SIBO Treatment Considerations 2023 Guide

Before we discuss SIBO treatment you may find these blog posts and podcast episodes also helpful:

• What Is SIBO?
• SIBO: What Causes It?
• The Ultimate Guide To IBS
• Hydrogen Sulfide: The good, the bad and the misunderstood
• The Alex Manos Podcast with Tracey Randell
• The Alex Manos Podcast with Dr. Jacobi (The SIBO Doctor)

What Is SIBO?

SIBO stands for small intestine bacterial overgrowth and, as the name suggests, is when you have an overgrowth of bacteria within the small intestine. The small intestine is home to far fewer bacteria than the large intestine but for reasons discussed in this blog post, what causes SIBO, an overgrowth can occur.

It is also possible however to have an imbalance of bacteria in the small intestine rather than an overgrowth per se.

What Are The Different Types Of SIBO?

Often people ask this question due to the fact there are three primary gasses that can contribute to symptoms, two which we can currently test for:

• Methane
• Hydrogen
• Hydrogen sulfide

The term ‘methane SIBO’ has been used to deescribe a positive breath test when methane levels are elevated.  This has been associated with constipation in the research.

If hydrogen comes back positive in a SIBO breath test then this confirms small intestine bacterial overgrowth. This can be referred to as hydrogen positive.

Hydrogen sulfide is the third gas, that currently doesn’t have a validated test to assess it (word on the street is its coming soon!). It is thought that when we get a flat lining SIBO breath test (i.e when gas levels for hydrogen and methane are both flat lining) that it may indicate excessive hydrogen sulfide production. This has been associated with both constipation and diarrhoea, fatigue, brain fog and other symptoms.

Each type of SIBO needs a different SIBO treatment.

How Do You Test For SIBO?

You test for SIBO via a hydrogen breath test. This is a three hour test which requires a 12 hour fast before hand, and a restrictive diet foe 12 hours before starting the test. The good news it that these days the test can be completed at home. When I did my first SIBO test back in 2015 I had to go to a clinic in London and fast for 24 hours!

Common questions I get asked are:

Can I treat SIBO naturally?

The short answer is, yes! I have spent a decade supporting people improve their gut health, including those with confirmed SIBO.

What Is The Best SIBO Treatment?

There is no one size fits all approach for successfully treating SIBO. The most important question to ask, which influences treatment, is what caused the overgrowth to occur? Read my blog SIBO: What causes it? to learn more. The four main categories however are:

• Motility issues due to such things as an under active thyroid or chronic stress
• Medications such as proton pump inhibitors
• Digestive deficits – meaning suboptimal production of stomach acid or digestive enzymes
• Inhibited flow of gut contents due to adhesions from abdominal surgery

Which Probiotics Are Best For SIBO Treatment?

Based on the research the best probiotic is a broad spectrum blend which includes both Bifidobacteria and Lactobacillus. We can also consider specific strains of probiotic for specific situations. For example the probiotic known as Culturelle can be helpful in diarrhoea and abdominal pain, where as Clinical GI by NOW may be helpful for those with constipation. Dr. Ruscio recommends triple probiotic therapy for SIBO which includes:

• Saccharomyces Boulardii
• Soil based organisms such as the probiotic Thrive
• A bifido and lacto broad spectrum probiotic such as Probiota 12.

Other Options For SIBO Treatment

So all this needs to be explored. In regards to the actual eradication of the overgrowth, while there is an argument that (at least for some) healing the underlying imbalance (when possible) may lead to natural radiation there are some evidence based recommendations that are almost always going to be considered:

• Antimicrobials: Herbs such as oregano oil can be used to help lower the overgrowth.
• Probiotics: The highest quality evidence indicates that probiotics can be helpful in “decontaminating the small intestine”.
• Prebiotics: Probiotics such as GOS, and partially hydrolysed guar gum have been shown to be helpful in lowering methane levels, and improving the microbiome.
• Micronutrients: Vitamins A and D are essentially for a healthy mucosal immune system which helps maintain a healthy microbiome.
• Prokinetics: such as ginger and 5-HTP. A product some find helpful is MotilPro.

Please please please do not forget the fundamentals though:

• Effective breathing (more on this soon)
• Stress management – stress is a deal breaker when it comes to healing from any chronic health condition, especially the gut. I have seen clients where this is the key factor in their healing having tried all avenues including antibiotics.
• Exercise – physical activity is essential for a healthy and diverse microbiome.
• Healthy sleep patterns

Resources

• The Alex Manos Podcast with Tracey Randell
• The Alex Manos Podcast with Dr. Jacobi (The SIBO Doctor)
• The Alex Manos Podcast with Dr. Sandberg-Lewis
• Alex’s e-book

SIBO References

• Al-Shboul (2013) The Importance of Interstitial Cells of Cajal in the Gastrointestinal Tract, Saudi J Gastroenterol.; 19(1): 3–15
• Allescher & Abdel-Aziz (2017) Mechanism of Action of STW 5 in Functional Dyspepsia and IBS: The Origin of Multi-Target, Dig Dis.;35 Suppl 1:18-24
• Banik et al., (2016) Hydrogen Sulphide in exhaled breath: a potential biomarker for small intestinal bacterial overgrowth in IBS, Journal Breath Research; 10(2): 02610
• Barrett (2017) How to institute the low-FODMAP diet, Journal of Gastroenterology and Hepatology; 32 (Suppl. 1): 8–10
• Begley et al., (2006) Bile Salt Hydrolase Activity in ProbioticsAppl. Environ. Microbiol., 72:3 1729-1738
• Bested et al. (2013) Intestinal microbiota, probiotics and mental health: from Metchnikoff to modern advances: Part II – contemporary contextual research Gut Pathogens, 5:3
• Bonaz B, Sinniger V and Pellissier S (2017) The Vagus Nerve in the Neuro-Immune Axis: Implications in the Pathology of the Gastrointestinal Tract. Front. Immunol. 8:1452
• Borghini F, Donato G, Alvaro D, Picarelli A. New insights in IBS-like disorders: Pandora’s box has been opened; a review . Gastroenterol Hepatol Bed Bench 2017; 10(2): 79-89
• Canavan C, West, J, Card T (2014) The epidemiology of irritable bowel syndrome, Clin Epidemiol.; 6: 71–80
• Catassi et al. (2017) The Low FODMAP Diet: Many Question Marks for a Catchy Acronym , Nutrients 2017, 9, 292
• Chumpitazi et al., (2018) Review article: the physiological effects and safety of peppermint oil and its efficacy in irritable bowel syndrome and other functional disorders, Aliment Pharmacol Ther.;47:738–752.
• Chen et al., (2017) Reduced interstitial cells of Cajal and increased intraepithelial lymphocytes are associated with development of small intestinal bacterial overgrowth in post-infectious IBS mouse model, Scand J Gastroenterol.;52(10):1065-1071
• Chided et al., (2014) Herbal Therapy Is Equivalent to Rifaximin for the Treatment of Small Intestinal Bacterial Overgrowth; Global Adv Health Med.; (3):16-24
• Choi & Chang (2015) Alteration of Gut Microbiota and Efficacy of Probiotics in Functional Constipation, J Neurogastroenterol Motil. 2015 Jan; 21(1): 4–7.
• Chumpitazi BP, Kearns GL, Shulman RJ (2018) Review article: the physiological effects and safety of peppermint oil and its efficacy in irritable bowel syndrome and other functional disorders, Aliment Pharmacol Ther.
• Costello et al., (2013) The importance of methane breath testing: a review, J. Breath Res. 7; 024001 (8pp)