Small Intestinal Bacterial Overgrowth (SIBO)

Small Intestinal Bacterial Overgrowth or SIBO deserves a separate page because this is a condition that is often misdiagnosed, missed, or only partially resolved. It is a hidden epidemic, and a lot of people need help they do not get locally where they live. That is one of the reasons my practice is fully virtual!

Do you feel bloated or gassy after meals, especially as the day progresses?

Do you feel distended even when drinking water and feel the best when not eating at all?

Have you been losing weight no matter what you do?

Do healthy foods like fruits, vegetables, or legumes make your intestinal distress even worse?

Are potato chips some of the few items that do not make your gut feel worse?

Are you constipated or running a diarrhea or both?

Does fiber makes things worse instead of helping with your chronic constipation?

Do you also have IBS?

Do you feel there was a particular time and place (e.g. food poisoning during your last trip to Mexico or hospitalization) since when you have not been quite all right?

Do you have restless leg syndrome and/or rosacea as well?

If you answered yes to at least 4 of these questions, you may have SIBO. And did you know that if you have IBS, you have up to 80% chance of getting SIBO?

The definition of Small Intestinal Bacterial Overgrowth (SIBO): “increase in the number and/or alteration in the type of bacteria in the upper gastrointestinal tract” (Bures et al., 2010). In plain language, your small intestine normally hosts beneficial Lactobacillus bacteria, but SIBO means that hydrogen-producing bacteria take hold and overgrow instead, sometimes accompanied with methane-producing archaea microbes, to complicate things more, with the latter adding constipation. When these microbes take hold, you will experience a lot of gut symptoms, and inflammation as well as gut permeability may take hold. Eventually, you stop being able to absorb nutrients, lose weight and become malnourished.

Small Intestinal Bacterial Overgrowth (SIBO) is not so much a disease and a cause as a syndrome of other things not being in balance and relates to gut/vagus nerve motility issues. If you look below at the protective mechanisms and then at the laundry list of medical conditions that can cause SIBO, you will appreciate how complex the case of each person can be.

The biggest challenge I see is that SIBO now is like Celiac was 30 years ago – you may have been misdiagnosed or wrongly diagnosed for months on end because not all doctors yet are aware of it. You may have gone from doctor to doctor and done a lot of testing, but no one can tell you what is wrong. Even worse, you may have been put on a wrong antibiotic or a wrong dose or duration of the right one…  Or your doctor never retested breath test.

Small Intestinal Bacterial Overgrowth literally breeds complications if you do not have experience in treating it. It is not a one time pass. Only about 1/3 of patients clear SIBO completely with one run of antimicrobials. Which means that 2/3 will need repeated therapy, depending on how high the hydrogen level is.

It is challenging BUT not impossible to tackle, but it depends on the reason you have SIBO. If you have scarring and adhesions from surgeries, no matter how many times you will clear SIBO, it will return unless you address these adhesions. One thing I have to say is: be patient. We may need a few rounds of herbal protocols and a few re-tests before we are successful. According to Dr Siebecker, ND, who did the ground work for global SIBO education and SIBO Symposiums and continues to educate us all, it may take up to 4 years to have a full success in some cases. We do have to treat SIBO as a possibly chronic syndrome.

When you are able to clear SIBO, you still need guidelines to not relapse, as relapse is very common and equally frustrating. Prevention of recurrence of SIBO depends on its original causes. It is as important as the treatment of it.

The worse cases are where the best we can do is manage the long term conditions behind SIBO and thus manage SIBO each time it returns. SIBO is frustrating….but patience pays off most of the time –  at the end of the day, it is SO WORTH IT to eradicate it.

How does your body keep you away from getting SIBO?

We normally have protective mechanisms that prevent small intestine from bacterial overgrowth. Here are some:

  • Gastric acid secretion
  • Intestinal motility
  • proper thyroid function
  • Intact ileo-ceacal valve
  • Immunoglobulins within intestinal secretion
  • Bacteriostatic properties of pancreatic and biliary secretion

What are risk factors for Small Intestinal Bacterial Overgrowth?

  • Achlorhydria (e.g. due to Gastric acid suppression medication use)
  • Pancreatic exocrine insufficiency or chronic pancreatitis
  • Immunodeficiency syndromes
  • Anatomical abnormalities (e.g. small intestinal obstruction, small or large intestinal diverticula, fistulae, surgical blind loop, redundant or torturous colon)
  • Motility disorders (e.g. scleroderma, autonomic neuropathy in diabetes mellitus, post-radiation enteropathy, small intestinal pseudo-obstruction, gastroparesis)
  • Celiac disease – this is particularly true if you have Celiac, but even though you are gluten free, you fail to improve
  • Crohn’s disease
  • Diabetes
  • Fibromyalgia
  • Gastric resection
  • Hypothyroidism
  • Interstitial cystitis
  • Irritable bowel syndrome
  • Recurrent antibiotic use
  • Renal failure
  • Rosacea
  • Restless leg syndrome
  • Surgical removal of the ileoceacal valve
  • There may be more causes…

Do you Test for SIBO? – Yes! Regardless where you live!

We provide breath test kits. We drop ship them to our patients all over the country! The golden standard is hydrogen breath test with lactulose substrate for 180 minutes of testing. Glucose substrate is also used but is less effective. Breath test is a non-invasive test that requires you to drink the substrate and exhale at 15-minute internals for 180 minutes to check for the presence of hydrogen and methane. Our small intestine does not produce those gases, so if we have a positive read, it means that the substrate was consumed by the microbes, which then produce these gasses as metabolism byproduct (to be exact, hydrogen is consumed by methane producers, so they rely on hydrogen producers for existence)…. Since I am not a medical doctor, I cannot prescribe medications, but I customize herbal protocols for my patients. You may be on antibiotics already, in which case, I provide the needed support.

Do You work with SIBO? Yes

Of course! I work with SIBO a lot. I started several years ago when I was at Hopkins Integrative Center working with a lot of Dr. Gerard Mullin’s complex patients, including his SIBO patients. And I have not stopped since. There is great need for clinicians familiar with SIBO, although in the most recent years, and with the number of annual SIBO Symposiums clinicians are now better prepared and more educated with SIBO then when I started. It is becoming such an epidemic! It seems that our intestinal track is taking a beating from stress, lifestyle, and poor food choices, especially changes in microbiome, and with the gut goes the immune system and health, plain and simple. Small intestine is the absorption site to most of your nutrients, so if SIBO has taken over, this can create a nasty cycle of malabsorption and malnutrition. To me SIBO epidemic reflects our times. We need support building up our gut, which means our immunity. That is where disease really starts.

How is SIBO treated? – it is completely customized.

I work with food and herbals. Diet is instrumental to turn SIBO symptoms down, but diet alone does not cause SIBO nor will diet alone not  eradicate it. Remember, you have an active overgrowth that is preventing your small intestines from absorbing most of your nutrients, adding inflammation and potential leaky gut to your plate. You will still need a treatment plan along with a dietary plan. Low FODMAP is the most successful type of protocol for SIBO although some people will follow other approaches. I find that people’s reactivity to food varies substantially even within the “allowed” food groups and rather than limiting diet to low FODMAPS, we want to expand food choices  as much as possible as long as they do not cause more symptoms. One common theme in SIBO is customization – we have to customize treatment for you. No two SIBO patients react the same way to the same foods and the same protocols. Treatment for SIBO is also complex and it takes time and patience. Repeating breath test is needed and timing of it is very important and depends on the type of treatment you underwent.

There are specific antibiotics that are commonly used for SIBO, while many health providers may choose herbal protocols instead. Some patients do well on one or the other. Some patients do well on antibiotics initially but become reactive later. Some patients cannot tolerate herbs. There is no one way that works for everyone. Dr Gerard Mullin was involved in a study suggesting that herbs are at least as effective as antibiotics (Chedid et al., 2014). While according to studies, only one in every 800 or so participants in research had to stop Xifaxan due to side effects, i have seen more cases of reactivity than that. At the end of the day, it really depends on one’s individual tolerance. Both have advocacy, benefits and disadvantages. SIBO prognosis is usually serious, and it has a high risk of recurrence – I have to honestly warn you about that. Recovery is typically a longer process, as the underlying causes of SIBO have to be addressed.

News on SIBO

A lot is happening in the medical community about what we know about SIBO. We know it is a motility issue and that one of the keys to SIBO is translocation of commensal (benign) colonic bacteria back into small intestine.  We also see that thousands and thousand people are affected by SIBO. What have we done to our food supply or lifestyle that is difference now that is causing this surge? We have already had 4 annual SIBO symposiums over the last 4 years, with the recordings accessible to both clinicians and patients, with updates, new tests, more clinical cases etc. You can purchase them here.  There is great need to educate doctors on the existence and proper treatment of SIBO, that’s for sure. If you have SIBO, you are likely far more educated on it and could teach a thing or two to your doctors!

Here is a video blog I recorded on the FDA approval  of Xifaxan – Xifaxan, IBS and SIBO from my video blog

Bures, J., Cyrany, J., Kohoutova, D., Forstl, M., Rejchrt, S., Kvetina, J., . . . Kopacova, M. (2010). Small intestinal bacterial overgrowth syndrome. World J Gastroenterol, 16(24), 2978-2990.

Chedid, V., Dhalla, S., Clarke, J. O., Roland, B. C., Dunbar, K. B., Koh, J., . . . Mullin, G. E. (2014). Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth. Glob Adv Health Med, 3(3), 16-24. doi: 10.7453/gahmj.2014.019

Pimentel M. A New IBS Solution. Sherman Oaks, Calif.: Health Point Press; 2006.


We plan to continue using Kasia’s nutritional guidance as an ongoing part of our health care and would highly recommend her services.~ P.S.