Recurrent SIBO: Symptoms, Causes, Testing and Treatment

Welcome to The Perfect Stool: Understanding and Healing the Gut Microbiome. Today I'm going to be talking about recurrent SIBO, or small intestine bacterial overgrowth, its symptoms, testing, prevention, and treatments. But before I dig in, if you haven't yet followed or subscribed to the show, be sure to do so. If you want to get transcripts of the podcast, pop over to my website, HighDesertHealthCoaching.com. And sign up for my newsletter. You'll also get my free ebooklet, Finding Your Root Cause Through Stool and Organic Acids Testing, when you sign up. 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. There are somewhere between 1 and 10 trillion bacteria in our intestinal tract. Most of them can be found in the colon or large intestine. The bacteria take care of the final breakdown of your food into a form where it can be absorbed into the body as nutrients or discarded as waste. Bacteria play a critical role in maintaining your health throughout your body. The small intestine normally contains far less bacteria compared to the large intestine. SIBO, or small intestine bacterial overgrowth, which is often referred to as IBS in reality, occurs when the bacteria in your small intestine become unbalanced and overgrow. And SIBO can damage the intestinal lining, leading to leaky gut, which can cause further health complications. For example, an imbalance in bacteria could lead to nutrient malabsorption, which causes you to get sick from a lack of vital nutrients, or histamine reactions, which surface as food sensitivities. So left untreated, SIBO has the potential to snowball into worse health conditions. Typical SIBO symptoms include bloating, gas, diarrhea, soft stool, constipation, or a mix of diarrhea and constipation. Burping, abdominal pain or cramps, food intolerances, B12 and iron deficiencies, fat malabsorption, flatulence, and if left untreated long enough, autoimmune diseases, skin disorders, or systemic diseases like fibromyalgia or chronic fatigue syndrome. SIBO is broken into 3 types: SIBO-D, or diarrhea, which is not exclusively diarrhea, can just be soft, messy stool which may or may not be very frequent. That's caused either by excess hydrogen or hydrogen sulfide-producing bacteria. Then SIBO-C for constipation, also known as IMO or intestinal methanogen overgrowth, which is not necessarily in the small intestine but can be throughout and may be more a question of dysbiosis or an imbalance of bacteria and methanogens. Methanogens are archaea, which is a different kingdom of microorganisms, rather than an overgrowth of anything per se. Methanobrevibacter smithii is the primary, most well-known methanogen, meaning methane producer. Hence methane smell may come along with that, which is sort of more of a metallic smell. SIBO-M is the third type, or mixed, which may have some constipation and diarrhea, sometimes because you break through diarrhea when you're constipated, or because as your diet, eating habits, or underlying root causes change, things may shift back and forth in your intestines. So about 70 to 80% of what's called irritable bowel syndrome, which is basically just a diagnosis of exclusion, is caused by SIBO. So I think of IBS and SIBO almost synonymously. There's a range of possible root causes of SIBO or IBS, some of which can lead to recurrent SIBO if not addressed. Some relate to impaired digestion, such as low stomach acid or hypochlorhydria, which is important for breaking proteins into amino acids, or a lack of pancreatic or brush border enzymes, which can come from celiac disease. Enzymes help digest all types of food, so undigested food can serve as a fuel source for bacterial overgrowth. Other potential causes are low secretory IgA, which is your gut immune defense system, which can follow from chronic stress, or poor bile flow, which is essential for digesting fats. Of course, if you've had your gallbladder out, which stores the bile produced by your liver, then you can assume you have insufficient bile. Medications such as opiates, narcotics, antidepressants, proton pump inhibitors, cholesteramine, antibiotics, and antispasmodics can also cause SIBO or IBS-like symptoms. Then there are physical issues like Ehlers-Danlos syndrome, adhesions from abdominal surgery, endometriosis, and ileocecal valve dysfunction that can cause SIBO. And there are environmental causes like mold toxicity and other health conditions like diabetes, prediabetes, hypothyroidism, and traumatic brain injuries that can be at the root of SIBO symptoms. Then what I suspect is the most common cause, an autoimmune dysfunction caused by an episode of food poisoning that impacts the migrating motor complex, is the final cause and the one that will definitely cause recurrent SIBO. This is what's called post-infectious IBS and is the reason I personally have recurrent SIBO. You can get tested for SIBO either using a breath test, and there's a number of different hydrogen or methane breath tests out there for SIBO. One type uses lactulose, which gets further down in the small intestine, and one uses glucose, which is higher up and apparently is the more accurate type according to the current research. Or there's one type of test called the Triosmart, which tests for all three gases, including hydrogen, methane, and hydrogen sulfide, and that's the only one that it has the hydrogen sulfide in it as well. Stool tests like the GI-MAP or GI-FX can also point to the presence of SIBO in conjunction with symptoms when you see many elevated opportunistic bacterial markers or even elevated good bacteria markers. And you can also see whether certain bacteria associated with different types of SIBO are present or elevated, such as Desulphybriopyger, Bilophila wedsworthii, or Fusobacteria for hydrogen sulfide SIBO, or Methanobrevibacter smithii for IMO or intestinal methanogen overgrowth. So the first round treatments for SIBO are either herbal antimicrobials or Rifaximin, which is the generic name of the antibiotic Xifaxan, which is a very expensive antibiotic that only impacts the gastrointestinal tract. And for people with methane dominant SIBO, the antibiotic Neomycin is often prescribed as well. I ended up taking a round of Rifaximin, which was about 2 weeks long at 3 pills a day, after I didn't feel that herbal antimicrobials had done the trick for me. This was years ago, mind you, and I have since taken different herbal antimicrobials that have worked better for me. The main drawback to Rifaximin is that it only kills bacteria, and many people I see have an overgrowth of Candida, which is a yeast that's a normal part of our digestive system, as well as from history of antibiotic use or from the same root causes that cause SIBO. And while the herbals kill both yeast and bacteria, Rifaximin only kills bacteria, which then offers yeast an opportunity to overgrow or overgrow even further. I should also mention elemental and semi-elemental diets. When all else fails, this is another route for dealing with SIBO that has shown good success. These are liquid diets of pre-digested nutrients, which seem to work equally well, with the semi-elemental being a bit more palatable than the elemental diet. One study in 2004 of a prescription elemental diet on 93 patients showed a SIBO lactulose breath test normalizing after 2 weeks for 80% of subjects, for 85% by 3 weeks, with a 65% improvement of IBS symptoms at 2 weeks. But since this does require you to eat no real food for 2 to 3 weeks, I don't think of it as a first-line option, as that doesn't sound appealing to most people. There's also good evidence to support the use of probiotics in SIBO, but since this is a little bit controversial and debated, I'm not gonna go too far into that topic right now. If you're going the route of antimicrobials, in conjunction with taking them, there are other things you can do to ensure success and prevent recurrence. First, making sure that you're observing good meal hygiene, so trying to eat in a relaxed parasympathetic or rest and digest state. Not while stressed out, working at the computer, on the run, et cetera. This will help your body produce the stomach acid and enzymes it needs to digest properly. A minute of 5-5-7 breaths, that's 5 in, hold for 5, 7 out, can help bring you into this state prior to eating if you sense you're in a stress state. And then maintaining this parasympathetic state while digesting, which can range from 30 minutes to 4 hours depending on the size of your meal. And then chewing each bite very well, like 25 times well. And they say not drinking too much liquid with meals, but that's something I personally struggle with, but you can certainly experiment with that and see if it's helpful. Second, not snacking between meals and spacing your meals out to every 4 to 6 hours is very important. The migrating motor complex stimulates peristalsis, which is how your body moves food and bacteria through your digestive system. And when you're in a fasted state, specifically when there's no more food in the duodenum or the first section of the small intestine, It secretes motilin, which starts off the peristaltic wave, emptying out your intestines. This helps clean out bacteria and move them towards the large intestine. This generally happens around 90 minutes after you're eating, but up to 2 to 3 hours after eating, and lasts around 2 hours. So if you've heard your stomach gurgling when you're hungry, what you're hearing is the migrating motor complex, which is a good thing. If you never hear stomach gurgles, it's because you're either eating too frequently or you've had some disruption to your migrating motor complex. Third, trying to have a solid overnight fast of 12, or even better, 13 hours will help prevent SIBO recurrence, or even longer if you're trying to lose weight, more in the 14 to 16 hour range. This will give your body a good chance to clean out the intestines. And I should mention that with particular types of SIBO, a diet change may be in order. So methane dominant SIBO, or SIBO-C, or EMO, tends to occur more in vegetarians and vegans as the archaea that are dominant in this condition, like Methanobrevibacter smithii, feed on carbohydrates. And protein sources in vegetarians and vegans like tofu, beans, lentils, etc., are pretty much all high in carbohydrates. Moving towards a more animal-based diet with higher fats and low in fermentable carbohydrates, like a low fermentation diet or low FODMAP diet, is in order. It is possible to do a vegetarian low FODMAP diet, but in my experience, it's people on vegan diets who have the most stubborn cases of emo. SIBO-D, which is characterized by an excess of hydrogen-producing bacteria, typically responds well to a low FODMAP diet. Or if you wanna get really fancy, a biphasic diet. And then hydrogen sulfide SIBO, which is characterized by an overgrowth of hydrogen sulfide-producing bacteria, also presents as diarrhea, but with the added benefit of it smelling like sulfur and often accompanied by visceral sensitivity, which is a lower threshold for pain in your internal organs and excessive flatulence. This is more likely to occur in someone who is on a ketogenic or primarily animal-based diet. So moving more towards a plant-based, low-fat Mediterranean diet with no dairy, but avoiding sulfur-containing vegetables like garlic, leeks, onions, scallions, and shallots, and and cruciferous vegetables if they bother you is recommended in this case. And sometimes, of course, there's overlap because methanogens eat hydrogen and hydrogen sulfide producers eat hydrogen. So killing off all types of bacteria and archaea and their food source, that is the hydrogen-producing bacteria, at once may be necessary to quell the overgrowth. Note that diet alone will not likely get rid of your SIBO, and all of these diets will result in nutritional deficiencies if followed in the long term. So doing some other primary treatment while using diet as an adjunct for symptom relief is generally how I view SIBO diets. If you have a history of food poisoning, meaning you've ever had unexplained diarrhea, the stomach flu, Montezuma's Revenge, or the like, and you're dealing with ongoing bloating or diarrhea or soft stool, you may wanna check if your SIBO is autoimmune. And mind you, like I said, if you have persistent soft, messy stool, this is also abnormal. It doesn't have to be full-on diarrhea. Autoimmune SIBO almost always tends towards the diarrhea type rather than the constipation type. And it starts because your body starts attacking its own protein, vinculin, that helps with the migrating motor complex because it resembles the toxin produced by the offending bacteria, which is called CDTB or cytolethal distending toxin B. So if you've succeeded in fixing your problem at least once using antimicrobials, prescription or herbal, and it's come back, then it may be time to determine whether your underlying cause may be autoimmune. Now, if you're constipated, you should also double-check that your constipation is not from H. pylori. Which is a bacteria that can cause ulcers and stomach cancer if you have the virulence factors for that, because it can also cause bloating and constipation. I like using the H. pylori profile from Diagnostic Solutions as a simple H. pylori test, although the full GI Map, which it comes from, is a more thorough test that includes the H. pylori profile and the virulence factors. And don't assume that you don't have H. pylori because your doctor tested you on an endoscopy. They miss it all the time. So to check for autoimmune SIBO or IBS, there's a test called the IBS Smart Test that will tell you. It's $199 and you can order it yourself online from the US, and they even show some international distribution of it now as well on their website, but that may require a doctor's prescription. It will show if your antibodies to vinculin and CDTB are elevated. If vinculin is elevated, you'll probably have a lifetime battle with SIBO like I do. Then the steps above I mentioned regarding meal hygiene and timing are especially important for you. In addition, you will likely want to start trying a prokinetic or a small intestine motility agent to help your migrating motor complex do its job, and I'll go into those more in a moment. If your IBS-Smart Test is negative but you are seeing SIBO recur, you may have some other underlying condition that's at the root of your symptoms. Some obvious ones are your prescription medications, so check their list of side effects and wean off them as directed by your doctor to see if it will impact your symptoms. Another is hypothyroidism that isn't properly addressed, either through your thyroid medication or by using autoimmune reversal protocols for Hashimoto's thyroiditis, like I did to reverse my Hashimoto's. Another common one, blood sugar dysregulation, can cause IBS symptoms. If you know that you're pre-diabetic or diabetic and you do not have your blood sugar under control, then getting completely off sugar and simple carbs, reducing carb intake to 100 grams a day including protein and healthy fats at every meal. And if you're having any snacks and including some intermittent fasting in your days or weeks are first steps to reversing that and getting things under control. And of course, seeing your doctor and getting prescription medications is necessary. Neurotraumatic brain injury or mental health trauma that's causing vagus nerve dysfunction could be at the root. If you have a traumatic brain injury or a history of concussion, you should check out my episode 73 with Dr. Corey Deacon called Head Injuries, IBS, SIBO, and the Gut-Brain Connection. And if you have a serious history of trauma and you're also experiencing depression, I would check out the book Accessing the Healing Power of the Vagus Nerve by Stanley Rosenberg. And if you have endometriosis or adhesions from abdominal surgery, visceral massage, hormone-based treatment or surgery may be necessary to address that. I also had endometriosis. I kind of had a bit of everything. If you determine that your SIBO is or will be recurrent, one of the best things you can do is take a prokinetic before bed or possibly between meals as well. There are some prescription ones which would require a very SIBO-informed gastroenterologist to prescribe. These include procalipride, which is the generic name of Motegrity, at half a milligram a day, which you get by cutting a pill in half. Low-dose erythromycin, which is 50 milligrams, or low-dose naltrexone, which is also often used for autoimmune conditions in doses ranging from 2.5 to 5 milligrams, usually more for the cases of constipation. There are actually services online for prescribing low-dose naltrexone where you can call and talk to a doctor virtually and then get a prescription. Then in terms of over-the-counter prokinetics, there's Iberogast, which is used before bed, 30 to 60 drops. That's a combination herbal product. And then there's GI Motility Complex, which you can find in my Fullscript dispensary, which contains a formulation called ProDigest. That's a combo of ginger that's formulated not to produce that ginger burn effect, but also helps with small intestinal motility and artichoke extract, which helps with stomach emptying. And apple cider vinegar powder. Then there are a few more formulations like Motility Activator, MotilPro, ProKine, SIBO MCC— all those are in the FullScript Dispensary if you want to try them— and BioRevive Kinetic. Some of these have 5-HTP, which is not just good for your intestinal motility because it's a precursor to serotonin, most of which is made in your gut and helps move the intestines, but is also good for your mental health because serotonin is your feel-good neurotransmitter, which helps anxiety and depression. These may be more helpful for people with emo or CVC. And the last one I mentioned, BioRevive Kinetic, is sold in the UK. I'm not sure about the US, and it has some of the ingredients of the Ayurvedic preparation Triphala, which is known to be good for constipation in particular. So say you've gotten rid of your SIBO and you're taking your prokinetic, but then you notice the telltale bloating, soft stool, diarrhea, or constipation coming back. What to do? Well, you might start by increasing the dose or frequency of your prokinetic. I take mine before bed, but you could also take it between meals, or you could try a different prokinetic. But if things get back to where they were, then you'll probably want to take another course of antimicrobials. I've also seen clients who just give themselves ongoing small doses of antimicrobials on a daily or every 2 to 3 day basis. For this, I've heard of them using products like oregano oil or BioCidin drops. Of course, the danger with any single agent like oregano oil is that the bacteria could become resistant to it. As I know this can happen when treating yeast with oregano oil. But recurrent SIBO has been my story for years now since I'm positive for the antibody tevinkulin. So I pretty much have gone the route of taking another course of antimicrobials whenever things get bad again, which for me is usually once a year or more frequently. But before I do that, I do try to curtail snacking, eat a clean diet, stop eating dessert before bed. Yeah, I know you probably think because I'm a gut health coach I'd follow my own advice, but we're human, right? And I get lazy and self-indulgent like everybody else. But if that doesn't work, then I know it's just time to kill off more bacteria. So if you're struggling with ongoing bloating, constipation, diarrhea, soft stool, etc., and you want to 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 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 Fullscript or Wellivate dispensaries. 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, or I'm on Instagram, Pinterest, and Twitter, and links for all those things are in the show notes or on my website, highdeserthealthcoaching.com. Thanks for listening, and here's wishing you all the perfect stool.