SIBO (small intestinal overgrowth of bacterial) is a relapsing, permanent condition that could cause 10-15 percent of the population. The most characteristic feature for SIBO is the fact that your small intestine gets colonized by normal gut flora. The small intestine is usually completely free of any colonisation by bacterial species but any changes to the microbiome within the small bowel could result in an increase in the number of bacteria, which manifests in a variety of symptoms that are characteristic of SIBO.
Signs and symptoms
When a patient is diagnosed with SIBO they might suffer from a range of symptoms, including bloating gas, abdominal discomfort, diarrhoea and fatigue among many other. For a long time, patients suffering from SIBO manifestations have been identified and classified as having IBS. This is mainly due to the fact that there isn’t any agreement and consensus internationally on the nature of the condition, the most effective method for diagnosing it, but also there is a lack of reliable information on the most effective treatment strategy for patients suffering from SIBO.
The small intestine does not typically colonized by bacteria. In SIBO the bacteria that are normally found in the large bowel begin to expand in the small bowel. They feed off small molecules of fermentable carbohydrates and sugars are ingested by us. The resulting gas production in SIBO could cause issues in digestion, absorption of food, and can damage the membranes of the intestinal lining and causing symptoms.
Risk Factors
Numerous risks have been listed to cause SIBO. In addition, it may occur in healthy individuals, but certain people might have anatomical problems, for example, prior small bowel surgery as well as gastric bypass. Certain medications can slow the gut’s motility like narcotic painkillers and anti-diarrhoeal drugs. They can cause an overgrowth of bacterial. There are a few individuals who are taking acid suppressing medication like proton pump inhibitors, which reduce levels of acid that goes through the small bowel could have bacterial growth but this isn’t confirmed. People with connective tissue diseases such as Ehlers-Danlos syndrome, fibromyalgia and rheumatoid arthritis could be more likely to experience the symptoms that recur from small intestinal bacteria overgrowth.
Diagnosis
The diagnosis of bacterial growth is still a subject of debate, with a variety of options being offered. There is no universally-acceptable gold standard test for SIBO and the use of the lactulose breath test has become extremely common over the past few years. The goal of this test is to attempt to recreate an environment within the small bowel which would take place on a regular basis for patients suffering from small intestinal bacterial growth and monitor the gas production which result from the production of gases in the bowel’s small intestine to determine the presence of SIBO. Quantification of methane and hydrogen gases in breath sample is one of the least expensive test, non-invasive and likely the most commonly used test to determine the presence of an overgrowth of bacterial cells in the United Kingdom. The gases found in breath of humans are a reflection of the metabolic process of fermentable carbohydrates found in the bowel’s small. It’s not evident how important it is to take the breath test after SIBO treatment.
Treatments
Treatment for SIBO is a combination of three strategies. The first is to induce an end-of-life of SIBO and secondly, keep the remission going and to prevent SIBO becoming recurrent, and thirdly and perhaps most importantly, is to address or alter the cause of SIBO or other factors that lead to the growth of SIBO.
The treatment of bacterial growth Although it’s controversial, the treatment is still mostly focused on reducing the number and growth of bacteria within the bowel. Antibiotics remain the most effective treatment currently. The dosage, choice and duration of treatment aren’t well understood, as there aren’t many studies of high-quality that can guide doctors on the best antibiotics to use. In the near future we will see more focused on more individualized treatments targeted at specific components of the microbiome. They aren’t yet available. We usually provide Rifaximin which is among the most researched antibiotics used in patients suffering from any type of functional bowel diseases. Studies have shown that it is reliable and safe for treating SIBO. It is especially effective for those suffering from hydrogen over production and diarrhoea, bloating and indigestion symptoms. The issue with it in the United Kingdom is that it is approved only to treat diarrhoea in travelers, but it is also used for those suffering from liver diseases so its usage in small intestinal bacterial overgrowths is usually difficult, since many clinics or hospitals do not prescribe it, and patients are often required to be charged for a 2 week duration of antibiotics. ALternatives include doxycycline, which is a lot less expensive but is not as scientifically backed to justify its usage.
M-SIBO – Production of Methane
It should also be noted that when we conduct breath tests to detect SIBO we also check at methane production. There is a solid evidence, which was presented in Digestive Disease Weekly in Chicago 2017 that shows methane production can cause slower transit and motility in the gut. These patients typically do not respond to Rifaximin on its own and require an additional antibiotic. Neomycin is an effective antibiotic that has been utilized in many other conditions and has been demonstrated to reduce methane production in patients. Pro-kinetics are a method of enhancing the efficacy of this group of patients, like a lower dose of a medication known as prucalopride could enhance the effectiveness of the antibiotics in boosting gut mobility and improve the effectiveness for the medication.
Herbal Antibiotics
In certain patients, there is the option of using herbal antibiotics.
Maintenance
Maintaining remission is crucial since SIBO is a chronic disorder that recurs in a variety of patients. In some studies, as much as one third of patients are likely to experience an occurrence of small intestinal bacteria and a close eye is essential for patients after the induction of remission SIBO to determine the presence of recurring symptoms that prompt treatment is initiated. A lot of practices employ the following strategies to stop SIBO from returning. One important aspect that patients must consider is the diet. By limiting the amount of fermentable carbohydrates, and following an eating plan such as one that is low FODMAP diet will ensure that the surrounding environment is exposed to less fermentable foods, and will create an environment that is less favorable for any remaining bacteria to grow. Research has shown that in a few patients, the low FODMAP diet alone may trigger the remission of patients suffering from an overgrowth of bacteria. In addition, the motility and movement in the small bowel need to be improved by making use of pro-kinetic drugs. Prokinetics boost and stimulate the MMC (migrating motor complex) of the small intestine, which helps prevent repeat infections and the recolonization of bacteria. I always suggest to patients that once they’ve completed their first course of antibiotic therapy, we are able to look at prokinetics. These fall under herbal alternatives like Iberogast drops that can be taken in the evening or pharmacological treatments, such as the low amount of Resolor (prucalopride) in the evening. I also suggest patients look into the use of pancreatic and digestive enzymes when seeking to optimize the bowel’s environment following treatment to avoid SIBO from recurring.
Diabetic Control for SIBO
In a few patients where these measures have not been effective, one could consider more thorough dietetic elimination, such as eating the essential diet. We must admit that this option is reserved for patients who have truly resistant symptoms, despite at least three or more cycles of antibiotics and the inability to test the lower FODMAP diet. In its simplest form, it is one comprised of a liquid formulation that is made up of digested carbohydrates, proteins, and fats. It has been utilized for a number of years for treating illnesses like Crohn’s disease. The reason for the elemental diet is that these nutrients are quickly absorbed by the digestive system. This can be beneficial for patients suffering from an overgrowth of bacterial organisms as it is not a good idea to have food to sit in the small intestines which could be used to produce gas to support the unwelcome overgrowth of bacteria. The elemental diet is an opportunity to feed the patient while reducing the bacterial. The implementation of the elemental diet is usually carried out under the supervision by one of our experienced dieticians. Patients take a drink instead of their normal meals for 2 to 3 weeks, based on the degree of their symptoms and their medical history. It should be noted that there aren’t any high-quality research about the benefits of the diet that is considered to be elemental, however there are a few studies that have demonstrated that for some patients who have followed one week of diet, there is an 80% response and a positive breath tests following treatment. There are clearly some disadvantages to this. The most significant one is acceptance; it is extremely difficult to limit diet to just the intake of liquids for a period of two weeks.
Probiotics
In the last, there is a great deal of attention paid to the role of prebiotics and probiotics over the past 10 years and I frequently get inquired by patients if they can play a role in treating the overgrowth of bacterial. The exact function of probiotics in managing of SIBO is still unclear and needs to be defined. It is evident that replacing harmful bacteria with beneficial bacteria, in a sense, will have positive effects on patients. However, I suggest caution with the use of probiotics following treatment for bacteria overgrowth because it could in certain patients cause the problem to be somewhat worse over the course of a short time.
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