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The Simple SIBO Solution (Our 7 Step Protocol)

Researched and Written by:
Jenna Swift, APD Dietitian Jenna Swift, APD Dietitian

SIBO is an increasingly problematic issue people face, especially those with IBS.  So let's see what the research say for tackling this big issue.

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Table of Contents

      Diagnosis & Confirmation of SIBO 

        It can be hard to differentiate symptoms of SIBO from other gastrointestinal disorders. After all, bloating, diarrhea, abdominal pain and nausea can be attributed to any number of digestive disorders. That is why diagnosis should be the first step in the road to SIBO recovery. Currently, two tools exist that measure bacterial overgrowth.  

        1. Small Intestine Aspirate and Fluid Culture- As the name implies, it involves taking a sample of fluid from the small intestine by inserting a flexible tube down your throat and feeding it through to your small intestine. This is accepted as the gold standard diagnostic tool. However the main drawback is the invasive nature of the procedure.  
        2. Breath Testing- This method is more popular for its non-invasiveness. It measures hydrogen or methane in breath samples after drinking a solution of glucose. If there is an abundance of bacteria in the small intestine, they will break down the sugar and produce hydrogen and/or methane and carbon dioxide. 

          Correct Underlying Cause 

            The gastrointestinal system has built-in defence mechanisms that naturally protect against bacterial overgrowth.

            • Acid in the stomach helps to destroy pathogens.
            • Ileocaecal valve, aka the gatekeeper between the last portion of your small intestine and first portion of your large intestine. It helps to stop the billions of bacteria tracking backwards to the upper digestive tract.
            • Intestinal motility which refers to the contraction of smooth muscles, propels food along the digestive tract and clears remnants from the small intestine.

            SIBO can occur when one or more of these natural defences fail. Without identifying and correcting the underlying cause, then the chance of relapse is very high. Research has found that approximately 44% of people with SIBO may experience a relapse of symptoms within 9-months. Conventional approaches aim to remove overgrowth and repair motility without targeting the underlying condition(s).

            Working with a health professional who specialises in SIBO can help identify the contributing cause which can be categorised into 3 main areas:

            1) Disorders of the protective antibacterial mechanisms

            • Low stomach acid caused by antacid and proton pump inhibitor (PPI) medications. 
            • Low fibre diet 
            • Stress reduces production of hydrochloric acid
            • Pancreatitis and pancreatic insufficiency 
            • Coeliac disease
            • Crohn’s disease 

            2) Motility Disruption

            • Altered bowel movements (constipation / diarrhea) 
            • Opiate painkillers slow transit time 
            • Snacking interrupts the migrating motor complex (MMC) which is the recurring motility pattern that occurs in the stomach and small intestine during fasting. 
            • Age (motility decreases with age)

            3) Anatomical Abnormalities 

            • Diverticula
            • Gastrectomy
            • Short bowel syndrome
            • Ileocaecal valve resections 
            • Small intestinal obstruction 

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            *** At this point, management of SIBO will likely occur in phases and will differ between health professionals. Regardless of the order of each phase, the common goal will be to remove overgrowth, provide symptom relief using diet and promote gut healing. Individuals will move through each phase as symptoms improve.***


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              Remove Overgrowth

                There are three main approaches to eradicating overgrowth of bacteria in the small bowel. Due to the stubborn nature of SIBO, some people may need to use a combination of these approaches to successfully remove overgrowth.

                1. Conventional antibiotics : Rifaximin is the most commonly used antibiotic for SIBO treatment. It is a non-systemic antibiotic which means that it does not pass the gastrointestinal wall into the bloodstream. It has reported success rates of around 50% for those with hydrogen-dominant SIBO. While less effective for methane-dominant SIBO, one study has reported success rates as high as 85% using a combination of Rifaximin and another antibiotic called Neomycin. 
                1. Natural herbal antimicrobials: Antimicrobials are herbs that help the body to destroy pathogens and target overgrowth. Berberine, cinnamon, pomegranate, garlic, oregano, thyme and neem are common herbs used to target overgrowth and support the immune system.
                1. Elemental diet: Often reserved for when the above approaches (antibiotics and antimicrobials) are unsuccessful. The elemental diet is a nutritionally adequate liquid meal replacement diet. Nutrients are broken down into their most elemental form and do not require further digestion. They are easily absorbed and rid the bacteria of an opportunity to feed on them. Without a fuel source bacteria are starved of nutrients.

                  Restore Movement 

                    Promoting movement through the gastrointestinal tract is achieved using medications and/or natural prokinetic agents. They help to stimulate the migrating motor complex, which are the waves of contractions that propel undigested food and bacteria along the gastrointestinal tract during fasting.  In other words, this allows bacteria to migrate towards the large bowel and prevents accumulation in the small bowel. 

                    Pharmaceutical Prokinetics- Motilium (Domperidone), Reglan (Metoclopramide), Zithromax (Erythromycin)

                    Natural Prokinetics- ginger, globe artichoke


                      Restrict Diet 

                        There are several elimination style diets that provide symptom management for SIBO. Unfortunately many of these diets lack the evidence to support them as a specific treatment protocol for SIBO. They include;

                        • Low FODMAP Diet: This may improve SIBO symptoms however there is no evidence to support it being a treatment option for SIBO. 
                        • The Specific Carbohydrate Diet (SCD): No studies have evaluated the use of the SCD to treat or manage SIBO.
                        • The SIBO Specific Food Guide: No research studies are available to support the use of the SSFG for any disease process, including SIBO.
                        • The Biphasic Diet: Developed by Dr Nirala Jacobi, it is a combination of the Low FODMAP diet and The Specific Carbohydrate Diet. 
                        • Low Fermentation Diet (also known as The Cedars Sinai Diet): Developed by Dr Mark Pimentel, this diet aims to reduce SIBO symptoms by avoiding fermentable carbohydrates like beans and pulses, fiber supplements, oats, high FODMAP sweeteners, gums and some dairy. Another feature of this diet is to allow a 4 hour gap between meals to stimulate your MMC. 

                        Alcohol should be avoided during SIBO treatment. Alcohol can disrupt gastric motility, disrupt the normal microbiome of the intestinal tract and promote inflammation. All of these factors can worsen SIBO symptoms and delay the healing process.   


                          Repair the Gut 

                            The gut healing stage aims to restore the intestinal lining using healing nutrients.

                            • Probiotics: There is research to suggest that probiotics such as Lactobacillus casei may enhance the effectiveness of antibiotics. Patients showed greater improvement in their symptoms with dual probiotic + antibiotic therapy compared to antibiotics alone.  

                            Conversely, some argue that taking probiotics while SIBO symptoms persist can contribute to an excess of bacteria in the small intestine. Recent studies have shown that taking probiotics may provoke symptoms like bloating and gas. In that case, some practitioners may advise against using probiotics until the repair phase to repopulate and heal the gut. 

                            Therefore timing of probiotics will depend on your individualised SIBO treatment protocol. It also highlights the need for additional large scale studies regarding the effects of probiotics on SIBO risk. 

                            • Digestive Supports: SIBO may cause digestive enzyme deficiencies, in particular lactase, maltase and sucrase which are produced in your small intestine. Adding in a digestive enzyme supplement  can facilitate the breakdown of food so that it can be easily absorbed and digested. This is particularly important as you start to reintroduce more variety back into your diet. 
                            • L-Glutamine: Dietary supplementation with glutamine directly supports gut health and digestion. It helps to regulate the composition of the gut friendly microbiota and minimises the inflammatory response when the gut lining is irritated. Glutamine is also considered the most important nutrient for healing of ‘leaky gut syndrome’. This is because it is the preferred fuel for the single layer of cells that line your small intestine. These cells are held together by tight junctions which serve as a protective physical barrier between the intestines and bloodstream This essentially determines what nutrients or molecules can be absorbed into the bloodstream and blocks the entry of pathogens. 
                            • Zinc: sf

                              Correct Nutrient Deficiencies 

                                Microscopic damage to the small intestine wall can diminish its absorptive capacity. This may lead to complications such as diarrhea, nutrient deficiencies, unintentional weight loss and conditions such as osteoporosis.

                                Fat malabsorption occurs when bile salts that are needed to break down fat are disrupted by bacteria. This may lead to deficiencies in fat soluble vitamins A, D, E and K. Majority of the most symptoms of deficiency are rare. However in severe cases it can lead to night blindness (vitamin A), osteomalacia and tetany due to hypocalcemia (vitamin D) and prolonged prothrombin times (vitamin K). 

                                Vitamin B12 deficiency and iron deficiency are also common complications of bacterial overgrowth. For this reason it is important to check vitamin and mineral status at baseline and throughout SIBO treatment (for example every 3-months). This will require a simple blood test and stool sample to check for fat malabsorption. 

                                Incorporating rich sources of omega-3s and vitamin D into the diet from salmon, mackerel or sardines will help to prevent and correct deficiencies. Along with liver which is a valuable source of vitamin B12, iron and vitamin A.

                                Evidence Based

                                An evidence hierarchy is followed to ensure conclusions are formed off of the most up-to-date and well-designed studies available. We aim to reference studies conducted within the past five years when possible.

                                • Systematic review or meta-analysis of randomized controlled trials
                                • Randomized controlled trials
                                • Controlled trials without randomization
                                • Case-control (retrospective) and cohort (prospective) studies
                                • A systematic review of descriptive, qualitative, or mixed-method studies
                                • A single descriptive, qualitative, or mixed-method study
                                • Studies without controls, case reports, and case series
                                • Animal research
                                • In vitro research

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                                References

                                1. Rao S, Bhagatwala J. Small Intestinal Bacterial Overgrowth. Clin Transl Gastroenterol. 2019;10(10):e00078. doi:10.14309/ctg.0000000000000078
                                2. Deloose E, Janssen P, Depoortere I, Tack J. The migrating motor complex: control mechanisms and its role in health and disease. Nature Reviews Gastroenterology & Hepatology. 2012;9(5):271-285. doi:10.1038/nrgastro.2012.57
                                3. Achufusi T, Sharma A, Zamora E, Manocha D. Small Intestinal Bacterial Overgrowth: Comprehensive Review of Diagnosis, Prevention, and Treatment Methods. Cureus. 2020. doi:10.7759/cureus.8860
                                4. Andrew C. Dukowicz G. Small Intestinal Bacterial Overgrowth: A Comprehensive Review. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099351/. Published 2022. Accessed January 13, 2022.