Understanding SIBO: Symptoms, Testing, and Holistic Management

Michael was 20 years old when he first came to see me for his ongoing gut symptoms tha included severe bloating, gas and constipation. “I’ve been to the hospital 3 times and seen 2 different GI docs. I don’t know what you can do to help, but I’ll give it a try.” I asked him if he’d ever been tested for Small Intestinal Bacterial Overgrowth (SIBO) and he said no - in fact, he had never heard of SIBO before. After getting a thorough history and doing extensive gut testing, we confirmed that Michael had SIBO.

SIBO is a condition that occurs when there is an abnormal increase in the number of bacteria in the small intestine. This overgrowth can lead to a variety of uncomfortable symptoms and can significantly impact an individual's quality of life. In this article, we'll delve into the common symptoms of SIBO, the testing methods used to diagnose it, and explore holistic approaches that I use in my practice to help patients like Michael manage these symptoms and successfully recover.

SIBO Symptoms

SIBO manifests in a range of symptoms, many of which overlap with other gastrointestinal disorders, making it challenging to diagnose.

Some common symptoms of SIBO include:

Bloating: Excessive gas production by bacteria in the small intestine can lead to bloating, which is often described as a feeling of fullness or tightness in the abdomen.
Abdominal Pain or Discomfort: Individuals with SIBO may experience cramping or discomfort in the abdominal region, which can range from mild to severe.
Flatulence: Increased bacterial fermentation in the small intestine can result in excessive gas production, leading to frequent flatulence.
Diarrhea or Constipation: SIBO can disrupt normal digestive processes, causing alterations in bowel habits. Some individuals may experience diarrhea, while others may have constipation, or they may alternate between the two. While this is not an exact rule of thumb, many clinicians like myself have found that diarrhea is more common in Hydrogen-dominant SIBO, while constipation is more common in Methane-dominant SIBO.
Nutritional Deficiencies: Malabsorption of nutrients due to bacterial overgrowth can lead to deficiencies in essential vitamins and minerals, resulting in fatigue, weakness, or other systemic symptoms.

Testing Options

Diagnosing SIBO can be challenging, as its symptoms mimic those of other gastrointestinal disorders like Irritable Bowel Syndrome (IBS).

However, several tests are available to help identify bacterial overgrowth in the small intestine:

Breath Tests: The most common method for diagnosing SIBO is through breath testing. Patients consume a solution containing a specific sugar (usually lactulose or glucose), and then breath samples are collected at regular intervals to measure the levels of hydrogen and methane gas, which are byproducts of bacterial fermentation. I like the Lactulose Breath Test by Genova.
Small Intestine Aspiration: Invasive procedures like small intestine aspiration can be performed to directly culture bacteria from the small intestine. However, this method is less commonly used due to its invasiveness.
Blood Tests: Blood tests may be conducted to assess for underlying conditions that predispose individuals to SIBO, such as celiac disease or Crohn's disease.

Holistic Management of SIBO Symptoms

While antibiotics (ex. Rifaximin) are often prescribed to treat SIBO, holistic approaches can also play a significant role in managing symptoms and promoting gut health.

Here are some holistic strategies that individuals with SIBO may find beneficial:

Dietary Modifications: Following a Low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet can help alleviate symptoms by reducing the intake of fermentable carbohydrates that feed bacterial overgrowth. The Monash University website & app is a great resource for all things Low FODMAP. Additionally, incorporating anti-inflammatory foods and probiotic-rich foods (ex. fermented foods like yogurt, sauerkraut and kimchi) can support gut health.
Probiotics and Prebiotics: Probiotic supplements containing beneficial bacteria strains, such as Lactobacillus and Bifidobacterium, may help restore microbial balance in the gut. Lactobacillus plantarum is known for its ability to inhibit the growth of pathogenic bacteria and promote a balanced gut microbiome (Niedzielin, K. et al, 2001). Bifidobacterium infantis is known for its anti-inflammatory properties and may help alleviate gut inflammation often associated with SIBO. Prebiotics, which are non-digestible fibers that serve as food for probiotics, can also be beneficial.
Herbal Supplements: Certain herbs and botanicals have antimicrobial properties that may help reduce bacterial overgrowth in the small intestine. Examples include oregano oil, berberine, and garlic extract. Currently, there is a clinical trial being conducted called a BRIEF-SIBO that will compare the effects of berberine compared to Rifaximin in patients with SIBO (Guo et al, 2023). Berberine, neem, oregano and thyme have all been found to be especially helpful for those with hydrogen-dominant SIBO (Chedid, V et al, 2010). Allicin, an anti-microbial component found in garlic, has been shown to be helpful for those with methane-dominant SIBO (Ankri, S. et al 1999).
Stress Management: Stress can exacerbate symptoms of SIBO by disrupting gut motility and immune function. Incorporating stress-reducing practices such as mindfulness meditation, yoga, or deep breathing exercises can be beneficial.
Gut Motility Support: Improving gut motility can help prevent bacterial overgrowth in the small intestine. Consuming foods rich in fiber, staying hydrated, and regular exercise can promote healthy digestion and bowel movements.

Conclusion

SIBO is a complex gastrointestinal disorder that requires a comprehensive approach to management. While conventional treatments like antibiotics can be effective, incorporating holistic strategies such as dietary modifications, probiotics, stress management, and herbal supplements can help alleviate symptoms and support long-term gut health. If you suspect you may have SIBO, it's essential to consult with a healthcare professional for proper diagnosis and personalized treatment recommendations. By addressing the underlying imbalances in the gut, individuals with SIBO can experience relief from symptoms and improve their overall well-being.

References

Ankri, S., & Mirelman, D. (1999). Antimicrobial properties of allicin from garlic. Microbes and Infection, 1(2), 125-129.
Chedid, V., Dhalla, S., Clarke, J. O., Roland, B. C., Dunbar, K. B., Koh, J., … Mullin, G. E. (2010). Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth. Global Advances in Health and Medicine, 2(4), 58-62.
Guo, H., Lu, S., Zhang, J., Chen, C., Du, Y., Wang, K., … & Duan, L. (2023). Berberine and rifaximin effects on small intestinal bacterial overgrowth: study protocol for an investigator-initiated, double-arm, open-label, randomized clinical trial (brief-sibo study). Frontiers in Pharmacology, 14. https://doi.org/10.3389/fphar.2023.1121435
Niedzielin, K., Kordecki, H., & Birkenfeld, B. (2001). A controlled, double-blind, randomized study on the efficacy of Lactobacillus plantarum 299V in patients with irritable bowel syndrome. European Journal of Gastroenterology & Hepatology, 13(10), 1143-1147.
Poddar, M., & Gupta, V. (2012). Gastrointestinal transit: The role of probiotics. Journal of Clinical Gastroenterology, 46(6), 469-477.
Upadhyay, S., & Singh, O. (2014). Antimicrobial activity of Azadirachta indica (Neem) against pathogenic bacteria. Journal of Analytical Science and Technology, 5(1), 40.
Van Boxstael, S., Nevens, F., & De Ridder, D. (2017). Treatment of constipation in older adults. Current Treatment Options in Gastroenterology, 15(3), 409-428.

THIS CONTENT IS FOR EDUCATIONAL PURPOSES ONLY. IT IS NOT INTENDED TO DIAGNOSE OR PROVIDE MEDICAL ADVICE. PLEASE CONSULT WITH YOUR DOCTOR, OR LICENSED HEALTHCARE PROVIDER, BEFORE TRYING ANY NEW SUPPLEMENTS AS THEY MAY INTERFERE WITH YOUR CURRENT MEDICATIONS OR BE CONTRAINDICATED FOR YOU.

About Dr. Anjali

Dr. Anjali Kasunich is a California-licensed Naturopathic Doctor and founder of Mantra Natural Medicine where she uses a heart-centered approach and evidence-based natural treatments to help her patients heal. When she’s not treating patients in her private practice, Dr. Anjali enjoys spending time with her husband and dog, dancing, and being in her garden. You can learn more about Dr. Anjali and her favorite healthy tips by visiting her Instagram or TikTok.