I recently posted the following about tests and treatments ive looked into and done in searching for the cause of fat in stool and other gi issues, since you mention fat in stools i figure it might interest you,
https://forums.phoenixrising.me/threads/pale-stool-and-bile-salts.79969/#post-2274251
though you're right, chances seem good it's sibo causing the fat in stool as sibo came up quite frequently as a cause of fat in stool on the websites i looked through that listed causes of fat in stool
Have you had an xray or other investigations of the small intestine done? Maybe you have some structural issue?
Also, if i remember correctly there is a test that can be run of the MMC but it isn't done frequently, I remember Allison Seibecker mentioning it, if prokinetics work and it looks like you will need them permanently then it might be something worth looking into
Finally, I put this together to use myself for figuring out what to do about sibo. I mainly took anything i thought might be useful from webinars, conferences, books, etc. and put them in different sections so i could boil it down into the most important things to focus on though I didn't include that summary section of the document here and the info was selected for whether or not it was useful to the part of sibo I've focused on so I might well not have saved much about hydrogen sulfide since none of my sibo breath tests showed a flatline. if you open below links and run a search for hydrogen sulfide you might find useful stuff i didn't save. Anyway, it's not meant as medical advice, I didn't look heavily into the background of the doctors and read all of their articles or anything but am posting this in hopes it might provide ideas, options for tests/treatments to investigate or things to look out for that might cause issues during treatment. There is a decent bit in this on prokinetics of various kinds as well
hope it helps
http://scdiet.scdrecipe.com/scdarchive/7archives/scd1/scd037.html
From someone who had CFS and probably SIBO as he has stated: I have been able to control the proliferation of this bacteria by eliminating its food source through Elaine's diet.
Through the help of a Naturopath I have changed the intestinal environment so that it is more
acidic and not alkaline. Pathogenic bacteria do not thrive in an acidic environment. I have added lemon juice(freshly squeezed) and ginger extract along with colloidal bentonite clay, digestive
enzymes, vitamins and minerals under the guidance of Dr. Jack Larmer N.D.
{02} SCDlifestyle
What to do if sibo test comes up methane dominant https://scdlifestyle.com/2017/05/new-solution-for-sibo/#more-13520
https://secure-hwcdn.libsyn.com/p/a...09700934&hwt=287bbf5984d5c54676694532eda3b356
SIBO webinar
This one features a Dr. who specializes in SIBO
The doc says she prefers a hydrogen/methane breath test that goes on for 3 hrs as all the research studies done have been w/ 3 hr tests and there have been cases where, had she not done the 3 hr testing, she would have had a false negative.
Says she prefers, when doing a breath test, to use lactulose as opposed to glucose as lactulose will reveal SIBO in the lower small intestine where as glucose wont. She says she has found lower small intestine sibo more commonly than higher small intestine sibo. Glucose is all absorbed in the first two feet so it wont show you the lower small intestine.
The lactulose will feed the small intestinal bacteria if they are there, that is how the gas is produced by feeding those bacteria but be aware you may feel temporarily worse
She strongly rec a followup breath test to make sure it is gone. If you are using a quick killing method like antibiotics, herbal antibiotics, or elemental diet you should do your followup breath test within two weeks after the last day of the quick killing method you used, preferably within 5 days, this quick followup is because the bacteria can recolonize the gut in around two weeks after your quick killing method if it is going to recolonize so you want to get the breath test done quickly to know how much of an impact your intervention had on the microbes
Mentions that elemental diets may not work if you have SIBO all the way up to your stomach as at that point the microbes might be absorbing the nutrients, elemental diets work best on lower small intestinal sibo as the nutrients in the elemental diet are predigested and will be absorbed very early on in the digestive tract, maybe even before the small intestine altogether, don’t know, she didn’t specify that clearly
Says that she often sees cases where diet isn’t enough to fix SIBO and where antibiotics are needed, these cases are often the ones who have constipation and are methane predominant, says methane predominant ones are in general much harder to treat and she will often need to use all three methods(antibiotics, herbal antibiotics, and elemental diet) in succession to treat them
She says that nuts, beans, lots of carbohydrates(from fruits), and yogurt seem to cause a lot of problems for scd people
Says that SIBO can cause fructose malabsorption which will leave fructose available for the bacteria to feed on which is why some scd people can have issues w/ honey
Says that Dr. Haas, the inventor of the diet, went very slow with veggies and fruits when introducing them.
Says that the soonest any of the cases of Dr Haas got over their symptoms on the diet was 3 months, it takes a long time, some people feel really well early on but they will take months to several years to become symptom free
Mentions prokinetics: erythromycyin and acitromycin or something, says that they are antibiotics but are used at levels where they wont function as antibiotics, you have to go to a compounding pharmacy to get them at these low doses. These prokinetics may be needed to fix your sibo or it may be that hydrochloric acid is needed or bitters or ACV and water to increase the HCL or that enzymes are needed. Alternative to prokinetics you could go to an acupuncturist and have them treat you for gastroparesis, which is also known as stomach paralysis, and there are some good studies showing that acupuncture can work for that.
Try and take 3-5 hrs between meals in the day to increase MMC, take things to increase MMC right before bed as the MMC is most active during sleep
{03} BTVC book
quite early in SIBO the normal absorption of vitamin B12 is disturbed. There is considerable evidence that B12 is poorly absorbed in microbes multiplying within the small intestine prevent uptake by the ileum. P 13
problems resulting from bacterial fermentation are: (one) production of excess amounts of short-chain volatile fatty acids (organic acids); (two) lowering of the pH of the blood as these acids are absorbed; (three) overgrowth of bacteria as the undigested carbohydrates provide food for bacterial proliferation; (four) mutation of some bacteria such as E. coli because of the change in pH in their colonic environment; and (five) excess toxin production caused by the overgrowth of some pathological bacteria P 55
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3752184/
FROM A PUBMED ARTICLE ON SIBO
THIS DATA IS ON THE CAUSES OF SIBO
Gastric achlorhydria
Due to long term use of a proton pump inhibitor [
Lombardo et al. 2010;
Compare et al. 2011;
Hamvas, 2012] or autoimmune etiology (chronic atrophic gastritis)
Anatomic abnormality of the small intestine with stagnation
Afferent limb of Billroth II gastrojejunostomy, small intestine diverticula [
Krishnamurthy et al. 1983], obstruction, surgical blind loop, radiation enteritis
Small intestine motility disorder
Diabetic autonomic neuropathy, scleroderma, chronic intestinal pseudo-obstruction, small bowel diverticulosis, irritable bowel syndrome (IBS) [
Pimentel et al. 2000]
Gastrocolic or coloenteric fistula
Crohn’s disease [
Funayama et al. 1999], malignancy, surgical resection
Miscellaneous
AIDS, chronic pancreatitis (in 30–40% of cases [
Trespi and Ferrieri, 1999]), liver cirrhosis (in up to 60% of patients), IgA deficiency, combined variable immunodeficiency, nonalchoholic steatohepatitis [
Compare et al. 2012;
Machado and Cortez-Pinto, 2012], fibromyalgia, celiac disease [
Ghoshal et al. 2004;
Krauss and Schuppan, 2006]
THIS DATA IS FROM THE TREATMENT SECTION:
In many patients, it is necessary to exclude lactose from the diet, to reduce other simple sugars, to increase coverage of energy needs by fat and to administer medium-chain triacylglycerol (MCT) oils [
Bures et al. 2010]. In cases where there is decreased motility, such as chronic pseudo-obstruction, methods to enhance motility can be attempted. Prokinetic agents that are commonly used and are available in the US include metoclopramide and erythromycin.
THIS IS FROM THE TREATMENT SECTION AS WELL, IT REC USING ANTIBIOTICS:
There is no common agreement concerning the choice, dosing and duration of antibiotic therapy. Broad spectrum antibiotics which affect enteric aerobes and anaerobes and numerous choices are available (
Box 3). These include ciprofloxacin, norfloxacin, amoxicillin/clavulanate, metronidazole, cephalexin and more recently rifaximin. Rifaximin has gained popularity since it is nonabsorbed, has few side effects and little evidence for resistance [
Frissora and Cash, 2007;
Koo and Dupont, 2010]. Rifaximin may therefore be the antibiotic of choice as clinical resistance is seen far less frequent than with other antibiotics
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2890937/
Bacteria in SIBO might significantly interfere with enzymatic, absorptive and metabolic actions of a human. Due to injury of the brush-border of enterocytes, the activity of disaccharideses may be decreased. If bacteria simultaneously metabolise fructose, lactose and sorbitol, malabsorption of saccharides may occur. Injured small intestinal mucosa can have undesirable consequences in increased intestinal permeability and/or protein-losing enteropathy. Deficiency of vitamin B12 results from the consumption of this vitamin by anaerobic micro-organisms. Bacteria may also utilise intraluminal protein in the small bowel, this may lead to protein deficiency for the macro-organism and excessive production of ammonia by bacteria. Deconjugation of bile acids by bacteria results in malabsorption of fat and liposoluble vitamins. Extensively formed lithocholic acid is poorly absorbable and acts enterotoxically
Bacteria produce various toxic agents that may have surprising systemic effects. These agents are ammonia, D-lactate, endogenous bacterial peptidoglycans and others.
SIBO is regularly associated with increased serum endotoxin and bacterial compounds stimulating production of (pro)inflammatory cytokines[
7,
96]. SIBO might be associated with endogenous production of ethanol (probably synthesised by
Candida albicans and
Saccharomyces cerevisiae). Serum ethanol disappears after successful treatment of SIBO
SIBO may be clinically asymptomatic or can resemble irritable bowel syndrome with non-specific symptoms (bloating, flatulence, abdominal discomfort, diarrhoea, abdominal pain). In more severe cases, there are signs of malabsorption (weight loss, steatorrhoea, malnutrition), liver lesion, skin manifestation (rosacea), arthralgias and deficiency syndromes (anaemia, tetany in hypocalcaemia induced by vitamin D deficiency, metabolic bone disease, polyneuropathy due to vitamin B12 deficiency, impaired barrier function of the gut,
etc.). Anaemia is usually macrocytic (megaloblastic) due to vitamin B12 deficiency. It could also be microcytic iron deficiency
(due to occult gastrointestinal blood loss)[could this be the cause of my occult blood] or normocytic (as anaemia of chronic disease)
The most important thing is always treatment of the basic underlying disease if possible. Nutritional support is mandatory in SIBO associated with malnutrition, weight loss and nutrient deficiency. We usually use individualised diet, enteral nutrition by fine-bore naso-jejunal tube or nutritional support by sipping of polymeric formulas. In several patients, it is necessary to exclude lactose from the diet, to reduce other simple sugars,
to increase coverage of energy needs by fat and to administer MCT oils (medium-chain triacylglyceroles).
Prokinetics seem to be a logical therapeutic step in SIBO due to motility disorders. Several studies tried metoclopramide, cisapride (which was later withdrawn from the market), domperidone, erythromycin, itopride, tegaserod and octreotide.
However, there are only limited data suggesting that this treatment would be effective over the long term[7,71]. Cyclic lavages of the small bowel (e.g. by polyethylene glycol) can be considered as supportive therapy in cases of relapsing SIBO[
7].
Surgical treatment must always be considered where possible to correct gastrointestinal pathology (entero-colic fistulae, blind loops, bowel obstruction, multiple small intestinal diverticula,
etc.). Specialised non-transplant surgery can provide interventions in short bowel syndrome improving intestinal motility (STEP - serial transverse enteroplasty), slowing intestinal transit (valves, reversed segments, colon interposition) or increasing mucosal surface area of the gut (creation of “neo-mucosa”, sequential intestinal lengthening)
file:///C:/Users/YAYA/Pictures/Dr_Allison_Siebecker.pdf
dr siebecker rec the elemental diet formula Vivonex Plus which dr Pimentel uses in his research and has found to have a high success rate for eradicating SIBO, about the same 80-90 percent success rate that pharmaceutical antibiotics(rifaxamin) have, she also says that herbal antibiotics have a similar success rate in her practice but that there aren’t studies around to say that they are as good.
Says when she is using the elemental diet she has the patient do it for 2 weeks and does an in house sibo breath test on the 14th day and if it’s still positive then she has them continue for another week. Says it is difficult to do elemental diet, some people feel hungry the whole time and the powder tastes bad
She likes to test the patient in 5-14 days after the treatment of antibiotics has concluded as it takes around 14 days for the gut bacteria to regrow and if you test before it regrows you can tell if your treatment is making a difference or if it is failing, for instance, if your treatment brings your gut’s hydrogen gas down by 40 points it is doing something and you should continue using that same treatment, you just didn’t use it long enough in other words(or maybe you did if bringing it down by 40 points brings it down all the way but if it brings it down only part way and the test is still positive for sibo you need more of your treatment), but if the gas didn’t even budge you’ll have to try something else
Says a lot of patients come to her from other doctors who have been treated with xifaxan and felt immensely well for several weeks or months only to relapse and she will ask if they used a prokinetic and typically their lack of prokinetic use turns out to be the issue
Rec clover honey, says a number of honeys aren’t tolerated by people who malabsorb fructose but that clover honey is just fine for fructose malabsorbers as are any other honeys which are 50% glucose/50% fructose.
Says she sees patients who have been on SCD or GAPS for years and years and who still have SIBO despite, so, diet alone is seldom enough to eradicate SIBO
The guy above who interviewed dr siebecker also has a full package of similar digestion experts he interviewed available for $100
https://shivansarna.simplero.com/purchase/65272-2nd-SIBO-SOS-All-Access-Pass
$400 for full access to large amounts of SIBO info, should be last resort
If it turns out
http://www.townsendletter.com/index.htm was right about needing either an antibiotic or a year and a half on scd to eliminate sibo consider subscribing to them
https://www.medicinenet.com/small_intestinal_bacterial_overgrowth_sibo/article.htm
Stuff caused by sibo:
Malnutrition may result in weight loss, and progress to excessive muscle wasting (cachexia). Inability to absorb
fats in the
diet may lead to steatorrhea (excess fat in the feces) that results in foul smelling oily stool, and may cause some anal leakage or
fecal incontinence.
https://universityhealthnews.com/da...ine-with-a-sibo-diet-for-even-better-results/
A group of 104 patients who tested positive for newly diagnosed SIBO took either a standard, high dose of rifaximin (1200 mg daily) or two capsules twice daily of
each of the two supplements in one of the two following herbal protocols:
The products were specifically chosen because they contained antimicrobial herbs, such as oil of oregano, thyme, berberine extracts, and wormwood, shown to provide broad-spectrum coverage against the types of bacteria most commonly involved in SIBO.
Of the patients who received herbal therapy, 46 percent showed no evidence of SIBO on follow up testing compared to 34 percent of rifaximin users. Those using a natural SIBO treatment were significantly more likely to test negative for SIBO at follow up than those taking rifaximin.
The participants who did not improve on the rifaximin were then prescribed either one of the herbal protocols or triple antibiotics (clindamycin, metronidazole, neomycin) for four additional weeks. Of the 31.8 percent of rifaximin non-responders that then took the herbal therapy, 57.1 percent tested negative for SIBO compared to 60% of those taking the triple antibiotic therapy.
Adverse effects reported among those taking rifaximin included anaphylaxis, hives,
diarrhea, and Clostridium difficile, while only one case of diarrhea and no other side effects were reported in the herbal therapy group.
“Herbal therapies are at least as effective as rifaximin for resolution of SIBO …” concluded the study authors.
(lane’s note: study is below with relevan data posted
https://www.ncbi.nlm.nih.gov/pubmed/?term=24891990
One hundred and four patients who tested positive for newly diagnosed SIBO by lactulose breath testing (LBT) were offered either rifaximin 1200 mg daily vs herbal therapy for 4 weeks with repeat LBT post-treatment.
SIBO is widely prevalent in a tertiary referral gastroenterology practice. Herbal therapies are at least as effective as rifaximin for resolution of SIBO by LBT. Herbals also appear to be as effective as triple antibiotic therapy for SIBO rescue therapy for rifaximin non-responders. Further, prospective studies are needed to validate these findings and explore additional alternative therapies in patients with refractory SIBO.
https://feedmephoebe.com/the-best-natural-sibo-treatments/
1. Antibiotics (2 weeks)
There are several pharmaceutical antibiotics which are commonly prescribed for SIBO: Neomycin (better for Methane dominant), Metronidazole, and Rifaximin. The benefits of antibiotics top out after 3 weeks, so a 2 week course is the sweet spot.
Rifaximin (generic: Xifaxan) has the best reputation of the group, even among naturopaths, as it’s an antibiotic with “
eubiotic effects.” It specifically targets the area we need to eradicate—only killing bacteria in small intestine. According to studies, the side effects are mild and the die-off of beneficial species of bacteria in the colon is minimal. For those who are wary of antibiotics, this
isn’t a bad one.
However, the main problem with Rifaximin (and all other pharma options in this category) is that with repeat use, you increase the likelihood of becoming resistant. Meaning, it might be worth one try, but you don’t want to get into a cycle of use, especially when there are other natural options that have been
proven equally effective with fewer long-term risks.
2. Herbal Antibiotics (4 – 6 weeks)
People don’t necessarily gravitate towards herbal options just because they’re more “natural.” Rather, certain combinations of herbal antibiotics have been proven in studies to be just as effective, if not more effective than their pharma counterparts.
The downside: more pills, for longer, with the possibility of GI side effects. Just because herbs are natural doesn’t mean they’ll be tolerated by everyone. I certainly experienced discomfort and an increase in my constipation symptoms while on the
Biotics formula.
The upside? You can purchase these herbs without a prescription and experiment on your own. Which, considering you can now take a
SIBO test at home, is an affordable option for those who aren’t able to invest in the helping hand of an integrative doctor.
So what are the best protocols for herbal antibiotics? The two most commonly used herbal blends in
Dr. Alison Siebecker’s practice, who is commonly thought of as the pioneer of SIBO, are:
Metagenics Candibactin-AR +
Candibactin-BR (this is the most studied option)
Biotics FC Cidal +
Dysbiocide (the one I used!)
Typical dosing is:
2 caps, twice a day, for 4 weeks. For what it’s worth, I did the Biotics system for 6 weeks.
The two protocols above combine several individual herbs that are thought to be helpful, including berberine herbs, ginger and oregano. There’s definitely a big pro to having a formula already sussed out for you. But another route is to design your own treatment using a
combination of the below herbs. Dr. Allison Siebecker recommends
1-3 in combination, for 4 weeks, at highest dose suggested on product labels.
Allicin: Though it’s derived from garlic, this strong antimicrobial doesn’t contain the FODMAP’s found in other parts of the clove. The highest potency formula is
Allimed. This is the only single use herb that’s been studied with SIBO, and was found to be effective for methane-dominant SIBO. It can be added to one of the above protocols, or used in conjunction with Berberine and Neem.
Berberine Complex: these herbs are also found in the Metagenics formula. It’s derived from Goldenseal, Oregon Grape, Barberry, and other herbs. Many use this in conjunction with oil of oregano and neem for hydrogen-dominant SIBO.
Neem Plus: Neem is a tropical evergreen tree and is said to enhance the positive effects of the two herbs above.
Oil of Oregano: This herb has been known as a longtime antifungal, antimicrobial, antiviral powerhouse. During my Biotics protocol, I habitually added two drops to my water or took a veggie capsule of it with my other pills.
3. The Elemental Diet (2 weeks)
If all else fails, there’s always the elemental diet. It is thought of as a last resort because of the extreme unfun-ness of the protocol, which involves drinking a
medical solution for all meals for a 14 day period. I can’t imagine ever doing this, but it’s a relatively quick strategy that’s proven 85 percent effective at starving out the bacteria, while, on a purely elemental level, feeding the person.
The mixture includes liquid nutrients in an easily assimilated form that is used in hospitals on GI patients whose system needs to heal. The nutrients get absorbed quickly and easily in the first leg of the digestive labyrinth, meaning they never make it to the area of the small intestines where unwanted bacteria congregates in SIBO patients.
The protocol is suggested for 14 days, with a retest taking place on the 15th day. Overnight results should be requested so that you can immediately start the diet for an additional week if there’s still a positive.
Again, this is if all other protocols fail. It’s not recommended to take antibiotics or herbs during the elemental diet because the bacteria, without food sources, will essentially be hibernating or die off on their own, as intended by the diet
Iberogast:
https://smile.amazon.com/Iberogast-...eywords=stw+5&qid=1554637413&s=gateway&sr=8-2
Iberogast oral drops 100ml Iberogast oral drops is a herbal medicine formulated to treat digestive disorders, gastritis, stomach pain, abdominal bloating, flatulence, gastrointestinal colic, nausea and also heartburn. In the composition of Iberogast oral drops a variety of medicinal plants that their joint action allows to effectively combat the symptoms mentioned above. These plants are as follows: Angelica archangelica L. (angelica) Melissa officinalis L. (melissa) Carum carvi L. (caraway) Chelidonium majus L. (celidonia) Chelidonium majus L. (licorice) Matricaria recutita L. (chamomile) Silybum marianum L. Gaertner (Marian thistle) Mentha piperita L. (peppermint)
The dosage, dosage and method of use of Iberogast oral drops are detailed below: in adults, adolescents and children over 12 years must take 20 drops of Iberogast, 3 times daily before or after meals, mixing the drops with a little liquid. If after 2 weeks of treatment the symptoms do not get better or worse you should consult your doctor. The most common side effects of Iberogast oral drops are very few and very unusual: have reported hypersensitivity skin reactions such as rashes, itching or respiratory discomfort.
100 servings per bottle
https://smile.amazon.com/gp/custome...iewpnt?ie=UTF8&ASIN=B00FMZGWZK#R182GRQXDZFDAN
I have taken FC-Cidal and Disbiocide by Biotics Research. The two work well to cure SIBO. However you need to take this between meals and not with food. I've tried it both ways and found it didn't work when I took it with meals. You also need to lower your carbohydrate intake. This last round I discovered that sugar and fruit do not aggravate SIBO but bread products certainly do. I suspect simple sugars and fruit are absorbed before they reach the site of infection (distal small intestine) where bread products are still present and feed the bacteria. That would also explain my observation that if I eat a lot of non-fruit carbohydrates I develop SIBO again a lot sooner than if I just stick to fruit.
The beneficial effects of these bacteria are eradicated when large numbers of foreign bacteria – chiefly those which are found in the large intestine – begin to grow in the small intestine. Once the small intestine is colonized by these strains, there is a multitude of consequences. The orderly process of digestion is now undermined by bacteria that deconjugate bile before it can be used, leading to an inability to digest fats and producing nausea and cholecystitis-like symptoms. Carbohydrates, which are normally broken down in the large intestine, are now fermented in the jejunum, leading to bloating, distension and gas. Moreover, the action of these bacteria on proteins leads to excess ammonia production, which, in essence, acts like a poison if not adequately cleared from the system. Once digestion is impaired (dysbiosis), deficiencies of fat soluble vitamins (A, D, E), as well as deficiencies of B12, thiamine (B1), and nicotinamide (an amine of B3 involved in cognitive function) will result. Most deleterious of all is the resultant inflammation of the lining of the intestine, which leads to malabsorption, leaky gut, immune system upregulation and numerous food allergies and sensitivities. Because SIBO affects every aspect of small intestine digestive function, it produces a wide range of GI symptoms: diarrhea, weight loss, GI pain, anemia. SIBO has also been linked to the inflammatory skin condition, rosacea. Several studies have shown that once SIBO is treated, rosacea disappears.
Joint pain related to inflammation also improves dramatically when SIBO is treated. Interestingly, treatment of SIBO improves cognitive symptoms in CFS/ ME patients, providing further evidence of the link between the gut and the brain. The most common cause of SIBO is antibiotic treatment. Slow motility can also lead to SIBO as can hypochlorhydria. Diagnosis of SIBO is made through breath testing. Because Xifaxan is a non-systemic antibiotic, it is currently the drug of choice for treating SIBO. Generally, antibiotic treatments are given for one week once a month until the infection has cleared. The second line of treatment, often given simultaneously and/ or immediately after treatment with antibiotics, is probiotics. In milder cases of SIBO, antibiotics may be skipped altogether in favor of a probiotic course of treatment. Probiotics of varying strains have been used for treating SIBO, but the more successful varieties have been Acidophilus GG (marketed as Culturelle), and Bifidobacterium infantis (marketed as Align).
Follow a low-carbohydrate diet. Enteric-coated peppermint oil has been shown to be lethal to bacteria. In one case study, only ten days of treatment with enteric-coated peppermint oil resulted in not only a significant reduction in hydrogen production in the hydrogen breath test, but a reduction in bloating, pain, and belching. It is important to note that the peppermint oil must be enteric coated in order to avoid heartburn. Increase stomach acid. Hypochloridia is so common in CFS/ ME patients that low stomach acid is among the most likely culprits of SIBO. Fortunately, increasing stomach acid is fairly easy. Supplementation with
Betaine Hydrochloride (HCl ) will increase stomach acid and aid the production on pancreatic enzymes. Start with one tablet with a meal. If you get heartburn, stop and try again in a week or so.
(Don't take the supplement before or after the meal, but during.) Stomach acid can also be aided by taking vitamin C with a meal, or by sipping a dilution of apple cider vinegar (1-2 TBS to 4 oz water.) Pancreatic enzymes are important adjuncts in SIBO treatments. Enzymes are frequently under-utilized in people with SIBO, due to hypochloridia and bacterial deconjugation of bile. Supplementation with Ultrazyme or another broad spectrum enzyme will aid the process of digestion
Alpha Ketoglutarate rec for aid in krebs cycle(ATP production), for fighting SIBO, strengthening intestinal mucosa, and producing several nonessential amino acids(lots more info on AKG in section)
finally a weak ileocecal valve (the valve that separates the bacteria rich: contents from the ileum, the final segment of the small intestine) can lead to overpopulation ans small intestinal bacteria. A weak ileocecal valve is most often the consequence of long-term constipation or straining excessively at defecation; in both these cases a low fiber diet is most often responsible.
From Valerie balandra: mentions biocidin as an antimicrobial for sibo, she also rec rifaxamin for it
Dr mark Pimentel on chris kresser
https://secure-hwcdn.libsyn.com/p/d...25257129&hwt=0713d165afb35c033b39387a5630c8af
any methane rise over 3ppm in breath test is 90% of the time a positive test
2/3rds of SIBO patients relapse after rifaximin(and I think for that matter any antimicrobial for sibo), those that relapse within a week or two often have issues going beyond a weak migrating motor complex, something like damage to the gut systems that would need to be investigated
Says rifaximin doesn’t affect the microbes in the colon for some unknown reason, it works fine in the small intestine but is rendered ineffective once it enters the colon. Rifaximin isn’t causing increase in yeast or any sort of change whatsoever in the microbiome of the colon
Bacteria are much more vulnerable when they are able to eat, when they aren’t able to eat they go into dormant mode and wall themselves off making it hard for the antibiotics to harm them. When you give guar gum or other prebiotics they start eating and their defenses go down. Patients shouldn’t be eating low fodmap or low carb diets while on rifaximin or other antibiotics that are designed to treat sibo.
As for prokinetics he doesn’t like to use don peridon(might have misspelled) b/c of heart related side effects. The two he uses is very low dose erythromycin, at that dose it is prokinetic without any antibiotic effects(erythromycin is usu a antibiotic), resalor(maybe misspelled) is the other prokinetic he uses.
Rifaximin can be used over and over again, it causes very little resistance and when resistance does come about it disappears within a week.
{08} misc from curezone(med list overall doc)
http://forums.phoenixrising.me/inde...he-upper-gut-be-worthwhile.52537/#post-869705
I will share with you what I believe are the most important things that have and are helping me. #1- diet- 95% starch free. #2- Rifaximin- I took a 10 day course and a 15 day course at 1,200mg a day.
That brought down the bacterial overgrowth and allowed me to tolerate a high enough dose of antimicrobial herbs like oil of oregano, berberine, cinnamon, thyme, amla and grape seed extract. If you can't get Rifaximin, high doses of herbs have been shown to work just as well.
#3- I take a high dose probiotic (60 billion cfu). That is basically my protocol. I have learned through trail and error, that a very low starch diet and fairly high doses of
STRONG antimicrobial herbs, long term, are absolutely necessary to get rid of sibo.
By long term, I mean at least 6 months or even longer. I'm 4 months in and just really noticing some big improvements. I have been very strict with both diet and anti-microbials but I also got a big jump start with the Rifaximin.
Like I said though, if you can tolerate fairly high doses of antimicrobial herbs, they are just as effective, but take longer to work. I think you will need very strong antimicrobials like oil of oregano, neem, thyme, cinnamon extract, at fairly high doses to get sibo/dysbiosis under control, based on my experience, but it IS do-able!
{09} Genova
SIBO clinical considerations gdx
https://www.gdx.net/clinicians/medi...ebinars/small-intestinal-bacterial-overgrowth
Lactulose is a synthetic sugar that wont pass through the gut wall and so will only be digested by gut bacteria, when the breath test results come back and the levels rise slowly to a single peak at or near the end that is likely not SIBO but when it rises to a peak near the beginning, goes down, and rises again to a peak that represents SIBO as the small bowel produced the first peak which then receded as the lactulose passed through an uncolonized part of the small bowel before reaching the colon which is supposed to be colonized.
The small intestine aspirate and fluid culture, something done by the mayo clinic, involves passing a tube through the upper gut into the small intestines to take a culture from there to be grown out, this test unfortunately has many false negatives.
Breath tests should look for more than hydrogen alone since in many people hydrogen gets converted into methane. So by getting a test that includes both hydrogen and methane you avoid false negatives.
Sibo therapeutic interventions
- Rifaximin
- Rifaximin in combination with other antibiotics (neomycin)
- For methane predominant SIBO
- Herbal antibiotics
- Dietary interventions
- Low FODMAPs
- Low Carbohydrate diet
- Elemental diets
Another option is to treat the underlying cause such as maldigestion(hypochlorhydria/pancreatic insufficiency), motility issues, poor diet (high starch/refined carbs)
“while there has only been one published report of herbal antibiotics in the treatment of SIBO, our experience is that they have similar effectiveness to antibiotics. We have used the following botanicals: Allium sativum, Hydrastis Canadensis, and other berberine containing herbs, Origanum vulgare, cinnamon, and azadirachta indica. We have used these as both single angents and in various combinations at dosages that are at the upper end of lael suggestions x 30 days. Specific single dosages we have used include allicin extract of garlic: 450 mg b.i.d.-t.i.d., goldenseal/berberine: 5g q.d. in split dosage, emulsified oregano: 100mg b.i.d., and neem: 300mg t.i.d. our breath testing has validate the need for the longer treatment period of 30 days for herbal antibiotics compared with 14 days for antibiotics. We have also observed with this method prolonged dio-off reactions, which can last for the duration of treatment course. Studies on herbal antibiotics for SIBO are needed, particularly to identify botanicals effective in reducing methane.
from
http://www.townsendletter.com/FebMarch2013/ibs0213.html
Other tests that may be helpful in the case of SIBO:
Pancreatic insufficiency
Inflammation
Dysbiosis
Yeast overgrowth
Parasitic infection
- Food antibody panel
- Celiac and gluten sensitivity panel
Important:
GI effects profile can
not identify SIBO
There are markers on this profile that can be suggestive of SIBO in the right patient population:
- Elevations in products of protein breakdown
- Elevations in fecal fats (due to interrupted enterohepatic recirculation
- Unexpected or extreme elevations in beneficial SCFAs and n-butyrate
If any of these is elevated and the patient is symptomatic you may consider doing a SIBO breath test to be definitive
Nutritional testing (nutreval/ION) if you suspect SIBO is causing deficiencies on the level of B vitamin status, fatty acid profile, fat soluble vitamin status.
Additionally, if you suspect leaky gut has arisen from prolonged SIBO leading to gut damage(leaky gut) you may run an Intestinal permeability panel and a Food antibody panel
When working to eliminate SIBO probiotics are a good thing to take but make sure there are no prebiotics taken as part of that same capsule or separately, prebiotics are meant to feed bacteria in general and wont distinguish between helping probiotics and pathogenic bacteria. Prebiotics are things like FOS, inulin, arabinogalactan, and GOS (galactoligosaccharide).. Though if the patient gets worse on probiotics then it might be a good idea to back off on them
From
http://www.townsendletter.com/FebMarch2013/ibs0213.html
(If it turns out
http://www.townsendletter.com/index.htm was right about needing either an antibiotic or a year and a half on scd to eliminate sibo consider subscribing to them)
The following may indicate SIBO:
• when a patient develops IBS following a bout of acute gastroenteritis.
• when a patient reports dramatic transient improvement in IBS symptoms after antibiotic treatment
• when a patient reports worsening of IBS symptoms from ingesting probiotic supplements which also contain
prebiotics
• when a patient reports that eating more fiber increases constipation and other IBS symptoms
• when a celiac patient reports insufficient improvement in digestive symptoms even when following a gluten-free diet
• when a patient develops constipation type IBS (IBS-C) after taking opiates
• when a patient has chronic low ferritin levels with no other apparent cause
An important protective mechanism against SIBO is proper small intestine motility via the migrating motor complex because stasis promotes bacterial growth.18 Also key in prevention is gastric, pancreatic, and gall bladder secretion, since hydrochloric acid, enzymes, and bile are bactericidal/static.19 The use of proton pump inhibitors encourages overgrowth, especially of the hydrogen producing type.20,21
We also suspect an important role for proper ileocecal valve function in preventing reflux of colonic bacteria into the small intestine.22
Methane has been shown to slow gastrointestinal motility by 59% in animal studies, and the volume of methane overproduction correlates with the severity of constipation
Therefore when both hydrogen and methane are present, diarrhea, constipation, or a mixture of both can be present based on the relative amounts of gases.29
The bacterial consumption and uptake of host nutrients, such as B12 and iron, can lead to macrocytic and/or microcytic anemia or chronic low ferritin, in addition to general malabsorption and malnutrition in more severe cases.8,33 Finally, continuous fermentation of host nutrition by repeated exposure to daily meals, perpetuates bacterial overgrowth and its symptoms, creating a vicious cycle
Preparation for the (hydrogen/methane breath) test varies from lab to lab, but a typical prep diet is limited to white rice, fish/poultry/meat, eggs, clear beef or chicken broth (not bone broth or bouillon), oil, salt, and pepper. The purpose of the prep diet is to get a clear reaction to the test solution by reducing fermentable foods the day before. In some cases, two days of prep diet may be needed to reduce baseline gases to negative. Antibiotics should not be used for at least 2 weeks prior to an initial test; some sources recommend 4 weeks.39
We have found that an absolute level of gases at or above the positive ppm levels provided by Quin Tron, without a rise over baseline, correlates well with clinical SIBO. This is especially true for methane gas, which can have a pattern of elevated baseline (over 12 ppm) which remains elevated for the duration of the test. In cases such as these, methane may only rise 5 ppm over baseline, but the ppm level is consistently above positive. Interpretation of elevated hydrogen or methane on the baseline specimen (pre-lactulose ingestion) is controversial, but we prefer to consider a high baseline to be a positive test.31,40
The classic positive for SIBO has been considered to be a double peak, with the first peak representing the SIBO and the second peak representing the normal large intestine bacteria. This is an infrequent presentation in our experience. More frequently we see one peak that rises highest in the third hour, representing distal SIBO and then the normal LI bacteria.
If the measured gases do not rise until after 120 minutes, it is possible that this is due to a prolonged transit time, which we have seen in patients with severe constipation. In such a patient with the expected symptom picture for constipation type SIBO, a significant rise at 140 minutes may be interpreted as a positive test.
SCD(specific carbohydrate diet) or (GAPS) Gut and psychology syndrome diet are rec for sibo patients
We have found that using the SCD or Gut and Psychology Syndrome Diet (GAPS) as the core diet (Table 1), with the incorporation of the fruit and vegetable recommendations from the Low FODMAP Diet (Table 2), is an effective approach. The Low FODMAP Diet is an IBS treatment diet that has investigated the fermentable levels of carbohydrate foods (fruits, vegetables, and grains) and has a success rate of 76%.47 The FODMAP Diet is not specifically designed for SIBO and therefore does not eliminate polysaccharide and disaccharide sources such as grains, starch, starchy vegetables, and sucrose. Eliminating these poly- and disaccharides is essential in SIBO because SIBO creates a situation in which these normally well-absorbed carbohydrates, foods that usually go to feed the host, can now feed bacteria inappropriately located in the small intestine, creating symptoms and worsening the problem
Low-carbohydrate diets are weight-loss diets. Particular attention must be paid to those who are low weight or underweight. If a low-carb SIBO diet is causing too much weight loss, this dietary strategy will need to be altered to allow for more carbohydrates. In these circumstances, one or more of the other three treatment options should be considered along with white rice, glucose, and other carbohydrate sources.
Diet is also essential for prevention, post SIBO treatment.
Elemental Diet
An elemental diet can be used in place of antibiotics or herbal antibiotics to rapidly decrease bacteria. Elemental diets are powdered predigested nutrients that are mixed with water and used in hospitals for various gastrointestinal disorders to give digestion a rest. The concept behind this treatment for SIBO is that the nutrients will be absorbed before having a chance to feed the bacteria, thus feeding the person but starving the bacteria. It is used in place of all meals, for 2 to 3 weeks, and has a success rate of 80% to 85%.48 Elemental diets are not protein powders or cleansing/detox formulas. They are available over the counter and are not covered by insurance, which can make this treatment course costly.
SCD resources: breaking the vicious cycle by Elaine gottschall. www.breaking the visciouscycle.info www.scdlifestyle.com
GAPS resources: Gut and psychology syndrome by dr. Natasha Campbell-mcbride. Gaps guide by baden lashkov. Gutandpsychologysyndrome.com
See: sibo fruit and veggie guide which is an image saved in documents giving info on fermentability
Rifaximin is local and does not act as a systemic antibiotic. rifaximin has several unique benefits: it does not cause yeast overgrowth,
it decreases antibiotic resistance in bacteria by reducing plasmids, antibiotic resistance does not develop to it, making it effective for retreatments, and it is anti-inflammatory, decreasing intestinal inflammatory cytokines and inhibiting NF-kb via the PXR gene.52–54 Rifaximin is best used for SIBO when hydrogen is present, but when methane gas is present, double therapy of rifaximin plus neomycin (500 mg b.i.d. × 14 days) is more effective.55 Many gastroenterologists use metronidazole (250 mg t.i.d. × 14 days) as an alternative to neomycin (unpublished). Since different antibiotic regimens are recommended based on the gas type, breath testing is necessitated when considering this treatment.
SIBO is a disease that relapses because eradication itself does not always correct the underlying cause.57,58 Pimentel's 2006 treatment algorithm includes 2 essential preventions: diet and a prokinetic (motility agent). Our approach offers 3 optional additions: hydrochloric acid, probiotics, and brush border healing supplements
A key underlying cause of SIBO is thought to be deficiency of the
migrating motor complex (MMC), which moves bacteria down into the large intestine during fasting at night and between meals.59 Prokinetics stimulate the MMC, symptomatically correcting this underlying cause.
Prokinetics studied for SIBO include low-dose naltrexone 2.5 mg q.d., h.s., or b.i.d., low-dose erythromycin 50 mg h.s., and tegaserod 2–6 mg h.s.59,60 Tegaserod has a higher success rate for SIBO prevention versus erythromycin, but has been withdrawn from the US for safety reasons.59 Prucalopride 1–4 mg h.s. is not yet available in the US but is a safer alternative to tegaserod.61
A trial removal of the prokinetic at ≥ 3 months is suggested but continued long-term use may be needed.
To our knowledge, only one study has examined the rate of healing post SIBO, which found that intestinal permeability normalized four weeks after successful SIBO eradication in 75% of patients.37 While this report is very encouraging, it may or may not reflect the other repair needed post SIBO.
Therefore we currently suggest continuing a SIBO diet for three months post successful eradication. At this point, the Cedars-Sinai Diet, FODMAP Diet, or a similar lower-carb diet may be adopted long term, as the patient tolerates. Spacing meals 4 to 5 hours apart, with nothing ingested but water, allows migrating motor complex (MMC) to occur.28 We have found this to be very helpful clinically. If a low-carb SIBO diet does not correct hypoglycemia, this strategy will need to be altered to allow for more frequent meals.
Probiotics are a controversial intervention in SIBO because lactobacilli have been cultured in SIBO and there is concern about adding to the bacterial overload, particularly in this situation of dysfunctional MMC.25 Despite this, the few studies that have focused directly on SIBO have shown good results, with a SIBO eradication rate of 47% from Bacillus clausii as the only treatment, and a clinical improvement rate of 82% from Lactobacillus casei and plantarum, Streptococcus faecalis, and Bifidobacter brevis (Bioflora) as the only treatment.63,64 Probiotic yogurt containing Lactobacillus johnsonii normalized cytokine responses – reducing the low-grade chronic inflammation found in SIBO, after 4 weeks.65 We have used various multistrain and single probiotics as well as yogurt and cultured vegetables in our SIBO patients, with good results.
Brush border healing supplements may be given to assist the repair of small intestine tissue. While mucilaginous herbs are traditionally employed for this purpose (licorice, slippery elm, aloe vera, marshmallow), their use is controversial post SIBO, due to their high level of mucopolysaccharides, which could encourage bacterial regrowth. Specific nutrients that we have used include colostrum: 2–6 g q.d., L-glutamine: 375 mg–1500 mg q.d., zinc carnosine: 75–150 mg q.d., vitamins A and D, often given as cod liver oil: 1 Tbs q.d., curcumin: 400 mg–3 g q.d., resveratrol: 250 mg–2 g q.d., glutathione (oral liposomal): 50–425 mg q.d. or glutathione precursor N-acetylcysteine 200–600 mg q.d. Supplements are given for one to three months, though may be continued long term for general benefit.
Higher dosages of curcumin and resveratrol are given for two weeks for the purpose of downregulating NF-kb, a mediator of increased intestinal permeability, and then reduced to maintenance levels
In our practices we have found that the following circumstances increase the chances for an unsatisfactory patient outcome:
•
Failure to continue treatment courses until SIBO is eradicated (negative breath test or patient ≥90% better).
•
Failure to use double antibiotic therapy for methane producers. Methanogenic bacteria need different antibiotic treatment than hydrogen-producing bacteria.
•
Failure to utilize breath testing to identify if the patient has SIBO, the type of gas he/she produces, and the overall level of gas. This information is necessary for diagnosis, treatment choice, duration, and prognosis.
•
Failure to use a prokinetic immediately following treatment. Prokinetics along with diet are needed to prevent relapse of this commonly recurring condition.
•
Failure to use a low-carb preventative diet following treatment. Diet along with prokinetics are needed to prevent relapse of this commonly recurring condition.
•
Failure to tailor diet to individual tolerances with personal experimentation. No fixed diet can predict an individual's complex bacterial, digestive, absorptive, immunological, and genetic circumstances; therefore customizing is necessary.
• Failure to identify underlying causative conditions. A recent report found the following conditions led to a poor response to antibiotics: anatomical abnormalities, chronic narcotic use, Addison's disease, scleroderma, colonic inertia,
inflammatory bowel disease, and NSAID-induced intestinal ulceration.
Human Gut Microbiome
Just having positive H Pylori doesn’t mean anything, if a person is asymptomatic it doesn’t need to be treated
It isn’t that h pylori causes ulcers but rather perpetuates it. If the person is symptomatic he uses triple antibiotic therapy but makes sure to use lots of probiotics after to prevent dysbiosis.
Says he doesn’t like treating sibo w/ pharmaceutical antibiotics even if it is xifaxan. He uses betaine hcl, enzymes, herbal antimicrobials instead as the herbal antimicrobials are gentler. He prefers combination products, says they are more powerful than any one alone.
{10}Allison Siebecker
https://www.invivoclinical.co.uk/files/sibo_class_2_siebecker-invivo-new.pdf
IBS/SIBO Differential Diagnosis Sx: bloating, pain, constipation, diarrhea(in other words, things that can cause sibo type symptoms):
• Yeast Overgrowth • Parasitic Infection • LI Bacterial overgrowth/ infxn • H pylori infection • Celiac Disease/NC Glut Intol • IBD: Crohn’s/ Ulcerative Colitis • Carbohydrate Malabsorption – Lactose, Fructose, Polyol… • Food Reaction: protein, histamine, salicylates… • Hypochlorhydria • Pancreatic Enzyme Insufficiency • Hypo/Hyper Thyroid • Bile Acid Malabsorption • VIPoma • Zollinger Ellison Syndrome • Abdomino-phrenic dyssynergia • Chronic Abdominal Wall Pain • Endometriosis • Cancer- Panc/St/SI/LI, Ovarian… • SI Obstruction • Immune Deficiency (CVID) • Stress • Insufficient Chewing
IBS/SIBO DDX Lab Testing:
• Carb Malabsorption: Breath- Lactose, Fructose, Mannitol/Sorbitol, Sucrose •
Yeast: Blood- Candida Ab/Ag Complex. Stool Urine OG Acid • Parasite, LIBO, LI Infection: Stool • H pylori: Breath- Urea. EndoscopyCulture, Rapid Urease. Blood- Ab • Celiac: Endoscopy- biopsy. Blood- IgA: tTG, EMA, DGP, IgG: DGP. Saliva/Cheek, Stool- Gene • N-C Gluten Intol: Diet- Elim/Chall, StoolGene •
IBD: Colonoscopy, Stool- Calprotectin, Lactoferrin • Immune Deficiency: Blood- Ab Total/Vaccine, T cell, WBC •
Dyssynergia: Manometry • Endometriosis: Imaging, Surgery • Food Reaction: Diet- Elimination/ Challenge, Blood- Food Ig, DAO • VIPoma: Blood- VIP • Zollinger-ellison Syn: Blood- Gastrin. Imaging. Endoscopy • Cancer/Obstruction: Imaging • Hypochlorhydria: Heidelberg. 24 hr pH Metry. String? • Pancreatic Insufficiency: Stool- Fat, Elastase, Chymotrysin © Dr. Siebecker 2012 • Stress: Saliva- Cortisol/DHEA
Diagnostics Tests
1. Endoscopy: Culture • 38% reproducibility (Quigley 2006, PMID: 16473077)
2. Breath Hydrogen & Methane: Lactulose or Glucose • 92% reproducibility (Quigley 2006, PMID: 16473077)
3. Blood: Cdt B & Vinculin Antibodies (IBSChek) • Dx PI-IBS (SIBO from food poisoning); diarrhea/mixed type • 91% specificity, 95% dx accuracy (Pimentel 2015, PMID: 25970536)
Not Diagnostic
• Stool - dx LIBO not SIBO (LI different organ) • Urine OG Acid - can’t distinguish btw SI & LI • Types of Breath Tests – not all are for SIBO • Urea: H pylori • Carbohydrate Malabsorption: Lactose, Fructose, Sorbitol…
When breath testing for sibo
3 hour version of test needed for hydrogen sulfide (HS) & helps methane dx, HS causes a distinct pattern on HMBT= “flat line”/zeros entire test
Meant to lower the baseline & allow a clear reaction to the substrate. • Ideal= Meat and Fat, No Carbs • No Fruit, Veg, Juice, Nuts, Beans, Grains, Bone Broth, Milk, Alcohol… • White Rice/Wheat allowed - only if it’s known not to aggravate sx
Retesting on Prokinetics • Ok in my opinion • Not advised by Breath Testing Consensus. Concern: False (+) if substrate moves faster into LI, showing LI bact gas in SI time.
LBT Positive Test Criteria: Numbers My Opinion • Hydrogen: ≥ 20 ppm w/in 120 min, after baseline w/in 140 min with constipation • Methane: ≥ 12 ppm w/in 180 min, including baseline 3-11 ppm w/in 180 min with constipation • Combined H & M: ≥ 15 ppm after baseline • H at any time-point + M at any time-point • Hydrogen Sulfide: all zeros or close (0-6ppm H, 0-3ppm M w/in 180 min)
LBT Positive Test Criteria: Severity My Opinion Mild= up to 45ppm Moderate= 45-70ppm High= 70-100ppm Severe= 100+ppm Note: sx severity may not correlate with gas severityv
Breath testing patterns:
- Improper Prep = High baseline that plummets over 120 min
- highest # within 120 min is baseline, may rise in 3rd hr due to LI bact
- Methane = starts high, stays high (no real rise) • Hydrogen Sulfide = no rise H or M in the 3rd hour: “flat line”
- Proximal SIBO clearing On Retest= lower #’s earlier (a good sign)
- • Hydrogen Rises when Methane decreases On Retest
- Common; 4 H’s make 1 M
- Double Peak- 1 st indicates SIBO, 2nd normal LI bacteria
Hydrogen Sulfide Testing
• LBT: “flat line” on 3 hr LBT (not 2 hr or GBT) • Or: 0-6ppm Hydrogen, 0-3ppm Methane the whole test • B/c 3rd hr should show LI bact gas; if it doesn’t it’s been converted to untested gas • Urine: Immune balance (Th1/TH2) urine test • Unvalidated- “research purposes only” • At home test. No Dr’s order needed (pt can order) • Urine turns dark purple quickly if (+) • Follow up testing after successful tx= paler color or turns dark slowly
Migrating Motor Complex Testing
- Antroduodenal Manometry:
• Direct test for MMC
• Endoscopy (invasive, expensive, only a few places perform it)
• Interpretation: reported by performing Dr.
-Cdt B & Vinculin Antibodies (IBSchek):
• Indirect test for MMC via ICC damage
• Blood
• Interpretation: Positive=if either Ab is (+)
• Negative= ”inconclusive” b/c can have IBS from another cause
Altered Anatomy/structure testing
Barium SI Series:
• Direct test for flow/passage through SI
• Indirect test for extra intestinal adhesions
• X-ray Imaging
• Interpretation: reported by performing radiologist
(+) narrowing with dilation above it
(+) 90 angles indicate adhesions (SI should have rounded/curved features)
The following instructions are needed on Order Form to get a sufficient test: “Rule out adhesions with multiple spot films and positional changes to visualize each segment of bowel”
1st line treatment for sibo: treat anemia/lowferritin/adrenals/thyroid/other hormones/other present conditions
2nd line treatment: probiotics:
Some docs= no Pbx in SIBO. Some= Pbx for all SIBO. – I go case by case (ask each pt how Pbx have effected them in the past, factoring in Prebx)
• Note: avoid Prebiotics as main ingredient (w/mg listing) – Inulin/FOS/GOS/MOS/Arabinogalactan. Often Ok as a base ingredient.
• Not included in Algorithm. – Good idea to use probiotics w/Neomycin, Metronidazole & Berberine. Not needed w/Rifaximin.
Patients typically relapse between 2-3 months after treatment, most patients do relapse
100% symptom resolution is not expected – 80-90% is standard. 100% can happen but it’s not standard • Underlying cause generates sx & has not been treated in most cases – I try for 90% & often get it- if 80% better = I do another round • 10-20% left – 1 st & 2nd line Therapies
Standard Tx course for the majority: – Takes months of multiple rounds to get an initial test negative – Work this through with rapid follow ups/next Tx courses, till achieved • 1-2 week break btw Tx courses, otherwise they may relapse & progress just made may be lost. Ok to go right into next Tx w/o break. Retest every 2nd round- recommended.
• Then Relapses begin & that can take months to get well controlled into longer remissions (however it’s usu shorter to get to neg test again)
Anti-biofilm agents offer no clinical improvements, aren’t worth using
Standard- wait at least 2 wks – For Re-Test results – To Asses Sx – For a Abx/HAbx holiday • can refresh effect of a tx that’s stopped working
Important to be on Prokinetic between Tx’s- to hold gains made
• Back to back Tx– If gas is high
• GI Docs often wait 1 month to re-test or re-treat – But 2 weeks is such a common relapse time I don’t advise waiting that long
Average Gas Reduction of Treatments Abx and HABx reduce gas by 30ppm on average, Elemental Diet = 70-100+ ppm, Diet = unknown – Fodmaps= on day 2: hydrogen ↓180ppm for IBS pt but that’s without prep diet & while eating (incomparable) –
SIBO diet could cause a lowered test score
Tx Concerns
• SIBO Diets (restricted diets) – Malnutrition - Weight loss - Hypothyroid – Microbiome alteration - Eating disorder
• Abx/HAbx – C diff infection - Side Effects, allergy – Microbiome alteration - Abx/HAbx resistance
• Elemental Diet - Side Effects -Weight Loss
• Prokinetics - Side Effects, allergy
Successive Treatment Rounds are often needed to treat sibo (Abx/HAbx) – 1 tx course lowers gas 25-35 ppm avg (Abx=2wk, HAbx=4wk)
Different Tx needed for Methane &/or constipation – Add Neomycin or Metronidazole, or Allicin
Vary Tx method PRN between Abx, HAbx & ED – Often only 1 method of 3 is effective. I use all 3 interchangeably.
https://www.jenbroyles.com/dr-allison-siebecker-talks-sibo/
siebecker talking to sean crockston(might have misspelt his last name)
2 studies showed that those w/ sibo have a 50/50 chance of having leaky gut, healthy controls only have a 4% chance of having leaky gut
In one study, 100% of leaky gut was healed once the SIBO was eradicated. In the other study, 75% of the people had their leaky gut healed upon eradication of SIBO. The only thing these patients did to heal their leaky gut was eradicate the SIBO. In the studies, this was done using pharmaceutical antibiotics. No supplements or diet intervention was given. This proves that when you remove the cause, the body will heal on it’s own.
Siebecker’s experience, roughly ¼ of her patients with SIBO also have Candida. Therefore, SIBO and Candida don’t go together. Candida can also cause leaky gut, just like other infections.
Herbal antibiotics are also antifungals, so they can treat SIBO, candida, and parasites.
When choosing a probiotic, look for one that makes you feel better and stick with it. The three most beneficial strains for SIBO have shown to be bifidus infantis, bifidus lactis, and lactobacillus plantarum.
Biofilm disruptors do nothing to treat SIBO but are important in treating candida
Herbal antibiotics can disrupt gut microbiota. One herbal antibiotic that has shown not to kill probiotics, specifically lactic acid bacteria is allicin from garlic.
Some peoples iliocecal valves are open too much and allow bacteria from the colon to invade the SI, there are different massages the patient can do to correct this or they can go to a chiropractor to have it fixed
Q: How long does it take to heal from SIBO and Leaky Gut?
A: Everyone is different, so there’s no solid answer. Studies on patients with alcohol-induced leaky gut showed 2 weeks to heal the gut. Patients with Celiac seem to take longer; between 6 months to 1 year.
For patients with SIBO and leaky gut. Leaky gut generally heals less than a month after SIBO is eradicated.
The time is takes to get rid of SIBO can take 2 weeks to 1 year depending on the method used. It usually takes about 2 months. In many cases of SIBO, there is damage to the ICC cells which are responsible for the migrating motor complex. It can take 1 month to 6 years to heal these damaged cells.
Q: How do you prevent a relapse of SIBO?
A: Prevention requires some type of low carb diet with a prokinetic. There are both pharmaceutical and natural options for a prokinetic. According to Dr. Siebecker, the pharmaceutical options are the best. These include Erythromycin, Resalor, and LDN (Low Dose Naltrexone). While many people love LDN because it has a number of other benefits, it isn’t strong enough for everyone. For approximately ¼ of people, LDN doesn’t work well enough. In that case you can switch to a stronger prokinetic or add a natural prokinetic with the LDN. Resalor is the strongest and Erythromycin is in the middle.
If you prefer to avoid prescriptions and go the natural route, your options include Iberogast, MotilPro, and ginger. Ginger seems to work well, but many people become tolerant to it, so it stops working after a few months. Additionally, ginger can cause acid reflux and what’s known as “ginger burn”. MotilPro is a combination of ginger and 5-HTP. Many people also have problems with it because of the “ginger burn”. In terms of natural prokinetics, Dr. Siebecker recommends Iberogast. It’s been around for many years, and it’s been well studied. In fact, studies have been done comparing Iberogast to 2 pharmaceutical prokinetics (not the ones mentioned above), and Iberogast was shown to work better.
Below is Dr. Siebecker’s recommended dosing for all of the prokinetics mentioned.
**All prokinetics should be taken at night before bed.**
Erythromycin – 50 mg
Resalor – ½ mg
LDN – 2.5 mg for those who tend toward diarrhea, 4.5 or 5mg for those who tend toward constipation
Iberogast – 20 drops
MotilPro – 2-3 capsules
Ginger – 1000mg
http://undergroundwellness.com/podcasts/sibo-undiagnosed-and-undertreated/
bone broth often bothers people with SIBO cause the mucopolysaccharides in the joints/bones feed bacteria. Rec meat broth instead and only cook the meat broth for a shorter amount of time as opposed to the long cook times on bone broth
the writer of the GAPS diet doesn’t like the use of baking soda as it can be alkalinizing which can go against the stomach HCL so when baking don’t use baking soda
lot of people cant tolerate the squashes in the SCD diet, electrolytes can get low on the scd, and on the scd it is important to get carbs, honey and whatnot
slideshow by dr siebecker on sibo
https://www.slideshare.net/ancestralhealth/allison-siebecker
takeaways:
fiber/prebiotics:
indigestible to us cause no enzymes to break bonds
digestible to bacteria because they have enzymes
fiber exclusively feeds bacteria is therefore prebiotic
soluble fiber: inulin, psyllium, flax, chia, hemp, gums(guar, xanthan, locust bean, acacia/Arabic, mastic), beta glucan (oat bran/mushroom), alginate, glucomanan(konjac mannan), carrageenan, agar agar, arabinogalactan, pectin
0ligosaccharides:FOS, GOS, MOS
Sibo pathophysiology:
Sibo causes increased inflammatory cytokines, deconjugates bile, and destroys the brush border which can lead to steatorrhea and fat soluble vitamin deficiency
The damage to the brush border leads to decreased disaccharidases, reduced carb transporters, blunted villi, elongated crypt depth and intestinal permeability. Can’t tell for sure but it looks like she’s written that everything here but the intestinal permeability causes GI sympotoms and that the intestinal permeability causes systemic symptoms(more likely) or maybe that all of these issues cause both gi sx and systemic sx(less likely)
Indications of sibo
Chronic low ferritin with no other cause
Pancreas obscured by gas bubble on CT scan
Prokinetic
Take for 3mo after tx, take at bedtime:
prucalopride 1-4mg hs
Erythromycin 50mg hs
LDN 2.5-5mg
Key sibo treatment points for success
Multiple rounds of treatment are needed if gas is above 35-45 ppm
Avg gas decreases from abx/habx about 25-35ppm
Diets
Diets that will treat sibo over a long period of time: SCD, GAPS, Modified low fodmap diet that contains no grains, tubers, sugar, and is combined with the SCD/GAPS
Diets which are for prevention only, after sibo is gone: Low fodmap, cedar Sinai, less strict paleo/primal diets, diet may expand as tolerated by adding back in grans/tubers/sugar
and this one which is a food guide(all slides are in a file in med notes n tests)
https://www.slideshare.net/maushard/sibo-food-guide-jan-13-2014
Complex clinical study review: advanced sibo and GI testing
- https://www.gdx.net/livegdx/2019/january-complex-clinical-study-review-advanced-sibo-and-gi-testing
- Presenter: Jill Carnahan
- If the first reading of the sibo test comes up with high hydrogen you’re doing something wrong and the test may well be invalid, methane on the otherhand can be high to start and be high the whole way across
- Methane over 5 is positive for sibo, used to be 3 was positive but now she says 5 is positive. 3-9 ppm methane is mild, 10 is very positive for sibo
- Does breath testing, stool testing and organic acid testing before treating. Organic acids show markers for both bacterial overgrowth and fungal overgrowth, if they have high fungal overgrowth markers and you treat with antibiotics alone you’ll get a bad result because it’ll flare the fungus
- Autonomic motility: diabetes, tickborne infections, and other things affect motility and can lead to sibo
- Low IgA is a risk factor for sibo. Use S boulardii, bovine immunoglobulins, colostrum
- Poor pancreatic function/biliary secretion is risk factor for sibo
- Rec bitters for increasing bile acids
For hypochlorhydria she rec otc use of betaine hcl or the Heidelberg capsule to determine it.
With hypochlorhydria you will often see low serum zinc, low ferratin, osteopenia, b12 deficiency; gluten sensitivity can cause hypochlorhydria. Lines and ridges on fingernails can be cause by hypochlorhydria, they are a sign of zinc malabsorption. Bloating/belching within 30min of a meal, weak peelin or cracked fingernails, acne rosacea(sibo sign too), undigested food in stool, problem with protein, chronic intestinal infections, multiple food allergies. Rec ramping the dose up till warmth/burning then lowering it.
Never go beyond 3500mg per meal even if there is no warmth burning tho she has had some patients who have had autoimmune conditions that cause low stomach acid who have responded well to 16-20 caps per meal.
Some people(the presenter included) don’t tolerate pepsin with the betaine HCL and so the betaine HCL has to be taken alone
3hr breath test better than 2hr
Organic acids test wont indicate sibo
Rec low fodmap diet, follow 4-6mo after treatment
She rec Allison siebeckers combination diet of FODMAP/SCD(see sibo food guide file in medical notes and test)
Elemental diet is 80-88% successful for treating sibo, very successful
Xifaxan rec, every 20-30 ppm hydrogen will be eliminated with 14 days xifaxan, so if it’s near 60ppm then 30 days straight will be needed
Neomycin or metronidazole for methane sibo, doses are 500 BID for 14 days
Prokinetics: LDN, low dose erythromycin, resolor(Canada), iberogast, ginger
Take prokinetics for 4-6mo after sibo treatment
Herbal antibiotics should be used 4-8wks, they treat not only sibo but sifo which is an advantage over Rx stuff which leaves fungus intact: berberine up to 5g’s daily(500mg-1500mg BID/TID), oregano 200mg TID x 2-6wks, garlic: allicin extract 450mg BID x 4-6wks, neem. Rec 6-8wks rather than just 14 days when using HAbx
May use biofilm disruptors if having trouble: garlic(allicin extract specifically, 450mg 2-3x/day), NAC up to 2-3g’s spread into three doses, EDTA(the product Interface Plus). Some biofilms are there with a reason so only use biofilm disruptors if needed
Use only spore probiotics during treatment, add lactobacillus/bifido after treatment but not before that
Don’t restrict diet till after treatment as you don’t want them to go dormant, guar gum is often added during treatment and makes at least rifaximin more successful. Don’t use after treatment
PAA high on organic acids(I have high PAA) can indicate pancreatic insufficiency
Rec nystatin for yeast
Methane can hide hydrogen, methane bacteria can eat the hydrogen gas so when the methane is treated sometimes you’ll find hydrogen goes up on the breath test
Xifaxan isn’t systemic, has little fx on colonic bacteria, and doesn’t cause resistance
Three hour breath test doesn’t increase data on hydrogen but does increase relevant data about methane
HAbx are good for treatment of SIBO where gas isn’t too high(like my levels feb 2019), she rec candibactin AR/BR, and that other combination from the study that compared HAbx to Abx(xifaxan) that was mentioned above in misc section
Average decrease of gas with round of antibiotics is 25-35ppm, may need successive rounds of treatment if gas is greater than 35-45ppm
Garlic extract(allicin) rec for methane sibo, sometimes biocidin and olivirex can be used as well
If failure then must use prokinetic
Diet is a must or relapse will occur
Retest 2-4wks after tx to see if issues have resolved
Don’t use low fodmap long term, fodmap diet works by starving bacteria including probiotics
Other reasons xifaxan might not work: gas levels too severe, not treating methane, bacteria don’t respond to xifaxan
Breath prep: 48 hour: no beans. 24 hour: just white rice/water then 12hr fast. Don’t do immediately on waking. Do 10 clearing breaths before(breathe in and out through the nose 10 times to make sure the airways are clear, 4 count in 4-8 counts out breath.
If Sx remain but breath and stool tests come back negative then try organic acid test which may show fungus/bacteria the other two missed
. If Sx are present but dunno what is going on then use herbs, they will do less damage to probiotic populations and will also treat yeast if that is present. She has treated several patients who didn’t test positive for sibo but she treated anyway and they responded well, suspected hydrogen sulfide sibo.
Yeast treatment with herbs: caprylic acid, grapefruit seed extract, pau da arco, ginger, oregano, unilasayic acid, turmeric.
Only use guar gum while taking rifaximin, 2g guar gum per day. Bacteria feed on guar gum and die more readily from the antibiotic
She always uses stool test, stool and organic acids first, sometimes breath test will be used right away to if ibs Sx is obvious
Sibo patients sometimes feel worse for a while during treatment
Yeast treatment is worse though and has much more in the way of die off, rec yeast treatment 2-4 months
Spore based probiotics are good for sibo patients both before and during treatment, usually she doesn’t give lactobacillus/bifido/enterococcus probiotics till after the Tx and after the 4-6months on the diet/motility agent.
Alimed/Alimex pro 450mg of Allicin extract per cap, for methane sibo 4-6 capsules per day for 4-6wks, that’s her preference.
Alinia is good for protozoa, parasites, tough sibo, methane sibo, viruses. Rec alinia 30 days for Tx. Can flare yeast. Uses it if other Tx fails
She waits 2 weeks after tx to retest, if patient is doing really well she’ll wait a bit longer, then will wait until sx return before testing again(months later usually)
She mainly mentions the fodmap diet, only one mention of the fodmap/scd diet as per siebecker so I guess fodmap diet alone is the go to diet
From another webinar in General GDX stuff:
GDX webinar: Interactions of the microbiome and the neural immune system https://www.gdx.net/clinicians/medi...-of-the-microbiome-and-the-neuroimmune-system
Says when he comes across SIBO it usually has something to do with delayed gastric emptying, decreased parastalsis, constipation, hypochlorhydria
https://www.naturalmedicinejournal.com/journal/2017-05/takeaways-2017-integrative-sibo-conference
Presenter: Allison siebecker
- Rifaximin is not a typical antibiotic; rifampin
is not systemically absorbed (<1%)
works best in the small intestine (bile soluble)
increases
Bifidobacteria and
Lactobaccilli (eubiotic effects)
has anti-inflammatory activity via stimulation of human nuclear receptor pregnane-X receptor (PXR)
does not cause
C. difficile or yeast overgrowth
has very low side effect profile (≤placebo)
prevents antibiotic resistance of neomycin by inhibiting plasmids
does not lead to antibiotic resistance, and continues to work after 6 rounds of treatment
- Berberine, oregano, and neem are used in diarrhea-predominant cases; stabilized allicin is added to these herbs for constipation predominant cases
- Overarching diet tips for active SIBO:
- Avoid raw food, salad, and beans
- Be careful with whole grains, nuts/seeds, winter squash
- Choose low-FODMAP fruit and vegetables (see Monash University Low-FODMAP app)
- Starch may be tolerated: white rice, white potato, white flour (if gluten is tolerated); often one starch is tolerated but not another
- Lactose-free dairy, sugar, clover honey, and cocoa are often tolerated
- Quantity matters-small amounts of individual foods may be tolerated when larger amounts aren’t
- Experimentation and customization is necessary for best success
- Prokinetics are used between treatment rounds and after eradication to prevent relapse by stimulating the MMC
- Common prokinetics: low-dose erythromycin, low-dose prucalopride, low-dose naltrexone, Iberogast, MotilPro, ginger
Presenter: Nirala Jacobi, BSc, ND
- Mucosal repair is important for both phases
- Tight junction repair
Vitamin D helps mucosal barrier homeostasis and decreases inflammation
Vitamin A
Quercetin
Zinc carnosine
L-glutamine
Increases production of human growth hormone
Major fuel source for enterocytes/epithelial cells
Supports tight junctions
Reduces interleukin (IL)-6 and IL-8, increases IL-10
comment: Jacobi stated that she sees many patients with reactions to histamine, salicylates, and oxalates.
- Histamine can be elevated in SIBO due to 2 main causes:
Food-sourced histamine (exogenous histamine absorption)
Mast cell infiltration (endogenous histamine release)
Comment: Jacobi had 11 slides on histamine, an excellent summary of review of literature and of Charles Lewis (
Enteroimmunology, Psy Press 2013). The most interesting slide was how to tame the mast cells naturally.
DAO supplement with food
B6, Magnesium, Copper
Pantothenic acid 1,000-2,000 mg
B12, folic acid – she stated that this needed to be started slowly
B1 100-200 mg
Vitamin C to bowel tolerance
Quercetin
Albizia
Perrilla
Comment: Jacobi had 11 slides on salicylates and stated that interaction with patients who have SIBO and dysbiosis is common.
Natural plant substances, which help the plant defend itself against bacteria, fungi, and other pests. Salicylates are toxic to everyone in very high doses, but with a salicylate sensitivity the threshold is much lower before a reaction occurs.
Salicylates are chemically very similar to the manmade chemical acetylsalicylic acid, a key ingredient in aspirin and other pain medications.
Sources include:
Herbal products (most will contain salicylates)
Curcumin (especially high)
Medications: most NSAIDs
Cosmetics, fragrances, shampoo
Cleaning products
Air fresheners
Breath mints, lozenges, gum
- Support for phase 2 clearance of toxins
Glycine conjugation: Glycine 1,000-1,500 mg daily
Glucuronidation: calcium d-glucarate 1,500 mg daily
Support for kidney clearance
Alkalizing minerals
Trace mineral
Herbal Considerations to Effectively Treat SIBO and SIFO
Multiple mechanisms that overcome bacterial resistance
Inhibits biofilm formation
Reduces H2-producing bacteria
Dosage: 2-3 g/d
Reduces CH4-producing bacteria
- Syzygium aromaticum (clove)
Antibacterial, antifungal
Stimulates gastric mucous production
Cholinergic: stimulates motility in IBS-C
May increase bleeding time
- Punica granatum (pomegranate)
Antibacterial, anticandidal, antiparasitic
Significantly enhances growth of
Lactobacillus spp,
Bifidobacterium breve,
Bifidobacterium infantis
Inhibits growth of pathogenic
Clostridia and
Staphylococcus aureus
Dosage: 10 mL daily of 1:2 tincture
- Small intestinal fungal overgrowth (SIFO)
SIFO comorbid with SIBO in 20%
SIFO found in 26% of patients with “unexplained GI symptoms”
Issues with
Candida spp:
Often cause similar symptoms to SIBO
Commonly forms biofilm
Overgrowth easily evades detection
Classic antifungal herbs: Pau D’Arco, Uva Ursi, berberine-containing herbs
Essential oils of clove, oregano, and thyme
Oregano
Effective against Candida spp, S. aureus, Pseudomonas a., Blastocystis hominis
Effective for SIFO and methanogens
Effective against candida biofilm
Dose: oil of oregano (50-100 mg 2x daily)
Pseudowintera colorata (horopito)
Strong antifungal activity against
Escherichia coli and
Salmonella,
C. albicans,
C. utilis,
C. krusei,
Cryptococcus neoformans,
S. cerevisiae,
T. mentagrophytes,
T. ruburum and
Penicillium marneffei
Moderate antibacterial activity against both gram-positive bacteria (including
Bacillus subtilis and
Staphylococcus aureus) and gram-negative bacteria
- Liquid antimicrobial formulas
SIBO formula-7.5 mL 2x daily:
Oregon grape (or coptis/goldenseal)
Pomegranate
Artemisia
Burr marigold
SIBO/SIFO formula-7.5 mL 2x daily:
Pomegranate
Usnea
Horopito
Oregon grape (or coptis/goldenseal)
Dr. J’s Herbal Bitters formula:
Oregon grape/Gentian/Baical Skullcap/Dandelion root: 2-3 whole droppers in water 15 min before meal
"Iberogast”–Iberis amara, Angelica archangelica carumcarvi, Silybum marianum, Melissa officinalis, Chelidonium majus, Mentha piperitae, Glycerrhiza
Dose: 20 drops 3x daily before meals and before bed, or 60 drops at bed time
”Motil Pro”: Ginger, 5HTP, acetyl L carnitine, P5P
Dose: 3 caps morning and night
- Carminatives—gas removal from GI tract
Caraway seed – very effective carminative and spasmolytic
Fennel
Carminative tea (crush 1 tsp of each and steep for 20 minutes in 1 cup of water. Drink after each meal.):
Caraway seeds
Fennel seeds
Anise seeds
Comment: Parting thought: use herbs before microbiome-disrupting antibiotics
Manipulation of Gut Microbiota and GI Motility for Treatment and Prevention of SIBO
- Dysbiosis definition=bad coexistence of host and microflora
Consequences: damage to epithelium with increased cell turnover, toxin and/or gas production, immune weakening/reaction
PPIs, H2 blockers and antisecretory drugs can profoundly influence microbiota even more than antibiotics.
- SIBO definition: increase in number and/or change in type of bacteria (oropharyngeal or colonic)
Increased intestinal permeability occurs in SIBO with colonic type but not salivary bacterial overgrowth and is reversed when SIBO is eradicated
Common: gas-related symptoms (bloating, abdominal pain, flatulence, diarrhea)
Uncommon: malabsorption syndrome (B12 and iron anemia, Vitamin A/D/E deficiency, edema)
Malabsorption can occur when SIBO has been present for a long time
SIBO diagnosis is made with both presentation and breath test
Causes/risk factors
Generally: when homeostatic mechanisms that control small intestine bacteria are disrupted such as gastric acid lowering and motility abnormalities
Risk factors are endless and can include: demographics (old age), structural abnormalities (strictures, diverticula), organ system dysfunction (cirrhosis, chronic pancreatitis), and medications (PPIs, opioids)
“An absent or disordered migrating motor complex pattern is almost always invariably associated with SIBO.”
Associated conditions
SIBO and SIFO (small intestine fungal overgrowth) coexist in 34% of SIBO patients; many antibiotics (a prime treatment for SIBO) can increase fungal overgrowth.
SIBO and IBS: There is 5x more prevalence of SIBO in IBS compared to healthy controls.
SIBO is an umbrella term encompassing functional, organic, and hepatic conditions, so if you target SIBO you will be able to target many GI diseases.
- Rifaximin
- Rifaximin is the best antibiotic for SIBO because it is effective against gut bacteria, acts in gut only, prevents antibiotic resistance, is nontoxic, is safe in children/elderly/pregnant women, and has few side effects.
- Rifaximin is anti-inflammatory through NF-KB and the PXR gene, a master gene critical for maintenance of intestinal integrity.
- Rifaximin has eubiotic effects; it increases Bifidobacteria and Lactobacilli.
- A recent meta-analysis of rifaximin for SIBO showed an average eradication rate of 70% with significant (70%) improvement of symptoms.
- Two factors increase rifaximin eradication rate: higher dose and cotherapy with prebiotics/fiber or mesalazine (which can modify intestinal microbiota).
- Recurrence
- 45% recurrence by 9 months, especially if underlying cause is not corrected, which is often the case
- Cyclic use of rifaximin (7-10 days every 4 weeks), followed by probiotics (Lactobacilli-Bifido mix)
- Probiotics
- 47% eradication with Bacillus clausii spores
- Prokinetics prolong remission time
- “Maintaining well the housekeeping activity of the intestine is a must”
- Prucalopride is a safe option because it is very selective for the 5HT4 receptor
SIBO diagnosis and treatment 2007
The loss of activity of brush-border disaccharidases due to mucosal injury and the bacteria fermentation of sugars such as sorbitol, fructose and lactose could be responsible for carbohydrate malabsorption [4] . Enterocyte injury may alter the gut permeability, predisposing to the development of a protein-losing enteropathy. Moreover, bacteria may compete with the host for protein and lead to the production of ammonia [5] . Deconjugation of bile acids in the proximal gut induces fat and lipophilic vitamin (A, D, E) malabsorption and leads to the production of lithocholic acid, which is poorly absorbed and may be directly toxic to enterocytes [6] . Cobalamin (vitamin B 12 ) deficiency can occur in SIBO as a result of use of the vitamin by anaerobic bacteria. Levels of both folates and vitamin K, however, are usually normal or increased in SIBO as a result of bacterial production.
Rec wide spectrum antibiotics since it is hard to do testing in vitro of antibiotic vulnerabilities of bacteria
A study on patients w crohns found a good response for treating sibo using ciprofloxacin and metronidazole
Lauritano et al. [17]showed that higher doses of rifaximin (1,200 mg/day) were associated with a significantly higher therapeutic efficacy (60% of glucose breath test normalization) in terms of SIBO eradication with respect to doses of 600 mg/day (16.7% of glucose breath test normalization) and 800 mg/day (26.7% of glucose breath test normalization). Similarly, Cuoco et al. [18]assessed the efficacy of rifaximin (1,200 mg/day), followed by a 20-day course of probiotics, in the treatment of SIBO. The eradication rate of this schedule achieved 83% with a significant improvement of gastrointestinal symptoms. Neomycin, a non-absorbable aminoglycoside, was shown to be of little efficacy when used alone in SIBO. In a recent study by Pimentel et al. [19]on 111 IBS patients, treatment with neomycin achieved the normalization of lactulose breath test in 20% of patients with SIBO with respect to 2% in the placebo group. No relevant side effects were observed during the study and no dropouts occurred
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030608/
Conditions That Predispose Toward the Development of Small Intestine Bacterial Overgrowth
Achlorhydria (surgical, iatrogenic, autoimmune)
Motor abnormalities
Scleroderma
Intestinal pseudo-obstruction
Diabetic enteropathy
Vagotomy
Abnormal communication between colon and small bowel
Fistulas between colon and small bowel
Resection of ileocecal valve
Structural abnormalities
Systemic and intestinal immune deficiency states
Surgical loops (Billroth II, entero-entero anastomosis, Rou-en-Y)
Duodenal or jejunal diverticula
Partial obstruction of small bowel (stricture, adhesions, tumors)
Large small Intestine diverticulosis
Systemic diseases (celiac disease, cirrhosis, pancreatic exocrine insufficiency, non-alcoholic fatty liver disease)
Alcoholism
Protective Factors That Protect Against the Development of Small Intestine Bacterial Overgrowth
4,
8,
9
• Gastric acid
• Pancreatic enzymes
• Bile acids
• Cholecystectomy
• Motility
• Migrating motor complex
• Biofilm
• Secretory immunoglobulin A
Extrinsic Factors That Alter the Gut Microbiome and May Influence the Development of Small Intestine Bacterial Overgrowth
4
FODMAPsa (fructose, lactose, galactans, fructans, sugar alcohols)
Proton pump inhibitors
Anti-motility agents
Fiber
Prebiotics
Probiotics
Antibiotics
Note: from personal experience It seems like FC-cidal and dysbiocide make me feel improved more if I take them an hour or more apart from one another. FC-Cidal does more for me than dysbiocide, at least, I feel better after fccidal
https://www.mindbodygreen.com/articles/sibo-treatment-common-mistakes
While some people can't tolerate probiotics during SIBO treatment, it's important to add probiotics when the time is right for you. I use spore-based probiotics and find that my patients tolerate them even during the initial phases of the herbal
protocol.
Diet is part of the treatment, and carbohydrates feed bacteria, so it goes without saying that sugars from sweets, breads, pastries, soda, juices, alcohol, and others are not your best friends. Healthy carbohydrates in excess, or the wrong types of carbohydrates, can slow down your healing process as well. Some people can't tolerate simple sugars like lactose and fructose while others have a hard time with complex starches like potatoes and rice.
There's no one diet that works for everyone with SIBO, so it's important to identify which carbohydrates you can't digest and absorb because those are the ones that end up getting fermented by your small intestine bacteria. Depending on my patient's symptoms and medical history, I may use the low FODMAPs, Specific Carbohydrate Diet (
SCD), SIBO-Specific (combines the low FODMAPs and SCD), or the Fast Tract Diet. Avoid fiber early in the treatment. Ultimately, your goal is to eradicate SIBO so you can reintroduce healthy foods that some of these diets restrict like garlic, onion, and apple.
What interferes with proper motility? Food poisoning and infectious gastroenteritis with certain bacteria, viruses, or parasites can
damage the cells that act as the pacemaker and control the MMC.
Mentions gastroparesis as once cause of mmc not working
Unfortunately, SIBO can be stubborn to treat, and it can come back. So whether you chose antibiotics or herbals, retest within the first week of completing treatment to confirm that it's gone. If you wait too long, or never retest, and your symptoms come back a few weeks or months down the road, you're back at the starting line. When you confirm that the treatment was successful, you can confidently transition to a maintenance and prevention plan. If you test positive, your practitioner can prescribe a different medication or herbal protocol. Understand that your healing journey may include a plan B or C, or even a plan D, but without retesting, you have too many unknowns. If it turns out that your SIBO is stubborn, ask your provider about the
elemental formula diet.
Make sure the root cause is treated by:
Improving gut motility
Having adequate stomach acid
Boost digestion with supplements and herbs.
Incorporate digestive enzymes, bile, and digestive bitters. The ability of your intestine cells to produce brush border enzymes on their own should start to improve as SIBO clears
SIFO can cause sibo to recur
https://www.siboinfo.com/finding-a-doctor.html
