Just because a symptom is common, doesn’t mean it’s normal. For example, a lot of people have reflux or heartburn. Many have high blood pressure. Even more have fatigue. Know someone with a fungal infection their toenails? These are all common symptoms but just because they are common doesn’t mean it’s healthy or normal.
I’m here today to talk about SIBO. Small Intestine Bacterial Overgrowth. Sigh-Bow. Some say See-Bow. Either way, it’s common but not normal.
What is SIBO?
Technically it’s an overgrowth of bacteria or organisms in the small intestine. You see, our small intestine should be relatively sterile. It is where digestion and absorption take place. We should have about 10,000 bacteria in our small intestine. Now, when you hear us talk about “microbiome” or “gut flora”, we’re talking about the millions of bacteria in your large intestine. Again, the small intestine should be relatively sterile. But when it has an overgrowth, it is termed Small Intestine Bacterial Overgrowth.
2+ Forms of SIBO
1. SIBO-Hydrogen. These patients have an overgrowth of bugs that produce Hydrogen, which tends to give the patient fast transit time and/or loose stools.
2. SIBO-Methane. These patients have an overgrowth of the M Smithii organism which produces methane, which slows transit time. Patients may also have hard, compacted stools.
3. SIBO-Mixed. The patient has hydrogen and methane gases present in the small intestine. They may not have a BM for a few days, but then often have urgency and dumping.
4. SIFO – Small Intestine Fungal Overgrowth. The patient may have a fungus like Candida Albicans overgrowing in the small intestine too! If fungal overgrowth is suspected or confirmed, the treatment plan needs to incorporate anti-fungal treatment as well as anti-microbials for hydrogen/methane.
Dirty Dozen Causes of SIBO
1. Poor functioning ileocecal valve – the “trap door” between the small and large intestine. If the trap door isn’t properly closing, it literally opens the door for organisms to migrate up into the small intestine which is supposed to be relatively sterile as you just learned.
2. Snacking all Day and/or A dysfunctional Migrating Motor Complex (MMC). The MMC is like a janitor, sweeping the halls of your intestines between meals. If the janitor only has one arm, he doesn’t do as good of a job. As such, bacteria/organisms can accumulate. A variety of things can impair its function. The MMC runs about every 90 to 120 minutes but ONLY IF the stomach is empty. So if you find yourself snacking or drinking anything besides water all day, the MMC doesn’t get the signal to “clean the hallways”. This is a “lifestyle induced” way to increase the risk of SIBO.
3. An alkaline environment. Either through aging, or the use of proton pump inhibitors, we may not have enough hydrochloric acid. Acid is anti-microbial and so decreasing it allows bacteria to flourish. If I wasn’t clear, being on an antacid IS a risk factor for SIBO since it neutralizes your own intrinsic acid.
4. Very recent research indicates that food poisoning can cause an immune reaction, and while we are attacking the (CdtB) toxin produced by the pathogen (E Coli for example), we ALSO attack our own tissue. This can damage our nerves responsible for motility and thus allows bacterial overgrowth again.
5. Poor blood sugar control, over years, can damage the nerves responsible for motility. It’s commonly known as gastroparesis. Even if you don’t officially have diabetes, and you have pre-diabetes…if your blood sugar hovers in the low 100’s or you have an A1c of 5.5, you may have enough damage to the nerves to instigate poor motility and thus an overgrowth of bacteria.
6. Adhesions – whether from a surgery or inflammation within the peritoneal sac
7. Cholestectomy – removal of gallbladder which DOES change the flow of bile (& bile is anti-microbial)
8. Suppressed Immunity – whether its from steroids, chemotherapy, or other immunosuppressive drugs, secretory IgA (sIgA) is suppressed so our immune system isn’t as tough as it usually is.
9. Repeated use of broad spectrum antibiotics
10. Stress – although Dr. Pimental has documented in military studies of deployed personel that stress alone doesn’t cause SIBO, it does often fit in the picture. Stress decreases gastric secretions and slows motility and transit time. ANYthing that slows transit time increases the risk of SIBO.
11. Pain Meds – Opioid’s. Just like #10, if you slow transit time, you raise the risk of SIBO. You’ve got a stagant, fermenting pond….not a nice mellow creek.
12. Head Injuries/TBI’s. Who tells the gut what to do? The brain. Yes, we have the enteric nervous system and autonomic nervous system but we do still have what is called the Brain-Gut Axis. In rat studies we can document that you damage the brain, you’ll damage the gut.
Symptoms of SIBO
- Gas – especially as the day goes on. And for some, depending on the type of bacteria or organism present, they have have odorous sulfur-smelling gas.
- Gas and bloating are hallmark, classic signs!
- Pain or abdominal discomfort
- Diarrhea or constipation – or a mixture of both meaning you don’t have a BM for 2 days but then perhaps have a total bowel evacuation. And let’s define constipation as not having a BM each and every day. It should be soft and easy to pass.
- Weight loss
- Weight gain! Research indicates that SIBO can keep you from losing weight, even though you aren’t’ doing a good job of digesting and absorbing your food
- Floating BM’s – because of fat malabsorption, stools float.
- Night blindness – as a result of malabsorption
- Osteomalacia – softening of bones – again as a result of malabsorption
- The SIBO patient may also notice that he/she feels better while on antibiotics.
Conditions Associated with SIBO
- Restless Leg Syndrome
- Chronic Fatigue Syndrome
- Parkinson’s Disease
- Rosacea / Ocular Rosacea
- Migraine headaches
- Menstrual irregularities.
- It can mimic Celiac Disease and Crohns
- Malabsorption symptoms like thinning or breaking hair, soft nails,
Testing for SIBO
A Lactulose Breath Test (LBT) is the gold standard these days. It’s typically an in-home test. You eat a special diet for 1.5 to 2 days depending on current transit time, then blow into tubes and the gases are collected. It’s easy, painless, relatively inexpensive considering what an endoscopy or colonoscopy costs! And those don’t identify bacterial overgrowth although they do have their place & time in medicine.
How to Interpret Your Lactulose Breath Test Results
- A rise of 20 PPM (or more) hydrogen from the baseline score
- Methane (CH4) > 3 anywhere along the scores
- Hydrogen + Methane > 15 at the 2 hour mark
You need to understand that M Smithii and sulfite-reducine bacteria EAT hydrogen so hydrogen can look falsely low. What you hope to see is low numbers that increase sharply at the 90 and 120 minute mark’s.
If you see a test with hydrogen and/or methane elevated all the way across the test, it indicates the overgrowth has moved up the small intestine, toward the stomach. It also seems to indicate a longer length of treatment.
Why Test, Not Guess?
- It is possible that it’s not SIBO and the symptoms mimic celiac disease, non-celiac gluten intolerance, food allergies, lectin intolerance etc.
- It is also possible that the SIBO breath test is negative, and there is not an overgrowth of bacteria in the small intestine…but the large intestine has its share of dysbiosis. Perhaps from antibiotics, poor flora inherited from the mother, poor diet, etc.
- The numbers can be used to project the length of treatment. A hydrogen of 25 at 2 hours will correct faster than a hydrogen of 100 at 2 hours. Ditto for methane. A methane of 3 might only need one round of treatment. A methane of 25 might need several rounds. You don’t want to be treating and thinking it’s not working, when in fact you just haven’t given it long enough.
Do you have SIBO and need to know what to eat? What anti-microbials to take? Do you need a prokinetic? How’s your transit time? Did you get this via food poisoning and auto immune damage to your nerves that direct motility? Learn more in my SIBO Series!