What is SIBO?
SIBO, or Small Intestine Bacterial Overgrowth, is exactly what it sounds like - too much bacteria growing in your small intestine. The large intestine is typically where the majority of our microbiome lives, and ideally there is a diversity of different bacterial species. While small amounts of bacteria in the small intestine can be alright, an overgrowth is where we run into problems. This overgrowth can cause digestive symptoms, cognitive symptoms and even worsen the outcome of other diseases.
Usually SIBO is described as having two types - hydrogen and methane. Different bacteria species create hydrogen or methane in response to carbohydrates/sugars, and when there is an overgrowth, these gases build up.
Recently, SIBO has been redefined to only include hydrogen-producing bacteria, while overgrowth of methane-producing bacteria is now called IMO (intestinal methanogen overgrowth). This new classification is important as the presentation, underlying causes, risk factors and treatment for SIBO and IMO differ.
Symptoms of SIBO / IMO
Bloating
Excessive gas
Abdominal pain and cramping
Sense of fullness
Nausea
Heartburn and/or reflux
Diarrhea (SIBO)
Constipation (IMO)
Non-gut symptoms that are common include fatigue, brain fog and difficulty concentrating
Symptoms of SIBO are vague and can vary significantly between individuals. Essentially this means that SIBO cannot be diagnosed using symptoms alone.
In some cases, SIBO can be asymptomatic.
SIBO / IMO Diagnosis
The gold standard for diagnosing SIBO involves obtaining a sample of fluid from the small intestine and analyzing the bacterial content, a procedure known as small intestine aspirate culture. However, this method is costly, requires an invasive endoscopy, and carries a risk of contamination during sample collection.
Alternatively, the most common method for testing and diagnosing SIBO is through breath testing. It's not only easier and more cost-effective, but it is also the only way to diagnose IMO. Breath testing entails ingesting a solution containing either lactulose or glucose, followed by the measurement of gas production over a period of two hours. Determining the superiority of lactulose or glucose can be nuanced, but the criteria for a positive result are consistent:
Hydrogen-predominant SIBO: A rise in hydrogen levels of 20 parts per million (ppm) before 90 minutes.
Methane-predominant SIBO: Methane levels reaching 10 ppm at any point during the test.
It's crucial to acknowledge that false-positive or false-negative results can occur due to differences in individual physiology and testing methods, underscoring the importance of consulting a licensed healthcare provider to interpret test outcomes accurately before pursuing any treatment options.
SIBO / IMO Treatment
There are two main ways SIBO can be treated: antibiotics or herbal antimicrobials
While often only one method is used, there is growing evidence that using these together can improve outcomes!
Antibiotics
SIBO (hydrogen-predominant): Rifaximin
The Good: It is very effective and has less side effects than other antibiotics. It stays in the GI tract, and instead of completely wiping out bacterial populations, it helps modulate the microbiome - eliminating the bad and supporting the good.
The Bad: At this time there are no generic alternatives, and Rifaximin is a very pricy medication if it isn't covered by insurance.
IMO (methane-predominant): Rifaximin and Neomycin
The Good: Methane SIBO is generally much harder to treat, but using two antibiotics together has been shown to be much more effective than Rifaximin alone.
The Bad: Neomycin doesn't have the same safety profile as Rifaximin, so it can disrupt the microbiome overall by eliminating more bacteria. Ultimately, this can increase the risk of C. diff, a serious bacterial infection resulting in severe diarrhea.
Herbal Antimicrobials
Treatment of SIBO and IMO with herbal therapies is less straightforward than treatment with antibiotics, as there is less research dedicated to these treatments. Different providers will choose to treat with different formulas and protocols, either based on research or anecdotal evidence.
Science-backed supplements used in the treatment of SIBO:
Candibactin-AR and Candibactin-BR (Metagenics)
Dysbiocide and FC Cidal (Biogenics)
The Good: Herbal antimicrobials act similarly to antibiotics by killing off excess bacteria, though they typically have less side effects, resulting in lower risk for serious side effects like C. diff infections. Additionally, these protocols not only address SIBO/IMO, but they can simultaneously address other microbiome imbalances such as yeast, if present.
The Bad: These protocols take longer to complete compared to antibiotics (4-8 weeks v. 2-3 weeks), and can be more involved, taking several capsules several times a day. As these work more broadly, die-off reactions can be more intense and last longer.
Wait, what is die-off?
Die-off symptoms result from the bodies response to the waste products that are released from dying bacteria. Classically, die-off symptoms consist of worsening diarrhea, nausea and other flu-like symptoms like fatigue and brain fog, though other presentations are possible. Generally this is the "getting worse before you get better." This reaction shouldn't last more than a couple weeks, and can be minimized with the use of binders.
Other natural therapies that can be employed include probiotics and dietary interventions, such as low FODMAP and the elemental die. These are a bit more complicated and will not be discussed here.
TL;DR
SIBO (Small Intestine Bacterial Overgrowth) and IMO (Intestinal Methanogen Overgrowth), present complex challenges in diagnosis and treatment. As our understanding evolves, so do the approaches to managing these conditions. The symptoms of SIBO and IMO are diverse and can significantly impact one's quality of life, extending beyond digestive discomfort to include cognitive symptoms and exacerbation of other diseases. Diagnosis typically involves non-invasive breath testing, though this too involves many challenges and can sometimes be tricky to interpret.
Treatment options range from antibiotics to herbal antimicrobials, with even more variations not discussed here. However, the choice of treatment should be tailored to individual needs, considering factors like antibiotic resistance, side effects, and overall gut health. It's crucial to stay informed and work closely with healthcare providers to navigate the complexities of SIBO and IMO management effectively.
Keep exploring upcoming posts to delve deeper into specific treatments and emerging research in this field. Let's journey together towards better gut health and overall well-being. Stay connected for more insights and strategies to address SIBO and IMO effectively.
Disclaimer
The information provided in this blog and throughout the website is intended for educational purposes only and should not be considered, or used as a substitute for, medical advice. The content is not meant to diagnose, treat, or cure any medical condition. This blog does not constitute the practice of any medical, nursing or other professional health care advice, diagnosis or treatment. Always consult with a qualified healthcare provider before making any changes to your health regimen or starting new treatments, and never disregard professional medical advice or delay seeking care because of something that you have read on this blog, website or in any linked materials. Your individual needs and circumstances should be evaluated by a medical professional to ensure safe and appropriate care. If you are experiencing a medical emergency, please call 911 or call for emergency medical help on the nearest telephone immediately.
References
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