Small Intestinal Bacterial Overgrowth (SIBO), Diagnosis and Natural Treatment



A rarely recognized disease characterized by excessive growth of bacteria in the small intestine, SIBO should be suspected in any patient who has functional digestive symptoms and in patients with 

autoimmune disease, skin disease, mood disorders, or osteoporosis

The hydrogen/methane breath test is the newest simplest and most cost-effective way to diagnose SIBO and with natural targeted antimicrobial therapies, prokinetic agents and dietary changes supporting gastrointestinal functions health to these patients can be completely restored.

The number or the type of bacteria growing in the small intestine can change. There could be a bacterial overgrowth and whether it is a pathogenic (causing disease) bacteria or a  beneficial bacteria overgrowth, this Small Intestine Bacterial Overgrowth (SIBO)  becomes quickly of detriment to our gastrointestinal health.

Despite the general awareness of the causes, symptoms, and treatments of this condition,  there are still a few aspects that are still relatively unexplained.


There are various causes of SIBO and they are still undergoing investigation. There is suspect, not verified yet,  that SIBO can develop when the defense mechanisms against bacterial overgrowth become s compromised.

These defense mechanisms our gastrointestinal system has are basically four:

  • Hydrochloric acid level. Hcl destroys bacteria in the stomach;
  • Gut motility (ability to move food through its digestive tract). Motility keeps intestinal contents moving forward;
  • Immunoglobulins and pancreatic proteolytic  (that break down proteins into smaller polypeptides or amino acids.) enzymes. They have the ability to halt bacterial growth. Also, can halt bacterial growth;
  • Ileocecal valve (a sphincter muscle valve that separates the small intestine and the large intestine.) functioning. Has the task to prevent backflow of contents from the large intestine to the small intestine.

What are the risk factors for SIBO?

  • Achlorhydria. (the absence of enough hydrochloric acid in the gastric secretions)
  • The chronic use of acid-blocking medications, that in the long run will cause achlorhydria.
  • Chronic Pancreatitis. The pancreas has troubles secreting Pancreasdigestive juices, or enzymes, into the duodenum 
  • Diabetic neuropathy. Nerve damage caused by diabetes
  • immunodeficiency.  is a state in which the immune system’s ability to fight infectious disease is severely compromised or even entirely absent. 
  • Impairment of the MMC (migrating motor complex). The MM C is a model of electromechanical activity of the gastrointestinal smooth muscle in the period between meals. Its role is to sweep residual undigested material through the digestive tube with waves of smooth muscle contraction. MMC creates waves of smooth muscle contraction to cleanse the gastrointestinal tract, it is another important risk factor.
  • Gastroenteritis (ie, food poisoning) also may lead to problems and SIBO.

SIBO is prevalent in people who already have other types of existing gastrointestinal disorders, like celiac disease, Crohn’s, and irritable bowel syndrome (IBS). In fact, evidence of SIBO  in patients with IBS has been detected by doctors ranging from 4% to 84%, of them

A 2014 review by Ghoshal et al reported that the frequency of SIBO in patients with IBS ranges from 4% to 78%. Dr. Pimental and his colleagues at Cedars-Sinai Medical Center detected evidence of SIBO in 84% of patients with IBS.

The development of SIBO can be predisposed by the disruption in gut motility in conjunction with chronic digestive disorders. But it is still unclear whether  SIBO starts or results from other digestive disorders.


The progression of SIBO can be observed by the signs of malabsorption like steatorrhea  (presence of excess fat in feces). Stools are bulky, pale and rather foul-smelling), weight loss, painful joints, rashes, fatigue, even autoimmune diseases symptoms.

Laboratory results that can confirm the presence of SIBO are anemia, Vitamin B12 deficiency, deficiencies of fat-soluble vitamins, like A, E, and D., In contrast, increased levels of vitamin K and folic acid.

Other Clues that can underline presence of SIBO

  • Temporary improvement of chronic digestive problems after intake of antibiotics
  • Worsening of chronic digestive problems from intake of prebiotics or probiotics because they fuel bacterial growth)
  • Worsening of constipation from a high-fiber diet because fiber fuels bacterial growth.
  • Insufficient improvement from a gluten-free diet in patients with celiac disease
  • Chronic digestive symptoms after taking opioid medications because opioids compromise gut motility)

SIBO was a disease of difficult diagnosis because of the lack of standardized guidelines defining its diagnosis before the creation of the  hydrogen and methane-based breath testing

The North American Consensus group has recently started a work on hydrogen and methane-based breath testing. The Group has published a paper this year where 26 statements related to the indications, preparation, protocols, and interpretation of breath tests have been agreed upon. They have also totally agreed that the hydrogen/methane breath testing is indicated for the diagnosis of SIBO.


Is based on the concept that sugars that are fermenting by bacteria in the small intestine, create hydrogen and methane gases. These gases diffuse into the bloodstream and are released by expirations of breaths. Hydrogen and methane are exclusively produced in the large intestine in healthy humans but they are  produced also in the small intestine in patients with SIBO

Clinicians can use Glucose or lactulose for the test. Lactulose has the advantage to be more likely to detect SIBO in the most distal portion of the small intestine from where it passes all the way to the colon.

The established guidelines for preparation and performance of hydrogen/methane breath tests indicate up to a maximum dose of 75g of glucose with 1 cup (8 ounces) of water and is 10g of lactulose with 1 cup (8 ounces) of water.

The patient collects a baseline sample of expired air then consumes either glucose or lactulose in water.  then collects samples of expired air every 20 minutes for 3 hours.

Before taking the test

  • Antibiotics must be avoided for 4 weeks before the test.
  • Prokinetic drugs (drug which enhances gastrointestinal motility by increasing the frequency of contractions in the small intestine)  and laxatives must be stopped 1 week before the test
  • Fermentable foods, such as complex carbohydrates, must be avoided on the day before breath testing
  • Fasting 8-12 hours before breath testing is required.

The small bowel culture, historically been considered the benchmark test for SIBO diagnosis (the presence of more than 104 or 105 colony-forming units (CFUs) of bacteria per milliliter indicated a positive diagnosis) has not been considered satisfactory for the assessment of SIBO by the North American Consensus, the problem being the relying on small bowel aspiration to diagnose SIBO because the collection of fluid takes place in the proximal portion of the small bowel, and many cases of SIBO occur just in the distal portion. Besides, Small bowel aspiration requires invasive, time-consuming, and costly endoscopy ( the procedure used to examine a person’s digestive tract. ).

How The Test Works


The bacteria Enterobacteriaceae, Bacterioides, and Clostridium,produce primarily hydrogen.

The bacteria Methanobrevibacter and Methanospaere, of the domain Archaea,   because  produce the primarily methane, therefore they are called methanogens,

 The test requires that hydrogen, methane, and carbon dioxide all be measured simultaneously.


If the test result gives

  • A rise of ≥20 ppm from baseline in hydrogen by 90 minutes it must be considered positive for SIBO
  • A level of ≥10 ppm for methane should be considered positive for SIBO

Rifaximin is the most widely experimented and studied antibiotic for SIBO.

Rifaximin is generally a very effective antibiotic for diarrhea-predominant SIBO

For cases of constipation-predominant SIBO a combination of rifaximin and neomycin is used.

But almost 50% of patients treated successfully with antibiotics relapse within 9 months.


Herbal Antimicrobials

could be ideal for patients who do not respond to antibiotics.pomegranate

Many herbal antimicrobials also have a very important property:, they can simultaneously treat SIBO and SIFO (small intestinal fungal overgrowth) that coexist in almost half of the of patients. and SIFO is exacerbated by antibiotics. because they have both antibacterial and antifungal properties, mitigating this risk.

According to A study published by Chedid, et al in 2014 reported that herbal therapy is as effective as rifaximin in the treatment of SIBO.

A herbal combination of a dozen different herbs, including red thyme oil, oregano oil, berberine sulfate, ginger, and numerous traditional Chinese herbs was used for the study.

Other herbs of which there is anecdotal evidence that they are effective for treatment of SIBO are

• Berberine

• Oregon Grape (Mahonia aquifolium) or other berberine-containing herbs

• Mugwort (Artemesia vulgaris)

• Pomegranate (Punica granatum)

• Oregano (Origanum vulgare)

• Neem (Azadirachta indica)

• Enteric-Coated Peppermint Oil (Mentha piperita)Clove (Syzygium aromaticum)

• Allicin, an organosulfur compound obtained from garlic

Natural Prokinetic (enhances gastrointestinal motility) Agents

As MMC is common for many cases of SIBO, prokinetic agents can be gingerprescribed to stimulate gastrointestinal motility. They can be taken cyclically and at bedtime.

They are:

Ginger, gentian root, dandelion root and leaf, burdock root. chelidonium leaf (Chelidonium), milk thistle fruit (Cardui mariae), lemon balm leaf (Melissa officinalis), carum (Carvi fructus), licorice root (Glycyrrhiza), angelica root (Angelica), chamomile flower (Matricaria), and peppermint leaf (Mentha piperita). They are  I as effective as prescription prokinetic agents for relieving functional gastrointestinal symptoms.


Dietary changes are imperative for the successful treatment of any disease, so much more for gastrointestinal problems.

Because intestinal bacteria feed on carbohydrates—including starches, soluble fiber, any diet recommended for patients with SIBO must be low in carbohydrates.

One therapeutic option for patients with SIBO is the elemental diet. Other dietary recommendations for patients with SIBO are the Specific Carbohydrate Diet (SCD), the Gut and Psychology Syndrome (GAPS) diet, the low FODMAP diet, and the SIBO Bi-Phasic Diet.

Other dietary recommendations for patients with SIBO are the Specific Carbohydrate Diet (SCD), the Gut and Psychology Syndrome (GAPS) diet, the low FODMAP diet, and the SIBO Bi-Phasic Diet.

These diets all restrict certain carbohydrate foods, and  can be customized for each patient, depending on food sensitivities and allergies. They can be implemented during treatment, during maintenance, or for the prevention of SIBO.

In addition to the types of foods eaten, the timing of meals can also influence symptoms of SIBO. This is because of the action of the MMC.

Because The MMC produces waves of contraction through the gastrointestinal tract during periods of fasting., the timing of meals can also influence symptoms of SIBO.

To allow for the MMC to cycle effectively, meals must be spaced at 4-5 hours, and the overnight fast should ideally be 12 hours.

Until next time.

About Phil

A doctor taught me to never take pharmaceutical drugs or vaccines. I have made efforts to learn everything about natural cures and healing since.

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