If you’re like most people, you probably felt a mixed sense of frustration and relief when you found out that you have Small Intestinal Bacterial Overgrowth (SIBO). Relief, because all of your symptoms finally made sense. Frustration, because you’d heard how difficult treating SIBO could be; diet changes, herbs, antibiotics, pro-kinetics.  It’s a lot to learn about, let alone put into action!

You ran a breath test. You changed to a low FODMAP diet. You found a practitioner and took a protocol of herbs or supplements. All of this felt empowering, and, at first, your symptoms started to get noticeably better. In fact they may have even resolved for the first time in years! But, then things changed and those old familiar symptoms started to return….

When things don’t go as planned…

What is even more frustrating than finding out that you have SIBO, is when you complete the protocol…..and the bloating, discomfort, diarrhea, or constipation,  come right back, despite your best efforts. It’s just not fair, right?

What is even more frustrating than finding out that you have SIBO, is when you complete the protocol…..and the bloating, discomfort, diarrhea, or constipation,  come right back, despite your best efforts. It’s just not fair, right?

I’m doing everything right….so why won’t my SIBO go away?

There are a few main reasons why people repeatedly fail to resolve their SIBO, despite using appropriate treatment strategies:

1. Using the wrong cocktail of herbs and supplements

   A quick Google search will produce dozens of herbs that have been used to treat SIBO. But knowing which herbs or supplements to use for which type of SIBO (methane or hydrogen dominant, or mixed), or what dosage is necessary, is not always obvious.

2. Not treating for long enough  

   Duration of treatment should be based on several factors. Most important is what levels of hydrogen and methane gasses were found on your lactulose breath test, prior to the 120-minute mark. Many practitioners will recommend a standard treatment length of 2-4 weeks. While this is adequate for some cases, more progressed cases may require 8-12 weeks of continuous treatment with antimicrobials.

3. Not including probiotics during treatment 

   Many people hesitate to include probiotics during treatment, thinking that they might make SIBO worse. This is especially understandable if you took a certain probiotic formula and immediately felt symptomatic. Yes, some strains (especially d-lactate forming ones like acidophilus), can aggravate pre-existing SIBO. But some strains of antibiotics are shown to be more effective at treating SIBO than prescription antibiotics! Stick to soil based organisms, spore based probiotics, or Bifidus strains to be safe.

4. Not considering prescription antibiotics  

   I get it.  I’m a trained herbalist first, always. And that means that I am just as reluctant for you to use prescription drugs as you are. However, we learn in pharmacology training in medical school that everything is a toxin, taken in the right dose. That’s right; even water can be toxic if you drink too much of it.  Every medical practitioner eventually thinks about something called the cost to benefit ratio– “does the benefit given by this treatment, in this situation, outweigh the risk of using (or not using) it?”.  In the case of antibiotics used for SIBO–specifically Rifaxamin– the benefit almost always outweighs the cost.

   Rifaxamin is an antibiotic with several unique properties. It is not absorbed into systemic circulation– meaning that it stays in the gut. You can’t, for example, use Rifaxamin, to treat an ear infection, because it would never get to the inner ear.   Rifaxamin is largely inactive by the time it makes it through the small intestine and into the colon. This means that it doesn’t upset the beneficial flora in the large intestine, leaving our good bacteria intact.

   In other words, Rifaxamin isn’t associated with many of the negative actions that are associated with antibiotics in general. It is only used for one thing, and it does that thing very well. Dr Mark Pimentel, associate professor of medicine at Cedars-Sinai Medical Center, and a leading researcher in the area of IBS and SIBO diagnosis and treatment, says that he sees Rifaxamin be effective in at least 70% of patients SIBO.

   While it’s certainly not a magic bullet, it’s worth a second look, if you’ve written it off as a potential treatment option!

5. Underlying structural abnormalities

   While this isn’t the most common reason, it does exist, and won’t show up on breath testing. Changes in the intestine (like strictures, a blind-loop resulting from a GI tract surgery,  problems with the ileocecal valve, or other structural issues)  provide an ideal environment for bacterial colonization and overgrowth.  These cannot be detected by physical examination or on a breath test, and can only be seen on imaging studies like x-rays and MRIs.

6. Co-infections  

   “Hey, who invited that guy to the party?”  Some people with SIBO either haven’t had their stool tested for parasites, or, have used panels that weren’t good enough to catch them. If you have one or more parasites living in your gut, you will generally not get a full response to your SIBO treatments until you have properly diagnosed and treated the parasitic infections.

   Another common scenario is having a mixed pattern of candida or other fungal overgrowth alongside of SIBO. Some SIBO may in fact really be “SIFO”– small intestine fungal overgrowth. Although there is some overlap, fungal/yeast overgrowth tends to respond to different herbs and supplements than are used to treat bacterial overgrowth. Sometimes, people need to adjust the treatment approach to target both bacteria and yeast, in order to get full results.

7. The wrong diet at the wrong time

   Eating low FODMAP can be a helpful way to manage symptoms. But eating low FODMAP, or too low-carb whiletreating with anti-microbial agents can actually be counter-productive!

   Studies show that using Rifaxamin plus Partially Hydrolyzed Guar Gum (PHGG)  is more effective at clearing SIBO than Rifaxamin used alone. PHGG is a pre-biotic, which means that it feeds bacteria. So you would think that it would worsen SIBO by feeding the bacteria in the small intestine. In fact, it does exactly this, except that feeding the bacteria while using an agent that targets them while they are reproducing, yields exactly the opposite effect– it kills them off in higher numbers.

   In this way, prebiotics make the treatment work better. Feeding the bacteria (either with a prebiotic like PHGG, or with FODMAP foods, as tolerated) is generally a good idea while taking herbs or prescriptions to treat SIBO.

Cops & Robbers: Clearing SIBO isn’t all about “killing the bad guys”

Reason number 8 is its whole own section, because it is probably the most significant driving cause in your stubborn or recurrent SIBO.  Many people, in fact many practitioners, are treating SIBO as if it’s a parasite. If your SIBO treatment only consists of using things to “kill the bad guys”, you’re missing the boat.

To see why this is true, we have to recognize that SIBO isn’t an infection that we “pick up” from somewhere out in the world, but rather a situation that arises because the terrain of the gut has changed so that it is now hospitable to bacteria.  While we are supposed to house trillions of bacteria in the large intestine, the small intestine is supposed to be relatively sterile.  There are several aspects of the “terrain” that need to be considered.

1. Digestive secretions

   Pancreatic enzyme insufficiency, or inadequate stomach acid or bile production all set the stage for less-digested proteins, carbohydrates, and fats. This means less nutrition for you, but also means more fermentable matter for the bacteria causing the problem!

2. Motility and the MMC 

   People with SIBO have altered digestive motility. This can be either a cause or an effect of SIBO, depending on the individual case. Although most people with SIBO will have symptoms of diarrhea or constipation, the kind of motility that is most important when it comes to getting rid of SIBO, and keeping it gone, is the Migrating Motor Complex. The migrating motor complex is responsible for cleaning the small intestine, specifically between meals.  It functions like house keeping, in order to sweep bacteria, and undigested carbohydrates and fibers that might feed bacteria, out of the small intestine and into the colon.

   Re-establishing proper motility and MMC activity is critical to your recovery from SIBO, as well as for future prevention. There are many ways to encourage proper patterning of gut motility. Using prokinetic herbs or drugs is standard, but many therapies (like abdominal massage, acupuncture, and neurological chiropractic) can enhance the benefits.

   The vagus nerve is the main player here, and we know that vagal tone can be disrupted by trauma and ongoing stress. While physiologic approaches (like probiotics, prokinetics, abdominal massage, acupuncture, gargling, or chanting) are helpful, sometimes it is more important to find ways to gently face into the underlying mind-body issue. Therapy, hypnosis, and MBSR can prove to be indispensable in these situations. Often times the experience of having SIBO can facilitate an opportunity for deeper exploration of what is living in our hearts, minds, and spirit that is unresolved.

3. Dysregulated cortisol levels and the Immune system

   One of the main reasons SIBO can arise is if your digestive immunity is compromised. Around 86% of your total body immunity is located in the GI tract.

   Anything that suppresses or alters this immune activity can leave you more vulnerable to fostering bacterial growth where it shouldn’t be–in your small intestine!

   Adrenal fatigue (HPA-axis dysregulation) leads to imbalanced stress-hormone levels (cortisol). And having cortisol levels that are chronically either too high or too low can lead to reduced levels of immune secretions in the gut. They can also slow down repair of the tissues that make up our stomach and intestinal lining, leading to leaky gut.

   You need to test, to know.

4. Sympathetic Dominance

   If you are constantly in “fight-or-flight” (also known as sympathetic dominance), your gut is at a disadvantage. Chronic stress overstimulates the sympathetic branch of our nervous system (like the gas pedal), and suppresses the parasympathetic branch (like the breaks). We need both, in balance.

   Sympathetic dominance is known to slow motility; digesting the nutrients you’ll need tomorrow simply isn’t a priority if you’re running to save your butt, NOW!, if you’re running from a wild boar. It also shuts down digestive secretions, and suppresses immune activity, while up-regulating inflammatory compounds. Not a good look.

   Digestive-focused hypnosis, Heart-rate Variability training, and meditation techniques such as Mindfullness Based Stress Reduction are a great way to give input to the nervous system and retrain it to kick off it’s shoes and relax a little.

The factors leading to your SIBO were really the perfect storm.  Addressing these issues can make or break the success of your treatment.   To learn more about how to get rid of SIBO, please schedule an appointment, or, contact my office to set up a FREE 15-minute consultation.