You have SIBO (Small Intestinal Bacterial Overgrowth) and you completed all the necessary steps in the “kill phase” of treatment. You run a follow-up breath test and your gas levels have normalized! Or, you didn’t retest, but your symptoms are 90% better! This is great progress and it feels like you are finally moving forward!

But, if you’re just killing the bacteria – you’re only halfway there!!

Many SIBO patients get their initial SIBO treatments and feel good for a while. But then, all the bloating, gas, cramping, constipation, or diarrhea begin to make a very unwelcome comeback. For various reasons, too much bacteria will once again start colonizing the wrong part of the GI tract leading to SIBO relapse. 

Unfortunately, it’s common to have SIBO relapse. But, don’t get discouraged. You’re not wading through the murky waters of SIBO treatment alone.   

Let’s break down if your symptoms are IBS or SIBO, why SIBO relapse might happen, what you can do, and how to help prevent a relapse in the first place.

 

Are my symptoms IBS or SIBO?

When it comes to gut issues, it can be difficult to identify and understand your symptoms. In general, there are two common conditions of the intestines that can present very similarly: Irritable Bowel Syndrome (IBS) and SIBO.

IBS is a functional gastrointestinal disorder. It affects the two-way communication between your digestive system and your brain. When this communication system malfunctions it can throw off your entire digestive tract. Leading to symptoms like abdominal pain, bloating, and altered bowel habits such as constipation or diarrhea. Sounds a lot like SIBO, doesn’t it?

A single underlying cause of IBS has not been identified. But honestly, there are many factors that could lead to IBS including food sensitivities, severe infections, stress, or intestinal muscle issues. What’s interesting is that up to 78% of patients diagnosed with IBS have SIBO.

IBS and SIBO are complex conditions. But, since these conditions can present so similarly it’s important to rule out SIBO with a breath test so that we can customize your treatment plan.

 

What causes SIBO relapse?

I know what you’re asking…if I’ve done the work to identify the cause of SIBO and the SIBO treatment…why on earth is my SIBO coming back?! 

Unfortunately, approximately 45 percent of all SIBO patients will experience a SIBO relapse. There are three primary reasons that my patients experience SIBO relapse: diet, underlying gut conditions, and medications.

Diet

Let’s call it like it is, diet changes are never a quick fix, they are a lifestyle change. A diet that is high in sugar, refined carbohydrates, FODMAP vegetables, or alcohol can make SIBO symptoms like gas, bloating, constipation or diarrhea worsen or relapse. It’s important to introduce foods like starchy veggies in the long run because it feeds the good gut flora. But introducing too much too soon is when you run into issues. 

Underlying Gut Conditions

A physical obstruction in the gut can be both a cause of SIBO and subsequently the cause of SIBO relapse. Crohn’s disease, celiac, diabetes, and leaky gut are the four most common gut conditions that can cause SIBO. 

Medications

Some medications may help with certain issues while wreaking havoc on others. Medications like antibiotics, antihistamines, NSAIDs, acid-blocking drugs (PPIs), and steroids all disrupt your normal gut flora. Some kill healthy bacteria and others increase the permeability of your gut. But, they all increase your chance of SIBO relapse.

 

How To Prevent SIBO Relapse

Preventing SIBO relapse starts during the “kill” phase of your SIBO treatment. There’s a lot you can be doing during and after SIBO treatment to prevent SIBO relapse. Here are a few things I like to include in SIBO treatment plans:  

1. Address Low Stomach Acid and Pancreatic Digestive Enzymes – These antimicrobial enzymes help enhance nutrient absorption and assimilation.
2. Support your Oral Microbiome – 94 percent of Americans have some levels of gingivitis or bacteria in their oral cavities that can impact gut health. I recommend Blocidin toothpaste and dental rinse. Plus, don’t forget about flossing. Sorry, no water picks.
3. Liver Support – The toxins from SIBO have inundated your liver. The endotoxins (the toxic substances bound to bacterial cell walls) from having SIBO saturate the bile and add to your total liver toxic burden. These systems need their own love to get back up to speed. Resolving the excess gram-negative bacteria is the first step. My favorite for bile support is MegaGuard by Microbiome Labs.  Learn more about bile support and gut health.
4. Repair Leaky Gut/Mucosal Inflammation and Damage – SIBO has likely led to an inflamed gut and has damaged the cellular walls and lining. Not only do you need to kill off harmful bacteria and rebuild healthy gut flora, but you also need to repair any structural damage. I recommend Super Curcumin by Apex, with either MegaMucosa by Microbiome Labs, or GI Balance by Xymogen.

 

What To Do After You’ve Cleared the Bacteria Causing SIBO

The first phase of SIBO treatment is tough and you’ve survived it. Congratulations! But now what? 

Great question! There is a lot you can do after SIBO treatment to prevent relapse and stay healthy. 

1. Stay on a modified low FODMAP or SIBO Biphasic. To allow your microbiome to heal, I recommend following one of these diets for two to three months, followed by gradual reintroduction of foods that you have omitted.
2. Add a Prokinetic to address gastroparesis and support the Migrating Motor Complex (MMC). Gastroparesis slows your stomach’s motility preventing it from emptying properly. MMC sweeps residual bacteria and leftover carbohydrates and protein particles out of the small intestine. Waiting 4 hours between meals allows MMC to work because it is only triggered during a fasted state. So, if we snack all the time or chug large amounts of liquid, we’re inhibiting the MMC housekeeping wave. Limit snacks and sip, don’t chug, your fluids. So remember, eat, stop, eat.
3. Restore your vagal tone and your MMC by retraining your nervous system signaling.  All of the approaches to restoring vagal tone for improved digestion focus on promoting your parasympathetic nervous system activity, over your sympathetic activity. The parasympathetic nervous system helps restore the body to a calm and composed state and prevents it from overworking. Sympathetic activity, on the other hand, prepares the body for a stress-related activity. Depending on what may be causing your sympathetic activity several techniques can be personalized based on your symptoms. This includes vagal nerve stimulation, gut-focused hypnotherapy, Frequency Specific Microcurrent, acupuncture, or the Gupta Program. And, if there has been a big stress or trauma other treatments like EMDR can be considered. Check out inaura.com to identify additional personalized therapy options.
4. Add single-strain probiotics and prebiotics to your daily routine. Probiotics and prebiotics, added slowly to your diet, can help to rebuild and maintain your healthy gut flora. Because multi-strain probiotic blends are not generally tolerated by SIBO patients I recommend several single strain options based upon your specific symptoms and tendencies (i.e. bloating, constipation, diarrhea, histamine intolerance, etc.). I personalize your routine with some of my favorites including HU 58 (Microbiome Labs), BioGaia Protectis, probiomax by Xymogen, and Ideal Bowel Support (L Planetarium 299V). I start all my patients on a partial dose and work up to help bulk the stool without triggering SIBO. Once you are tolerating partial doses, we can reintroduce most FODMAP foods along with other strains of probiotics for continued gut repair. The key is going slow and steady. Adding any probiotics too soon or too quickly can flare SIBO.

To get you started, let’s focus on diet, probiotics, and prebiotics.

 

SIBO Treatment: Low FODMAP Diet and SIBO Biphasic Diet

Many of my SIBO patients hit the internet and find a lot of information on the “SIBO diet”. The SIBO diet is also known as a low FODMAP diet. 

I recommend following a low FODMAP diet during SIBO treatment and for a short time after. But, in the long haul, a low FODMAP diet can be too restrictive. It does not offer you the necessary food diversity required for a robust and diverse microbiome. But, after the initial treatment, you can slowly reintroduce foods that will support your gut health and regularity.

Some patients also have a lot of success with a SIBO biphasic diet. This diet plan is as restrictive as the low FODMAP diet to start. But, it slowly reintroduces the most tolerated and least fermentable foods back in overtime. The foods eliminated don’t change on the biphasic diet. Instead, it provides more guidance on what foods to reintroduce and when.

In reality, diet does not cause SIBO. Period. Diet can cause many other things like candida and poor microbiome health, but SIBO isn’t caused by diet. Instead, a highly-processed, low-quality diet tends to lead to increased symptoms and SIBO relapse. Diet is simply a way to manage your SIBO symptoms during the kill phase and long-term. And, it’s unique to each patient. Whether you follow a low FODMAP or biphasic diet, your SIBO treatment should include a full evaluation of your diet to help manage and control your symptoms. 

 

Benefits of Probiotics and Prebiotics

I know it sounds strange, but utilizing probiotic and prebiotic supplements in the treatment of SIBO can be beneficial. It seems counter-intuitive. If excess bacteria in the small intestine cause SIBO, why would you want to add more?

Probiotics help to reduce bacterial overgrowth and hydrogen concentrations. And, probiotic supplements can help improve symptoms and restore a healthy gut microbiome. Which in turn increases your resilience against SIBO or general dysbiosis by promoting healthy expression of gut immunity and maintaining a strong and resilient mucosal membrane. 

Prebiotic supplements, on the other hand, essentially provide the nutrients needed for healthy bacteria to flourish in your gut. 

Ongoing research shows that probiotic and prebiotic supplements can be very effective in the treatment of SIBO. They can help improve symptoms, improve lab values, and support long-term gut restoration. Yet, not all probiotics and prebiotics are equal. It’s important to introduce the right supplements to focus on helping resolve your specific issues slowly and only as tolerated. Too much, or the wrong things can lead to SIBO relapse if the body isn’t ready. Generally, I start with PHGG (Partially Hydrolyzed Guar Gum) and Acacia.

 

Get Help With SIBO Relapse

SIBO is an incredibly complex condition that requires a great deal of time and energy to resolve. 

Every case of SIBO requires personalized treatment. And as your health guide, we’re here to put the pieces of your puzzle together and get you back on track. You deserve to live your life freely and feel well every day!

So, if you find yourself feeling defeated in your journey to better gut health, we are here to help!

Start by scheduling a no-cost, no-obligation 15-minute consultation call to regain control of your health.

 

References

“Probiotics for Preventing and Treating Small Intestinal Bacterial ….” https://pubmed.ncbi.nlm.nih.gov/28267052/. Accessed 10 Feb. 2022.