Holistic Remedies for SIBO: Effective, Evidenced Based Options Without a Prescription

Small intestinal bacterial overgrowth (SIBO) is a condition characterized by excessive bacterial growth within the small intestine and can come with a slew of gastrointestional symptoms.

SIBO is known to impair digestive function and consequently, quality of life. Therefore, accurately finding and then diagnosing SIBO is important so interventions can be pursued!

However, patients are often mislabeled with irritable bowel syndrome (IBS) after accessing the healthcare system due to their symptoms. SIBO is a commonly overlooked cause of IBS like digestive symptoms.

There are many studies that explore IBS by itself, SIBO by itself, and SIBO amongst those with IBS; and then to complicate it there are subcategories of IBS (IBS-C, IBS-D, IBS-M) and subcategories of SIBO. There is so much back and forth on this in the literature, but the big point I want to highlight here is that when intestinal bacterial overgrowth is present, it tends to be missed and therefore not cared for with the correct intervention.

IBS is another real and common diagnosis that doesn’t always involve SIBO, but studies show 30-80% of IBS cases are really underlying SIBO.
This is a hot topic right now in healthcare! Allopathic medical doctors and functional medicine aligned doctors often do not see eye to eye on this and each area of medicine leans into their own professional organization, protocols, and care algorithms.

Functional Medicine alligned practitioners tend to be more apt to pursue testing to diagnose and effectively treat SIBO in patients with digestive (and other reported manifestations) of this bacterial overgrowth.

What are sign & symptoms of SIBO?

• Abdominal pain
• Abnormal bowel function- either constipation or diarrhea
• Burping or belching
• Excess bloating or abdominal distention that persists
• Flatulence or gas
• Heartburn or reflux
• Nausea
• Nutrient deficiences as seen in bloodwork
• Sometimes, unintentional weight loss

Note that the small intestine does have a some bacteria under normal circumstances, but when overgrowth occurs (which can happen for a variety of reasons) the excess bacteria leads to excess fermentation of dietary carbohydrates which next leads to excess gas and a slew of symptoms in many people.

What subcategories of SIBO exist?

There are 3 subtypes of SIBO, each distinguished by the gaseous byproducts produced by the excess bacteria in the intestines.

1. Hydrogen (H2)-dominant SIBO is the overgrowth of bacteria in the small intestine diagnosed by elevated hydrogen gas levels on the SIBO breath test. Overgrowth of Streptococcus, E. coli, Staphylococcus, Micrococcus, Klebsiella, Bacteroides, and Peptostreptococcus are associated with H2-dominant SIBO. This H2-dominant SIBO is also associated with diarrhea. Patient’s tend to get labeled with IBS-diarrhea (IBS-D) when it often should really be diagnosed as hydrogen dominant sibo.
2. Hydrogen sulfide (H2S)-dominant SIBO is characterized by excess bacterial production of specifically the H2S gas. Hydrogen sulfide-producing bacteria associated with the following strains of Proteus, Escherichia, Klebsiella, and Desulfovibrio. Patients that present with this often get labeled with IBS-D.
3. Intestinal methanogen overgrowth (IMO), also called “methane dominant SIBO” is the overgrowth of methanogens in the intestines. Methanogens, are technically “archaea” (and not bacteria). These methanogens can overgrow and then overproduce methane gas in both the colon and small intestine. Methane dominant SIBO usually presents with constipation and patients tend to be labeled with IBS-constipation (IBS-C).

Why is SIBO serious?

The excess bacterial fermentation within the small intestine can cascade to intestinal immune activation, inflammation, increased intestinal permeability (“leaky gut”), poor digestion, also absorption of nutrients (which can cascade into other issues), not to mention the decreased quality of life due to symptoms. Often times you will see low vitamin b12 levels, vitamin D or poor iron status and I will often request or get this bloodwork ordered too.

Leaky gut, again controversial in healthcare between allopathic and functional medicine which can be brought on by SIBO may be responsible for extraintestinal issues:

• Anxious or depressed feelings
• Brain fog
• Fatigue
• Headaches
• Joint pain

So what leads to SIBO in the first place?

SIBO can manifest from:

• Previous antibiotic use
• Living in a home with clinically significant levels of toxic indoor mold.
  • Do an ERMI Kit (buy ERMI kit 1 here to check the levels in your dust and its the only medically acknowledge way to test the home).
  • If levels around a 5 or higher, you must hire a certified mold inspector to find the WHERE and WHY it grew in the home
• Certain medical conditions can set the stage (like increased risk with celiac diease)
• Certain prescriptions (like hormonal birth control)
• Motility disorders and gastroparesis
• Surgical alterations (like when surgery happens near the ileocecal valve)
• Lifestyle habits (food grazing – which can impair the migrating motor complex, poor stress management, inadequate nutrients that support stomach acid production)
• Food poisoning (vinculin and CdtB)
• Chronic stress/lowered secretory IgA
• Previous cholecystectomy (gallbladder removal)
• H. pylori infection
• Use of proton pump inhibitors (nexium, omeprazole, etc.) or acid reducing medication
• Excess alcohol use (defined as more than 7 drinks per week)

How is SIBO diagnosed?

SIBO breath test is most commonly utilized to diagnose SIBO. Most available SIBO breath tests only measure hydrogen and methane gas levels, except for the trio-smart test which also includes the hydrogen sulfide gas.

Functional medicine tests are not ICD-10 code diagnostic for SIBO but are still so helpful to seeing the big health picture; to explain further, the GIMAP test provides data on intestinal markers and shows not just the tree but some of the forest. The GIMAP is a FDA approved stool test that measures fecal biomarkers that can provide insight into the underlying contributors and consequences of intestinal bacterial overgrowth

So now we have briefly gone into the “WHY,” now “WHAT” do you do?

While the SIBO in front of us needs cared for, remember this is only the first step and a crucial aspect of SIBO treatment to prevent recurrence.

Dietary measures for SIBO:

• Following a low FODMAP diet can be helpful in providing symptom relief as SIBO is being treated. However, this diet will not eradicate SIBO. Low FODMAP is symptom management and only meant for the short term. Long term use of this diet is controversial.
• The elemental diet is not a fan favorite due to its taste, but it is effective at SIBO eradiction. It involves consuming a formula of predigested nutrients. This approach seeks to starve the bacteria by replacing all meals with an elemental formula for weeks. Some formulas include Physicians’ Elemental Diet and Vivonex Plus.
• Meal timing: spacing out meals can encourage a healthy MMC and provide symptomatic relief. This helps reactively, but also a good proactive approach to prevent reoccurence.
• Screen for and correct nutrient deficiencies, especially those nutrients that help produce stomach acid which helps with proper digestion of food. This is something very much on my radar as a registered dietitian.

Antibiotics for SIBO

Rifaximin (Xifaxan) is the preferred prescription antibiotic for treating hydrogen and hydrogen sulfide SIBO. A course of antibiotic treatment is usually two weeks; however, multiple courses may be required for complete SIBO eradication. Neomycin is often added on when methane dominant bacteria is present. There is nuance to these common regimens, but you will see this prescribed from Physicians after a positive breath test or utilized for empiric treatment.

Herbal Antibiotic Protocol for SIBO

Certain herbal therapies have been shown to be equally as effective to Rifaximin for the treatment of small intestinal bacterial overgrowth.

An herbal antibiotic protocol for treating SIBO involves dosing herbs or combination formulas together for multiple weeks. As with prescription antibiotics, multiple courses of herbal antibiotics may be required for SIBO eradication. This is something that works best when personalized, but here is general SIBO protocol.

What are some studied herbal antimicrobials?

• Berberine is a broad-spectrum antimicrobial, effective against bacteria, fungi, viruses, and parasites. It is usually taken at dosage of 1,500-5,000mg daily for several weeks.
• Oregano is another herbal antimicrobial, but research does suggest that oregano selectively targets pathogenic bacteria while leaving Lactobacilli and Bifidobacterium of the healthy microbiome alone. It is often taken at doses of 150-300 mg daily for several weeks.
• FC-Cidal & Dysbiocide are combination formulas backed by evidence and often recommended at a dose of 2 capsules of each twice daily for several weeks.
• Candibactin-AR® and Candibactin-BR® are other herbal antimicrobials that are effective in eradicating SIBO when administered daily for several weeks at dose of 2 capsules of each twice daily.

Additional supplements to consider during SIBO treatment:

1. Prokinetic agents. Start during or immediately after antimicrobial therapy, and continue for up to 4 months after SIBO eradication. MotilPro, Motility Pro and Motility Activator are commonly used options.
2. Magnesium. Ensure drainage pathways are open and bowel movements are occuring regularly and daily. Supplemental magnesium is one supplement to consider as this mineral can help support bowel regularity for those who are constipated and/or not getting enough magnesium consistently from food sources.
3. Tailored vitamin and mineral supplements to correct deficiences that are commonly present
4. Biofilm busters: N-acetyl-L-cysteine (NAC), widely used in medical treatments, offers an interesting approach to biofilm destruction. A biofilm in layman’s terms is a protective layer/web/matrix that communities of bacteria will “hide” behind which can make them more difficult to eradicate. NAC supplements are effective biofilm buster.

When to repeat testing

Repeating the SIBO breath test is unnecessary after a course of antimicrobial therapy but does not hurt to get this data. If patients choose not to retest after completing a course of antibiotics, SIBO symptoms should be monitored instead to determine whether treatment should be continued or discontinued. As always, this needs to be discussed with your healthcare team. SIBO treatment is considered to be successful when the patient reports drastic improvement in SIBO symptoms.

Gotta figure out the “WHY”

Successful treatment of SIBO relies upon correcting the imbalances predisposing an individual to bacterial overgrowth. SIBO recurrence is common, because of the many factors that can contribute to SIBO development. Functional testing helps identify SIBO “root causes” so that measures can be implemented to prevent SIBO recurrence and support healthy gastrointestinal function.

It is in a Registered Dietitian’s scope of practice to provide medical nutrition therapy for SIBO. Registered dietitians are experts in nutrition related interventions for SIBO, ways to support healthy digestion, and in implementing gut microbiome based interventions.

As always, see your doctor for medical evaluation and management, and get with a skilled dietitian who can provide medical nutrition therapy.

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