Nora Gedgaudas

What you need to know about SIBO

What you need to know about SIBO

SIBO, or Small Intestinal Bacterial Overgrowth is a new area of gut health (and what is commonly referred to as dysbiosis) being diligently researched in recent years. New information about this once unknown, unheard-of condition is emerging daily—even as the information available to its sufferers has been somewhat scant until now.

SIBO, or Small Intestinal Bacterial Overgrowth is a new area of gut health (and what is commonly referred to as dysbiosis) being diligently researched in recent years. New information about […]

WHAT IS SIBO?

Small intestinal bacterial overgrowth is a very different form of dysbiosis (i.e., unhealthy imbalances of gut bacteria) than the kind you normally think of affecting your large intestine. Unlike the microbe-laden large intestine (colon), your small intestine –although not necessarily meant to be totally sterile—is not supposed to play host to large colonies of bacteria. Once these unwelcome bacteria take over, however, certain varieties such as gram-negative, rod-shaped bacteria produce an endotoxin called LPS (lipopolysachharides) that can inflame and directly damage your gut. Just as gluten-containing foods stimulate production of the enzyme, zonulin (that controls intestinal and blood-brain barrier permeability), so does LPS. This can result in a chronically leaky gut that can be very frustrating to successfully heal, even on a gluten-free diet. Also, and not trivially, these unwelcome bacteria tend to gobble up and use many of your nutrients (like iron, for instance) so you can’t. This commonly results in malabsorptive symptoms and can even result in chronic, seemingly idiopathic anemia (the low-ferritin type), among other things.

FIBER, PREBIOTICS AND RESISTANT STARCH—A DOUBLE-EDGED SWORD

Fiber and non-digestible sugars such as inulin or FOS (fructo-oligosaccharides), as well as the more recently popularized “resistant starches” (i.e., uncooked sources of starch such as raw potatoes or plantains….uh…”yum”) are technically also carbohydrates, but they are “non-utilizable” in the sense that their sugars are indigestible by us humans. Of course, fiber and non-utilizable starch makes a lovely fermentable source of nutrients for your internal wildlife (i.e., gut bacteria) and may be helpful for improving the health of your already healthy microbiome under normal circumstances, but fiber otherwise tends to pass through you as relatively unchanged. Your healthy gut bacteria happily manufacture butyric acid from fiber (a short-chained saturated fatty acid), which helps to feed the cells of your colon—and are your colonocytes’ favorite food. All this assumes, however, that you already have a prevalence of healthy and not harmful bacteria in your gut to begin with. If the bad guys have taken up residence (that condition called dysbiosis) then the effect of too much dietary fiber may be less than desirable, to put it mildly.

Dietary fiber—once lauded as seemingly essential to our health (which it is not, by the way)— can be either a help or hindrance to your wellbeing, depending on a couple of different factors.   —Too much fiber can start to bind too many minerals in your diet, for instance, making them more difficult to absorb and utilize. But another issue only more recently emerging from the literature and clinical presentations involves this phenomenon called small intestinal bacterial overgrowth, or SIBO for short.

The widespread and growing prevalence of SIBO[1],[2],[3],[4],[5] is underappreciated and an enormous amount of peer-reviewed literature has emerged in recent years. If you experience gas or bloating after meals—particularly after eating carbs—including low glycemic, fiber-rich vegetables and greens chances are this may be an issue for you. Gas, bloating and/or IBS-type symptoms, for instance, are classic presentations for SIBO[6],[7],[8]. The various consequences of SIBO may be complicated to address, and currently available testing for it maybe less then reliable. This condition can even lead to gut barrier compromise (and all that implies)[9]. The number one symptom of SIBO is experiencing distention (gas and bloating) after meals, followed by either diarrhea[10] or constipation[11],[12] (possibly even alternating). Carbohydrate foods (sugars and starches in particular, but also fiber) and prebiotic substrates such as inulin, oligosaccharides or “resistant starch” are primary culprits[13],[14] when it comes to fueling symptoms.

WHY ME?

There are many reasons why SIBO can develop and the causes of SIBO, overall are varied.   Causes may include neurological issues or traumatic brain injury leading to poor vagal tone and ileocecal valve insufficiency (where flora in your colon are able to back up into the small intestine and colonize there), impairment of systemic or local (IgA) immunity, chronic inflammatory changes (as with celiac disease, gluten issues, etc.). Poor protein digestion as a result of HCL insufficiency maybe a vector, as well.   Also, let’s just say that chlorinated/fluoridated water supplies and an industrialized food supply aren’t helping, either. Neither is excessive antibiotic use in medicine or in the livestock industry[15]. The widespread use of chemical agents such as glyphosate[16] (the primary chemical found in RoundUp herbicide) and the cancerous spread of GMO food production worldwide are leading to the emergence of pesticide-containing bacteria that damage and compromise human digestive and immune systems. Dysbiosis, in general is a virtual epidemic and make no mistake– SIBO is a very rapidly growing problem.

HOW CAN I FIND OUT IF I HAVE SIBO?

Well, as already mentioned, the tendency toward abdominal distention, gas and bloating after meals containing carbohydrate-based or cultured/fermented foods in addition to the presence of many of the risk factors listed throughout here can make for a pretty viable clue. All too often, gas and bloating are seen as something normal (which it isn’t, by the way), if not amusing (hey—pull my finger!), and are frequently ignored. The current means of attempting actual medical diagnosis of this condition can be complicated and less than reliable, though some of the available testing in tandem with other signs and symptoms can decidedly be weighed together in determining your probability of SIBO. Many factors, lab-based and symptomatic, must be taken into account for an appropriate determination.

SIBO can also lead to manifesting in a variety of common routine blood chemistry markers, such as chronically depressed ferritin levels (i.e., iron anemia), B-12 anemia, functionally depressed serum albumin levels (below 4.5), and elevated liver enzymes consistent with steatorrhea (fatty liver)[17]. One might also commonly notice depressed serum protein levels (below 7.0) as a result of malabsorption.

In fact, SIBO can be present in or the result of a wide variety of conditions[18]:

  • 15% of elderly populations[19],[20]
  • 33% of patients with chronic diarrhea[21]
  • 34% of patients with chronic pancreatitis[22]
  • 53% of patients with antacid medication use[23],[24]
  • 66% of patients with celiac disease with persistent symptoms[25]
  • 78% of patients with irritable bowel syndrome[26],[27],[28],[29]
  • 90% of alcoholics[30],[31],[32],[33],[34]

SIBO risk has been clearly associated with neurodegenerative conditions, head injury (leading to poor vagal tone)[35],[36], hypochlorhydria[37],[38] (insufficient HCl), kidney disease[39], diverticulitis[40], fistulas, malabsorption[41],[42], and significant immunodeficiency[43].   Small intestinal bacterial overgrowth is additionally associated with numerous other conditions, such as autoimmunity[44],[45], interstitial cystitis[46], restless leg syndrome[47], rosacea[48], systemic sclerosis[49], hypothyroidism[50], malabsorption[51],[52] and numerous others. This doesn’t necessarily mean that if you happen to have one of these conditions that you also necessarily have SIBO—but it DOES mean that SIBO may be well worth screening for/ruling out!

Our modern-day diet provides a veritable feedlot of fodder for bacterial overgrowth of all kinds (not to mention yeasts, fungi, other microbes and cancer cells) along with all the things in our modern-day environment that serves to suppress our immune function that clearly exacerbates the problem. Simple sugars, starches and so-called “resistant starches” really throw the gasoline on this fire. But even vegetable fiber can be problematic for someone with a pronounced case of SIBO and may need to be limited for a time until it is effectively it is treated or better managed.

What is the primary, #1 natural foundational treatment and management approach for SIBO, as well as its single best prevention, you ask?

–A very low carbohydrate diet[53].[54],[55],[56],[57],[58]!!!

The actual medical management of SIBO can become quite involved and may require a combination of both natural and pharmacologic (antibiotic) protocols for its remediation. This next step in treatment clearly leads well beyond the scope of this article. That said the growing prevalence of small intestinal bacterial overgrowth is simply one more reason (among innumerable others) why we all might want to consider minimizing sugar and starch in our diets!

SIBO Management (i.e., while you are healing)

During the process of addressing whatever type of bacterial overgrowth you may be suffering from, it is never too soon to restore your social life by addressing the gas and bloating issues. Supplementing with Saccharomyces boulardii (a helpful form of yeast), commonly available in health food stores can be helpful in thwarting gas, bloating and diarrhea. That said, you will probably want to avoid all fruit and root vegetables, and cook your fibrous veggies more thoroughly for a while (or avoid them for a while if even this doesn’t help). You will also need to avoid “prebiotic” kinds of supplements containing FOS or Inulin (which can feed the bad bacteria in your small intestine and make matters worse), as well as guar gum commonly found in even healthy processed foods.

My good friend and renowned SIBO expert, Dr. Allson Siebecker has a pdf list of many of the most effective management tools she has found here:

http://www.siboinfo.com/uploads/5/4/8/4/5484269/sibo_symptomatic_relief_suggestions.pdf

For even more information about SIBO, including some self-screening tools and treatment information, go to www.SIBOinfo.com.


 

[1] Elphick HL, Elphick DA, Sanders DS. “Small bowel bacterial overgrowth. An under recognized cause of malnutrition in older adults.” Geriatrics. 2006 Sep;61(9); 21-26

[2] J Clin Gastroenterol. 2009 Feb; 43(2): 157-161

[3] Bouhnik Y et al. Bacterial populations contaminating the upper gut in patients with small intestinal bacterial overgrowth syndrome. Am J Gastroenterol. 1999 May;94(5):1327–1331.

[4] Jones HF, Davidson GP, Brooks DA, Butler RN.”Is small-bowel bacterial growth an undiagnosed disorder in children with gastrointestinal symptoms?” J Pediatr Gastroenterol Nutr. 2011 May; 52(5):632-634

[5] Bouhnik Y, Alain S, Attar A, et al. Bacterial populations contaminating the upper gut in patients with small intestinal bacterial overgrowth syndrome. Am J Gastroenterol. 1999;94:1327-1331.

[6] Lin HC et al. Small intestinal bacterial overgrowth: a framework for understanding irritable bowel syndrome. JAMA. 2004 Aug 18;292(7):852–858.

[7] Peralta S et al. Small intestine bacterial overgrowth and irritable bowel syndrome-related symptoms: experience with Rifaximin. World J Gastroenterol. 2009 Jun 7;15(21):2628–2631

[8] Pyleris E et al. The prevalence of overgrowth by aerobic bacteria in the small intestine by small bowel culture: relationship with irritable bowel syndrome. Dig Dis Sci. 2012 May;57(5):1321–1329.

[9] Lauritano EC, Valenza V, Sparano L, et al. Small intestinal bacterial overgrowth and intestinal permeability. Scand J Gastroenterol. 2010 Sep;45(9):1131–1132.

[10] Teo M, Chung S, Chitti L, et al. Small bowel bacterial overgrowth is a common cause of chronic diarrhea. J GastroHepatol. 2004;19:904-909.

[11] Pimentel M, Lin HC, Enayati P, et al. Methane, a gas produced by enteric bacteria, slows intestinal transit and augments small intestinal contractile activity. Am J Physiol Gastrointest Liver Physiol. 2006 Jun;290(6):G1089–G1095. Epub 2005 Nov 17.

[12] Chatterjee S et al. The degree of breath methane production in IBS correlates with the severity of constipation. Am J Gastroenterol. 2007 Apr;102(4):837–841.

[13] Nieves R, Jackson RT. Specific carbohydrate diet in treatment of inflammatory bowel disease. Tenn Med. 2004 Sep;97(9):407.

[14] Staudacher HM, Whelan K, Irving PM, Lomer MC. Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. J Hum Nutr Diet. 2011 Oct;24(5):487–495. doi:10.1111/j.1365-277X.2011.01162.x. Epub 2011 May 25.

[15] Quigley EM, Quera R. Small intestinal bacterial overgrowth: roles of antibiotics, prebiotics, and probiotics. Gastroenterology. 2006 Feb;130(2 Suppl 1):S78–S90.

[16] Shehata AA, Schrodl W, Aldin AA, Hafez HM, Kruger M. “The Effect of Glyphosate on Potential Pathogens and BeneficialMembers of Poultry Microbiota In Vitro”Curr Microbiol. 15 November 2012. DOI 10.1007/s00284-012-0277-2

[17] Shanab AA et al. Small intestinal bacterial overgrowth in nonalcoholic steatohepatitis: association with toll-like receptor 4 expression and plasma levels of interleukin 8. Dig Dis Sci. 2011 May;56(5):1524–1534.

[18] Andrew C. Dukowicz, MD, Brian E. Lacy, PhD, MD, and Gary M. Levine, MD. “Small intestinal bacterial overgrowth: a comprehensive review.” Gastroenterol Hepatol (NY); 2007 Feb; 3(2):112-122

[19] Riordan SM, McIver CJ, Wakefield D, et al. Small intestinal bacterial overgrowth in the symptomatic elderly. Am J Gastroenterol. 1997;92:47-51.

[20] Parlesak A, Klein B, Schecher K, et al. Prevalence of small bowel bacterial over-

growth and its association with nutrition intake in nonhospitalized older adults.J Am Geriatr Soc.2003;51:768-773

[21] Teo M, Chung S, Chitti L, et al. Small bowel bacterial overgrowth is a common cause of chronic diarrhea. J Gastro Hepatol. 2004;19:904-909.

[22] Trespi E, Ferrieri A. Intestinal bacterial overgrowth during chronic pancreati-tis. Curr Med Res Opin. 1999;15:47-52

[23] Lombardo L, Foti M, Ruggia O, Chiecchio A. Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy. Clin Gastroenterol Hepatol. June 2010;8(6):504–508.

[24] Lo WK, Chan WW.  Proton pump inhibitor use and the risk of small intestinal bacterial overgrowth: a meta-analysis. Clinical Gastroenterology and Hepatology 2013; 11(5): 483-490.

[25] Tursi A, Brandimarte G, Giorgetti GM. High prevalence of small intestinal bacterial overgrowth in celiac patients with persistence of gastrointestinal symptoms after gluten withdrawal. Am J Gastroenterol.2003;98:839-843.

[26] Pimentel M, Chow EJ, Lin HC. Eradication of small intestinal bacterial overgrowth reduces symptoms in irritable bowel syndrome. Am J Gastroenterol. 2000;95:3503-3506

[27] Walters B, Vanner SJ. Detection of bacterial overgrowth in IBS using the lactulose H2 breath test: Comparison with the 14C-d-xylose and healthy controls. Am J Gastroenterol. 2005;1566-1570.

[28] Pimentel M, Soffer EE, Chow EJ, et al. Lower frequency of MMC is found in IBS subjects with abnormal lactulose breath test, suggesting bacterial overgrowth. Dig Dis Sci.2002;47:2639-2643

[29] Parisi G, Leandro G, Bottona E, et al. Small intestinal bacterial overgrowth and irritable bowel syndrome [letter]. Am J Gastroenterol. 2003;98:2572.

[30] Hauge T, Persson J, Danielsson D. Mucosal bacterial growth in the upper gastrointestinal tract in alcoholics (heavy drinkers). Digestion. 1997;58:591-595.

[31] Chang CS, Chen GH, Lien HC, et al. Small intestine dysmotility and bacterial overgrowth in cirrhotic patients with spontaneous bacterial peritonitis. Hepatology.1998;28:1187-1190.

[32] Morencos FC, de las Heras Castano G, Martin Ramos L, et al. Small bowel bacterial overgrowth in patients with alcoholic cirrhosis. Dig Dis Sci. 1995;40:1252-1256.

[33] Bauer TM, Schwacha H, Steinbruckner B, et al. Small intestinal bacterial overgrowth in human cirrhosis is associated with systemic endotoxemia. Am J Gastroenterol.2002;97:2364-2370.

[34] Gunnarsdottir SA, Sadik R, Shev S, et al. Small intestinal motility disturbances and bacterial overgrowth in patients with liver cirrhosis and portal hypertension. Am J Gastroenterol.2003;98:1362-1370.

[35] Stotzer PO, Bjornsson ES, Abrahamsson H. Interdigestive and postprandial motility in small-intestinal bacterial overgrowth. Scan J Gastroenterol. 1996;31:875-880.

[36] Husebye E, Skar V, Hoverstad T, et al. Abnormal intestinal motor patterns explain enteric colonization with gram-negative bacilli in late radiation enteropathy. Gastroenterology.1995;109:1078-1089

[37] Husebye E, Skar V, Hoverstad T, et al. Fasting hypochlorhydria with gram positive gastric flora is highly prevalent in healthy old people. Gut.1992;33:1331-1337.

[38] Saltzman JR, Kowdley KV, Pedrosa MC, et al. Bacterial overgrowth with-out clinical malabsorption in elderly hypochlorhydric subjects. Gastroenterology. 1994;106:615-62

[39] Strid H, Simren M, Stotzer PO, et al. Patients with chronic renal failure have abnormal small intestinal motility and a high prevalence of small intestinal bacterial overgrowth. Digestion. 2003;67:129-137.

[40] Akhrass R, Yaffe MB, Fischer C, et al. Small-bowel diverticulosis: perceptions and reality. J Am Coll Surg. 1997;184:383-388.

[41] Goshal UC, Goshal U, Das K, et al. Utility of hydrogen breath tests in diagnosis of small intestinal bacterial overgrowth in malabsorption syndrome, and its relationship with oro-cecal transit time. Indian J Gastroenterol.2006;25:6-10.

[42] Mitsui T, Kagami H, Kinomoto H, et al. Small bowel bacterial overgrowth and rice malabsorption in healthy and physically disabled older adults. J Hum Nutr Dietet.2003;16:119-122

[43] Pignata C, Budillon G, Monaco G, et al. Jejunal bacterial overgrowth and intestinal permeability in children with immunodeficiency syndromes. Gut. 1990;31:879-882.

[44] Ojetti V et al. Small bowel bacterial overgrowth and type 1 diabetes. Eur Rev Med Pharmacol Sci. 2009 Nov–Dec;13(6):419–423.

[45] Castiglione F, Del Vecchio Blanco G, Rispo A, et al. Orocecal transit time and bacterial overgrowth in patients with Crohn’s disease. J Clin Gastroenterol. 2000;31:63-66

[46] Weinstock LB, Klutke CG, Lin HC. Small intestinal bacterial overgrowth in patients with interstitial cystitis and gastrointestinal symptoms. Dig Dis Sci. 2008 May;53(5):1246–1251.

[47] Weinstock LB, Walters AS, Restless legs syndrome is associated with irritable bowel syndrome and small intestinal bacterial overgrowth. Sleep Med. 2011 Jun;12(6):610–613.

[48] Parodi A et al. Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication. Clin Gastroenterol Hepatol. 2008 Jul;6(7):759–764.

[49] Kaye SA, Lim SG, Taylor M, et al. Small bowel bacterial overgrowth in systemic sclerosis: detection using direct and indirect methods and treatment outcome. Brit J Rheumatol. 1995;34:265-269

[50] Lauritano EC et al. Association between hypothyroidism and small intestinal bacterial overgrowth. J Clin Endocrinol Metab. 2007 Nov;92(11):4180–4184.

[51] DiBaise JK. Nutritional consequences of small intestinal bacterial overgrowth. Prac Gastroenterol. 2008;69:15–28.

[52] Almeida JA et al. Lactose malabsorption in the elderly: role of small intestinal bacterial overgrowth. Scand J Gastroenterol. 2008;43(2):146–154.

[53] Singh VV, Toskes PP. Small bowel bacterial overgrowth: presentation, diagnosis, and treatment. Curr Treat Options Gastroenterol. 2004 Feb;7(1):19–28.

[54] Ong DK, Mitchell SB, Barrett JS, et al. Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome. J Gastroenterol Hepatol. 2010 Aug;25(8):1366–1373.

[55] Nieves R, Jackson RT. Specific carbohydrate diet in treatment of inflammatory bowel disease. Tenn Med. 2004 Sep;97(9):407.

[56] Staudacher HM, Whelan K, Irving PM, Lomer MC. Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. J Hum Nutr Diet. 2011 Oct;24(5):487–495. doi:10.1111/j.1365-277X.2011.01162.x. Epub 2011 May 25.

[57] Pimentel M, Constantino T, Kong Y, Bajwa M, Rezaei A, Park S. A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Dig Dis Sci. 2004 Jan;49(1):73–77.

[58] Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol. 2010 Feb;25(2):252–8. Review.

By Nora Gedgaudas

You Might Also Like

Back to Blog Home

Unlock the secrets to a happier, healthier life

Our experts are here to share with you some enlightening thoughts and viewpoints to help you on your own personal journey to become the best version of you. Discover more with our 10 Week Activation Program.

We would love you to join the Tribe!

Join Our 10wk Program