Causes, Diagnosis, and Treatment by Jeffrey Dach MD
Alfred, a 57 year old CEO of a high tech company, flew in from Europe to see me for symptoms of abdominal gas, bloating, pain and food sensitivities. Alfred also has frequent migraines triggered by foods. His local doctors have prescribed anti-fungal drugs thinking Alfred had Candida overgrowth in the small bowel. Alfred’s SIBO Breath Test was indeed positive, showing increased production of both hydrogen and methane gas. In this article we will discuss the diagnosis, causes and treatment of SIBO.
Header image: A schematic diagram that shows principle of hydrogen breath test. SIBO, small intestinal bacterial overgrowth; ppm, parts per million. Fig 1 courtesy of J Neurogastroenterol Motil. 2011 Jul; 17(3): 312–317. How to Interpret Hydrogen Breath Tests by Uday C Ghoshal
What is SIBO ?
SIBO stands for small intestinal bacterial overgrowth, and is commonly associated with underlying Achlorhydria (lack of gastric acid) and/or impaired gastric motility.
1) Achlorhydria (gastric atrophy or long term PPI antacid use).
2) Gastric Motility Disorder (autonomic dysfunction related to mitochondrial dysfunction) . Here, it is useful to check for the MTHFR gene mutation, and B12 deficiency, (and thiamine deficiency) which may cause autonomic dysfunction. Parkinson’s Disease is known to be associated with autonomic dysfunction and leaky gut, and has a high association with SIBO. Diagnosis is made by Hydrogen and Methane breath testing, now widely available.
SIBO is essentially a dysbiosis related to loss of gastric sterile barrier to passage of microbes from stomach to small bowel. It is frequently associated with other small bowel disorders such as leaky gut which may cause low level endotoxemia (as in Cirrhosis), and malabsorption of fat and fat soluble vitamins.
Treatment involves replacing gastric acid levels which restores the sterile barrier to passage of bacteria from stomach to small bowel. Discontinuing PPI Anti-Acid suppressing drugs, adding in Digestive Enzymes with Betain HCL, and replacing the vitamin and mineral deficiencies is a good first step in treatment.
Restoring healthy gut bacteria flora with gut-antibiotics (Rifaximin) and probiotics is described in the protocol sheet for treating SIBO which can be found HERE. Herbal alternatives are also listed for those wishing to avoid the antibiotics. Autonomic Dysfunction may be caused by underlying MTHFR mutation in which case methyl-folate, Benfo-thiamine and methyl-B12 may be useful.
William Davis MD Undoctored Blog recommends the following Herbal protocol for SIBO:
Product links to Amazon:
Small Intestinal Bacterial Overgrowth: Undoctored? Sep, 2017 By Dr. William Davis.
Use of Prebiotics May Worsen SIBO Symptoms
One tip off of underlying SIBO is worsening of symptoms after taking a prebiotic fiber supplement.
“In people with SIBO, most prebiotics will ferment excessively and create more gas that will cause your symptoms to worsen.” quote from fixyourgut blog John Brisson
Similarly FODMAP Diet (fermentable foodstuffs) may aggravate symptoms and cause more gas and bloating. Hence a LOW FODMAP diet is advised.
Conclusion: The wide availability of SIBO Breath testing has made SIBO the popular “Diagnosis Du Jour”. Understanding SIBO association with underlying gastric achlorhydria and/or autonomic dysfunction is important for successful management. Treatment options include herbal remedies and/or GI antibiotics and dietary modification.
Jeffrey Dach MD
7450 Griffin Road
Davie, Florida 33314
Articles With Related Interest:
Links and References
Nice overview three part series
SIBO 101: A Comprehensive Guide to Small Intestinal Bacterial Overgrowth by Admin – Cynthia Perkins on February 13, 2015
SIBO Treatment, Diet and Maintenance – Cynthia Perkins on February 24, 2015
Candida, SIBO or H. Pylori? – Cynthia Perkins on March 6, 2015
Townsend Letter February/March 2015
SIBO: Dysbiosis Has A New Name by Steven Sandberg-Lewis, ND, DHANP and Allison Siebecker, ND, MSOM
The most studied and successful prescription antibiotic for SIBO is rifaximin (brand name Xifaxan). It has a broad spectrum of activity and is nonabsorbable. Its luminal status allows it to act locally, and it is therefore less likely to cause systemic side effects common to other antibiotics.90
Rifaximin has up to a 91% success rate and is given at
550 mg t.i.d. × 14 days.
!!! Best !!!!!!!!!!!!!!!!!!!!!!!!!!
SIBO Treatment Protocol Pimentel Siebecker Sandberg Lewis 2014 From Townsend Letter Feb/March 2015 SIBO treatment
Small Intestinal Bacterial Overgrowth (SIBO)
by Well Balanced – Food – Life – Travel on January 22, 2014 kate scarlata
Okay, I am about to get all science-y on you. Are you ready? Thinking cap on? I attended a great conference last weekend, a SIBO symposium sponsored by the National College of Natural Medicine in Portland, Oregon. Top SIBO specialists that presented most of the information at the symposium included: Mark Pimentel, MD, FRCPC, Allison Siebecker, ND, MSOM, LAc, Leonard Weinstock, MD, FACG and Steven Sandberg-Lewis,
The SIBO Solution: Your Comprehensive Guide to Eliminating Small Intestinal Bacterial Overgrowth Jun 14, 2015 by Sylvie McCracken
A New IBS Solution: Bacteria-The Missing Link in Treating Irritable Bowel Syndrome Paperback – May 15, 2006 by Mark Pimentel (Author)
According to Dr. Mark Pimentel, Director of the Gastrointestinal Motility Program at Cedars-Sinai Medical Center, the majority of IBS cases can be treated successfully.Dr. Mark Pimentel believes that the “missing link,” or root cause of most IBS symptoms can be attributed to an overgrowth of bacteria in the small intestine. A New IBS Solution takes you through the historical evolution of conventional medicine’s views on IBS in a way that can be easily understood. In addition, Dr. Pimentel presents a simple treatment protocol that will not only help you resolve your IBS symptoms, but will also prevent their recurrence.
The Low-FODMAP Diet for Beginners: A 7-Day Plan to Beat Bloat and Soothe Your Gut with Recipes for Fast IBS Relief Paperback – October 10, 2017 by Mollie Tunitsky (Author)
The Complete Low-FODMAP Diet: A Revolutionary Plan for Managing IBS and Other Digestive Disorders Paperback – August 13, 2013
by Sue Shepherd PhD (Author), Peter Gibson MD (Author)
Autonomic Dysfunction ZZZ
Small Intestine Bacterial Overgrowth (SIBO) by Autonomic Specialists
Small intestine bacterial overgrowth (SIBO) is commonly found in patients with dysautonomia. Of the patients we treat for autonomic dysfunction at Autonomic Specialists, most test positive for SIBO. Because it is so prevalent in our patients, we’ve had to establish a treatment program specifically to address this problem.
SIBO – Symptoms and Complications
small intestine bacterial overgrowth sibo
SIBO is chronic infection of the small intestine. It can be seen with a number of conditions but is most strongly associated with irritable bowel syndrome (IBS). In fact according to Dr. Pimentel, SIBO is the cause of IBS. It is not necessarily an infection in the sense of a build up of pathogens, rather it is simply a build of bacteria in an area of the body that is normally free from bacteria.
SIBO can lead to IBS symptoms such as bloating, pain, constipation, diarrhea or both. Malabsorption may also occur in the presence of SIBO. Perhaps the biggest issue caused by SIBO is intestinal permeability, otherwise known as leaky gut. Intestinal permeability may lead to activation of the immune system which can result in food sensitivities. Fatigue, altered cognition, pain and other neurologic symptoms may also occur as a result of intestinal permeability.
Risk Factors for SIBO
Achlorhydria is a predisposing factor for SIBO as is extended antibiotic use. Dysautonomia is also a risk factor for SIBO. In fact in our practice most patients with dysautonomia are found to also suffer from SIBO. Several publications demonstrate a strong connection between SIBO and fibromyalgia.
Testing for SIBO
Diagnosis of SIBO is often confirmed by breath test. This involves the ingestion of a sugar solution followed by collection of the gases breathed out of the lungs over time. A rise in hydrogen or methane gas shortly after eating, indicating fermentation occurring in the small intestine, is indicative of SIBO.
SIBO Treatment at Autonomic Specialists
Successful treatment of SIBO can be challenging. However, treatment is important for more than just relief of IBS symptoms. SIBO is often present with other conditions, some of which are autoimmune or chronic inflammatory illnesses. Correction of intestinal permeability in those circumstances is particularly important.
We take a multi-pronged approach to treating SIBO using :
2) pro kinetic agents such as low dose naltraxone (LDN), and
3) low FODMAPS or elemental diets.
Dysautonomia SIBO Mito Action Webcast 2011 Richard G Boles Too Hot, Too Cold, Too High, Too Low -Blame it on Dysautonomia! MitoAction Webcast 6-May, 2011 Richard G. Boles, M.D. Medical Genetics Childrens Hospital Los Angeles Associate Professor of Pediatrics Keck School of Medicine at USC. Slides.
Mitochndrial Dysfunction causes Dysautonomy and SIBO MTHFR ? Methylfolate Rx
Parkinsons Disease Autonomic Dysfunction and SIBO
SIBO Small intestinal bacterial overgrowth in Parkinson’s disease Tan Parkinsonism 2014 Tan, Ai Huey, et al. “Small intestinal bacterial overgrowth in Parkinson’s disease.” Parkinsonism & related disorders 20.5 (2014): 535-540.
BACKGROUND: Recent studies reported a high prevalence of small intestinal bacterial overgrowth (SIBO) in Parkinson’s disease (PD), and a possible association with gastrointestinal symptoms and worse motor function. We aimed to study the prevalence and the potential impact of SIBO on gastrointestinal symptoms, motor function, and quality of life in a large cohort of PD patients.
METHODS: 103 Consecutive PD patients were assessed using the lactulose-hydrogen breath test; questionnaires of gastrointestinal symptoms and quality of life (PDQ-39); the Unified PD Rating Scale (UPDRS) including “on”-medication Part III (motor severity) score; and objective and quantitative measures of bradykinesia (Purdue Pegboard and timed test of gait). Patients and evaluating investigators were blind to SIBO status.
RESULTS: 25.3% of PD patients were SIBO-positive. SIBO-positive patients had a shorter mean duration of PD (5.2 ± 4.1 vs. 8.1 ± 5.5 years, P = 0.007). After adjusting for disease duration, SIBO was significantly associated with lower constipation and tenesmus severity scores, but worse scores across a range of “on”-medication motor assessments (accounting for 4.2-9.0% of the variance in motor scores). There was no association between SIBO and motor fluctuations or PDQ-39 Summary Index scores.
CONCLUSIONS: This is the largest study to date on SIBO in PD. SIBO was detected in one quarter of patients, including patients recently diagnosed with the disease. SIBO was not associated with worse gastrointestinal symptoms, but independently predicted worse motor function. Properly designed treatment trials are needed to confirm a causal link between SIBO and worse motor function in PD.
de Lacy Costello, B. P. J., M. Ledochowski, and Norman M. Ratcliffe. “The importance of methane breath testing: a review.” Journal of breath research 7.2 (2013): 024001.
In conclusion, the combined measurement of hydrogen and methane should offer considerable improvement in the diagnosis of malabsorption syndromes and SIBO when compared with a single hydrogen breath test.
Saad, Richard J., and William D. Chey. “Breath testing for small intestinal bacterial overgrowth: maximizing test accuracy.” Clinical Gastroenterology and Hepatology 12.12 (2014): 1964-1972.
The diagnosis of small intestinal bacterial overgrowth (SIBO) has increased considerably owing to a growing recognition of its association with common bowel symptoms including chronic diarrhea, bloating, abdominal distention, and the irritable bowel syndrome. . The measurement of methane in addition to hydrogen can increase the sensitivity of breath testing for SIBO.
Am J Gastroenterol. 1996 Sep;91(9):1795-803.
The lactulose breath hydrogen test and small intestinal bacterial overgrowth.Riordan SM1, McIver CJ, Walker BM, Duncombe VM, Bolin TD, Thomas MC.
To i) document the sensitivity and specificity of a combined scintigraphic/lactulose breath hydrogen test for small intestinal bacterial overgrowth and ii) investigate the validity of currently accepted definitions of an abnormal lactulose breath hydrogen test based on “double peaks” in breath hydrogen concentrations.
METHODS:Twenty-eight subjects were investigated with culture of proximal small intestinal aspirate and a 10-g lactulose breath hydrogen test combined with scintigraphy. Gastroduodenal pH, the presence or absence of gastric bacterial overgrowth, and the in vitro capability of overgrowth flora to ferment lactulose were determined.
RESULTS:Sensitivity (16.7%) and specificity (70.0%) of the lactulose breath hydrogen test alone for small intestinal bacterial overgrowth were poor. Combination with scintigraphy resulted in 100% specificity, because double peaks in serial breath hydrogen concentrations may occur as a result of lactulose fermentation by cecal bacteria. Sensitivity increased to 38.9% with scintigraphy, because a single rise in breath hydrogen concentrations, commencing before the test meal reaches the cecum, may occur in this disorder. Sensitivity remained suboptimal irrespective of the definition of small intestinal bacterial overgrowth used, the nature of the overgrowth flora, favorable luminal pH, the presence of concurrent gastric bacterial overgrowth, or the in vitro ability of the overgrowth flora to ferment lactulose.
CONCLUSIONS:Definitions of an abnormal lactulose breath hydrogen test based on the occurrence of double peaks in breath hydrogen concentrations are inappropriate. Not even the addition of scintigraphy renders this test a clinically useful alternative to culture of aspirate for diagnosing small intestinal bacterial overgrowth.
Gatta, L., and C. Scarpignato. “Systematic review with meta‐analysis: rifaximin is effective and safe for the treatment of small intestine bacterial overgrowth.” Alimentary pharmacology & therapeutics 45.5 (2017): 604-616.
Schwartz, Emily, Luigi Brunetti, and Jane Ziegler. “Antibiotic Treatment of Small Intestinal Bacterial Overgrowth: What Is the Evidence?.” Topics in Clinical Nutrition 31.4 (2016): 296-313.
The analysis of the available data suggests that antibiotics, particularly rifaximin, may be effective in normalizing breath tests and improving gastrointestinal symptoms in patients with SIBO.
Bures, Jan, et al. “Small intestinal bacterial overgrowth syndrome.” World journal of gastroenterology: WJG 16.24 (2010): 2978.
The greatest experience for treatment of SIBO was acquired with rifaximin[43,148-154]. Rifaximin is a semi-synthetic rifamycin-based non-systemic antibiotic, with a low gastrointestinal absorption and good bactericidal activity. The antibacterial action covers Gram-positive and Gram-negative organisms, both aerobes and anaerobes. According to different studies, rifaximin improves symptoms in 33%-92% and eradicates small intestinal bacterial overgrowth in up to 80% of patients[151,152]. Most authors recommend administering rifaximin for 7-10 d as one treatment course or as a cyclic therapy. Higher doses (1200 or 1600 mg/d) are more effective than standard doses (600 or 800 mg/d)[148,154]. Rifaximin is probably the only antibiotic that is capable of achieving a long-term favourable clinical effect in patients with irritable bowel and SIBO.
The relapse rate of SIBO after successful treatment is high. Lauritano et al found recurrence of SIBO in 44% (35/80) of patients nine months after successful treatment with rifaximin. Apart from the basic underlying disease, further risk factors for recurrence of SIBO have been identified including older age (OR 1.1), appendectomy in the patient’s history (OR 5.9) and long-term treatment with proton pump inhibitors (OR 3.5).
2014 excellent !!!!!!!
free pdf Small Intestinal Bacterial Overgrowth SIBO Salem J Gastroint Dig Syst 2014 Salem, A., and B. C. Ronald. “Small Intestinal Bacterial Overgrowth (SIBO).” J Gastroint Dig Syst 4.225 (2014): 2.
Rifaximin has been reported in several studies to improve symptoms in up to 92% of patients and additionally to eradicate bacterial overgrowth in up to 80% based on normalization of breath testing [39,40]. The recommendation regarding dosing and duration of treatment varies widely from one study to the next; however, it has been reported that higher dosing (1200 or 1600 mg daily) is more effective as a treatment course as compared to conventional dosing [38,41].
Tetracyclin has also been suggested as an initial therapy for SIBO (1000 mg daily for a 7 day course) and has been shown to result in both normalization of hydrogen breath testing and resolution of symptoms . In another study by Castiglione et al., patients with Crohn’s disease and concomitant SIBO were found to be effectively treated with a combination of Ciprofloxacin and Metronidazole .
Due to the malabsorptive nature of SIBO; vitamin A, B12, D and E levels should be routinely obtained and replaced if indicated.
Pancreatic enzyme supplementation should also be considered in those patients with severe bacterial overgrowth and evidence of fat
As carbohydrates are the primary source for bacteria, a low (FODMAP) diet, which refer to low intake of carbohydrates in the form of (fermentable Olig-Di-Monosaccharaides And Polyps), has been shown to significantly relieve symptoms, particularly in those with IBS .
Probiotics, herbals, and certain diet may also play a significant role
for relieving and treating SIBO. Chedid et al recently reported that
herbal therapies appear to be as effective as antibiotic therapy in the
treatment of SIBO based on resolution of hydrogen breath testing .
Probiotics are bacterial preparations that alter the bacteria in the bowel
to cause beneficial effect. The primary role for probiotics is to
strengthen the barrier function of the gut, to modify the inflammatory response of the bowel, and to potentially decrease visceral hypersensitivity as well [48,49]. Recent studies have also shown
beneficial effects in the setting of treating SIBO patients with enteric- coated peppermint oil .
Lastly, long term use of proton pump inhibitors (PPIS); have been
postulated to predispose to an increase in the number of bacteria in
the stomach and the small bowel. Therefore, stopping unnecessary
acid suppressive therapy (which is often prescribed erroneously) may play a significant role in relieving the symptoms for SIBO.
Khalighi, A. R., et al. “Evaluating the efficacy of probiotic on treatment in patients with small intestinal bacterial overgrowth (SIBO)-A pilot study.” The Indian journal of medical research 140.5 (2014): 604.
Lactol contains a combination of probiotic(Lactobacillus sporogenes) and prebiotic (fructo-oligosaccharides)
Background objectives: Small intestinal bacterial overgrowth (SIBO) leads to several gastrointestinal (GI) problems and complications leading to malabsorption. The effectiveness of probiotics in the treatment of SIBO syndrome has not been well studied. This pilot study was aimed to assess the efficacy of a probiotic consisting of lactobacilli in the treatment of SIBO.
Methods: In this study, 30 cases suffering from chronic abdominal pain or diarrhoea and with a positive hydrogen breath test were randomized in a double-blind manner into two groups: probiotic drug user and control group. After an initial 3-week aggressive therapy with broad-spectrum antibiotics, a 15-day maintenance antibiotic therapy with lactol was administered for the study group and the same regimen without lactol for the control group. After six months the HBT result and the GI symptoms were analyzed and compared between the two groups.
Results: The result of hydrogen breath test and the clinical symptoms in patients receiving the maintenance regimen with lactol probiotic showed a better response. The hydrogen breath test turned negative in 93.3 per cent of those receiving lactol compared to 66.7 per cent of the controls. In all the cases receiving lactol, the abdominal pain disappeared completely (P=0.002). In addition, other GI problems including flatulence, belching and diarrhoea significantly improved in the study group (P<0.05).
Interpretation & conclusions: Based on the preliminary data it seems that adding lactol probiotic to the maintenance therapy of small intestinal bacterial overgrowth patients on routine antibiotic therapy will be beneficial in preventing the complications of this syndrome.
Quigley, Eamonn MM, and Rodrigo Quera. “Small intestinal bacterial overgrowth: roles of antibiotics, prebiotics, and probiotics.” Gastroenterology 130.2 (2006): S78-S90.
Small intestinal bacterial overgrowth is common in intestinal failure. Its occurrence relates to alterations in intestinal anatomy, motility, and gastric acid secretion. Its presence may contribute to symptoms, mucosal injury, and malnutrition. Relationships between bacterial overgrowth and systemic sepsis are of potential importance in the intestinal failure patient because the direct translocation of bacteria across the intestinal epithelium may contribute to systemic sepsis: a phenomenon that has been well established in experimental animal models. The accurate diagnosis of bacterial overgrowth continues to present a number of challenges in clinical practice and especially so among patients with intestinal failure. The management of patients with bacterial overgrowth remains, for the most part, primarily empiric and comprises antibiotic therapy and correction of any associated nutritional deficiencies. Although evidence from experimental animal studies consistently indicates that probiotics exert barrier-enhancing, antibacterial, immune-modulating, and anti-inflammatory effects, which all could be benefits in small intestinal bacterial overgrowth and intestinal failure, their role in human beings remains to be evaluated adequately.
SIBO Cirrhosis and Endotoxemia (leaky Gut)- acid suppressive therapy.
Bauer, Tilman M., et al. “Small intestinal bacterial overgrowth in human cirrhosis is associated with systemic endotoxemia.” The American journal of gastroenterology 97.9 (2002): 2364-2370.
Systemic endotoxemia has been implicated in various pathophysiological sequelae of chronic liver disease. One of its potential causes is increased intestinal absorption of endotoxin. We therefore examined the association of small intestinal bacterial overgrowth with systemic endotoxemia in patients with cirrhosis.
METHODS:Fifty-three consecutive patients with cirrhosis (Child-Pugh group A, 23; group B, 18; group C, 12) were included. Jejunal secretions were cultivated quantitatively and systemic endotoxemia determined by the chromogenic Limulus amoebocyte assay. Patients were followed up for 1 yr.
RESULTS:Small intestinal bacterial overgrowth, defined as > or = 10(5) total colony forming units per milliliter of jejunal secretions, was present in 59% of patients and strongly associated with acid suppressive therapy. The mean plasma endotoxin level was 0.86 +/- 0.48 endotoxin units/ml (range = 0.03-1.44) and was significantly associated with small intestinal bacterial overgrowth (0.99 vs 0.60 endotoxin units/ml, p = 0.03). During the 1-yr follow-up, seven patients were lost to follow up or underwent liver transplantation and 12 patients died. Multivariate Cox regression showed Child-Pugh group to be the only predictor for survival.
CONCLUSIONS:Small intestinal bacterial overgrowth in cirrhotic patients is common and associated with systemic endotoxemia. The clinical relevance of this association remains to be defined.
William Davis MD Blog SIBO
Small Intestinal Bacterial Overgrowth: Undoctored? September 26, 2017 By Dr. William Davis unusual response to prebiotics fibers
Herbal SIBO Protocol
Biotics Reseach FC Cidal & Dysbiocide
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