How to Get Treated for SIBO

Targeting Small Intestinal Bacterial Overgrowth

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Researchers are finding that small intestinal bacterial overgrowth (SIBO) is affecting more people than was previously thought. In fact, it is estimated that a signficant number of people who have been diagnosed with irritable bowel syndrome (IBS) actually have SIBO.

SIBO is a health condition in which there are an excessive amount of bacteria in the small intestine. (In a healthy body, the presence of such bacteria within the small intestine should be minimal, with a large population of such bacteria being present in the large intestine.) SIBO can cause a variety of symptoms—including, at its extreme, nutritional deficiencies.

It is most commonly diagnosed through breath testing, although other means are available.

If you have been told by your doctor that you have SIBO, you will be reassured to know that it is a treatable condition. In this overview you will learn about the ways that SIBO is currently being treated, as well as some other options that are under investigation. This information will be of help to you as you work with your doctor to formulate a treatment plan.

1) Antibiotic Therapy

For now, the "gold standard" treatment for SIBO is the use of antibiotic medications aimed at reducing the bacterial overgrowth in the small intestine. These medications are also thought to reduce any inflammation of the lining of the small intestine that might be causing nutritional malabsorption.

Unfortunately, the science behind the use of antibiotics for SIBO is still in its infancy stage. Researchers recognize that so much more needs to be learned as to which types of antibiotics are optimal for each individual person, and what dosages and treatment lengths will be most effective.

For now, the primary antibiotic used is Xifaxan. Research indicates that Xifaxan can be quite effective in treating SIBO, with a large majority of patients benefiting from the treatment. Xifaxan has been shown to eradicate a variety of strains of bacteria. In many clinical trials, it has been proven to be more effective than placebo and other types of antibiotics for improving symptoms and breath test results.

However, researchers are continuing to investigate the efficacy of other types of antibiotics so as to open up the potential for additional effective treatment options.

In the body, Xifaxan is not absorbed into the bloodstream, thus minimizing side effects and maximizing its ability to act directly on the bacteria present within the small intestine. And unlike many of the antibiotics you may have been on, Xifaxan does not have much of an impact on the bacteria within the large intestine and so should not cause you the gastrointestinal symptoms or yeast infections that you might have experienced with prior courses of common antibiotics. In general, Xifaxan is considered a safe medication, although rare side effects have been reported.

As stated above, there is as of now no general consensus as to what the optimal dosing and duration are for using Xifaxan. In most clinical trials, higher dosages have been shown to be more effective than lower doses. In clinical practice, Xifaxan is most often prescribed in courses of two weeks, with repeated courses prescribed as necessary. It should be noted that, as of early 2017, Xifaxan has not been approved by the FDA for the treatment of SIBO (although it is approved for the treatment of diarrhea predominant IBS and travelers' diarrhea).

Therefore, prescribing Xifaxan for SIBO is considered an "off-label" use.

In spite of Xifaxan's high success rates, SIBO relapses are common, thus patients often need multiple courses for adequate relief. For some, more than one antibiotic might be prescribed at the same time. For others, addressing underlying medical problems or changing diet and lifestyle habits may be necessary.

2) Address Underlying Issues

Antibiotic treatment as discussed above is the primary method of treating SIBO in people for whom no underlying cause for the condition can be identified. However, sometimes there is an underlying health problem that needs to be addressed so as to eliminate anything that is fostering the overgrowth of bacteria in the small intestine.

This underlying problem may be a disease or it may be something that affects the structure of the small intestine itself.

Underlying disease: Some examples of underlying diseases that contribute to the onset of SIBO include those that impair the motility (speed) of the stomach or small intestine, such as gastroparesis or small bowel dysmotility. These can be treated with prokinetic medications.

Another example is celiac disease, as it has been found that people who have celiac disease are at higher risk for SIBO. For these individuals, strict adherence to a gluten-free diet (essential for their health!) may also help to improve symptoms.

Structural defects: The following are some examples of structural defects that can contribute to the development of SIBO. Some of these defects may be correctable through surgery.

SIBO may also be experienced by those who have undergone a partial (otherwise known as a subtotal) colectomy, due to a possible resulting impairment of the ileocecal valve which can thus allow colonic bacteria to flow backwards into the small intestine. In addition, a slowing of the small intestine's cleansing wave, due to the colectomy, can set the stage for the bacteria to proliferate.

Medication side effects: In some cases, a medication that is used to treat a different health problem may be contributing to the conditions that foster SIBO. Discontinuing their use may help to reduce SIBO symptoms. These medications include:

3) Dietary Interventions

Dietary interventions for SIBO are aimed at either addressing nutritional deficiencies or addressing SIBO directly through the use of particular diets.

Addressing Nutritional Deficiencies: If you are diagnosed with SIBO, you should work with your doctor to identify and address any possible nutritional deficiencies. Supplements should be taken for any or all of the following vitamins and minerals if a deficiency is found:

  • Vitamin A
  • Vitamin B12
  • Vitamin D
  • Vitamin E
  • Calcium
  • Magnesium

If your doctor believes that steatorrhea and/or another type of fat malabsorption is present, they may recommend that you take a pancreatic enzyme supplement.

Elemental Diet: The elemental diet involves complete dietary restriction to a specific liquid diet formulation. Some integrative health practitioners are recommending the use of an elemental diet as a non-drug way to treat SIBO. One clinical study was conducted in which the majority of participants experienced a reduction in symptoms, and a normalization of breath test findings, after two weeks on an elemental diet.

Clearly, more research needs to be conducted to see if this hard-to-follow diet is a viable SIBO treatment. It is recommended that you do not try this at home with a homemade formulation due to the risk of significant nutritional deficiencies, which might put your health in jeopardy.

The Low-FODMAP Diet: The low-FODMAP diet was designed to reduce the symptoms of IBS by temporarily restricting the consumption of FODMAPs, carbohydrates found in ordinary foods that can contribute to IBS symptoms. With SIBO, two of the various FODMAP types, lactose and fructose, may be malabsorbed due to inflammation along the lining of the small intestine. In addition to these two, other non-absorbed FODMAPs may be fermented by the bacteria residing inappropriately in the small intestine, leading to bloating and other digestive symptoms.

Therefore, the low-FODMAP diet may theoretically be helpful for SIBO because the reduction in carbohydrate consumption might "starve" the bacteria in the small intestine. However, as of yet there are no clinical studies on the subject. Along the same lines, the efficacy of the low-FODMAP diet for people who have IBS may be attributed in some to the effect of the diet on non-diagnosed SIBO, but again as of now, this is purely speculative.

Not much is known as to the appropriateness of the low-FODMAP diet for a person who is currently taking antibiotics for SIBO. It is speculated that the diet may reduce the effectiveness of the antibiotic treatment due to putting the bacteria into dormancy. Therefore, it is generally recommended that a person eat a normal diet while on the antibiotic and then follow the low-FODMAP diet after the medication course has been completed as a way to prevent future SIBO recurrences.

As you can clearly see, the role of diet in the onset, maintenance, and treatment of SIBO remains poorly understood. Hopefully continued research on the subject will reveal helpful information as to the interplay between diet and SIBO.

The Future of SIBO Treatment

As SIBO is being given more research attention, new treatments are likely to emerge. A particularly exciting avenue of research is the development of advanced technology which will offer the ability to accurately identify the presence and type of bacteria present in a person's small intestine. In the meantime, the treatments in this section are all things that are being looked into for their safety and effectiveness for SIBO.

Herbal Formulations

There is one published study in which an herbal formulation was found to be as least as effective as Xifaxan for treating SIBO. Herbal formulations also hold promise as a way of avoiding the side effects of antibiotic medication, for treating those for whom antibiotic therapy does not work, and/or for the prevention of the recurrence of SIBO.

Prokinetic Medications

As discussed above, prokinetic medications, used for people who have gastrointestinal motility disorders, may prove to be helpful in treating SIBO. Preliminary research suggests that the use of these medications may be especially helpful for those whose SIBO exists alongside scleroderma. Such medications are thought to be helpful for SIBO, as they enhance the power of the small intestine's own "cleansing wave" to wash bacteria out.

Probiotics

In theory, probiotic supplements may be helpful for treating SIBO because they have been shown to have a positive effect on bacterial makeup, to improve the health of the gut lining, and to reduce inflammation. However, significant research on the effectiveness of probiotics in treating SIBO is lacking.

Preventing Relapse

As noted above, in spite of successful resolution of SIBO through the use of Xifaxan, the risk of relapse can be quite high. Not much is known as to whether successive or planned intermittent courses of the antibiotic medication would be helpful in preventing relapse. As of now, the recommended course of action is a regimen in which people modify their diet following a course of the antibiotic as a way to try to maintain symptom improvement, and to take repeated courses of the antibiotic as needed.

As mentioned above, the understanding of what those diet modifications would look like is poor. It may be helpful to follow the low-FODMAP diet for a short period of time. It may also be helpful to avoid foods containing artificial sweeteners such as aspartame, saccharin, and sorbitol, which hold the potential for interacting with bacteria present within the small intestine. If you have found, through the use of a breath test or elimination diet, that you have either lactose intolerance or fructose malabsorption, you may want to avoid foods containing these sugars for the same reason.

Sources:

Bohm M, Siwiec RM, Wo JM. "Diagnosis and Management of Small Intestinal Bacterial Overgrowth" Nutrition in Clinical Practice 2013;28(3):289.299.

Bures J, Cyrany J, Kohoutova D, et al. "Small intestinal bacterial overgrowth syndrome." World Journal of Gastroenterology 2010;16(24):2978–2990.

Chedid V, Dhalla S, Clarke JO, Roland BC, Dunbar KB, Koh J, Justino E, Tomakin E, Mullin G. "Herbal Therapy Is Equivalent to Rifaximin for the Treatment of Small Intestinal Bacterial Overgrowth." Global Advances in Health and Medicine. 2014;3:16-24.

Grace E, Shaw C, Whelan K, Andreyev H. "Review article: small intestinal bacterial overgrowth – prevalence, clinical features, current and developing diagnostic tests, and treatment" Alimentary Pharmacology and Therapeutics 2013;38(7):674-688.

Salem A, Roland BC "Small Intestinal Bacterial Overgrowth (SIBO)" Journal of Gastrointestinal & Digestive System 2014;4:225

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