FUNCTIONAL MEDICINE APPROACH TO SIBO

You may be one of many patients suffering with bloating, abdominal pain, constipation, or diarrhoea and your GP has diagnosed you with irritable bowel syndrome (IBS) and your symptoms have not responded to treatment. Alternative you have given no diagnosis at all for your suffering.

Persistent bloating and bowel symptoms have several possible causes. SIBO is one possibility; symptoms alone cannot confirm it. [1]

What is Small Intestinal Bacterial Overgrowth? (SIBO)

When there is an abnormal increase in the total bacterial population in the small intestine, especially bacteria that are not typically found in that region of the digestive tract, it is known as small intestinal bacterial overgrowth (SIBO).

SIBO frequently develops when a condition, such as surgery or illness, delays the movement of food and waste items through the digestive tract, providing a favourable environment for the growth of bacteria. In addition to frequently causing diarrhoea, the extra bacteria can lead to malnutrition and weight loss.

While stomach (abdominal) surgery complications are a common cause of SIBO, this illness can also be brought on by structural issues and certain diseases. Antibiotics are the most widely used form of treatment, but surgery may occasionally be required to fix the issue.

What are the symptoms of SIBO?

SIBO and irritable bowel syndrome can cause similar symptoms, but they are different diagnoses. Estimates of overlap vary with the patients studied and the test used. A positive breath test does not show that SIBO explains every symptom. [1]

Response to treatment varies, and recurrence is possible. Methane is produced by archaea rather than bacteria; excess methane is described as intestinal methanogen overgrowth and is often associated with constipation. [1]

The most common symptoms of SIBO are:

Diarrhoea

Flatulence

Tummy pain

Bloating

Constipation

Belching

Nausea

Reflux – heart burn

Malabsorption of food and nutrients – especially fats

Unintentional weight loss needs medical assessment; weight gain is not a diagnostic sign of SIBO. [1]

The following problems are non-specific. They need their own assessment and should not be used as a checklist to diagnose SIBO: [1]

Rash (rosacea)

Headache

Body pain

Fatigue

Depression

Anxiety

Brain Fog

Tingling and numbness in arms and legs

Anaemia

B12 deficiency

What can cause SIBO?

Small intestinal bacterial overgrowth (SIBO) can be caused by:

• Abdominal surgical complications, such as gastric bypass for obesity and gastrectomy for the treatment of peptic ulcers and stomach cancer

Structural changes, including small-bowel diverticula and adhesions after surgery, can alter intestinal flow. Conditions affecting gut movement can also increase risk. Diverticula are pouches; adhesions are bands of scar tissue. [1]

How SIBO Causes the Symptoms of IBS?

Bacterial fermentation can contribute to symptoms in people with SIBO, but it does not explain all IBS. [1]

First, bacteria can ferment carbohydrates and consume other nutrients ingested by the host simply by their inappropriate location in the small intestine. This allows them premature exposure to host nutrition before there is time for absorption.

Bacterial fermentation can produce hydrogen. Methanogenic archaea can use hydrogen to produce methane. Breath-test findings must be interpreted with symptoms, risk factors and the limitations of the test. [1]

How is SIBO being treated?

Clinicians may use a prescription antibiotic for symptomatic SIBO after assessment. Treatment also considers an underlying cause and any nutritional deficiency. There is no single success rate that applies to every patient, and repeated treatment needs a clinical review. [1]

The Functional Medicine Approach to SIBO

A unique valve connects your small intestine, which is about three and a half times as long as your body, to your much shorter colon. The majority of the nutrients in your meal are absorbed there. On the other hand, water is taken from your large intestine, waste is processed for excretion, and microorganisms ferment dietary fibre to release additional vitamins.

It makes natural that various microorganisms would inhabit the two quite distinct habitats in the small and big intestines. You may be aware of the vast number of bacteria that call your large intestine home and coexist with you there. In contrast, your small intestine naturally has a much smaller population of bacteria than your large intestine, and these bacteria are of very different sorts. If the large intestine's resident bacterial species begin to thrive in the small intestine, they may proliferate out of control, leading to SIBO.

Diagnosis

• You might undergo tests to look for bacterial overgrowth in your small intestine, inadequate fat absorption, or other issues that may be causing or contributing to your symptoms in order to identify small intestinal bacterial overgrowth (SIBO). Common tests consist of:

• Breath testing measures hydrogen and methane after a glucose or lactulose drink. Preparation, transit time and the substrate can affect results; false positives and false negatives occur. Methane results concern methanogen overgrowth, not bacterial overgrowth alone. [1]

Small-bowel aspirate culture is an invasive specialist test with sampling, contamination and interpretation limitations. Neither culture nor breath testing is a perfect test, and neither is needed for everyone with bloating. [1]

We might also advise blood tests to check for vitamin deficiencies or stool tests to check for fat malabsorption in addition to these procedures. In some circumstances, we can advise imaging tests to look for structural abnormalities of the intestine, such as X-rays, CT scanning, or magnetic resonance imaging (MRI).

Diet

Diet changes may help manage symptoms, but a restrictive diet is not proven to eradicate SIBO. Avoid progressively removing foods without a clear purpose and review. [1]

FODMAPs are fermentable carbohydrates. A limited, supported low-FODMAP trial can help some people with IBS; it should include reintroduction and personalisation rather than permanent broad restriction. [2]

When carbohydrates can't be broken down, they remain in your gut and can result in symptoms like bloating and diarrhoea. Additionally, bacterial overgrowth results in the small intestinal bacteria fermenting carbohydrates earlier than they should, which results in a variety of symptoms.

Foods to avoid

The food lists below are examples, not instructions to exclude every item. FODMAP content depends on the portion and preparation. Ask a dietitian for advice if restriction is being considered, especially where weight loss or poor intake is a concern. [2]

• Focus on the primary categories when removing FODMAPs from your SIBO diet, including:
• fructose, simple sugars commonly found in fruits and some vegetables, honey, and agave nectar
• lactose, a sugar molecule in dairy products
• fructans, a sugar compound found in gluten products, fruits, some vegetables, and prebiotics
• galactans, a compound found in some legumes
• polyols, a sugar alcohol often used as a sweetener

Foods that may contain more FODMAPs, depending on the portion and product, include: [2]

• high-fructose corn syrup
• agave nectar
• honey
• soda and soft drinks
• garlic
• onions
• asparagus
• butternut squash
• cauliflower
• artichokes
• beans
• apples
• dried fruits
• sausage
• flavored yogurt
• ice cream
• sweetened cereals
• barley
• rye
• grains
• peas

Foods to eat

A low-FODMAP approach is a short, structured symptom trial with reintroduction. It is not simply a high-fibre, low-sugar diet, and it should still meet your nutritional needs. [2]

Portion size matters: a food may be tolerated in a small serving even when a larger serving causes symptoms. The following examples are not a universal safe-food list: [2]

• meat
• fish
• eggs
• crackers, gluten-free
• oatmeal
• unsweetened cereal (made from low FODMAP grains)
• spaghetti squash and summer squashes
• broccoli (heads only, less than 3/4 cup)
• leafy greens
• carrots
• rice or gluten-free noodles
• olives
• peanuts
• potatoes
• pumpkin
• quinoa
• seeds
• some fruits (blueberries, grapes, oranges, and strawberries)

Rest & Recovery

You may be experiencing a wide range of various symptoms if you have SIBO. SIBO symptoms commonly include gas, bloating, stomach pain, diarrhoea, and/or constipation. But how do you feel physically? Even if you're getting good sleep at night, you could feel like you have no energy. Additionally, you might experience emotional helplessness, annoyance, or even loss.

Persistent tiredness deserves assessment rather than being attributed automatically to SIBO. Poor intake, anaemia, sleep problems and other conditions may also need attention. [3]

Exercise

• It enhances your gut microbiota, the population of beneficial gut bacteria that aids in regulating digestion, immunity, mood, and metabolism. It's obvious that we need to satisfy these guys!
• It maintains the strength and tone of the muscles of the digestive system. Who knew that exercising helps to strengthen your intestines?
• When you have constipation, it might be quite vital for your muscles to be stimulated so that they can push digestive waste through your body. Things can keep moving if you move!
• A 10-minute walk after meals is a terrific way to start with some mild exercise if your doctor gives the go-ahead. Also consider yoga, bike riding, hiking, or other forms of low to moderate impact exercise.

The Benefits of Herbal Antibiotics and Supplements for Treating SIBO

Herbal products are not an established substitute for prescribed SIBO treatment. This retained heading does not imply proven benefit. [1]

Herbal products are not interchangeable with prescription antibiotics. Evidence is insufficient to recommend them as established SIBO treatment or to claim that conventional clinicians routinely miss a single cause of IBS. [1]

Previous antibiotic use does not establish that SIBO is present or that a herbal alternative will prevent recurrence. Review the diagnosis and previous treatment with a clinician. [1]

The products listed below are historical examples from this article. They are not a treatment plan, and laboratory antimicrobial activity does not prove benefit or safety when swallowed. [4]

Oregano Oil

Oregano oil is one of the most popular natural antibiotics for SIBO. The oregano plant is used to make oregano oil, which has antiviral, antifungal, and antibacterial properties.

This retained wording describes historical or laboratory claims. It does not establish that the product safely or effectively treats SIBO in people. [1]

2. Uva Ursi Herbs

Because bears devour its red berries, ava ursi, a plant, is also known as bearberry. The berries are not utilised for treatment; instead, the leaves are. It is frequently used to treat bacterial infections like SIBO as well as fungal and urinary tract infections.

This retained wording describes historical or laboratory claims. It does not establish that the product safely or effectively treats SIBO in people. [1]

3. Hydrolyzed Silver

Do not take silver preparations by mouth for SIBO. The retained product heading is not a recommendation. [4]

Do not swallow colloidal or similar silver preparations to treat SIBO. Silver has no established benefit for this purpose and can cause lasting skin discolouration, interact with medicines and cause other harm. [4]

Liquorice Root

Liquorice root has been used traditionally for digestive symptoms, but that does not establish it as a SIBO treatment. Discuss any herbal product with a pharmacist or clinician before use, including possible interactions. [5]

Aloe Vera

Aloe vera applied to skin is different from an aloe product taken by mouth. Oral aloe is not an established SIBO treatment and should not be presented as a way to heal the gut lining or as a substitute for assessment. [5]

6. Marshmallow Root

Marshmallow root has a history of traditional use for digestive discomfort. Evidence does not establish that it eradicates SIBO. Using several herbal products together also needs a safety review. [5]

I use a multi facet functional medicine approach to treat my patients with SIBO.

The first step is to adequately assess the function of organs and systems that are integral to your ability to maintain a healthy microbiome.

Further testing should answer a defined clinical question and change the next step in care. Specialist stool, nutrient or metabolic tests are not automatically necessary for everyone with these symptoms. [1]

If you have persistent symptoms, seek medical assessment to review the diagnosis and appropriate next steps. No treatment can promise a return to normal for every person. [1]