenic bacteria that you ingest through your mouth. If acid is low, bad bacteria or excess bacteria may sneak into your small intestine & thrive there.

Can get tested for low stomach acid with the Heidelberg test- a capsule is swallowed & attached to string that remains in your mouth. The capsule in your stomach emits radio waves that are picked up by a necklace that records the pH of the stomach. Then you swallow baking soda, which will raise the pH of your stomach. The capsule in your stomach will monitor how much time it takes to re-acidify the stomach to the proper pH. This is helpful because it’s testing the functionality of the stomach. You may be okay at resting pH, but functionally deficient if you can’t produce enough when it’s needed.

~60% of people, in general, have low stomach acid

~40$ have high acid

But both have heartburn!

Can do a test w. Betaine Hcl:

If you get burning/pain/pressure with just 1 Betaine Hcl pill w. meals, then you probably have high stomach acid.

But this test is not conclusive… with low acid, you could have a lax sphincter between the stomach & throat. Taking betaine Hcl would increase the acid, and if the sphincter doesn’t tighten instantly, your could get reflux… so it’s not perfect… Heidelberg test is best.

If stomach acid IS low, taking supplemental Betaine Hcl is a good idea. Start w. 1 pill at the beginning of each meal. If no burning or reflux, increase dosage to 2 pills, etc. until you finally DO experience a burning or warming sensation. Then you know you’ve gone too high, and the proper dosage is actually 1 pill less than that. Some people can get all the way up to 8+ pills per meal before they feel the burn.

Herbal bitters may also help increase stomach acid production naturally.

If you have high stomach acid, you’ll probably feel nauseous too.

Why might you have high Hcl?

  • signals sent to increase
  • parietal cells increasing output
  • less related to diet & stress (hypo is more related, since stress turns off digestive secretions)

2. Low bile

If the gallbladder was removed, or if just have a poor functioning gall bladder.

3. Deficient in digestive enzymes

4. Malfunctioning ileocecal valve (or.. missing due to bowel resection)

5. Immune system dysfunction

6. Tumors or organs pressing on the small intestine

7. Strictures or adhesions narrowing the small intestine

(endometriosis, appendicitis, surgeries, inflammation, injuries from fights or accidents, etc. can cause adhesions)

8. Deficiency of the migrating motor complex

MMC occurs in between meals and overnight. Cleans the small intestine.
  • Why could you have a deficiency?
    • Diabetes
    • Hypothyroid
    • Opioid use
    • Food poisoning…. (acute gastroenteritis, caused by bacteria)
      • Pimmentel studied this
      • The bacteria of the food poisoning are pathogenic. They secrete CBTD toxin.
      • The B portion of the toxin looks like the nerve cells that trigger the MMC…
      • So your body starts attacking it, and messes up your MMC.
      • This is the same thing as post-infectious IBS (10-20% of people who get food poisoning get this!)
        • SIBO develops…
        • = constipation or diarrhea, bloating, pain.
Can do an IBS-check test to evaluate the MMC
  • Quest does it
  • Commonwealth lab does it
  • Checks for antibodies to the neural cells and also the CBTD toxin
  • Indirectly checks for deficiency in the MMC caused specifically by food poisoning

9. Food poisoning

10. Overuse of antibiotics, leading to dysbiosis… etc.