This section of the article focuses on the diagnosis of Small Intestinal Bacterial Overgrowth (SIBO), continuing to explore key aspects that were not addressed in the first part. While the first part discussed the main symptoms and causes of SIBO, this part delved into diagnostic methods that help identify the syndrome and determine the optimal therapy. Differentiating between the various types of SIBO, such as hydrogen, methane, and hydrogen sulfide, requires precise diagnostic approaches to ensure the correct treatment is selected. It is essential to understand that diagnosing SIBO not only helps identify the syndrome but also rules out other potential conditions with symptoms that may mimic SIBO.
Diagnosis of Small Intestinal Bacterial Overgrowth (SIBO)
Three Types of SIBO:
- Hydrogen-dominant SIBO: This type is commonly associated with diarrhea. Bacteria in the small intestine ferment carbohydrates, producing hydrogen, which disrupts food digestion and leads to rapid intestinal transit.
- Methane-dominant SIBO: This type typically causes constipation. Methanogenic bacteria ferment carbohydrates to produce methane, which slows down intestinal motility, leading to stool retention and constipation.
- Hydrogen Sulfide SIBO: This type is often linked to diarrhea but can also cause constipation. Hydrogen sulfide is a gas produced by certain bacteria, and it may have a toxic effect on the gut, causing symptoms similar to other types of SIBO.
Why is Diagnosis Important?
Diagnosing the type of SIBO is crucial for selecting the correct treatment strategy. Identifying the type of gas (hydrogen, methane, or hydrogen sulfide) and its concentration allows doctors to precisely understand which microbiome predominates in the patient’s intestines and how it should be treated.
SIBO is diagnosed using a lactulose breath test. The patient drinks a solution of lactulose, which serves as a substrate for bacteria in the small intestine. If bacteria are present, they begin fermenting this sugar, leading to the production of gases. The test measures hydrogen and methane levels in the exhaled air:
- A hydrogen increase of more than 20 ppm (parts per million) within the first 2 hours confirms the presence of hydrogen SIBO.
- Methane levels above 10 ppm at any time indicate the presence of methane SIBO.
- A new test has been developed to detect hydrogen sulfide, helping identify this specific gas.
SIBO contributes to inflammation and leaky gut syndrome.
Treatment of SIBO
The Importance of Addressing the Underlying Cause
SIBO often arises as a secondary condition associated with other diseases or disorders. Therefore, for effective treatment of SIBO, it is crucial to address the underlying cause. Without treating the primary problem, SIBO therapy may be ineffective, leading to disease recurrence.
Stress can be a key factor in the development of SIBO by disrupting intestinal motility. For example, it weakens the migratory motor complex (MMC) — the contraction waves that cleanse the small intestine between meals. This allows bacteria to accumulate and multiply.
Furthermore, if left untreated, SIBO can lead to the development of other conditions. For example, SIBO is the root cause in about 70% of irritable bowel syndrome (IBS) cases, which affects around 25% of the global population. Therefore, treating SIBO not only helps eliminate symptoms but also significantly improves the quality of life.
Three Stages of SIBO Treatment:
- Starvation of Bacteria through Special Diet:
- At this stage, a low-FODMAP diet with low lectin content is used to restrict the amount of carbohydrates available for bacterial fermentation. This helps reduce bacterial counts and alleviate symptoms. The diet typically lasts for 1 month, after which foods are gradually reintroduced.
- FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) are substances that cause fermentation and gas production. High FODMAP foods include beans, dairy products, asparagus, artichokes, garlic, and onions. You can use this list: SIBO Specific Diet: Food Guide.
- Lectins are protective plant compounds found in the skins of legumes, whole grains, and seeds. High-lectin foods include tomatoes, cucumbers, peppers, eggplants, beans, and whole grains. It is especially important to note that gluten-containing grains (such as wheat, barley, and rye) contain large amounts of lectins. Exception: white basmati rice does not contain lectins and is easily digested.
- Bacterial Eradication with Antimicrobials:
- Antibiotics like rifaximin or plant-based antimicrobials (berberine, oregano, allicin) can be used to suppress excessive bacterial growth. The choice of treatment depends on individual preferences.
- Stimulating Intestinal Motility:
- This involves creating regular intervals between meals (4-5 hours) to maintain normal migratory motor complex (MMC) function.
- Intermittent fasting for 14-18 hours further supports MMC function by lengthening the period of small intestine cleansing.
- Prokinetics, such as magnesium citrate and vitamin C, can also be used to improve intestinal motility and prevent food and bacteria stagnation.
- Regular bowel movements: Daily bowel evacuation plays a crucial role.
- Frequent snacking disrupts normal MMC activation, as the intestine is continuously processing food, not allowing time for cleansing. This can lead to bacterial and food residue accumulation in the small intestine, creating conditions for SIBO development.
- Restoring Intestinal Microflora:
- Using appropriate prebiotics and probiotics (spore-based) can help restore the normal balance of the intestinal microbiota and improve its barrier function.
- Treating “leaky gut” focuses on restoring intestinal mucosal integrity, reducing inflammation, and improving overall gut microbiota health.
- Digestive enzymes accelerate food breakdown, preventing bacterial nourishment in SIBO.
- Lifestyle:
- Stress management: Stress can significantly impact intestinal motility and overall digestive function, so it is essential to develop stress management strategies.
- Meal schedule: Maintaining a regular eating schedule is necessary to support normal intestinal function and prevent bacterial stagnation.
These stages help comprehensively address the SIBO problem and restore normal intestinal function.
Not All Digestive Issues Are SIBO
Anyone who has read this far and is experiencing symptoms similar to SIBO (Small Intestinal Bacterial Overgrowth) is likely thinking it is their problem. However, SIBO is just one possible cause you might not have heard of. This is why diagnostics are essential to understand the exact cause of your symptoms. Here are several conditions that may resemble SIBO but have different causes, and thus require a different approach to diagnosis and treatment.
SIFO (Small Intestinal Fungal Overgrowth)
SIFO often presents with symptoms similar to SIBO, such as bloating, abdominal pain, irregular stools, and gas.
- Diagnosis of SIFO is based on clinical findings and laboratory tests.
- Stool tests: These can reveal an excess of fungi, such as Candida, which may indicate microbiota imbalance.
- Breath tests are ineffective for diagnosing SIFO, as they are designed to detect bacterial overgrowth.
- Treatment of SIFO:
- Diet: Exclude foods that promote fungal growth, such as sugar, grains, dairy, alcohol, and high-glycemic fruits.
- Antimicrobials and antifungal medications: Herbal remedies and antifungal drugs are used to combat fungal infections.
- Probiotics and beneficial yeasts: Saccharomyces boulardii effectively helps to outcompete Candida.
Other Conditions That May Imitate SIBO:
- Irritable Bowel Syndrome (IBS): While frequently co-occurring with SIBO, IBS itself is not caused by bacterial overgrowth.
- Gastroenteritis: Symptoms are caused by pathogenic microorganisms, such as bacteria, viruses, or parasites, but are not related to microbial overgrowth.
- Lactose or Fructose Intolerance: Caused by a lack of enzymes, leading to the fermentation of sugars, but not related to changes in microbiota composition.
- Celiac Disease: Causes damage to the villi of the small intestine and malabsorption, leading to bloating and diarrhea, but the cause is not bacterial overgrowth.
- Parasite Infections: For example, Giardia lamblia can cause symptoms like diarrhea and bloating, but this is due to a parasitic infection, not bacterial overgrowth.
All these conditions require a specific treatment approach. Mistaking them for SIBO can lead to ineffective therapy, which is why accurate diagnosis plays a crucial role in ensuring the correct and effective treatment.
Conclusion
Accurate diagnosis of SIBO is essential for selecting the right treatment, as different types of conditions require distinct approaches. Diagnosis through breath tests helps identify the dominance of hydrogen, methane, or hydrogen sulfide, which is crucial for determining the appropriate therapy. A comprehensive treatment plan, including diet, antimicrobials, and microbiota restoration, effectively reduces symptoms and prevents relapses. Accurate diagnosis also helps rule out other conditions with symptoms similar to SIBO, ensuring successful restoration of gut health.
A breath test to diagnose SIBO can be performed at SIBO Diagnostics