SIBO THE COMPLETE GUIDE TO SMALL

INTESTINAL BACTERIAL OVERGROWTH

OCTOBER 12, 2019 6 COMMENTS

Today we will be covering everything you need to know about small

intestinal bacterial overgrowth. This complete guide to SIBO, in all it’s
10,000 plus words glory, covers the key points on SIBO including testing
options, conventional and alternative treatments and the common
underlying causes of this gut disorder.

If you suspect you have SIBO and are simply looking for help treating
it, head over to our appointments page to organise a suitable time for a
consult.

Small intestinal bacterial overgrowth, also known as SIBO, is a digestive

disorder that is becoming more widely recognised in the digestive health
community. It is associated with a wide range of health issues such as
nutrient deficiencies, intestinal hyperpermeability (aka leaky gut) and even
liver damage.
 Read on to learn more about this digestive imbalance or if you know what
you are looking for you can use the table of contents below.

Table Of Contents

 What is SIBO
 Why is SIBO an issue?
 Symptoms Of SIBO
 Different types of SIBO
o Hydrogen dominant SIBO
o Methane dominant SIBO
o Mixed SIBO
o Hydrogen Sulfide dominant SIBO
o Fungal SIBO – or should we say SIFO
 Underlying Causes of SIBO
o Causes of SIBO Category 1. Disorders of protective antibacterial
mechanisms
 Low stomach acid
 Exocrine pancreatic insufficiency
 Immunodeficiency syndromes
o Causes of SIBO Category 2. Anatomical Abnormalities
 Ileocecal valve pressure
o Causes of SIBO Category 3. Motility Disorders
 Post Infectious SIBO
 Comorbidities associated with SIBO
o Intestinal permeability
o Cirrhosis/Liver damage
o Malnutrition
o Inflammatory Bowel Disease
o Irritable Bowel Syndrome
o Diabetes
o Rosacea
o Diverticular Disease
 Bacteria Found in SIBO Patients
 Testing For SIBO
o Specificity and Sensitivity in Testing
o The Gold Standard Test
 Breath Testing
o The North American Consensus on SIBO Breath Testing
o Glucose
  Positive Glucose Breath Test
 Pros of glucose breath testing
 Cons of glucose breath testing
o Lactulose
 Positive Lactulose Breath Testing
 Issues with Lactulose breath testing
 Pros of lactulose SIBO breath testing.
 Cons of lactulose SIBO breath testing.
o Fructose
 Pros of fructose SIBO breath testing.
 Cons of fructose SIBO breath testing.
o Which Test is Best when Screening for SIBO?
 SIBO diets
o The low FODMAP diet
o Risks with the low FODMAP diet
 Conventional treatment for SIBO
o Antibiotics in SIBO
o Pros of Rifaximin over other Antibiotics
o Prokinetic Drugs
 Natural Treatments for SIBO
o Herbal antimicrobials
o Herbs to avoid
o Tailored Herbs for Specific SIBO Types
o Herbs to Treat the Underlying Cause of SIBO
o Probiotics in SIBO
o Prebiotics in SIBO
 Elemental Diet
o The Issues with the Elemental diet
 Why Does My SIBO Keep Coming Back?
 Preventing SIBO recurrence
 Work with a SIBO savvy gut clinician
 References and Resources

WHAT IS SIBO
First off a definition is helpful.

SIBO is much like it sounds. An overgrowth of bacteria in the small

intestine. There has been debate over what the exact cut off is for SIBO.
The most widely held definition is a growth of bacteria greater than
1,000,000 (thats 10 to the power of 5) colony forming units per ml while
some researchers are pushing to reduce that number down to 10,000 (10 to
the power of 3) colony forming units (1).

Either way the definition stands.

More bacteria in the small intestine than there should be.

Originally the thinking was that the small intestine was sterile.

As our technology to assess microbes has improved we have learned that a

healthy small intestine has a microbial community. That said, the small
intestine has far less bacteria when compared to the large intestine due to a
range of factors including the flow of the contents (known as peristalsis –
 we will be coming back to this concept later) as well as bactericidal
substances such as bile acids keeping the level of microbes low (2).

WHY IS SIBO AN ISSUE?

Small intestinal bacterial overgrowth is associated with a whole range of
comorbidities – additional conditions – as well as changes to the digestive
tract structure and function.

SIBO may be responsible for

 Vitamin deficiencies
 Malabsorption
 Malnutrition
 Intestinal permeability (aka leaky gut)
 Liver damage
 Changes in bowel pattern
 Abdominal pain (and many other symptoms!)

SYMPTOMS OF SIBO
Now that we have covered the different types of SIBO we can talk about
the different symptoms that digestive health clinicians should be familiar
with. While no specific symptom can determine whether SIBO is present
the following symptoms should raise some red flags and lead to SIBO
testing.

Some of the following symptoms can be present in both methane dominant

SIBO and hydrogen dominant SIBO. Other symptoms are more common
in one or the other.

But remember, symptoms aren’t enough to diagnose which type of SIBO

you really need to test if you suspect!

Symptoms (3).

 Bloating – common in methane and hydrogen dominant

 Flatulence – common in methane and hydrogen dominant
 Abdominal pain – common in methane and hydrogen
dominant
 Tenderness – common in methane and hydrogen dominant
  Weight loss – common in methane and hydrogen dominant
 Steatorrhoea (aka fat in the stool due to poor fat digestion) –
more common in hydrogen dominant SIBO
 Diarrhea – more common in hydrogen dominant SIBO
 Constipation – more common in methane dominant SIBO

DIFFERENT TYPES OF SIBO

While the umbrella concept of SIBO is simple enough to understand – an
overgrowth of bacteria in the small intestine. The different forms of
SIBO can make the picture slightly more complicated. And what can
make it slightly more complicated is the fact that a number of
different types of SIBO can be present at the same time.

Confused yet?

Don’t be.

We will take each different type of SIBO one at a time.

HYDROGEN DOMINANT SIBO

In the human gut certain bacteria produce certain gases as a by-product of
their growth and replication. Hydrogen production is common among
bacteria that make up the gut microbiota. In a healthy gut hydrogen
producing bacteria reside mainly in the large bowel. However, in the
context of SIBO, certain hydrogen producing bacteria can take up
residence in the small bowel and become what we call hydrogen dominant
small intestinal bacterial overgrowth (4).

The testing section of this guide will outline how to test for hydrogen
dominant SIBO by using certain sugars that these particular bacteria use as
a food source.

METHANE DOMINANT SIBO

Moving onto the second form of SIBO we come to methane dominant
SIBO.
Where hydrogen production in the human gut can come from a wide
variety of bacteria, methane production is limited to just a few. These are
known as methanogens, and are technically not bacteria, but archaea. The
most common methane producer in the human gut is known
as Methanobrevibacter smithii. Methanobrevibacter smithii (and other less
commonly found methane producers) use hydrogen – remember
hydrogen is in good supply in the gut – to make methane or CH4 (4).

The number one symptom of methane dominant SIBO

is constipation (5).

If a patient is presenting with bloating, abdominal distention after meals and

constipation I would immediately be thinking methane-dominant SIBO.

The next step her, after a thorough intake and history, would be ordering a SIBO
breath test to confirm this suspicion.

More on that soon

 Image
taken from: Methane Production During Lactulose Breath Test Is
Associated with Gastrointestinal Disease Presentation showing the
prevalence of constipation and methane production in patients with
SIBO.
MIXED SIBO
The third type of SIBO is what is known as mixed type SIBO.

I’m sure that some of you have already put two and two together. If
methane producers use hydrogen to make methane then there must be
hydrogen producing bacteria present as well.

When we test for SIBO using SIBO breath tests there is the possibility that
both methane and hydrogen producers are found in the small bowel
leading to the mixed SIBO diagnosis.

It is also possible for the methane producing archaea to be using all of the
hydrogen (produced by the hydrogen bacteria). It is common to test for
and find methane dominant SIBO, treat the methane producers
successfully, then retest and find hydrogen dominant SIBO.

What has happened here, most likely, is the methane producers have
hidden the hydrogen producers by using up all of their byproduct –
hydrogen.

HYDROGEN SULFIDE DOMINANT SIBO

A final form of small intestinal bacterial overgrowth is called hydrogen
sulfide dominant SIBO.

We have covered hydrogen sulfide production in the large bowel before by

covering the different bacteria that form hydrogen (Desulfovibrio and Bilophila) as
well as their implication in leaky gut and inflammatory bowel disease.

Now let’s talk about hydrogen sulfide production in the small intestines.
The main problem with diagnosing hydrogen-sulfide dominant SIBO is
that there is, currently speaking, no test available that screens for this gas.
Our best people are working on that as we speak.

The lack of testing for hydrogen sulfide SIBO is problematic to say the
least.

In one recent study the researchers found that screening for hydrogen
sulfide was better correlated with patient symptoms. Patients with higher
levels of hydrogen sulfide had more diarrhea, constipation, abdominal pain
and even fatigue (6).

Image taken from: Measurement of Hydrogen Sulfide during Breath

Testing Correlates to Patient Symptoms
Below is an image that shows some of the clinical associations between
the different gases and the possible mechanisms – ie how they affect the
body.

Image taken from: Gas and the Microbiome showing different gases
and their implication in gastrointestinal disorders.
FUNGAL SIBO – OR SHOULD WE SAY SIFO
This may be an article for a different time.

Small intestinal fungal overgrowth (such as Candida) is not commonly

talked about. The idea that bacteria can take up residence in the small
bowel should be a clear sign that fungal overgrowth can occur as well (7).

If this is the case then proper fungal treatments may be necessary when
addressing SIBO cases.
Image taken from: Small Intestinal Fungal Overgrowth showing the
budding of Candida from a harmless unicellular yeast into a
pseudohyphal fungal overgrowth.
UNDERLYING CAUSES OF SIBO
What sets the stage for bacterial overgrowth in the small intestine? The
answers can be numerous and much like the different types of SIBO a
number of underlying causes can be present at the same time.

As SIBO is relatively recent to the game (remember back when all gut
issues were Candida infections?) the underlying causes don’t seem to be
addressed by many people that treat SIBO. Many times it is simply
antimicrobial herbs, possibly followed by probiotics and you’re done.

As the underlying causes that led to SIBO are often not addressed with this
approach the relapse rates can be high.
These causes for SIBO can be broken down loosely into three categories
including disorders of protective antibacterial mechanisms, anatomical
abnormalities and motility disorders. Remember there may be one or many
predisposing factors that can encourage small intestinal bacterial
overgrowth (8).

Let’s cover each category one by one.

CAUSES OF SIBO CATEGORY 1. DISORDERS OF

PROTECTIVE ANTIBACTERIAL MECHANISMS
LOW STOMACH ACID
Known in the medical world as achlorhydria may lead to SIBO. A
healthy stomach is acidic. Damn acidic! This helps to kill off many of the
microbes that are present in your food, on your pets (think of a dog’s love
for licking your face), in unfiltered water (beaver fever is
usually Giardia, contracted from river and pond water) and many, many
other places.

So low stomach acid can cause SIBO, but what causes low stomach acid?

The first offender are pharmaceutical drugs known as proton pump

inhibitors – or PPIs. These drugs effectively shut off the production of
acid in the stomach. Originally this class of drugs were prescription and
only intended for short-term use. Now many of them are available over the
counter and are commonly taken long term.

PPIs are associated with small intestinal overgrowth and there is high
quality science to back this up, including two meta-analyses (one
from 2013 and one from 2017).

PPIs are also associated with other non-SIBO related issues (seen in the
image below) including magnesium and vitamin B12 deficiencies and
possibly even Clostridioides difficile (previously Clostridium difficile),
chronic kidney disease and dementia (11).

While there may be a place and time for these commonly used drugs they,
much like antibiotics, may be overprescribed.
Image taken from: Proton Pump Inhibitors: Review of Emerging
Concerns
EXOCRINE PANCREATIC INSUFFICIENCY
This is a less-clear underlying cause of SIBO but worth covering anyway.

SIBO appears to be more common in patients with chronic

pancreatitis (12).

The thinking here is, due to the reduced function of the pancreas and it’s
antibacterial proteolytic enzymes, bacteria is permitted to grow in the
small intestine (8).

There would be other symptoms associated with chronic pancreatitis that a

primary care physician would be well aware of and capable of managing.

IMMUNODEFICIENCY SYNDROMES
Finally immunodeficiency syndromes including IgA deficiency and even
AIDS can predispose one to SIBO (13, 14).

Narrowing in on the selective IgA deficiency we can see that it is one of

the more common primary immunodeficiencies, which may predispose
one to mucosal infections (SIBO would fit in here) as well as atopy and
even autoimmune diseases (15, 16).
CAUSES OF SIBO CATEGORY 2. ANATOMICAL
ABNORMALITIES
Moving onto the second category of conditions we can see that anatomical
abnormalities can predispose one to small intestinal bacterial overgrowth.
These conditions include small intestinal obstruction, diverticula, fistulae,
surgical blind loop and previous ileo-caecal resections (8).

This is a fairly simple concept to understand but one that is often

overlooked. Anything that impairs the flow through the small intestinal
lumen will lead to stagnation and bacterial overgrowth.

Often these conditions are associated with previous surgeries (17).

One anatomical abnormality that is not necessarily associated with

previous surgeries is diverticular disease. Diverticular disease is associated
with slower oral-coecal transit time – remember anything that slows
down the flow through the intestines may predispose you to
SIBO (18).

One study found that transit time was delayed in 74.44% of patients with
diverticulitis and that 58.88% of patients from the trial had SIBO
diagnosed by a lactulose breath test (19).

ILEOCECAL VALVE PRESSURE

The ileocecal valve connects the end of the small bowel to the start of the
large bowel. For quite some time, poor ileocecal valve function it has been
theorised to be involved in SIBO. As our technology to assess what is
actually happening in the gastrointestinal tract develops we are started to
get a clearer picture of how important the ileocecal valve is in health and
disease.

We know that the large bowel has significantly (let’s say exponentially!)
more microbes when compared to the small intestine. The ileocecal valve
keeps the microbes from being refluxed from the large bowel back into the
small bowel. You can think of it as a gatekeeper. It allows contents to flow
in one direction only.

SIBO patients were shown to have lower ileocecal valve pressure, leading
to a ‘lazy’ ileocecal valve and the possibility that microbes could make it
back into the small intestine. These microbes, if given the right
environment, could then overgrow into a case of SIBO (20).

CAUSES OF SIBO CATEGORY 3. MOTILITY

DISORDERS
The third category of SIBO causes include a range of gastrointestinal
motility disorders. Again we can see the same pattern emerge here with
poor flow through the small intestine leading to bacterial overgrowth.

These conditions include

 Scleroderma
 Autonomic neuropathy in diabetes mellitus
 Post-radiation enteropathy
 Vagal nerve dysfunction
 Migrating motor complex dysfunction

POST INFECTIOUS SIBO

Irritable bowel syndrome can be broken down into a number of different
sub-categories (constipated, diarrheal, mixed and post-infectious) but the
idea that infections could predispose you to SIBO is rather new and still
needs to be worked out by the scientific community.

Still, I felt it was worth including in this SIBO guide because it makes so
much sense.

How many people have developed SIBO after acute gastroenteritis. Maybe
it was during a trip to a third world country or maybe (as in my
experience) it was from consuming contaminated drinking water.

So what does the literature say on this concept?

First off, there has been new developments in diagnosing post infectious
IBS.

After being exposed to any number of different bacterial infections

including Campylobacter jejuni, Salmonella, Escherichia
coli and Shigella different toxins have been found including cytolethal
distending toxin A, B and C. Our body then produces antibodies against
these toxins.

It all makes sense so far right?

Then, possibly due to the molecular mimicry model of autoimmunity,

there is some cross reactivity and the antibodies start targeting a very
important protein found in the gut called vinculin.

Vinculin has a number of key roles in the gut. It is involved in neuronal

cell motility, and gut wall formation (21).

This is pretty big news.

Infections by certain common bacteria can predispose you to poor gut

motility, a hall-mark of SIBO!

COMORBIDITIES ASSOCIATED WITH SIBO

Small intestinal bacterial overgrowth is associated with a long list of other
health issues. Some may be caused by SIBO, some may be caused by the
same thing that caused SIBO (a bit of a tongue twister there).

The image below lists some of the more common conditions associated
with SIBO.
Image taken from: Breath Testing for Small Intestinal Bacterial
Overgrowth: Maximizing Test Accuracy outlining some of the
conditions associated with small intestinal bacterial overgrowth.
INTESTINAL PERMEABILITY
Intestinal hyper-permeability (aka leaky gut) is associated with small
intestinal bacterial overgrowth.

In fact, SIBO may be causing leaky gut in certain people.

One small study found that clearing the bacterial overgrowth in SIBO
patients improved their leaky gut.

Plus, increased intestinal permeability – leaky gut – is associated with a

number of commonly seen issues in SIBO such as food intolerances
and histamine sensitivity.

CIRRHOSIS/LIVER DAMAGE
Liver damage may not be the first thing you think of when you think of
SIBO but the connection between the gut and liver is well documented.

Seeing as the liver is connected to the gut via the portal vein, and receives
a continuous supply of nutrient and microbe laden blood, this should be
fairly obvious.

In cases of SIBO and leaky gut the liver takes on an extra load of
endotoxin (also known as lipopolysaccharide or LPS) laden bacteria which
can promote localised inflammation, liver cell damage and even body wide
inflammation (24).
Image taken from: Review article: the gut microbiome as a
therapeutic target in the pathogenesis and treatment of chronic liver
disease showing a healthy gut on the left and a dysbiotic gut on the
right and their association with inflammation, liver function and
damage.
A recent systemic review with meta analysis, published in the European
Journal of Gastroenterology & Hepatology, concluded that there was a
‘significant association between NAFLD (non-alcoholic fatty liver
disease) and SIBO was observed in this meta-analysis’

MALNUTRITION
Both fat soluble vitamins including vitamin D, vitamin E and possibly
even vitamin A may be deficient in SIBO cases whereas vitamin K levels
may be normal or even raised. This vitamin is synthesised by bacteria so
this makes sense when you think about it.

Other nutrients which may be low in SIBO cases include vitamin B12
(keep an eye out for megaloblastic anaemia and the associated
polyneuropathy) as well as iron deficiency which may lead to microcytic
anaemia.

There are a few reasons to explain these possible nutrient deficiencies

associated with SIBO including bacterial metabolism, the damage that
SIBO can cause to the mucosa of the small intestine and even the restricted
diets that many people use to either treat their SIBO or minimise their
symptoms. Finally chronic diarrhea and fat malabsorption may lead to
nutrient deficiencies (26).

INFLAMMATORY BOWEL DISEASE

Are inflammatory bowel disease (IBD) and SIBO connected in any way?

We know that IBD, including Crohn’s disease and ulcerative colitis, have
an altered microbiota in the large bowel that could be driving the disease
(more here and here). We also know that SIBO is a condition of an altered
microbiota in the small intestine. But is there an overlap?

One systemic review with meta-analysis (very high level science) found
that SIBO was present in 22.3% of patients with inflammatory bowel
disease. Looking into the subtypes of IBD they found that SIBO positive
Crohn’s patients did not have elevated CDAI (Crohn’s disease activity
index) compared to Crohn’s disease patients without SIBO. One study
included in the review found that there was significantly higher levels of
calprotectin (which can be tested by your doctor and is also found on the
GI-MAP) in SIBO patients with Crohn’s disease compared to SIBO
negative Crohn’s disease patients.

So what do we make of this?

It is early days in the SIBO and IBD world. The study covered above was
published this year (2019) and only included 1175 IBD patients. The
second issue here is that the studies included only used one type of sugar
in their SIBO breath test (we’ll cover why that is an issue later on) so they
may be underreporting the incidence of SIBO in IBD.
For now I think it is worth keeping in mind that if you have IBD then it is
possible that SIBO is also present as well. Treating your SIBO (if present)
may improve some of your gut symptoms but current thinking is that it is
not a driver of IBD.

Again this may change as we learn more.

IRRITABLE BOWEL SYNDROME

Irritable bowel syndrome has been correlated with SIBO for quite some
time now. It is quite common for patients that had originally been
diagnosed to have SIBO and, when treated, many of their symptoms
improve.

The question is, how common is SIBO in IBS and if someone has SIBO
do they still have IBS?

The answer to the first question varies depending on which study you read.

 One of the most recent systemic review with meta

analysis found SIBO to be present in over ⅓ of the patients
with IBS
 Another, older systemic review with meta-analysis found that
SIBO was present in 54% of IBS patients when using a
glucose or lactulose breath test but only 4% when using the
gold standard SIBO test, aspirate and culture.

The list of papers linking IBS to SIBO could go on and on.

I’ll leave it to the researchers to work out exactly how strong the
connection is between the two gut disorders. For now it’s worth pointing
out that if you have been diagnosed with IBS and fit the symptom
picture of SIBO it may be worth getting tested to rule it out.
 Image
taken from: Small Intestinal Bacterial Overgrowth and Irritable
Bowel Syndrome: A Bridge between Functional Organic Dichotomy
DIABETES
Diabetes, both type 1 and type 2, are possible comorbidities associated
with SIBO.

In type 2 diabetes, the more common of the two, the poor blood sugar
control (both hyperglycaemia and hypoglycaemia) can alter the gut
motility. Type 2 diabetes have been shown to have slower oral-cecal
transit time and higher rates of SIBO (31).

ROSACEA
Does SIBO cause rosacea or are they simple correlated?

One study found that SIBO was much higher in patients with rosacea. Plus
when they treated and cleared the SIBO the skin
condition cleared or greatly improved in over 90% of the patients.

True it was a small study and there is not much science to confirm these
results but it does make you wonder. The gut-skin axis may be the driver
in at least some people with rosacea.
We have covered that particular study in more depth here for your to read
at your convenience.

DIVERTICULAR DISEASE
Most people would think that diverticulitis is associated with a low-fiber
diet and much of the research is confirming that suspicion. While there is
very little research connecting diverticulitis and SIBO, other predisposing
factors for diverticular disease such as motility disorders (slowed transit
time through the intestines) is a major factor that leads to SIBO in the
first place (as we discuss here).

One study looking into the connection between SIBO and diverticulitis
found that 58.88% of patients with diverticulitis had SIBO using the
lactulose breath test – don’t forget here that the lactulose breath test can
miss some cases of small intestinal bacterial overgrowth as we covered in
the testing section.

The same study also found that treating SIBO in patients with diverticulitis
resulted in significantly improved symptoms.

Image taken from: Gastrointestinal bacterial overgrowth:

pathogenesis and clinical significance
BACTERIA FOUND IN SIBO PATIENTS
So we now know that SIBO is an overgrowth of bacteria in the small
intestine but what types of bacteria are responsible?

This question is harder to answer than you might think.

A number of bacteria have been found in SIBO cases via duodenal aspirate
and culturing including

 Streptococcus
 Enterococcus
 Klebsiella
 E. coli

For SIFO it was predominantly Candida species of fungus (34).

Other bacteria include gram positive, aerobic or facultative anaerobic

bacteria such as:

 Staphylococcus
 Micrococcus
 Lactobacillus
 Corynebacterium
 Bifidobacterium

Gram positive anaerobic bacteria:

 Fusobacterium
 Peptostreptococcus

Gram negative, aerobic or facultative anaerobic bacteria:

 Proteus
 Acinetobacter
 Enterobacter
 Neisseria
 Citrobacter

Gram negative, anaerobic bacteria

 Bacteroides
 Clostridium

References for bacteria found in SIBO (35, 36).

This list of bacteria associated with SIBO was put together from microbes
found using the culture and microscopy techniques – basically sampling
the small intestine and trying to grow what you have sampled.
The real problem here is that not every microbe can be cultured!

The percentage of microbes that cannot be cultured ranges from paper to

paper (from 20-60% all the way up to 80%) although this number changers
as our culture techniques improve (39).

To date there has only been a few studies using DNA based (non-
culturable) assessments of the microbiota in SIBO patients.

One study sampled the jejunum (the middle section of the small intestine)
from 20 patients which was then cultured to diagnose SIBO (remember
over approximately 10 to the 5th factor – 10 to the 7th factor would
indicate an overgrowth). They also assessed the samples using a common
DNA based assessment known as 16S ribosomal RNA – I think of this
almost as a unique fingerprint that each bacterial genera has. A great way
to assess bacteria without culturing.

The most abundant microbes were similar to bacteria found in the mouth
including

 Streptococcus (28%)
 Prevotella (13%)
 Veillonella (7%)
 Fusobacterium (6%)
 Haemophilus (5%)
 Actinomyces (3%)
 Rothia (2%)
 Leptotrichia (2%)
 Gemella (2%)
 Neisseria (2%).

As well as other bacteria including a few from the Proteobacteria phylum

which we have covered before including:

 Escherichia (7%)
 Klebsiella (2%),
 Citrobacter (2%)
 Actinobacillus (1%)
 Enterobacter (1%)
 Bacteroides (1%)
 Lachnoclostridium (1%)
The study concluded that few to no colonic bacteria were found in the
jejunum in patients with SIBO. We will circle back to this when we talk
about different causes for SIBO.

Image taken from: Jejunal Flora of Patients with Small Intestinal

Bacterial Overgrowth: DNA Sequencing Provides no Evidence for a
Migration of Colonic Microbes. From this study 12 out of 20 patients
were diagnosed with SIBO due to excessive bacterial counts from
the aspirate taken from their small intestine.
Another recent DNA based study found an increase in the Proteobacteria
phylum in SIBO patients and a decrease in the Firmicutes phylum. They
also found a decrease in bacterial diversity in SIBO patients as well.
The image below shows DNA based assessment of patients without SIBO
(the 0’s along the x axis) as well as upper aerodigestive tract SIBO (the
1’s) and coliform SIBO (the 2’s).

Image taken from: Characterization of Proximal Small Intestinal

Microbiota in Patients With Suspected Small Intestinal Bacterial
Overgrowth: A Cross-Sectional Study
TESTING FOR SIBO
Testing for SIBO is complicated.

To date there is not one test that is as specific and sensitive as many
clinicians (myself included) would like. Each and every one of the SIBO
tests available are unreliable in their own special way.

Before we get into the different testing options let’s cover exactly what I
mean by specific and sensitive.
SPECIFICITY AND SENSITIVITY IN TESTING
Specific testing. A test that is highly specific means that there is a
very low chance of what it known as a false positive. A false positive in
the pathology world is when a test comes back positive for a marker (in
this case we are talking about SIBO) but it is wrong.

Definitely not what we want.

With tests that have low specificity we get these false positive test results.
In the case of SIBO if the testing came back with a false positive you
might end up treating SIBO when in fact there was no SIBO!

Sensitive testing. On the other hand there is the concept of the sensitivity
of a test. Tests that are highly sensitive rarely miss. Highly sensitive
testing means there is a low chance of a false negative (a false negative is
when the test says there is no infection when in fact there is). In the case of
SIBO a highly sensitive test would catch SIBO every time. On the other
hand testing that has poor sensitivity (meaning it has low sensitivity)
would miss SIBO even when it was there!

Again not what we want.

So circling back to the point above, currently we don’t have one readily
available test that is both highly specific and highly sensitive. Let’s cover
what we do have and the best way to get around this massive problem in
SIBO testing and diagnosis.
Image taken from: Gastrointestinal bacterial overgrowth:
pathogenesis and clinical significance
THE GOLD STANDARD TEST
The gold standard test used to diagnose SIBO is what is known as a small
bowel aspirate and culture. The small bowel is sampled and then
cultured. If the cultured microbes reach a certain threshold it is considered
small intestinal overgrowth (22).

A few issues have been raised around this invasive and costly procedure.

 Where the sample was taken in the small bowel (the bacterial
overgrowth may have been missed).
 Sample handling and culturing techniques vary
 How much is considered an overgrowth?
 Many bacteria sampled cannot be cultured

These issues and more have led researchers and gut health clinicians to
look for better alternatives in assessing someone for small intestinal
bacterial overgrowth.

Introducing the SIBO breath test with all of its pros and cons!

BREATH TESTING
An overview of the concept of breath testing is shown in the image below.

Sugar is consumed. If there is sufficient bacteria in the small intestines

then they will ferment the sugar and produce hydrogen and/or methane and
carbon dioxide. Excess hydrogen and methane gas makes their way into
the bloodstream and out of the body via the lungs which is then captured
and assessed.

A sufficient rise in either one or both, within a given time, would indicate
SIBO.

If there is a significant rise beyond the given time this indicates that the
sugar has passed through the small intestines and into the large bowel
where it has been fermented by the bacteria there.

Image taken from: Breath Tests for Gastrointestinal Disease: The

Real Deal or Just a Lot of Hot Air?
THE NORTH AMERICAN CONSENSUS ON SIBO
BREATH TESTING
In 2017 a paper was published in the American Journal of
Gastroenterology outlining a panel of SIBO researchers consensus on
SIBO breath testing. Did I mention it was complicated? The paper outlined
a number of key points that you need to be aware of when considering
which SIBO breath test is best and how to interpret it.

Key points from the paper include the following

1. Avoid antibiotics for at least 4 weeks prior to SIBO breath

testing.
2. Stopping prebiotics and probiotics was unclear – some say
yes some were uncertain
 3. Stopping promotility and laxative agents for 1 week prior to
SIBO breath testing was recommended.
4. Avoiding fermentable foods (complex carbohydrates,
FODMAPS etc) should be avoided for 1 day prior to SIBO
breath testing.
5. Fasting for 8-12 hours before the SIBO breath testing was
recommended.
6. Patients should avoid smoking and exercising before the SIBO
breath test.

Each SIBO breath testing provider will have their own approach and best
practices for getting the most from the test. It is best to follow their
recommendations (or the health clinician you are working with) to the
letter. The worst scenario would be a user error which normally means
you have to pay for another test.

GLUCOSE
Glucose is a very well studied sugar used in SIBO breath testing. It is
considered very specific but not very sensitive.

When glucose is used as a breath testing sugar to diagnose SIBO there are
very little chances of it saying you have SIBO when in fact you do not
(only when the proper pre-test diet is followed as outlined above).
However, there is a higher chance of a glucose breath test saying you do
not have SIBO when in fact you do!

Here is why.

Glucose is very easily absorbed in the upper small intestine. Why is that
important? If the intestinal overgrowth is located further down in the small
intestine (what is known as distal in medicine speak) then the glucose may
not be available (as in it has already been absorbed into the bloodstream)
to be fermented by the bacteria and produce a rise in gas levels as seen in
the image below (44).
Image taken from: Is It Useful to Administer Probiotics Together
With Proton Pump Inhibitors in Children With Gastroesophageal
Reflux? showing no significant increase in hydrogen (left)
indicating no SIBO and a significant increase (right)
showing SIBO. Quality breath tests will also record methane levels
simultaneously.
POSITIVE GLUCOSE BREATH TEST
For hydrogen dominant SIBO a rise of 20ppm of hydrogen over baseline
in the first 90 minutes is thought to be a positive reading. This conclusion
was drawn by the The North American Consensus paper on SIBO breath
testing paper.

Methane dominant SIBO is less precise. The The North American

Consensus paper on SIBO breath testing agreed that a level equal to or
greater than 10ppm of methane was indicative of SIBO. Here there is the
issue of methane production in the large bowel. Some clinicians would
want to see a rise in methane of 10ppm or more within the first 90
minutes to help distinguish between large bowel methane production and
methane dominant SIBO.

PROS OF GLUCOSE BREATH TESTING

Glucose breath testing is highly specific. If there is a significant rise in gas
production (and you have followed the proper test prep instructions) then
SIBO is probable.

CONS OF GLUCOSE BREATH TESTING

Glucose breath testing is not very sensitive. If there is no rise in gas
production then you may still have SIBO.

LACTULOSE
Moving onto the darling sugar used in SIBO breath testing we come to
lactulose. It has been getting a ton of press lately for reasons that I will
outline below.

First off what is lactulose?

Lactulose is a semi-synthetic disaccharide formed from lactose. It acts as a

prebiotic, meaning it reaches the large intestine undigested and can be
fermented and consumed by beneficial bacteria (45).

Image taken
from: Medical, nutritional and technological properties of lactulose.
An update
When consumed as a sugar for a SIBO breath test lactulose makes its way
through the small intestine and into the large intestine where it is
fermented by colonic bacteria, resulting in the production of hydrogen and
possibly methane (if methanogens are present). If there is an overgrowth
of bacteria in the small intestine – if SIBO is present – then there will be a
rise in hydrogen and/or methane before the lactulose reaches the colon
(46).

There have been a range of different interpretations proposed for the

interpretation of a positive lactulose breath test ranging from the ‘double
peak’ – the thinking here is that the first peak signifies bacterial
fermentation in the small bowel and the second peak signifies bacterial
fermentation in the large bowel – and the ‘early rise’ – a rise in hydrogen
above 20 ppm over baseline within 90 minutes – (both seen in the image
below)

In the The North American Consensus paper on SIBO breath testing they
agreed that the ‘early peak’ was a better indication of a SIBO positive
patient and that the ‘double peak’ was not necessary for a positive result.
 Image taken
from: The diagnosis of small intestinal bacterial overgrowth: Two
steps forward, one step backwards? Showing the ‘double peak’ and
the ‘early rise’ of hydrogen on a lactulose SIBO breath test. Both of
these diagnostic criteria have been called into question.
POSITIVE LACTULOSE BREATH TESTING
This is much the same as the glucose breath test taking into account the
issues with lactulose breath testing outlined below.

For hydrogen dominant SIBO a rise of 20ppm of hydrogen over baseline

in the first 90 minutes is thought to be a positive reading. This conclusion
was drawn by the The North American Consensus paper on SIBO breath
testing paper.
Methane dominant SIBO is less precise. The The North American
Consensus paper on SIBO breath testing agreed that a level equal to or
greater than 10ppm of methane was indicative of SIBO. Here there is the
issue of methane production in the large bowel. Some clinicians would
want to see a rise in methane of 10ppm or more within the first 90
minutes to help distinguish between large bowel methane production and
methane dominant SIBO.

ISSUES WITH LACTULOSE BREATH TESTING

As with every other SIBO test available lactulose breath testing does have
its own issues.

First off we have patients with fast oral-cecal transit time. This is common
in people suffering from diarrhea – a common SIBO symptom. Secondly
lactulose is commonly used as a laxative and has been shown to speed up
transit time! With a faster transit time an early rise in gas production could
mean that the lactulose has reached the colon – here we could suffer from
a false positive diagnosis of SIBO (22).

The last issue, and one that many clinicians miss, is the fact that lactulose
is very selective in which bacteria it feeds. This is why it has commonly
been used as a prebiotic. Certain bacteria cannot use lactulose as a food
source. If these bugs were making up the small intestinal overgrowth there
is a high chance of getting a false negative.

Image
taken from: Small intestinal bacterial overgrowth showing differing
results for sensitivity and specificity of both the glucose SIBO
breath test and the lactulose SIBO breath test.
PROS OF LACTULOSE SIBO BREATH TESTING.
It is a commonly used SIBO breath test sugar, is widely available and is
relatively affordable

CONS OF LACTULOSE SIBO BREATH TESTING.

Lactulose SIBO breath testing may miss certain cases of SIBO due to the
selectivity of the sugar. Using it may also result in false positives due to
the increased transit time.

FRUCTOSE
A third sugar, very rarely used in clinical and research settings to identify
SIBO, is fructose. Commonly this sugar is used to identify fructose
malabsorption issues. In a healthy small intestine fructose should at least
partly be absorbed. When there is fructose malabsorption the sugar makes
its way down to the large bowel where it can cause issues such as bloating,
nausea and even diarrhoea.

Fructose malabsorption is such a common issue that some researchers are

even considering it as one of the issues causing irritable bowel
syndrome (47).

The image below shows fructose malabsorption leading to excessive

fructose reaching the colon and the classic symptoms of fructose
malabsorption being produced. What is not shown in the image below, and
what few gut health professionals are aware of, is the possibility of the
malabsorbed fructose being fermented in the small intestine even before it
reaches the large intestine. If there is an early rise of gases on a fructose
SIBO breath test then, you guessed it, you could be dealing with SIBO.

Image taken
from: Fructose malabsorption
PROS OF FRUCTOSE SIBO BREATH TESTING.
Including the fructose SIBO breath test covers more area when testing for
SIBO.

Often times SIBO patients have trouble absorbing fructose in the small
intestine due to the damage done to the microvilli. If this is the case then
the poorly absorbed fructose will be fermented in the small bowel and turn
up as a positive SIBO breath test.

CONS OF FRUCTOSE SIBO BREATH TESTING.

Fructose is not a commonly used sugar for detecting SIBO.

There is very little research available and no consensus on proper

interpretation guidelines. As such it is best used in combination with other
breath tests (glucose or lactulose)

WHICH TEST IS BEST WHEN SCREENING FOR SIBO?

And now the million dollar question. Which test is best for proper SIBO
diagnosis?

Seeing as each test, from the aspirate and culture to everyone of the three
breath test sugars (glucose, lactulose and fructose) all have their issues
and proper diagnosis of SIBO is so important before any microbiome
restoration can happen in the large bowel we need to use a combination
of tests to be sure.

The best practice, as outlined by Dr Jason Hawrelak, one of the top gut
health practitioners here in Australia, is to use multiple breath tests each
with a different sugar.

Screening for small intestinal bacterial overgrowth using glucose, fructose

and lactulose (each on different days) makes up for each of the different
sugars shortcomings. Plus noting which sugar is fermented in the small
bowel and which isn’t can help when it comes to the treatment of SIBO.

SIBO DIETS
The approaches to dietary interventions for SIBO vary depending on who
you speak to. A few of the top diets for SIBO include the low FODMAP
(stands for fermentable oligosaccharide, disaccharide, monosaccharide and
polyol) diet, the SCD (specific carbohydrate) diet and the GAPS (gut and
psychology syndrome) diet.

Below is a short snapshot of the low FODMAP diet which is commonly

used to minimise the symptoms associated with SIBO.

Just a quick note here.

I am including these dietary interventions here due to the fact that they are
frequently recommended for SIBO patients by different clinicians.

I wouldn’t personally endorse one over the other to (or any to be frank) for all
SIBO patients. Again it comes down to the individual patient, how they are
presenting and also which test was used to screen for SIBO.

THE LOW FODMAP DIET

The low FODMAP diet is the most frequently diet used to manage
symptoms associated with SIBO.

First off what is a low FODMAP diet?

The quick answer here is that it is a very restrictive diet.

The low FODMAP diet restricts a whole range of carbohydrates that can
be fermented by the bacteria that reside in your gastrointestinal tract
including

 Fructose (particularly in excess of glucose)

 Oligosaccharides found in many foods including wheat and
onions
 Galacto-oligosaccharides – found in legumes
 Sugar polyols – sorbitol and mannitol
 Lactose – particularly if it is poorly absorbed

The idea around this diet stems from the idea of limiting poorly absorbed
short-chain carbohydrates, thus limiting fermentation and gas production
which is associated with symptoms of SIBO such as bloating and
distention (49).
It has been commonly prescribed for patients with IBS and has shown
good success in reducing their symptoms (50).

Remember when we covered the connection between SIBO and IBS? Due
to the overlap, many things that improve IBS symptoms may also improve
SIBO symptoms.

It is important to note that a low FODMAP diet is not a no FODMAP

diet. The particular approach involved restricting these foods, noting
whether symptoms have improved, then reintroducing different types of
FODMAPs one at a time and finally customising your personal low
FODMAP diet (51).

RISKS WITH THE LOW FODMAP DIET

The low FODMAP diet does come with a few possible downsides as listed
in a 2017 review paper Controversies and Recent Developments of the
Low-FODMAP Diet

1. Using the low FODMAP diet to ‘diagnose’ IBS is used by

some clinicians. This is considered poor practice and proper
diagnostic procedures are much better suited. An example
here would be using the ROME criteria for IBS and excluding
other pathologies like SIBO, gluten sensitivities and large
bowel dysbiosis.
2. Disordered eating. As with many restrictive diets the low
FODMAP diet can lead to eating disorders in certain
predisposed people.
3. Altered gastrointestinal microbiota. This may be the top
offender when it comes to issues with the low FODMAP diet.
Many FODMAPs, due to their fermentable nature, have
prebiotic like effects on the gut microbiota. Low FODMAP
diets have been shown to reduce levels of beneficial bacteria
in the large bowel. Other possible negatives of the low
FODMAP on the gut microbiome include a reduction in the
butyrate producing beneficial bacteria.

Due to these issues it is best to limit the low FODMAP diet to the
treatment phase and begin to reintroduce fermentable carbohydrates as
quickly as possible.
CONVENTIONAL TREATMENT FOR SIBO
Conventional treatment for SIBO is antibiotics. The thinking here is that if
there is a bacterial overgrowth then the treatment is to remove the bacteria
that are overgrowing. Pretty straight forward right?

ANTIBIOTICS IN SIBO
Commonly used antibiotics include

 Clindamycin
 Metronidazole
 Neomycin
 Rifaximin
 Tetracycline

Each of these different antibiotics have different success rates with

successful interventions ranging from 35% up to 100% (53).

Rifaximin appears to be the antibiotic of choice for hydrogen dominant

SIBO. The archaea involved in methane dominant SIBO
(Methanobrevibacter smithii) appear to be more antibiotic resistant. When
methane dominant SIBO is present the most common conventional
approach appears to be a combination of both neomycin and rifaximin
(54).

PROS OF RIFAXIMIN OVER OTHER ANTIBIOTICS

As a herbalist and a microbiome explorer and admirer I am not a huge fan
of antibiotics and their overuse. The rise of resistant microbes and the
negative impact on the gut microbiota puts me off antibiotics unless
absolutely necessary. More on that here.

With that out of the way rifaximin appears to be safer than most other
antibiotics.

First off it is effective against both anaerobic and aerobic bacteria plus it is
very poorly absorbed into circulation. Rifaximin seems to be well tolerated
with few adverse events noted (55).
One in-vitro study even showed some prebiotic effects of rifaximin on the
large bowel gut microbiota. An increase
in Bifidobacteria and Faecalibacterium prausnitzii were observed in a
colonic like simulation (56).

These prebiotic effects on the colonic gut microbiota have been seen in a
number of other studies (shown in the table below).
 Image taken
from: Eubiotic properties of rifaximin: Disruption of the traditional
concepts in gut microbiota modulation
While it seems that rifaximin is better tolerated than most other antibiotics
and that it does not appear to cause microbiome damage and disruption in
the large bowel it does not treat the underlying cause in many patients who
eventually relapse (8).

PROKINETIC DRUGS
Prokinetic pharmaceuticals are often used in conventional medicine to
encourage healthy movement through the small bowel in SIBO patients
post antibiotic treatment.

These mainly include one of three drugs although others may be used (54).

 Erythromycin
 Domperidone
 Prucalopride

Erythromycin is actually an antibiotic, and although it is only used in small

amounts as a prokinetic drug, it is still worth knowing that it’s primary use
is to kill bacteria.

NATURAL TREATMENTS FOR SIBO

HERBAL ANTIMICROBIALS
Herbal medicine can be very effective in treating SIBO.

In fact, one particular study compared the use of herbal antimicrobials

against rifaximin (a popular antibiotic for SIBO). They found that the
herbal antimicrobials were actually more effective at treating SIBO than
the antibiotic (58).

The study does have a few inconsistencies, mainly the smaller than
recommended dose for rifaximin as well as the timing of the intervention.
Either way it does show that herbs can be used to successfully treat SIBO.

Different herbs that are commonly used include ones high in different
active constituents including those high in

 Berberine
 Tannins
 Volatile oils

Berberine rich herbs include

 Philodendron
 Coptis chinensis
 Goldenseal
  Oregon grape root
 Barberry

There may be an overemphasis on berberine at the moment when treating

different gut infections and overgrowths. There has even been talk about
berberine-resistance.

Plants rich in polyphenols are often a suitable alternative to berberine rich

herbs. Some of these herbs are also rich in volatile oils (a major win!).

These include among many many others

 Pomegranate husk
 Propolis
 Cloves
 Oregano leaf (not oil as it may be too damaging to the gut
ecosystem)
Finally volatile oils from selective herbs have been used in the treatment
of SIBO.

These include

 Oregano oil
 Thyme oil
 Clove oil
 Peppermint oil
There is some concern around the damage to the gut microbiota
composition when using such strong herbal oils. Many of these oils can
almost be seen as broad-spectrum as antibiotics.

As a clinical herbalist I would only recommend taking the whole plant, often in
tincture form, instead of the isolated plant oils.

Here we are still getting the oils (although at lower concentrations) along with all
of the other active constituents that would be missed by going the oil only route.

HERBS TO AVOID
Apart from the long term use of herbal oils and berberine rich
herbs there is one other herb that should be absolutely avoided.

Grapefruit seed extract, often used as a potent herbal antibiotic, has been
shown again and again to be a contaminated product spiked chemicals
like benzethonium chloride and triclosan.

Some preliminary (and unfortunately unpublished data) has shown that it

has broad-spectrum and devastating effects on the gut microbiota, possibly
as bad as broad spectrum antibiotics.

Grapefruit seed extract, often used as a potent herbal antibiotic, has

been shown again and again to be a contaminated product spiked
chemicals like benzethonium chloride and triclosan.
TAILORED HERBS FOR SPECIFIC SIBO TYPES
When it comes down to it you really need to know which type of
SIBO you are treating. Then the herbal formula can be specifically
tailored to treat the specific bacterial overgrowth.
Just throwing herbs and supplements at SIBO generally won’t get you very
far.

Best case scenario you may clear the overgrowth, worse case scenario you
will be throwing money away and prolonging your healing journey.

HERBS TO TREAT THE UNDERLYING CAUSE OF SIBO

Specific herbal medicines can be used to treat the different underlying
causes of SIBO.

If the underlying cause for your specific case of SIBO was low stomach
acid then bitter herbs can be used to increase stomach acid production
and digestive flow.

If poor gut motility was the underlying cause then prokinetic herbs such
as ginger can be used.

The herbal formulation is very much dictated on each individual person’s

needs.

PROBIOTICS IN SIBO
Here we are venturing into controversial territory.

Are probiotics helpful when treating SIBO?

It very much comes down, once again, to the type of SIBO and the type of
probiotic.

Thanks to all the hard work that Dr. Jason Hawrelak has done in educating
naturopaths on probiotics it seems clear that probiotic strains come are key
here (61).

Some probiotics may be helpful in reducing methane dominant SIBO

(Lactobacillus reuteri stands out here) and some may help to speed gut
transit time.

Working with a healthcare provider that really and truly understands

probiotics and their appropriate use is important here. They may be hard to
find and in high demand but don’t let that stop you from looking!
One study assessed a probiotic in the treatment of SIBO in patients with
chronic liver disease.

They found that the probiotic group, taking a product called Duolac Gold
resulted in SIBO symptom alleviation in 24% of the treatment group (it
wasn’t clear whether they retested)

The probiotic contained the following strains and was given at a dose of 2
capsules daily for 4 weeks.

 Bifidobacterium bifidum (KCTC 12199BP)

 Bifidobacterium lactis (KCTC 11904BP)
 Bifidobacterium longum (KCTC 12200BP)
 Lactobacillus acidophilus (KCTC 11906BP)
 Lactobacillus rhamnosus (KCTC 12202BP)
 Streptococcus thermophilus (KCTC 11870BP)

Image taken from: Short-term probiotic therapy alleviates small

intestinal bacterial overgrowth, but does not improve intestinal
permeability in chronic liver disease
In another study probiotics were assessed for the treatment of SIBO in a
Chinese group of patients with gastric or colorectal cancer.

They found that taking a certain probiotic called Bifidobacterium triple

viable capsule was effective in treating SIBO in 81% of the probiotic
group.

The major issues with this study includes

1. The diagnostic testing issues to determine SIBO. They used a

glucose breath test and a cutoff of only 12 ppm of hydrogen
increase over baseline. Now it is considered 20 ppm
2. The authors did not describe what probiotics were
Bifidobacterium triple viable capsule product so we don’t know
what type were used!

Just from these two studies it should be clear that probiotics are a possible
treatment option for SIBO. Combining them with herbal antimicrobials
may very well improve their effects.

PREBIOTICS IN SIBO
Again very controversial territory. Prebiotics in SIBO?

The use of prebiotics in SIBO treatment is a hotly debated topic. Many

clinicians would advise against prebiotics when treating SIBO. Afterall,
the low FODMAP diet, which restricts prebiotics, can be helpful for
improving SIBO symptoms.
The real art and science of prebiotic prescribing for SIBO comes down to
determining which specific bacteria are overgrown in the small intestine.
Seeing as we don’t have the technology to determine this educated guesses
can be made. The second crucial part of this is symptom improvement or
worsening by the patient when certain prebiotics are introduced.

Personal note here.

I have found that fructo-oligosaccharides are generally not well tolerated in SIBO
patients. Things like FOS and inulin are best avoided *personal opinion here*
until after the SIBO has been cleared.

Other prebiotics seem to be better tolerated depending on the patient.

One study found that combining a prebiotic, in this case partially
hydrolysed guar gum, with antibiotics significantly improved
eradication rates compared to the antibiotic alone.

The debate goes on between clinicians and researchers that believe that
this is due to the prebiotic feeding up the bacteria so that they were happy
and rapidly dividing (thus more exposed to the antibiotic treatment) and
the other side who believe that this particular prebiotic helped to modulate
and rebalance the small intestinal gut microbiota.

Other than that specific study there are very few papers available looking
at prebiotics and SIBO.

One fascinating paper (which we have covered here) outlined an

interesting case study where a patient, suffering from long term IBS, was
treated successfully with a prebiotic called lactulose.

Lactulose shouldn’t be used in certain SIBO cases, mainly the ones that
have been diagnosed with a lactulose breath test. That makes perfect sense
when you think it through. If a lactulose SIBO breath test has shown that
there are bacteria in the small intestine that can utilise lactulose as a food
source you wouldn’t want to be feeding them up.

ELEMENTAL DIET
Finally the elemental diet is commonly used in difficult to treat SIBO
cases.
The elemental diet is a specifically formulated diet which is absorbed in
the proximal small bowel. Basically the nutrients in this liquid diet are
completely absorbed quickly before they can be used as food by the
bacterial overgrowth.

The success rate of the elemental diet is approximately 80% for a two
week diet. At two weeks if the SIBO breath test is still positive an
additional week of the elemental diet bumps the success rate up to about
85% (66).

Image taken from: A 14-day elemental diet is highly effective in

normalizing the lactulose breath test showing the before (dotted
lines) and after (straight line) of patients on an elemental diet.
THE ISSUES WITH THE ELEMENTAL DIET
1. Cost. The elemental diet can be quite costly. That said, you
are eliminating your shopping bill for the time that you are on
the elemental diet so that needs to be factored in.
2. Palatability. The elemental diet is reported to taste terrible for
some people.
3. Weight loss. It can be difficult to maintain weight on the
elemental diet.

The pros and cons of the elemental diet (67) needs to be weighed up for
each SIBO patient.

WHY DOES MY SIBO KEEP COMING BACK?

SIBO relapse is common. Very common.

It may be the one issue that few clinicians know how to address when
treating SIBO.

For some patients it may be next to impossible to address the relapse issue.

One paper found that SIBO recurrence was upwards of 40% in a 9 month
follow up of successfully treated patients.

Another study found that in patients who had cleared SIBO with
antibiotics it returned in 13% in 3 months, 28% in 6 months and 44% in 9
months (68).

Treating the SIBO overgrowth in the first place is straightforward enough

for most cases. True there are very tough to treat cases but with proper
diagnosis (is it hydrogen dominant SIBO, methane dominant SIBO or
both?) and targeted therapy most SIBO cases can be successfully cleared.

Preventing a relapse is another thing.

Getting to the bottom of why you had SIBO in the first place is key to
working towards prevention of relapse.
PREVENTING SIBO RECURRENCE
Maintaining remission in treated SIBO patients means addressing the
original issue that led to the overgrowth in the first place.

Motility agents may be required long term to keep the flow through the
intestines and prevent stasis, stagnation and an overgrowth of bacteria.

Conventional approaches rely on prokinetic drugs. Alternative

practitioners (naturopaths, herbalists) rely on prokinetic herbs.

One approach is to limit your food intake to windows of the day. The
fasted state encourages the migrating motor complex in the intestinal tract
to sweep through and keep things moving along. That is akin to the
grumbling of your stomach when you are hungry.

In the table below we can see the approach taken by modern medicine to
treat the underlying cause of SIBO.

Image taken from: How to Test and Treat Small Intestinal Bacterial
Overgrowth: an Evidence-Based Approach
WORK WITH A SIBO SAVVY GUT CLINICIAN
As you have now learned small intestinal bacterial overgrowth can be
more complicated than simply treating the bacterial overgrowth in the
small bowel. There are high rates of relapse and underlying causes that are
often not addressed.

If you suspect you have SIBO and would like to organise a consultation
with us here at Byron Herbalist then head over to our appointments page to
organise a suitable time.

We use targeted herbal medicine, prebiotics, probiotics and microbiome

restoration techniques to address the bacterial overgrowth and ensure that
the underlying causes for your SIBO have not been neglected.

We covered a lot there!

Now over to you.

Currently there is no test to assess for fungal overgrowths in the small bowel. I often assume that there is some
form of fungal overgrowth in SIBO patients and include antifungal herbs in the mix, especially when there is a
history of antibiotics.

In regards to the parasite testing. I am quite confident in the PCR based technology to assess for parasites in the
large bowel. Here in Australia they are standard of care with most doctors and are covered by our medicare
(free). They will assess for protozoan parasites and significant bacterial infections. They don’t screen for fungal
overgrowths, bacterial overgrowths or worm infections (helminths). Here you would need a more
comprehensive, DNA based lab.

The GI MAP is the most comprehensive one I am familiar with here – https://www.byronherbalist.com.au/gut-
health/australia-gi-map-gut-testing/
Unfortunately this won’t give you a full picture of the bacterial makeup of the large bowel, and it won’t assess
for SIBO either, both of which are possible issues in many many patients. That is why I recommend working
with a skilled gut health clinician. In the long run it saves money and gets people better faster.

Todd