This blog is very near and dear to my blog as myself, and many of my patients suffer from one or a combination of these conditions. Many times, patients are told these conditions aren’t interrelated, it’s all in their head, and/or that the only thing that can be done for their condition is an anti-depressant or a medicine to help the pain. Many suffer in silence as Dr. Mark Pimentel points out in his book, “The New IBS Solution”. Research into bacterial overgrowth of the small intestine, aka SIBO, is an exciting area that shows promise on the role of bacterial overgrowth in these conditions. So let’s get into a discussion about small intestinal bacterial overgrowth aka SIBO. I am convinced a good percentage of people are walking around with undiagnosed SIBO. In this blog, I am going to outline the symptoms and predisposing factors for SIBO and treatment options that are available.
What is SIBO?
Simply put, it is an overgrowth of bacteria where bacteria are not supposed to be. The human body has several mechanisms to prevent overgrowth of bacteria. To prevent overgrowth in the small intestine, the primary defense are pancreatic enzymes, bile released from the gallbladder, and Hydrochloric acid released from the stomach. Also, there is a sphincter, called the ileocecal valve that prevents bacteria from the colon from moving backward into the small intestines. The final protection mechanism that prevents overgrowth is a cleansing wave of the small intestine. This process begins in the stomach and continues into the small intestine to push leftover food particles into the colon for elimination. When we are fasting, this happens every 90 minutes, so the body can absorb nutrients and prepare for the next meal. Those that don’t have a normal cleansing wave pattern are susceptible to bacterial overgrowth. Okay shew, sorry for the science lesson but I think it’s important to understand normal function so we can know why this occurs.
- Low stomach acid, which can be the result of chronic acid reducers or diseases that are associated with low stomach acid, such as hypothyroidism
- Irritable bowel syndrome-gas, bloating, indigestion, constipation, and/or diarrhea
- Celiac Disease
- Crohn’s Disease and Ulcerative Colitis
- Prior bowel surgery that resulted in adhesions
- Impaired function of the ileocecal valve
- Endometriosis, where abnormal uterine tissues can grow into the bowel
- Insufficient production of pancreatic enzymes and pancreatic function
- Food poisoning, this can cause post infection IBS due to inflammation and changes in the white blood cells that line the digestive tract
Intestinal symptoms include things such as bloating, belching, gas, diarrhea and constipation, and reflux. However, extra intestinal symptoms such as allergies, fatigue, rashes, joint pain, brain fog, depression, pelvic and bladder pain, weight loss, and anemia are also very common. So what is the connection with these symptoms and possible bacterial overgrowth? Dr. Pimentel’s research team has done some exciting studies in this area and found that for instance, fibromyalgia patients had overgrowth more often than irritable bowel patients. How might overgrowth cause symptoms such as the pain that is associated with fibromyalgia? This is because bacteria, when overgrown, produce toxins (known as endotoxins) that enter the blood stream through the small intestines. Usually, these are cleared in the liver, however, if the load is too high for the liver to detox, these toxins can enter the bloodstream. It is known in research that these endo toxins can cause pain and a heightened sensitivity to pain. This is the best explanation I have ever found for the strange muscle burning/ pain that myself and a lot of my patients get!
Although research is just beginning to connect interstitial cystitis with bacterial overgrowth, there is potential research by Europeans that suggests there a dysfunctional of the protective cleansing wave that can lead to bladder dysfunction. In one study researchers, 80 to 90% of all trips to the bathroom were proceeded by cleansing waves of the gut. If researchers discover that deficiencies in the cleansing wave mechanism cause or contribute to dysfunction of the bladder, this could explain the overlap of symptoms between IBS and Interstitial Cystitis.
A final example of how these conditions may overlap include the brain fog and chronic fatigue many IBS sufferers experience. A possible explanation for this, other than endotoxin release by bacteria, could be the hypoglycemia. Dr. Pimentel’s group has done research on those with Irritable Bowel Syndrome. These patients all showed some degree of hypoglycemia after a carbohydrate challenge and was more pronounced in those who’s breath test showed elevated levels of hydrogen in the small intestine. Much research is still needed in these areas, but it is encouraging to know that connections between these conditions are being made. So now that we have talked about associated symptoms and causes let’s move on to how you find out if you have SIBO and what the treatment options are.
Although there is no gold standard, testing is done most commonly with a breath test, either lactulose or glucose. Make sure whoever you work with checks levels of both hydrogen and methane as overgrowth can be missed if only hydrogen is checked, and the treatment plan for the gasses is different. Some doctors have this available at their office, but a lot of practitioners work with an outside lab dedicated to breath testing. At our clinic, we work with commonwealth laboratories. For the test, a sugar solution is consumed (lactulose is the one we prefer at our clinic) after a one to two-day preparatory diet and methane and hydrogen levels are tracked over a period of several hours after an overnight fast. A graph with gas values over the three hour period are measured to determine how much is produced and whether the test is positive or negative.
Here is where it gets complicated. In functional medicine, we are always looking for a cause because if you don’t find the cause, there is a good chance it will return. There are several different treatment routes available and these depend on which gas is positive and what each clinician has seen work best in their practice. Choices include antibiotic therapy, herbal antibiotic therapy, and a strict elemental diet known as Vivonex. A final option is to treat with a low fermentable carbohydrate diet, created by Dr. Allison Siebecker and known as the SIBO diet, which is a combination of the Specific Carbohydrate and low FODMAP diets. The problem with this is if diet alone is used, it can take up to a year to two to treat and many times, diet alone is not enough. My preference is to use a diet low in fermentable carbohydrates to starve the bacteria along with herbal antibiotics. Treatment regimens are complicated, and this is why it’s very important you work with a practitioner who is very knowledgeable in SIBO.
Prevention is key to keep SIBO from returning. If you only treat with an antibiotic and don’t change your diet or correct the underlying abnormality that caused SIBO, chances are it will come back. Motility agents that help move food through your gut are necessary, at least for three months after treatment. If low stomach acid is a concern, supplementing with Betaine HCL, a combination of Betaine HCL and enzymes, or digestive bitters is helpful. SCD, GAPS, and FODMAP should be continued and/or started with tailoring to individual tolerance. There is also a prevention diet developed by Dr. Pimentel called the Cedars-Sinai diet. All these diets are similar in limiting highly fermentable carbohydrate foods, but the Low Fodmap, and Cedars-Sinai do allow certain grains.
Prebiotics, such as FOS and inulin should be avoided as they are a food source for the bacteria, especially in the first couple of months post treatment. Meal timing and spacing is very important to allow the cleansing wave to clean out the small intestine.The use of probiotics is controversial, but I think very important in re-establishing your gut flora post treatment. If you have had an abdominal surgery where adhesions are contributing, a referral to a physical therapist may help.
Sheww….that’s a lot of information. A list of resources is listed below. I will be blogging more in depth on treatment options and the different dietary interventions to come. As I really like these diets for many other conditions as well. Until next time…..
Emily Kopek PA-C
The New IBS Solution by Dr. Mark Pimentel