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Treatment For Small Intestinal Bacterial Overgrowth Syndrome (SIBO), And Its Link To Other Diseases

by Jo Jordan

Small intestinal bacterial overgrowth syndrome (SIBO) has not been well studied yet, nor has a great deal been written about it, but it’s more common than many people realize. Also referred to as small bowel bacterial overgrowth (SBBO), SIBO is a condition wherein the small intestine (small bowel) becomes ripe with abnormally large amounts of bacteria.

Normally, the number of bacteria is highest in the colon (large intestine) and substantially lower in the small intestine. As well, the types of bacteria within the small intestine (the part of the gastrointestinal tract connecting the stomach to the colon) are different than those within the colon. However with SIBO, the types and amount of bacteria resemble colonic bacteria rather than those normally present in the small intestine.

High concentrations of bacteria in the colon are necessary for optimum health. In the small intestine, however, high numbers of bacteria interfere with proper nutrition, and are connected to various other health problems.

How SIBO works against your good health

A healthy small intestine is required for the proper absorption of nutrients; this means that desirable levels of bacteria are necessary. But when the small intestine becomes overgrown with bacteria they begin to compete for nutrients, which results in the production of by-products that can irritate, inflame, and damage the absorptive surface of the small intestine.

This damage disrupts the absorption of carbohydrates (sugars) fats, fat-soluble vitamins, and sometimes proteins, leading to malabsorption and malnourishment. In the process, a lot of gas is produced, resulting in bloating, flatulence, gassiness, diarrhea, and a great deal of discomfort. In severe SIBO cases, weight loss is a factor as the bacteria consume most of the calories leaving little left over for the host.

Common SIBO symptoms

While symptoms tend to be patterned and chronic, they may also come and go; sometimes they persist for years before signs of malnutrition present. Severity depends upon the type of bacteria present as well as the extent of overgrowth, and not all of the symptoms occur for everyone:

  • Abdominal bloating and/or belching soon after eating
  • Abdominal cramps, discomfort, and pain
  • Bulky, floating, frothy, loose, smelly stools
  • Loud rumbling noises in the belly soon after eating
  • Nausea and vomiting, especially after meals
  • Weight loss

Rather than diarrhea, some SIBO sufferers complain of chronic constipation. Others report symptoms seemingly unrelated to the gastrointestinal tract, such as body aches and/or fatigue.

Other problems created by SIBO1

When the overgrowth is severe and prolonged, damage to the absorptive surface of the small intestine can interfere with the absorption of fats, proteins, sugars, and vitamins:

  • Poor digestion of fats results in weight loss and steatorrhea (stools that have excess amounts of fat, and characterized by a foul smell, and a loose, floating, and greasy appearance).
  • Poor digestion of proteins results in increased susceptibility to infections and hair and weight loss.
  • Poor digestion of sugars – Symptoms vary in intensity depending on sugar consumption: belching, bloating, cramping, gas, and watery diarrhea.
  • Vitamin B12 deficiency may result from bacteria utilizing B12, and rendering it unavailable for absorption: causes anemia.
  • Vitamin A deficiency may occur resulting in night blindness, sensitivity to sunlight, and other vision problems as well as skin changes.
  • Vitamin D deficiency may lead to bone softening and joint pain.
  • Vitamin E deficiency may lead to nervous system problems.
  • Calcium / Magnesium deficiency may cause problems with tetany (painful intermittent muscle cramping that occurs in calves, fingers, and/or toes).

SIBO causes and risk factors

What causes SIBO? Risk factors tend to fall into three categories:

    1) Problems with motion/muscular activity;

    2) Immune system disorders; and

    3) Conditions that encourage colonic bacteria to move into the small intestine.

Healthy muscular activity flowing through the small intestine is important not only for the proper digestion of food, but it also clears out bacteria and controls bacterial count in the small intestine. Muscular interference allows bacteria to remain in the intestine longer and multiply. Bacteria may also be allowed to spread backwards from the colon into the small intestine when muscular activity is disrupted.

SIBO can develop as a result of any condition disrupting motility/muscular activity throughout the small intestine:

  • Diabetes damages nerves that control intestinal muscles.
  • Muscular and neurologic diseases can alter activity of intestinal muscles.
  • Obstruction, partial or intermittent, of the small intestine interferes with food transport and bacteria through the small intestine. Causes of obstruction leading to SIBO include surgical scarring and Crohn’s disease.2
  • Out-pouchings of the small intestine; fistulae and diverticuli are anatomical problems that allow bacteria to multiply.
  • Scleroderma damages the intestinal muscles directly; it slows the bowel leading to an increase in bacteria.
  • Surgery – Bacterial overgrowth can result following duodenum and/or stomach surgery.

Disorders of the immune system can foster bacterial overgrowth.3 Chronic pancreatitis, inflammation of the pancreas, inherited immunodeficiency conditions, and the use of immunosuppressant medications to treat various conditions can be linked to SIBO.

Conditions that cause colonic bacteria to enter the small intestine are also linked to SIBO.4 Diseases of the ileum (i.e. Crohn’s disease) may require removal of a patient’s ileocecal valve, which connects the small and large bowel, and an increased reflux of bacteria into the small bowel may result. Following bariatric surgery, there may be an increase in the bacterial load of the small bowel. Use of proton pump inhibitor medications decreases stomach acid, and can also lead to bacterial overgrowth.

SIBO can develop when food remains in the stomach too long. This state of stagnation disrupts gut flora balance, and causes bacterial overgrowth from fermentation, which can result in SIBO.

Patients on TPN (total parenteral nutrition) – intravenous feeding for malnourishment – are at increased risk for developing SBBO.

Additionally, consuming large amounts of sugars (which bacteria feed on) can encourage opportunistic bacteria to relocate from the colon to the small intestine; there they will thrive, but you will not!

The IBS-SIBO connection

There is much speculation regarding a possible relationship between SIBO and irritable bowel syndrome (IBS). The similarity between IBS and SIBO symptoms has led researchers to suggest that SIBO may be responsible for the symptoms experienced by some IBS patients. IBS is difficult to diagnose and treat, and diagnosis is based on symptoms and testing to rule out other illnesses rather than anything definitive.

Though research is only in the preliminary stages, scientists have noticed that significantly more IBS patients experience abnormal hydrogen breath test (HBT) results than unaffected people. In addition, many patients report a significant decrease in IBS symptoms after being treated with specific antibiotics.

Diagnosing SIBO - the hydrogen breath test (HBT)

Patients must fast for twelve hours prior to testing. On test day, they’re given a (pleasant-tasting) carbohydrate syrup solution such as glucose, lactulose, or sucrose to drink, and then asked to breathe into a balloon-type device every fifteen minutes over a two-hour period.

Bacteria feed off carbohydrates, emitting gases as by-products absorbed into the blood stream and released via the lungs. The test assesses the presence of gas in breath. In a healthy individual, hydrogen or methane wouldn’t be present until two hours after swallowing the solution. A positive gas result prior to two hours after swallowing the sugar solution is evidence of bacteria higher up in the digestive tract, at the level of the small intestine.

HBT testing for SIBO has several drawbacks:5

  • Other conditions such as celiac sprue and pancreatic insufficiency can produce abnormal breath test results.
  • Individuals with slow transit would prolong testing by several hours.
  • Crohn's disease of the small intestine, small intestine strictures, or other anatomical abnormalities can cause bacterial overgrowth, and produce similar symptoms.

The one definitive way to determine whether symptoms are SIBO-related is to treat and eliminate harmful bacteria. If symptoms disappear, then SIBO has likely been responsible for the previous symptoms.

Treatment for SIBO

For less severe SIBO cases, some patients find a change in diet helpful. A SIBO diet requires restricting dietary carbohydrates and increasing fats. In order to maximum the potential health benefits of a low carbs/high fat diet, a dietitian ought to be consulted.

As the body heals, the intestine may have difficulty digesting sugars, making the replenishment of minerals and vitamins essential. Additionally, some health care providers recommend B12 injections and iron supplementation.

A variety of antibiotics are also sometimes prescribed to treat SIBO:

  • Augmentin (Amoxicillin™)
  • Bactrim
  • Colistin
  • Ciprofloxacin (Cipro™)
  • Gentamicin (Garamycin™, Gentacidin™)
  • Keflex
  • Levofloxacin (Levaquin™)
  • Levofloxacin (Levaquin™) combined with Metronidazole (Flagyl™)
  • Metronidazole (Flagyl™)
  • Neomycin
  • Rifaximin (Xifaxan™)
  • Tetracycline

Many health care providers recommend standard doses of antibiotics for one to two weeks.

But there are certain drawbacks to antibiotic use. While treatment is often very effective, it doesn’t address the underlying disease causing SIBO. Symptoms often recur once a course of treatment has been completed, which necessitates prolonged and/or repeated treatment.

Though rarely dangerous, there are sometimes side effects such as diarrhea, nausea, and vomiting. Fungal infections of the digestive tract, mouth, and vagina are common because antibiotics destroy the good bacteria as well as the bad. Another disadvantage is that antibiotic-resistant bacteria may begin to emerge.

For these reasons, one treatment option is to prescribe a short course of antibiotics to begin treatment, followed by probiotic use over the long term. Probiotics are live bacteria, the most common of which are lactobacilli and bifidobacteria. A good treatment option for some bacterial overgrowth cases, probiotics replenish the gut’s good bacteria. Certain organic yogurts contain a variety of healthy living bacterial species as well.

Even after bacterial overgrowth has been successfully treated, damaged tissue can take six months or more to heal. Known for their healing properties, probiotics may be helpful throughout SIBO treatment.6 Be sure to use probiotics in moderation as high dosages can sometimes trigger diarrhea.

Probiotics are used alone, in combination with antibiotics, and/or for long-term maintenance.

SIBO and links to other diseases

  • In 2009, the Journal of Clinical Gastroenterology reported that recent studies suggest SIBO as a likely cause for non-responsive celiac disease.7
  • A large number of people who suffer from rosacea also have SIBO. When treated for SIBO, many patients reported that the rosacea disappeared.8
  • Research has shown that twenty to forty percent of diabetic patients who suffer with chronic diarrhea do so because they also have SIBO.9

Small intestinal bacterial overgrowth syndrome (SIBO) is thought to be an underlying root cause of – or at least is linked to – various frustrating and perplexing illnesses. A good theory since bacterial overgrowth can wreak a great deal of havoc on one’s entire system.

So if you suffer from abdominal pain, bloating, gas, and diarrhea, it makes good sense to schedule an HBT test to check for SIBO. Though testing is not an exact science at this point in time, antibiotic and probiotic treatment is inexpensive, relatively simple, and quite often extremely successful.

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Notes: 1. The Gastroparesis & Dysmotilities Association, “Small Bowel Bacterial Overgrowth & Digestive Motility Diseases,”http://www.digestivedistress.com/files/pdf/sbbo.pdf (accessed August 4, 2010).
2. MedicineNet.com, “Small Intestinal Bacterial Overgrowth - SIBO,”http://www.medicinenet.com/small_intestinal_bacterial_overgrowth/article.htm (accessed August 10, 2010).
3. Wikipedia, “Small bowel bacterial overgrowth syndrome, Risk Factors and Causes,” http://en.wikipedia.org/wiki/Small_bowel_bacterial_overgrowth_syndrome#Risk_factors_and_causes (accessed August 10, 2020).
4. Ibid.
5. MedicineNet.com, “Small Intestinal Bacterial Overgrowth - SIBO,” http://www.medicinenet.com/small_intestinal_bacterial_overgrowth/article.htm (accessed August 10, 2020).
6. The Gastroparesis & Dysmotilities Association, “Small Bowel Bacterial Overgrowth & Digestive Motility Diseases,”http://www.digestivedistress.com/files/pdf/sbbo.pdf (accessed August 4, 2010).
7. Celiac.com, “Researchers Hunt Causes of Non-responsive Celiac Disease,” http://www.celiac.com/articles/21768/1/Researchers-Hunt-Causes-of-Non-responsive-Celiac-Disease/Page1.html (accessed August 11, 2010).
8. Acne Help, “Rosacea & SIBO,” http://acneve.com/rosacea-sibo (accessed August 11, 2010).
9. The Gastroparesis & Dysmotilities Association, “Small Bowel Bacterial Overgrowth & Digestive Motility Diseases,”http://www.digestivedistress.com/files/pdf/sbbo.pdf (accessed August 4, 2010).

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