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Sometimes a simple low FODMAPs diet, or a course of prescription or botanical antimicrobials, is enough to shift a case of SIBO. But if your experience is anything like ours, some cases are much harder to address and can be much more prone to recurrence. If you’re presented with a difficult SIBO case (or if you yourself feel like a difficult case!), read on to find out what else you should be thinking about.
What is SIBO?
SIBO stands for Small Intestinal Bacterial Overgrowth. Normally, the bulk of our gut microbiome resides in the large intestine. In SIBO, we see an overgrowth of bacteria (even otherwise healthy bacteria) in the small intestine, where they are not usually present to such a high degree. Those bacteria are then able to act on poorly-digested, fermentable carbohydrates, producing uncomfortable symptoms such as bloating, gas, abdominal pain, diarrhea and/or constipation.
The effects of SIBO can extend beyond direct gastrointestinal symptoms. The excess levels of bacteria excrete acids that can underlie some neurological symptoms including brain fog and fatigue. Increased gut permeability can occur causing translocation of bacteria and insufficiently digested food particles that trigger immune activation that can lead to pain and other symptoms. It also predisposes an individual to food sensitivities. Nutrient deficiencies can arise as the bacteria consume some of the ingested foods; B12 and iron, for example, which can lead to anemia, and deconjugation of fatty acids from bile that reduces absorption of fat-soluble vitamins. Patients with SIBO also tend to have altered secretory IgA values, demonstrating that SIBO directly alters immune activity in the gut.
Practicing Functional Medicine thinking
Addressing SIBO with diet and botanicals, while clearly important, represents a rather ‘top down’ approach to treatment. In many cases, we may need to be combining that with ‘bottom up’ (root cause) support.
In Functional Medicine, we should always be thinking about the root cause, regardless of the condition we’re trying to address, and SIBO is no exception. There are a number underlying factors that may need to be considered to support successful resolution and prevent recurrence of SIBO.
For those that are familiar with the terminology used by the Institute for Functional Medicine, we’ll review these as Antecedents, Triggers and Mediators (ATMs for short). Don’t worry, if you’re not yet familiar with these terms, you’ll still be able to follow along. Since the pathophysiology may be better understood this way, we’re going to start with Mediators first, and work backwards.
SIBO mediators
Mediators are factors that contribute to the ongoing, or active, state of the condition, in this case of bacterial overgrowth. Three primary mediators stand out:
1. Lengthened transit time. The migrating motor complex is critically important for enabling peristalsis, the smooth muscle contractions of the intestines that propel its contents along, and avoiding stagnancy within the lumen of the small intestine. A disruption to the migrating motor complex encourages bacterial overgrowth and prevents excess bacteria from being cleared out of the small intestine. This is the reason why SIBO protocols often include motility agents, or advice to space meals 4-5 hours apart.
2. Shorter transit time. Food that passes through the bowel too quickly, such as in short bowel syndrome, can also be problematic since there is insufficient time for proper digestion and absorption.
3. Altered digestive secretions. Sufficient stomach acid, bile and enzymes all act to keep bacterial levels in the small intestines in check. If those digestive secretions are compromised, bacteria can start to flourish. Once again, SIBO protocols may also include digestive support to replace and/or improve digestive secretions. This can be accomplished with dietary supplements as well as practices that improve digestion, such as thorough chewing and mindful eating.
SIBO triggers
Single or short-term events are known to trigger SIBO in some cases. Examples include acute gastroenteritis, acute stress, or medications such as proton-pump inhibitors which inhibit gastric acid secretions.
If the SIBO was triggered by one of these events, without any of the antecedents that we will review next, then it is more likely (though not always guaranteed) that diet plus a course of antimicrobial botanicals will be effective at resolving the condition. If the trigger is no longer present, of course.
However, if any of the following antecedents are present to a sufficient degree, causing the SIBO mediators to persist, then they may be interfering with long term resolution of the SIBO.
SIBO antecedents
Here’s where some of the most difficult cases of SIBO may be getting stuck. These predisposing factors were likely present before the onset of SIBO and set the stage for the condition to take hold. By simply addressing the bacterial overgrowth directly (or ‘top down’), we may not have addressed factors that will encourage SIBO to return at the first opportunity. This is not an exhaustive list, but represents some more common underlying issues:
1. Hypothyroid. Low thyroid function can affect all cells of the body, including the cells of the GI tract. Hypothyroid can reduce the activity within the gastrointestinal tract, slowing the migrating motor complexes that trigger peristalsis.
2. Diabetes. We know that the oxidative damage caused by high blood sugar in diabetes can lead to deterioration of vision, kidney function and peripheral blood vessels. And it can also damage the nerves that regulate and control intestinal migrating motor complexes.
3. Chronic stress. When the body enters the sympathetic fight-or-flight state, gastric function is altered. We are not in the rest-and-digest state anymore. This also affects the enteric nervous system that controls the migrating motor complex. In our experience, stress appears to be a contributing factor in virtually all cases to some extent.
4. Depressed immunity. Various immunodeficiency syndromes have been associated with increased risk for bacterial overgrowth, including IgA deficiency. Secretory IgA in the gastrointestinal tract is the largest fraction of immunoglobulins secreted in the body, and aids in preventing bacterial proliferation.
5. Stealth infections. The potential complications arising from acute or chronic infections from lyme or other tick coinfections are many, and include gut dysfunction, even so-called ‘palsy of the gut.’ Gut dysmotility has been associated with infectious agents including varicella zoster, Estein-Bar virus, and Lyme disease.
6. Abdominal adhesions. Abdominal adhesions, otherwise known as scar tissue, which can arise from chronic inflammation (e.g. Crohn’s Disease), infection or surgery, can create an obstruction or distortion of the intestines and/or impair the enteric nervous system’s migrating motor complex, both of which can predispose to SIBO.
7. Excess estrogens. Estrogen-induced gallstones are a common form. Excess estrogens can inhibit the excretion of bile salts from the liver into the intestines. Since bile salts have antimicrobial activity, their deficiency can be a predisposing factor for SIBO. Estrogen also delays gastric emptying and motility.
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I am a 72 year old female with SIBO. This is my second time at a full round of antibiotics. I was good for a year and now it is back. What else should I be doing?
In our clinic, when we see refractory SIBO, we find that cycling prescriptions with herbal antimicrobials to be helpful. We also make sure to address GI motility, pH, and overall microbiome balance (boosting good bacteria). I highly suggest working with a functional medicine practitioner that specialized in addressing tough SIBO cases. Take a look at our services to see if they may fit your needs, https://www.drkarafitzgerald.com/our-clinic/make-an-inquiry/
Very well written, inclusive summary! It has taken me years to accumulate this info in bits and pieces from many sources and I have yet to find a physician who will systematically treat me with all this in mind – no, I think it is fair to say with very little of this in consideration.
I would add another antecedent to the list perhaps related to physical adhesions. My G.I. specialist reluctantly believes from MRI testing that I have SMA syndrome because the angle between my aorta and systemic artery(where sm interesting passes through) is very small; however, I believe I have always had this condition and SIBO has resulted from other factors tipping the balance in my MMC. I have followed FODMAP diet for way too long (years) and tried all antibiotics although never in correct timing with testing and prekinetics. I am discouraged and anxious about the long term effects on my health and longevity from not treating the SIBO. I am encouraged, however, to read your article acknowledging current information.
@Linda
I have also been diagnosed with SMA syndrome in the past. Symptoms include: intense abdominal pain, piercing to back/spine, almost always after eating and even can’t tolerate small amounts of liquids; full feeling/early satiety and nausea. I am a male and was 73-75 kg and 171 cm length when diagnosed. SMA-aorta distance in one test was 3mm, but during gastroscopy, the doctors also found a large amount of h.pylori bacteria. Received a feeding tube, since I had lost 5-10kg weight from not eating for 2-3 weeks and for conservative treatment of the SMA syndrome diagnosis. Conservative treatment didn’t result in weght gain. At the same time received I abx treatment for the h.pylori bacteria. I felt that symptoms alleviated after abx, and after a 2nd course treatment abdominal pain and other symptoms mostly disappeared. About half year after the diagnosis I went to a professor specialised in compression syndrome, and he told me that my SMA-aorta distance is 8.5 mm and that normal food can pass through. Been abled to eat large portions of solid food last 2,5 years but now symptoms have appeared again. I also believe that my small sma-aorta angle is congenital and that I might close/symptoms appear due to possible bacterial overgrowth.
Wondering how you are doing now. Have you been able to treat your symptoms?
Article is good. But it would be make it awesome if you can give natural remedies/supplemental information and tests that can detect in this article. I’m sure many of them will find it useful.
If I got sibo from food poisoning and it’s now gone am I at high risk for reoccurrence? I’m scared it will come back! It was so painful!!!
SIBO can be painful and difficult to treat. Hopefully if you’re working with a Functional Medicine practitioner, he/she supported the rebuilding of your gut microbiome, supporting stomach digestion and acidity, as well as ensuring good motility to prevent recurrence. These will help to reduce risk of recurrence.
Eight months ago, aged 51, I had abdominoplasty surgery to correct diastasis recti. Since then I have been experiencing severe bloating and a pain that’s present above my belly button, deep in the tummy. After some online searching I found a website with a whole lot of women complaining of the same thing! All of their plastic surgeons, including mine, say the surgery has nothing to do with the bloating. Mine told me that its just ‘you’. Well I’ve NEVER had this before until AFTER the surgery! I also am experiencing yeast infections, also on arms and legs, and my toenail fungus has come back with a vengeance, even after completing the round of pills given to me by my podiatrist. Someone mentioned that SIBO could be the cause. And on another site a well known Dr explains that one of the many causes of SIBO is abdominal surgery! Do you believe there is a correlation?
Sharon, thank you for reaching out. SIBO could definitely be a piece. Scaring could be influencing as well. It’s time for a full functional work-up. Take the time to get to the bottom of all the pieces contributing to your symptoms, and correcting them. You’ll be so pleased you did! DrKF
I am very sick with sibo nothing is working for me can someone help me
I’m getting tested for Sibo on Monday. I saw this post and I too am someone who never had these issues before abdominal surgery. Beyond an intolerance, to egg yolks, issues with soft cheeses, fish oil, and probiotics I didn’t have issues with foods. Now I can’t even eat breakfast because I’m immediately bloated and when I do eat no matter what it is I puff up. I had a butchered tummy tuck in 2018 and another surgeon corrected it in 2019 by completing a lower body lift. (Not by choice, but my only option because of how badly it was screwed up). It’s now become one of my biggest regrets and I would’ve left the loose skin. I’m now 2 years post my LBL and my stomach is no longer flat, I have stomach issues, my abs are gone (I lift and had them prior to surgery minus my pannus skin), I have some nerve damage and I keep getting fluid behind my knee. Between the swelling, I’ve had and now full-body retention. I’m even grabbing skin on my back and on my legs I never had. I’ve been having issues with bloating getting worse since I was 7 months post-op rather than better. I was told 18 months the swelling would ease up and get better but it got worse followed by nausea and swelling. I didn’t have many symptoms others did until they put me on ulcer meds. My surgeon did a full muscle repair and had to reconstruct my belly button as my first surgeon went past the point of threshold which made it uneven. I’ve been dealing with a host of other issues which everyone wants to blame on stress since we dealt with a massive trauma during the last few months. They sent me to the spine doctor who completed an MRI and found no reason for my swelling or problems. I had an EMG done again with nothing abnormal. I asked for a referral to gastro and they put me on FDguard to try which made my stomach worse! She had me get an endoscopy and they found I have an ulcer. My biopsy and bacteria test came back negative. I was put on a PPI which I had an allergic reaction too. Then prepcid which was also causing digestion upset and she put me on another med which I’m not reacting too but I’m barely eating now and have had even more bloating and inflammation.
The next stop is SIBO testing. Today was a rheumatoid appointment to rule out more (which also apparently connects to sibo testing) and tomorrow 10 vials of blood get taken including testing my thyroid levels. I only found out tonight that almost all my aunts had thyroid issues. So, I’m nervous about that.
My point of posting though is that surgeons are extremely dismissive as soon as you bring new issues up. I personally feel there is a correlation that needs to be looked into. Many women seem to have this issue post abdominal surgery especially if they had muscles repaired or tightened. Many surgeons don’t even want to consider it as a complication because no literature I found in the medical journals seems to cover this yet and anything I did find was often based around gastric bypass patients. Even if it’s not a “complication” of the surgery itself based upon my own searching for answers I’m finding many women find out issues after the surgery when they had zero issues beforehand. I also was reading that many people don’t discover thyroid issues until they need to have a SIBO test.
My 14 year old son (200 lbs) has SIgA D and chronic recurring SIBO. He has been treated once with low dose Rifaximin and had good results in seeing the symptoms abate but after just 3 months, his symptoms returned and by 6 mo post treatment, he was back to diarrhea 3-4 times a day and then eventually became severely constipated. We are about to retreat with a higher dose of Rifaximin for a slightly longer period of time. Our Gastroenterologist has prescribed a Low FODMAP diet for our son but in all my research, I am finding very mixed reviews about the efficacy of combining this diet with antibiotic treatment of SIBO, especially for someone who has an underlying immunodeficiency. I would like to know your opinion on this as well as your thoughts on using probiotics and/or probiotics alongside antibiotic treatment. I am also curious about your thoughts on how a child with these conditions (he has had chronic diarrhea all his life) can end up struggling to maintain a healthy weight. We eat real food and I cook from scratch. We eat a balanced diet and rarely eat out.
Thank you in advance for your insight.
Sincerely,
Bethany P
It’s not uncommon that we see recurrence of SIBO and/or symptoms after rifaximin. Depending on the kind of SIBO, single therapy with the antibiotic may not be enough to eradicate. In these “resistant” cases, we have seen success with coupling antibiotics depending on the kind of SIBO (including accounting for possible fungal overgrowth), as well as alternating with herbal antimicrobials. We do use low FODMAP diet to help manage symptoms, but it’s not great to lean on long-term so our nutrition team will usually guide on a gradual and safe reintroduction parallel to treatment. Sounds like you’re doing a great job keeping the diet clean, which is not easy! But I can see how it’s also frustrating and difficult to manage. At this stage, I would suggest working with a Functional Medicine trained practitioner to help guide you and get the diarrhea and body composition under control. One option is working with our Nutritionists available remotely. They are trained in managing SIBO and highly qualified for managing complex cases – you can learn more about them here if you want to explore that option https://www.drkarafitzgerald.com/our-clinic/nutrition-services/ . The other option is work with one of our FxMed physicians, or find a local provider at http://IFM.org. Please call or email our office if you’d like more information.
You really need to see a functional natural path for your son who specializes in sibo.i too have sibo but I have siboc i am currently seeing a natural path who is a expert on sibo she had what your son has she cured hers
You must know sibo can also come from a underling condition .mine was from scar tissue but so.many other inderling disease or condition.sibo is a journey to what cause it in the first place.gastro doctors only treat natural path finds the root causes
I got test results back today that show that I have methane dominant SIBO. I also have Hashimotos. My GPL mycotox profile shows zearalenone (8.19), ochratoxin A (7.73) and mycophenolic acid (8.11). I’m supposed to do a challenge test for heavy metals but I already feel pretty bad and am concerned about heavy metals on the move in my body. My question is if there is a specific order thats best to treat these? I will be working with a functional meds. dr. Thank you!
Unfortunately, we cannot give medical advice here. Your FxMed doc should help guide. The order to approach is going to be individualized for each case, prioritizing based on your symptoms, FxMed matrix, and overall health and nutritional status.
I’m suspicious SIBO is my problem. Wondering if it can cause dizziness and or motor skill problems?
In our practice, we have found those symptoms not to be uncommon in patients with SIBO.
Found this article by accident. Recovering from bowel resection surgery +ve documented for low thyroid , Lyme, Adhesions
One week post surgery mental function better. Brain fog better.
I was NOT searching for this. But now I’m here what do I do to get even better.
If Epstein-Barr virus is an antecedant, what can be done to mitigate recurrence of SIBO? I have had Epstein-Barr twice, and believe it could cause my SIBO.
Supporting the immune symptoms to improve resilience to both prevent/eradicate EBV as well as simultaneously supporting motility, digestions, and microbiome balance – it often takes a broad FxMed approach to prevent SIBO in susceptible individuals.
Looking for help with sibo
I am seeking a functional medicine GI doctor who accepts insurance in the Washington DC/suburban MD area. While this article seems to offer hope for the recurring SIBO sufferer, the policies indicate the cost ranges from $2000-$3600 dollars for new patient intake plus $650 an hour thereafter with no insurance accepted. This is not a tenable solution for me, and, I expect, many others.
Hi Mary, there is a register of functional medicine practitioners on ifm.org you might try. Best of luck in your search – there are fxmed clinicians out there who accept insurance, but they are few and far between because the insurance model is not very compatible with the depth of practice in functional medicine.