Monday, December 8, 2014

What's SIBO all about?

by Glen Depke, Traditional Naturopath

The acronym SIBO has been thrown around quite a bit lately and many are unaware of what this even stands for, let alone what it's all about. SIBO stands for small intestinal bacterial overgrowth at a level of more than 10 to the 5th power of bacterial organisms per milliliter of fluid present in the small intestine. The normal level is 10 to the 3rd power for the small intestines and 10 to the 8th power for the colon or large intestine.

Understanding SIBO is a significant key to irritable bowel syndrome(IBS). One of the clues for SIBO would be distention or bloating after meals that contain starch or fiber. When you consume sugars, galactans, fructans or starch that is then fermented by an abundant overgrowth of intestinal bacterial this will lead to gas formation. This can then lead to the production of methane or hydrogen which can then lead to either constipation or diarrhea. SIBO can arise from the failure of the gastric acid barrier, failure of small intestinal motility, anatomic alterations or impairment of systemic and local immunity.

Here are the mechanisms for abdominal distention or bloating accompanied with SIBO:
  • Low gastric acid to suppress growth of ingested bacteria
  • Significant mucosal immune suppression
  • Injury to enteric motor complex resulting in lower motility
  • Weakened gut/brain axis with low activation of vagal motor nucleus resulting in lower motility
  • Anatomical or structural changes to small intestine or ileocecal valve
This then leads to a disrupted homeostatic mechanism that controls the enteric bacterial population, thus leading to a bacterial translocation from the large intestine or colon into the small intestine. This leads to the bacterial over colonization of the small intestine leading to the utilization of sugars and starches for fermentation. The end result is gas formation and distention or bloating.

You should consider SIBO if you feel abdominal discomfort after consuming:
  • Starches
  • Sugars/fructose
  • Fructans
  • Prebiotics
  • Probiotics
  • Fiber supplements
  • Rice or pea powder 
  • Galactans
This lead us to thinking for the foods fermented by this overgrowth of small intestinal bacteria:
  • Sugars
  • Artificial sweeteners
  • Corn syrup
  • Rice
  • Wheat
  • Quinoa
  • Millet
  • Amaranth
  • Tapioca
  • Beans
  • Peas
  • Chickpeas
  • Soybeans
  • Lentils
  • Lettuce
  • Onions
  • Artichokes
  • Beets
  • Broccoli
  • Cabbage
  • Brussels sprouts
  • Peas
  • Asparagus
  • Okra
  • Shallots
  • Mushrooms
  • Green peppers
  • Cauliflower
  • Grapes
  • Apples
  • Watermelon
  • Cherries
  • Kiwi
  • Bananas
  • Blueberries
  • Mangos
If you feel abdominal discomfort after consuming different carbohydrate containing foods as listed, SIBO should be considered. The severity of SIBO can vary from mild to no symptoms, to bloating after meals, to bloating with malnutrition and constipation to bloating with nutritional deficiencies, to bloating with anemia, low albumin and low cholesterol and severe bloating with weight loss, chronic diarrhea and malabsorption. SIBO is actually one of the most common causes of malabsorption in older adults and for those with IBS should be evaluated for SIBO. This can easily be detected with hydrogen and methane breath testing with chronic bloating as a solid predictor.

There is also a significant higher prevalence of SIBO in children with chronic abdominal pain and may be more common in children with gastrointestinal symptoms and apparent carbohydrate malabsorption than previously thought.

Poor motility or movement through your gastrointestinal tract and proton pump inhibitor use are independent risk factors for SIBO or fungal overgrowth. Here are some interesting risk factors tied into SIBO:
  • 9.3% with celiac disease
  • 66% with celiac disease with persistent symptoms
  • 15% of the elderly population
  • 53% of those with antacid medication use
  • 78% with irritable bowel syndrome (IBS)
  • 33% with chronic diarrhea
  • 34% with chronic pancreatitis
  • 90% alcoholics
There are two types of testing for SIBO. One is direct testing that requires a gastroenterologist that is expensive, invasive and many species of bacteria do not grow in your culture. The culture may also underestimate the bactria population and aspiration of sufficient samples is difficult and must be handled promptly for accurate results. The indirect testing is the breath testing for hydrogen and methane. Here the substances my not be useful in determining all species of bacteria, optimum protocol for timing is unpredictable, recent antibiotic use may lead to inaccurate results and increased transit time can cause false positive results.

Hypothyroid and SIBO is another area to review. When a person is hypothyroid the thyroid hormone activation of the enteric motor complex and vagal motor complex can lead to poor ileocecal valve control of trafficking bacteria from the large intestine to the small intestine, cause poor gut motility leading to poor small intestine bacteria overgrowth and/or low vagal activation of hydrochloric acid release leading to inability to suppress bacterial growth. Any or all of these can lead to SIBO creating bacterial disruption in the small intestines, interference with thyroid medication absoption and low thyroid response to receptors, this completing the cycle to worsening the hypothyroid condition. Since many with hypothyroid conditions may be due to autoimmunity and elevated cytokines from autoimmunity, this can disrupt thyroid receptor expression and the management of autoimmunity may be crucual for hypothyroid induced SIBO.

So what are the main risk factors for SIBO?
  • Age related enteric nervous system degeneration
  • Brain injury leading to poor vagal tone
  • Neurodegenerative disease
  • Abdominal anatomical disturbances such as fistula, diverticula or post-surgical alteration
  • Proton pump inhibitor for gastric reflux
  • Hypochloridria
  • Antacid medication
  • Chronic diabetes
  • Radiation exposure
  • Hypothyroidism
  • Chronic pancreatitis
  • Scleroderma or Celiac disease causing scarring on the intestinal wall
  • Significant immunodeficiency
So what to you do if SIBO is a problem for you?
  1. Understand the underlying trigger and address appropriately
  2. Nutritional support the small intestine and its terrain
  3. Stimulate the motor complex with activation
One trigger that is often overlooked is the neurological trigger. This is such a key because of the gut/brain connection but most do not think of brain function when the thought of SIBO come up. Many are living with undiagnosed brain imbalances or degeneration. To assess your likelihood of neurological imbalance, you can use our complimentary brain/neurotransmitter assessment. Go to and click on the online forms at the top of the page. Here you will find the free neurotransmitter form. You may find some brain or neurotransmitter imbalances that need to be addressed to assist you in overcoming SIBO.

There are also strategies to activate the migrating motor complex of your gastrointestinal system:
  • Gargle aggressively with several glasses of water throughout the day to activate the vagal moto
  • Induce repeated gag reflexes by gently pressing down on the tongue throughout your day
  • Perform coffee enemas to induce activation of enteric motility and hold enema contents for as long as possible to activate the gut/brain axis
Of course it would also be essential to eliminate the sugars, starches and fibrous foods that tend to ferment in the small intestines due to the overgrowth of bacteria. Eliminating these foods, while addressing your triggers with proper nutritional supplemental support is the key for eliminating SIBO.

For my clients challenged with SIBO I recommend the combination of:
  • L- glutamine power 
  • Probiotic formula containing Lactobacillus and Bifidobacterium 
  • Enzyme containing Betaine HCI, Pepsin (porcine), Bromelain, Protease I, Protease II, Protease III, Protease IV, Glucoamylase, Cellulase, Sucrase (invertase), Maltase, Phytase, Pectinase, Lactase, Alpha-galactosidase, Lipase, Amylase I, Amylase II, Peptidase
  • Combination of fatty acids with minerals and antioxidants
  • Liver drainage support   
If you have any comments or questions, feel free to post these below.


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