SIBO (Small Intestine Bacterial Overgrowth) is one of the main causes of IBS. SIBO can be a very complex condition to treat. Even though treating SIBO properly can result in up to an 87% success rate, there is about a 50% chance of recurrence. This is a frustrating statistic as many patients with SIBO have had a hard long road of ill health. In this article, we will explore what is required for a successful treatment outcome for SIBO and suggestions to help prevent a relapse.
SIBO, as a simple definition, is an overgrowth of bacteria in the small intestine which can impair your ability to digest and absorb nutrients from food. This can lead to a variety of IBS symptoms like:
- stomach pains
- stomach bloating (from gas build up)
- flatulence (gas), burping
- diarrhea, constipation (or both)
- halitosis (bad breath)
- muscle and joint pain
- skin problems
- brain fog
Eradication rate of SIBO can be as high as 87%. However, the recurrence rate is about 50%.
SIBO is a complex condition to treat. First, there is no gold standard diagnostic test and there a lack of agreement on how to interpret those tests. When you don’t have a gold standard test and clinicians can’t agree on what constitutes a positive SIBO test, it makes treatment more difficult.
The test most widely used to diagnose SIBO is a breath test that measures methane and hydrogen gases. Diagnosis of SIBO is determined by how high the gases are at 20 minute intervals within a 2 to 3 hour period. However, there are three schools of thought (criteria) on what is high and what is not. So if you have SIBO, you could show your breath test results to three different practitioners and get three different interpretations. The potential problems with the tests extend further than this, but again it’s the best we got at the time of this writing.
Deciding to treat SIBO or not?
As I have brought in functional nutrition (aka functional medicine) into my chiropractic practice, I have learned quickly to take a conservative approach to SIBO. I look at the test results, compare them with the criteria for diagnosing SIBO, and look at the patient’s symptoms and presentation. I also look at whether SIBO is the patient’s major issue or whether I should be focussing on treating something else instead. For example, if a patient has SIBO and a H Pylori infection, perhaps it might be more important to focus on the H Pylori infection instead.
Treating SIBO is a five step process
I introduced the concept of three steps involved with treating SIBO in a previous article: kill off the SIBO that are present, heal your gut lining, and prevent a relapse primarily by rebuilding your healthy gut flora (good or beneficial gut bacteria). It’s a little more complex than that and there isn’t a fine line between all of these steps. There is often overlap between all steps. In this article, I will focus on step 1 and step 2, which is the kill phase of the SIBO treatment and the retesting phase.
Step 1- Kill off SIBO
How long you treat SIBO (duration) depends on the amount of gas (hydrogen, methane, or both) measured by the breath test. The higher amounts of gas usually require longer treatment duration. Treatments last any where from 30 to 90 days followed by a retest.
The second thing to consider is whether hydrogen, methane, or both are elevated. There are different schools of thought on whether this matters when using herbal antimicrobials. Some practitioners use a shot-gun approach and use multiple herbs at once that would kill off both hydrogen and methane producing “bugs” and some use single herb antimicrobials and rotate them. At this point in my functional medicine career, I have been leaning more towards a single herb approach. Again, I think it depends on the patient presentation. For example, are we dealing with other gut infections like parasites? Has the patient already tried single herb antimicrobials? Have they tried pharmaceuticals? Does the patient have a really sensitive gut when it comes to reacting to foods or different supplements? There are a lot of variables when dealing with SIBO and you have to weigh out all of your options.
A herb that tends to target methane producing organisms is called allicin which is from garlic. A product myself and many colleagues have had success with is called Allimax PRO.
A herb that tends to target hydrogen producing organisms is called berberine. Berberine is a compound found in the roots, rhizomes, stems and bark of several plants. Here are a couple of options for berberine: Thorne Research Berberine and Designs for Health Berb Evail.
Monolaurin is an extract of lauric acid found in coconut oil and mother’s milk. Lauricidin has activity against yeast, viruses, and bacteria, and also some activity against biofilm.
Biofilm is any group of microorganisms that stick together, in this case, on the inner lining of the intestine and form a slimy protective layer around them. This biofilm is their own way to protect themselves from antimicrobials in our own immune system or even prescribed antibiotics. Interfase Plus and Lauricidin can be used to help to break up biofilm (biofilm disruptor) so the herbal antimicrobials or prescribed antibiotics have a better chance of killing off the microorganisms.
Partially hydrolyzed guar gum (PHGG)
PHGG is a soluble fiber that most patients with gut problems can tolerate. PHGG provides food for the “bugs” so they keep dividing. Antimicrobials are more effective at killing off SIBO when the “bugs” are dividing. Otherwise, if you’re not feeding the “bugs” they can go into a dormant state (go into “hiding”) and it’s harder to kill them. This is why low-FODMAP diets work to relieve symptoms of IBS, because they stop feeding the bacteria. Low-FODMAP diets are good to help prevent a recurrence of SIBO, but not a good idea while you are getting treated with antimicrobials.
Taking probiotics during your SIBO treatment is important as they help regulate your immune system and support your good gut bacteria. Remember from a previous article, dybiosis (imbalance between good and bad bacteria) is likely one of the main causes of SIBO. Probiotics help support those good bacteria while you are taking herbal antimicrobials or an antibiotic.
Contrary to popular belief, the microorganisms within the probiotics supplement generally don’t stay in your gut long-term and contribute to rebuilding your good flora. They have multiple functions, but to simplify things they provide support to your good gut flora to help limit SIBO.
The two main probiotics I recommend when treating SIBO are: Primal Defense and Primal Probiotics. They contain microorganisms that mimic the flora in traditional hunter and gatherer diets. They are generally well-tolerated by patients with SIBO and IBS. Patients with SIBO and IBS usually don’t tolerate the typical probiotic supplement with Lactobacillus species in it.
Additional supplements when treating SIBO
Many SIBO patients have constipation issues likely related to gut motility problems. Iberogast is a blend of 9 botanical “bitters” that help improve gut motility. If you recall from my previous article, impaired gut motility is one of the potential causes of SIBO.
Some patients respond well to MotilPro as well. So if you have SIBO and constipation or alternating constipation and diarrhea, try one of these supplements.
Patients with SIBO and other gut problems will need to support their digestion with Betaine hydrochloric acid (HCl) with pepsin and digestive enzymes. Betaine HCl increases your stomach acid and contains pepsin which will help break down proteins you ingest. High potent digestive enzymes are also added to help breakdown, protein, fats, and carbohydrates. The following are two supplements I have recommended to patients: SpectraZyme Metagest and SpectraZyme Pan 9X ES.
Chiropractic care and SIBO
Having a healthy brain and nervous system are vital to successful healing. Chiropractic adjustments improve the alignment and mobility of the spine which improves nerve input into the brain and nerve output from the brain.
A portion of the nervous system called the parasympathetic nervous system (via the vagus nerve from your brain) supplies your gut. The vagus nerve sends nerve messages to your gut while also relaying nerve messages about your gut to your brain. Gut motility relies on strong nerve messages from the vagus nerve. This allows the smooth muscle in your gut to contract to propel or sweep debris through the tube of your intestine.
Chiropractic adjustments to the upper part of your neck and skull can help stimulate the vagus nerve and restore proper communication between your brain and gut.
There are some chiropractors who know how to work with your ileocecal valve (via visceral manipulation) to help improve its’ function as well. The ileocecal valve is a valve between your small and large intestine, If it doesn’t open and close properly, that may predispose you to SIBO as well. Remember, your gut bacteria make their home in your large intestine. If your ileocecal valve is not functioning properly, your gut bacteria can move up from your large intestine into your small intestine and overgrow.
Gargling is another way to strengthen the nerve signals from the vagus nerve. Gargle vigorously 2-3 times a day for a couple of minutes each time.
You can do all of the above treatment recommended and not get anywhere with it until you address your lifestyle. Getting a good amount of physical activity, getting enough sleep, and especially managing stress are vital to have successful treatment results. Chronic stress will wreak havoc on your gut, and if you aren’t managing stress well, all of the antimicrobials and dietary changes you make will not heal you completely. The gut and nervous system/brain are closely connected (gut-brain axis) which is why stress management and lifestyle/behaviour modification should always be part of a gut protocol.
Step 2 – Retesting
Retesting is important regardless if the patient feels better or not. Without it, we really have no idea what’s going on. For example, if the patient doesn’t feel better after the treatment, it could be because the treatment wasn’t successful. So their breath tests are still not normal and the patient still has symptoms. Or maybe the breath tests do normalize, but the patient still has symptoms, and the SIBO wasn’t the cause of their problems in the first place. Without retesting, you can’t really know which is which.
If herbal antimicrobials fail to get rid of the SIBO it may be necessary to work in conjunction with a pharmacist and use conventional antibiotics.
This is a lot of information to “digest”. Sorry, had to throw that in. The whole SIBO treatment process can get complex and overwhelming. Ultimately, you’re going to need a practitioner to help you who is familiar with this type of approach and process. In saying that, I hope this information helps you on your journey to recover your health. In Part 2 of this article, I will cover the final three steps on treating SIBO.