Bloating Beyond Dysbiosis: If it's not SIBO, SIFO or IMO, What Is It?

Welcome to The Perfect Stool: Understanding and Healing the Gut Microbiome. This is your host, Lindsey Parsons, and today I'm going to be talking about reasons for bloating beyond SIBO, SIFO, and EMO. But before I do that, if you want to get transcripts of the podcast, you can subscribe to my newsletter at HighDesertHealthCoaching.com. And if you haven't yet followed or subscribed to the show, be sure to do so. And if you'd like my free ebooklet, Finding Your Root Cause Through Stool and Organic Acids Testing, you can get that by signing up for my newsletter at HighDesertHealthCoaching.com. And if you haven't yet done my quiz on which stool test would help you get to your root cause, you can find a link in the show notes and take that. Now on to the show. My fellow bloating friends, if there's anyone who can relate to bloating, it is most certainly me. Although I haven't had SIBO my whole life, I have certainly dealt with bloating at least since my teens, when anytime I ate too much I'd have a food baby and feel miserable. But once I got SIBO, it was on a whole other level, with the bloating happening before I even got up from the table with almost any meal, and often continuing through to the morning, waking up bloated. Some clients don't really know if they're bloated, and I usually say, then you probably are not, because it's a just a distinct feeling that's not like extra fat on your belly that's soft and jiggly. It's like distension that's tight and sort of hard and feels like you like you have a balloon inside you. At my worst, I can easily pass for 6 months pregnant after eating. So I'll start with the most obvious causes of bloating just to get them out of the way, but this podcast is specifically about why you may be bloated if you don't have one of these functional causes falling under the label of dysbiosis, or the wrong bugs in your gut. If you've already done stool and organic acids testing and nothing came up, you can jump ahead 30 seconds or so a few times to skip over this part. So the most common cause of bloating is SIBO, or small intestine bacterial overgrowth, which is usually caused by stagnation in the small intestine due to a variety of causes, the principal being an episode of food poisoning in the past. And by that I mean it could have happened years before, as well as medications like PPIs, steroids, and antibiotics. Any stagnation in the small intestine leads to a buildup of excess bacteria and possibly yeast and general dysbiosis, or an overgrowth of the wrong types of bacteria. If you have mostly hydrogen-producing bacteria, you'll usually also have occasional diarrhea, usually softer, loose, and messy stool, but sometimes you'll have normal stool depending on what you've eaten. If your overgrowth is of the hydrogen sulfide-producing bacteria, then you'll likely also have gas that smells like sulfur or rotten eggs and excessive belching and diarrhea or loose stool. I just did a whole episode on that, number 114, from early February 2024. Other possible signs of hydrogen sulfide SIBO include intolerance to sulfur-containing foods and salt supplements, weight loss, brain fog, exercise or stress intolerance, burning bladder syndrome, elevated heart rate, insomnia, and low blood, blood pressure after eating. And then if you're constipated and bloated, you may have IMO or intestinal methanogen overgrowth, which used to be known as SIBO-C or SIBO with constipation, which is an overgrowth of archaea, which are like bacteria but of a whole different domain. Usually the particular organism is called Methanobrevibacter smithii, which produce methane gas by metabolizing hydrogen produced by bacteria fermenting carbohydrates. You'll often have bloating gas with a metallic smell when this happens, although often gas gets trapped with bad constipation. So my emo clients will often say they don't have much gas or gas that smells, or only occasionally have gas. Or if you have negative SIBO breath tests and are bloated, you can have an overgrowth of Candida or small intestine fungal overgrowth, or SIFO. Candida is a normal resident of your gut but can overgrow and even become systemic in severe cases, which can form hyphae or tail-like structures that go out between cells lining the small intestine. This can be caused by a diet high in sugar and starches, post-antibiotics, from estrogen dominance or supplementation through the pill or hormone replacement therapy, or from low secretory IgA or stomach acid, which may result from chronic stress. Usually bloating after eating sweets or carbs, food sensitivities, Skin issues and brain fog are signs of invasive candidiasis. And finally, you can have parasites, which usually come with diarrhea or loose stool, possibly anal itching, stomach pain or tenderness, nausea or vomiting, fatigue, abdominal pain or cramping, teeth grinding at night, or you may pass strange things in your stool like worms or flukes. Suspect that if you've recently come back from a trip to a developing country where they tell you not to drink the water and you didn't realize that meant not to eat salads or washed fruit or brushing your teeth with the water. I've done podcasts on all these things, so I'll link to some possible episodes to listen to in the show notes, or you can scan back over old titles. Okay, so onto the meat of the episode, other reasons for bloating. Let's start with low stomach acid, which is the beginning of the digestive process. If you have bloating issues when eating meat or eggs, or feel like meat just sits in your stomach and nothing moves, it may be low stomach acid or hypochlorhydria, which incidentally can lead to SIBO because sitting food will breed bacteria. Other signs that hypochlorhydria may be at play are bad breath, no hunger in the mornings, feeling tired or nauseous after eating meat, indigestion, rotten egg smelling gas, acid reflux, hair loss in women, anemia, which can be from low iron or B12 levels, or hunger after eating. I actually experienced this a lot. I would feel what felt like hunger, but sort of in the upper middle of my chest, like midway up my esophagus, which was really a feeling of reflux, not hunger. Also, weak peeling or cracked fingernails, stinky sweat, acne, and either constipation or diarrhea can be signs. There are also signs in your standard blood tests called the CMP, or comprehensive metabolic panel, and CBC, or complete blood count, that you may have low stomach acid. So if you see one or more of these signs, you may wanna test yourself. Chloride levels under 100, high or low serum protein or serum globulin levels, low phosphorus levels, especially with a vitamin D deficiency, high BUN levels of 20 or more, abnormal MCV, MCH, MCHC, or below-normal hematocrit or hemoglobin indicative of iron deficiency. You can test yourself with a trial of betaine HCl. Take 1 capsule of betaine HCl, and most of them are between 550 and 650 milligrams, halfway through a meal with 6 ounces of animal protein. If you feel burning or warmth in your chest, you probably have adequate stomach acid. You can always neutralize the acid with Tums or a little baking soda in water if the burning is uncomfortable. But you should check a few— at a few different meals just to be sure. If you don't, you can add another pill every couple days until you hit a max of 5 per meal with animal protein. Another way to check is with the baking soda test, although I have no verification that this is actually a legitimate test. But it's done by drinking a mixture of 1/4 teaspoon of baking soda with 4 ounces of cold water first thing in the morning before drinking or eating anything. Time how long it takes you to burp after drinking it. If it takes longer than 5 minutes, your body likely produces insufficient stomach acid. If you have immediate burping or you burp several times, it may be due to too much stomach acid. But just be careful you're not having small burps from taking in air when you drink. Some possible causes of low stomach acid include chronic stress, an overgrowth of the bacteria H. pylori, aging, zinc deficiency, food sensitivities, stomach cancer, autoimmune gastritis, and allergy medications, specifically H2 blockers, which include famotidine, like Pepcid AC, Pepcid Oral, Zantac 360, cimetidine, which is Tagamet and Tagamet HB, nizididine capsules, which could be Axid AR or Axid, and ranitidine, which is Zantac, although that's been removed from the US market due to safety concerns. Another common reason for bloating is poor digestive enzyme production, which would be more suspect if you have issues eating vegetables, especially cruciferous ones, fruit, and legumes. Signs beyond bloating that this may be the case are diarrhea or constipation, abdominal cramping, gas, or poor tolerance to high-fiber foods or high FODMAP foods. One possible way to test it is by eating a bowl of plain steamed broccoli and seeing how you do. You could also try digestive enzymes with the meal to see if you feel better. While many people with gut health issues have low digestive enzymes, there's a more serious condition called exocrine pancreatic insufficiency, or EPI, that a doctor may diagnose you with. It can be diagnosed through a fecal elastase 1, or FE1, test, which is also included in the stool tests I use, like the GI-MAP and my new favorite, the US Biotech Advanced GI Stool Test, which seems to combine the best of the GI-MAP and the GI-FX. And is in between the cost of those two. I've just added it to my Rupa Health lab shop if you're interested in looking at a sample report. Keep in mind, however, that low stomach acid is often at the root of low digestive enzyme production because it's the release of the stomach acid that triggers the release of enzymes from the pancreas. But causes of full-blown EPI include chronic pancreatitis, pancreatic cancer, cystic fibrosis, non-alcoholic fatty pancreas disease, surgeries including pancreatic and gastric resections, short bowel syndrome, Crohn's disease, diabetes, uh, obstruction of the pancreatic duct, celiac disease, or Zollinger-Ellison syndrome. But SIBO and dysbiosis can also cause insufficient pancreatic enzymes. So that's usually an area I support with digestive enzymes when helping people with SIBO and related gut issues. My favorites are the Pure Encapsulations Digestive Enzymes Ultra, which are nice and small and come in big bottles at a reasonable price. And there's also ones with betaine HCL included you can choose, or Enzymaticas Critical Digestion, which specifically have a lot of lactose and gluten digesting enzymes. And then there's a formulation called FODMATE, which is specifically designed for people with FODMAP issues, which are fermentable fibers found in grains and vegetables, and which would be especially relevant to someone with SIBO. And note that because food is not digested well with low pancreatic enzymes or EPI, it can also lead to SIBO. Another reason for bloating is poor bile flow. Since bile's role is to emulsify fat to prepare it for digestion, you'll most likely experience this bloating and possibly stomach pain and nausea after fatty foods like pork belly—my personal downfall—and other fatty cuts of meat, cheese, high-fat meals, and deep-fried foods. You may also have light-colored stool, greasy stool that may be foul-smelling or float, diarrhea or erratic bowel movements, weight loss, stomach cramps, itchiness, or jaundice, which is yellowed skin or eyes. Of course, if you've had your gallbladder removed and aren't supplementing with ox bile or bitters, you may need to address that. While the liver produces bile, the gallbladder stores it so it can send out a bolus when fat is detected in your duodenum. Low bile flow can also result from low stomach acid, which prompts the release of bile. Decreased secretion of bile can also come from certain drugs, sex hormones, inherited defects, and ductal diseases like primary biliary cirrhosis and primary sclerosing cholangitis. There's a long list of drugs that can cause liver damage and impact bile flow, including estrogens, NSAIDs, antibiotics, statins, metformins, antifungals, and many more. I'll link to an article on drug-induced cholestasis that lists them in a chart. And then bile ducts are most commonly blocked by gallstones, but could also be from cancers of the bile duct or pancreas. But usually you have severe abdominal pain either in the center or on the right side under your ribs, possibly spreading to your side or shoulder blade and lasting from 1 to 5 hours if that's the case. So the bloating won't be your most obvious symptom. If you're on a ketogenic diet and get this kind of pain, that's a pretty good sign that it's not for you. Some people's bodies just can't handle a high-fat diet. Bitter herbs like arugula, dandelion, and radicchio, lime or lemon water and rind, beets, artichokes, coffee, and dandelion tea are great for promoting bile flow. Then supplements like gentian or bitters can promote bile flow, and ox bile supplements can supplement your bile, or you can try a betaine HCL supplement that contains gentian like the Doctor's Best one, which I'll link to in the show notes. Note that low bile flow can also lead to SIBO. Food sensitivities and intolerances are another reason for bloating. While it's not specifically a food sensitivity but rather an autoimmune disease, I'll mention that celiac disease that's undiagnosed and untreated through the avoidance of gluten can cause bloating, as can gluten sensitivity, dairy sensitivity, lactose intolerance, and other food sensitivities. And it could take several days for other symptoms to manifest. So sometimes it's challenging figuring out what you're sensitive to, but my general rule is it's usually what you're eating the most of because you won't develop a sensitivity without eating something frequently. Some of the most common food sensitivities are to eggs, soy, sugar, corn, and nuts. Personally, I know for sure I'm lactose intolerant. I used to just feel unwell after eating ice cream. My stomach would hurt and I'd just have a miserable sick feeling. But it took a while to separate that feeling from eating too much, which invariably I'd done when eating ice cream, as it was usually a dessert some insufficient amount of time after a meal. But once I targeted it through taking lactose digestant tablets or lactase enzymes and avoiding dairy, it became really obvious when I had dairy, as I would have painful liquid voluminous stool that burned as it came out and often had me having hot flashes and collapsing on the bathroom rug in pain. See, if you are lactose intolerant and still eating dairy, you'll still have some gut bugs that will help break it down. But when you give it up altogether and those gut bugs decrease or disappear, then eating it is much worse. But when I stopped eating dairy, I also saw most of my issues with acid reflux disappear. My mucus production decreased significantly and a good amount of bloating decreased. The easiest way to test for lactose intolerance is just by taking cheap lactose digestion pills when you're eating dairy. You can get those at the drugstore, or you can take nicer ones like Enzymatica's Lacto that also has enzymes that target casein. A potentially problematic protein in dairy, and see if it changes your symptoms. The highest lactose foods are milk, ice cream, and soft cheeses. Hard cheeses, butter, yogurt, and kefir have much less, and ghee is lactose-free. When I have clients dealing with diarrhea or loose stool, I always tell them about tributyrin, which is the best absorbed form of butyrate, which is normally made by bacteria fermenting fiber in your colon. Supplemental tributyrin can help slow your motility down and feed the cells lining your colon, firming up stool, and helping create an oxygen-free environment in the colon, which helps the butyrate-producing bacteria to survive and multiply. Those bacteria are often wiped out after taking antibiotics, which is why tributyrin is a great accompaniment and follow-up supplement if you have to take antibiotics. My new supplement, Tributyrin Max, has 750 milligrams of tributyrin, which is the highest dose currently available in a capsule. You can find it at tributyrinmax.com That's T-R-I-B-U-T-Y-R-I-N-M-A-X.com and use code INTRO15 for 15% off your first order. And I'm sure you recall that I've mentioned that I don't really put much weight into IgG food sensitivity testing because the things that tend to come up are basically everything you've been eating if you have a leaky gut, which dysbiosis can cause. However, there is one test I do think is valid, which is the mediator release blood test from Oxford Biomedical Technologies, which tests for all 7 types of food sensitivities at the cell level. One of my recent guests mentioned it and I thought I couldn't get access to it, but then I was really excited to find out that I was able to establish an account and get training on it. So if you're interested in that testing, you can contact me to get it at Lindsey@highdeserthealthcoaching.com. They also create a LEAP food plan for eating the foods that will help you heal. That's very successful in helping people with digestive issues that aren't otherwise identified. There are 3 other food-related issues that may be causing bloating, fructose malabsorption, and intolerances to inulin and sorbitol. For fructose, some people can only deal with a small amount of it, and then any unabsorbed leftovers are fermented by microbes, creating bloating. You may also see irregular motility, abdominal pain, gas, or nausea. There are only small amounts of fructose in fruit, so usually this isn't where you'd have an issue. A medium apple has about 10 grams of fructose, but a Coke has around 40 grams of high fructose corn syrup in a 12-ounce can. Foods that impact you if this is your issue would be sodas, dried fruit, added high fructose corn syrup, foods with added sugar, sauces like ketchup, pasta sauce, honey, fruit juices, and desserts. An easy test would just be drinking a can of soda alone. You can also use the FoodMarble to test if you get their food intolerances kit. You may have heard of the FoodMarble. It's an at-home SIBO testing device that you can use multiple times and test and retest yourself for SIBO and food intolerances. Some of the top SIBO doctors seem to be getting behind it, and I have an account. So if you want to get one with the SIBO test kit and get a discount, you can find a link in the show notes to take a look and then email me at Lindsey Parsons at High Desert Health Coaching dot com so I can submit a request for you. Its price is about the same as getting one commercial SIBO test, so I think it's a great idea if you're starting from ground zero or have recurrent SIBO or EMO issues so you can test and retest before and after treatment. In the Food Marble webinar training, they said that 84% of those with IBS find that food triggers their symptoms. While most of IBS is in fact SIBO or EMO, something like 60% for the remainder folks is not. So finding out the specific foods you react to is important. You can test your reaction to individual foods using it, as well as getting a kit to test for food intolerances. And for most people, while a low FODMAP diet may be great for reducing your symptoms, you may not in fact need to avoid all high FODMAP foods, as usually it's just one or two types of FODMAPs that are causing issues, and FoodMarble could help you identify those. If you get the device, you can get a kit to test all four food intolerances. That's lactose, fructose, sorbitol, and inulin. And interestingly, what they have found in their test results is that lactose, which most people think is the cause of their issues, has the lowest rate of intolerance at 36%, whereas sorbitol, which is in fruit and is used as a sweetener in various things, has the highest rate at 74%. Symptoms of sorbitol intolerance are bloating, gas, stomach pain, diarrhea, and nausea. Fruits with the most sorbitol are the fresh stone fruit like peaches, cherries, and plums, and dried fruit. But there's also sorbitol in apples and pears. It's also found in juices and jams made from those fruit, most chewing gum, light or low-calorie packaged products, and processed meats. Of course, it's easy enough to look at a label to find sorbitol in packaged products, but also look for the word sorbitan. It's also used in bread baking as a humectant and will be listed as E420 on the label if you get a label. But if bread's sold freely from bakery, sorbitol doesn't have to be declared. Of course, even if you're intolerant, you will probably still be able to deal with a small amount of sorbitol. And the final food you can test for intolerance with the FoodMarble is inulin, which is found in garlic, onions, wheat, bananas, leeks, artichokes, and asparagus, among other foods. In the FoodMarble testing, inulin has the second highest positivity rate in every country in their database except Spain, where it has the third highest positivity rate. You may not suspect inulin, however, because it ferments more slowly, so you may not have digestive symptoms until later in the day or even the next day. And many foods high in gluten like bread also have inulin. So you may have issues with bread, but for a different reason than gluten. I'll link to a blog from Food Marble on inulin intolerance that may be helpful. Of course, doing an elimination diet is also a great way to find out if you have common food sensitivities. To do that, for 3 weeks, take gluten, dairy, refined sugar, soy, corn, eggs, and if you really wanna be thorough, all grains, vegetable oils, shellfish, tree nuts, legumes, and nightshades, which are tomatoes, eggplants, Peppers and potatoes and their derivative spices out of your diet. Then add them back one eliminated group at a time for 2 to 3 days to check for a reaction. If you react, stop eating that and move to another one. If you don't, keep it in and add another. The hardest part of an elimination is after the 3-week deprivation to not just add everything back in at one time because you don't seem that improved. But often you can't tell how badly you react to something unless you had time off of it, and you can't quite recall how bad you were feeling before you started. So keeping a symptom diary with how often and how severe your symptoms were is also helpful, but an elimination diet will be less useful for more uncommon food sensitivities. So what else can cause bloating? There's several additional other things that can cause bloating. First, constipation that isn't from emo, but rather just from a poor diet with too little fiber, some physical issue impeding motility, lack of magnesium, insufficient water intake, insufficient movement, ileocecal valve dysfunction, vagus nerve dysfunction, or hypothyroidism. That backup of stool can block gas from exiting and cause bloating by itself. So if your intestines are full of stool, that may be your issue. Getting the bowels moving with vitamin C— and you can always start out with a vitamin C cleanse to clean things out entirely and determine your best dose of C. See the link to the PERC ascorbate cleanse protocol in the show notes. And magnesium citrate. I like the Natural Vitality Calm powder, starting at 1/2 teaspoon and increasing by 1/2 teaspoon every 2 days before bed in water until things get moving. It's magnesium carbonate but turns into citrate when you put it in water. Other forms of magnesium that help with motility are magnesium oxide, sulfate, and chloride. For vagus nerve dysfunction, you can check if that's an issue by looking at your uvula in the mirror and saying ah, ah, ah and seeing if it pulls to one side or another or goes straight up and down. If it pulls to one side, that could be a vagus nerve issue. You should check out the book Accessing the Healing Power of the Vagus Nerve by Stanley Rosenberg for exercises to fix it. Regarding ileocecal valve dysfunction, it's the valve that goes between the ileum, the last part of the small intestine, and the cecum, the first part of the large intestine, and it can get stuck. You usually have constipation, although diarrhea is also possible. And pain in your pelvic region on the right side if that's the case. But you could also have flu symptoms, nausea, dizziness, fainting, lower back pain, heart pain, tinnitus, bad breath, a pale face, headaches, or dark circles under your eyes. If you think this may be your issue, there's a maneuver you can do yourself to unblock this valve, which I'll link to in the show notes. Another possible cause of bloating and constipation, as mentioned above, is hypothyroidism. So if you have other symptoms like hair loss, dry skin, weight gain, feeling cold all the time, and tiredness, you should get your thyroid checked to see if that may be at the root of it. Ideally, that would include a TSH, free T3, free T4, reverse T3, and both thyroid antibodies. That's the thyroglobulin and thyroid peroxidase antibodies to check for Hashimoto's thyroiditis if you're symptomatic. Another reason you could have bloating, and this is more if it's intermittent, not constant, is poor meal hygiene. This means eating while under stress and not in rest and digest mode, but while, while working, multitasking, watching TV or scrolling social media, eating too much in a meal, eating too quickly, or not leaving enough time to digest. And let your stomach empty between meals. Ideally, you'll spend at least 20 minutes eating a meal, chew each bite 25 times, pause between bites, limit water to small sips or drink most of your water away from meals, and just focus on eating. One trick is if you tend to arrive at the table full of stress, try taking 3 breaths before starting to eat: in for 5, hold for 5, out for 7. This will switch your body into parasympathetic mode and maximize your digestive processes. Then you should leave at least 3, but more ideally 4 to 6 hours between meals and stop eating after dinner and at least 2 hours before bedtime. And of course, there are physical reasons you may be bloated. So while most people I talk to get frustrated when they see a gastroenterologist because they may not be well versed on the functional reasons for bloating or gastrointestinal issues, they're best suited to diagnose physical reasons for bloating. Of course, some you'd be aware of, but others would require an endoscopy or colonoscopy to diagnose. So physical reasons include prior gastroesophageal surgery such as fundoplication or bariatric procedures, gastric outlet obstruction, gastroparesis, ascites, which is flu— fluid buildup in your abdomen, usually as a result of cirrhosis of the liver, a gastrointestinal or gynecologic malignancy, small intestine diverticulosis, chronic intestinal pseudo-obstruction. Which is a rare disorder in which intestinal nerve or muscle problems prevent food, fluid, and air from moving through the stomach and intestines, which appears to be primarily an issue discovered in childhood, or an abnormal viscerosomatic reflex, which controls gas clearance through the contraction and relaxation of the diaphragm and the muscles in your abdominal walls. I always recommend people start with conventional doctors when they have gut health issues like bloating, and once they've exhausted their arsenal, then you can come and see me or another functional medicine practitioner about what we call functional digestive issues. Issues. But if you just need some immediate relief from bloating, you can take 2 to 3 capsules of activated charcoal in between meals. Wait at least an hour after eating or other supplements and another hour before eating again to relieve bloating. But note that activated charcoal can suck up nutrients, so it's not something you want to take in the long term to deal with bloating, and it can also cause constipation. So better to find the root cause. So if you are struggling with bloating or gas, excessive burping, nausea, constipation, diarrhea, soft stool, acid reflux, IBS, IBD, SIBO, Candida growth, fatigue, or migraines, or other symptoms of bodily dysfunction and wanna get to the bottom of it, that's what I help my clients with. You're welcome to set up a free 30-minute breakthrough session if you think you might like to sign up for a 3 or 5 session package or a 12-week weight loss program, or I offer individual consultations as well. You can find links for those in the show notes. If you'd like to support the show, you can make a regular donation on Patreon or buy vetted high-quality supplements from my full script dispensary, or links in the show notes to iHerb, Bulk Supplements, or Amazon, or give me a 5-star review on Apple Podcasts. To reach out to me in other ways, I have a gut healing Facebook group for asking questions. I'm on Instagram, Pinterest, TikTok, and X. Links for all those are in the show notes or on my website, HighDesertHealthCoaching.com. Thanks for listening, and here's wishing you all the perfect stool.