Treating Small Intestine Bacterial Overgrowth – SIBO

SIBO, or small intestine bacterial overgrowth, is a condition where bacteria that should normally be found only in the colon end up populating the small intestine. This leads to gas, bloating, and other digestive issues.

What is SIBO?

The small intestine is designed to absorb nutrients, not host large amounts of bacteria. When bacteria overgrow in this area, it causes problems. Patients with SIBO often experience bloating, abdominal pain, nausea, acid reflux, diarrhea or constipation. SIBO can also cause systemic symptoms like fatigue, joint pain, brain fog, weight loss, and food intolerances.

Symptoms and Effects of SIBO

Gas and Bloating

The main symptom of SIBO is gas and bloating. This happens because the bacteria in the small intestine ferment carbohydrates and release hydrogen, methane, and hydrogen sulfide gas. Unlike gas in the colon, this gas is trapped in the small intestine which can cause pain and stretching of the intestinal wall. Patients report looking 6 months pregnant or extremely bloated after eating a meal.

Leaky Gut and Inflammation

The bacteria and gas produced also cause inflammation in the small intestine. This leads to leaky gut, where tight junctions between intestinal cells are disrupted. When this happens, food particles and bacterial toxins can escape into the bloodstream. This inflammation is thought to be a cause of joint pain, rashes, headaches, and autoimmune reactions in SIBO patients.

Food Intolerances

People with SIBO often develop food intolerances, especially to sugars and carbohydrates. This happens because the bacteria damage the brush border of the small intestine, interfering with proper digestion and absorption of nutrients. Patients become afraid to eat certain foods that they know will cause them discomfort.

Nutrient Malabsorption

SIBO can also lead to fatigue and weight loss through malabsorption of nutrients. Bacteria use up nutrients before the body can absorb them, leading to deficiencies in iron, vitamin D, vitamin B12, and other essential vitamins and minerals.

Systemic Effects

Because inflammation in the gut can affect the whole body, SIBO often causes systemic symptoms. Patients report brain fog, joint pain, anxiety, depression, disrupted sleep, and more. Through the gut-brain axis, an unhealthy gut microbiome affects mental health and focus.

Causes and Risk Factors for SIBO

There are several known causes and risk factors for developing SIBO:

  • Food poisoning – damages gut motility
  • Chronic constipation – causes bacteria backup
  • Medications like PPIs – reduce stomach acid
  • Low stomach acid (hypochlorhydria)
  • Autoimmune diseases
  • Diabetes
  • Gut infections
  • Food sensitivities
  • Stress – impairs motility
  • Hypothyroidism
  • Structural issues like diverticulosis

Food poisoning is a major cause of SIBO. Certain bacteria like E. coli and salmonella release toxins that damage the migrating motor complex (MMC) which sweeps the intestines clean. Chronic constipation can also lead to SIBO by allowing too much bacterial growth in the colon.

Diagnosing SIBO

SIBO is diagnosed using a lactulose breath test. This test measures hydrogen and methane gas production after ingesting lactulose, an indigestible sugar. Gases are produced when bacteria in the small intestine ferment the lactulose.

  • Hydrogen over 20 ppm in the first 2 hours indicates hydrogen-predominant SIBO.
  • Any methane over 10 ppm indicates methane-predominant SIBO.

There are 3 types of SIBO:

  • Hydrogen SIBO – causes diarrhea
  • Methane SIBO – causes constipation
  • Hydrogen sulfide SIBO – causes diarrhea or constipation

Getting an accurate diagnosis allows proper treatment based on the type and severity of the overgrowth.

Treatment Approach for SIBO

Treating SIBO requires a 3-pronged approach:

  1. Starve the bacteria through diet
  2. Kill the bacteria using antimicrobials
  3. Promote motility to sweep bacteria out

The SIBO Diet

The diet is a crucial part of treatment. It starves bacteria by removing fermentable carbs that feed them. A low FODMAP and low lectin diet is recommended. Simple rules:

  • No sugars, starches, grains, beans or legumes
  • Limit fruits and starchy vegetables
  • Allow white rice, nuts, seeds, eggs, animal protein
  • Remove garlic, onions, asparagus, artichokes

This diet is followed strictly for 4-6 weeks to starve bacteria and reduce symptoms. Slowly, foods are added back in one at a time. Many patients lose 5-10 lbs on this diet as inflammation goes down.

Antimicrobial Treatments

In addition to diet, antimicrobials are used to kill off the overgrowth. Patients can choose between pharmaceutical antibiotics or natural herbal antibiotics.

Pharmaceutical antibiotics: Rifaximin, Neomycin, Metronidazole

Herbal antimicrobials: Berberine, Oregano oil, Allicin (garlic)

Herbals have the advantage of also being anti-inflammatory, anti-fungal, and able to penetrate biofilms that protect bacteria. The treatment course is usually 2-4 weeks.

Promoting Motility

To prevent SIBO from recurring, motility must be improved. Methods for this include:

  • Meal spacing – 4-5 hours between meals
  • Intermittent fasting – 14-18 hour overnight fast
  • Daily bowel movement
  • Magnesium supplements
  • Ginger, Iberogast, prokinetics

Prokinetics enhance contractions in the small intestine to sweep it clean. Common prokinetic supplements are ginger, Iberogast, and low-dose naltrexone.

Dealing with Die-Off Symptoms

As bacteria start dying off, patients can experience “die-off” or Herxheimer reactions. This causes flu-like symptoms, nausea, fatigue, and upset stomach. Methods to manage this:

  • Peppermint essential oil for nausea
  • Digestive enzymes
  • IGG to bind endotoxins
  • B vitamins
  • Epsom salt baths
  • Massage with digestive oils

Die-off symptoms are a sign of bacterial death and that treatment is working. It usually lasts 3-7 days as the body detoxifies.

Improving Treatment Success

Other tips to improve SIBO treatment success include:

  • Digestive enzymes – improve digestion and prevent malnutrition
  • Spore-based probiotics – restore good bacteria
  • LDN – aids nerve function for motility
  • Aloe vera – helps constipation
  • IGG antibodies – binds toxins during die-off
  • Methyl B complex – gives energy, improves mood

For stubborn SIBO cases, a 2-week elemental diet may be used. This is a liquid formula diet that starves SIBO bacteria while providing nourishment.

Preventing Recurrence of SIBO

To prevent SIBO from recurring after treatment:

  • Take a prokinetic supplement regularly
  • Continue digestive enzymes if needed
  • Have good bowel motility daily
  • Avoid excessive snacking between meals
  • Manage stress levels
  • Treat underlying causes like hypothyroidism

Even with prevention methods, some patients need periodic antimicrobial treatments to keep SIBO under control. Catching recurrences early is important.

Diet Change, Antimicrobials and Motility Agents for SIBO Treatment

While SIBO can be challenging to treat, with a systematic approach focused on starving, killing, and improving motility of bacteria, significant improvements are possible. Diet change, antimicrobials, and motility agents together can help patients overcome SIBO and improve their quality of life. With proper treatment and prevention methods, patients find relief from their SIBO symptoms.

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