Small Intestinal Bacterial Overgrowth, Part Eight: Treatment Options For SIBO
Leaping for joy because his SIBO is gone!
This is the eighth and last installment of the Syontix series on small intestinal bacterial overgrowth (SIBO). In this post, I want to talk about treatment options for SIBO.
Antibiotics
Assuming you test positive for SIBO what’s next? Well, the standard course of medical treatment involves antibiotics. The problem for the physician, however, is determining which antibiotic to choose.
What works against one type of pathogen may not work against another. And since it’s rarely just one type of pathogen causing SIBO, the options can get complicated. Throw in yeast issues and the treatment conundrum gets worse. For this reason, there is no common agreement about the choice, the dosage or how long to prescribe a course of antibiotics. A perfect illustration that medicine is as much art as science.
Long-term, broad-spectrum antibiotic use is not an ideal choice as they are more likely to cause a growth of pathogenic bacteria like Clostridium difficile, a blooming of Candida albicans and potentially lead to the growth of antibiotic-resistant bacteria in the patient.
Tetracycline was the treatment of choice for a long time but in one clinical trial, only 3 out of 11 subjects experienced a normalization in their breath tests after their course was finished. Granted, this is a very small trial, but so are most of the studies examining SIBO treatments.
Other antibiotics that have shown promise include amoxicillin-clavulanic acid, ciproflaxacin, chloramphenicol, doxycycline, metronidazole, neomycin, norfloaxin, trimethroprim-sulfamethoazole and rifaximin.
Of these, rifaximin (brand name Xifaxan) has shown the most promise in clinical trials for treating SIBO in irritable bowel syndrome (IBS) sufferers. It’s a semi-synthetic antibiotic that is usually given for 7 to 10 days. Depending on the clinical trial referenced, symptoms improve for 33% to 92% of participants taking it and rifaximin completely eradicates overgrowth in 80% of infections.
As with any drug, there are side effects involved with taking any antibiotic which I’ve covered in a previous post. So I recommend that you supplement with a good probiotic and prebiotic while taking them.
Even though I’m a huge fan of fermented, probiotic-rich foods, there is no way these foods will replenish your gut flora quickly enough to counteract the effects of a course of antibiotics. You can read why here. Look at probiotic-rich foods as a long-term dietary strategy to keep your gut flora happy, not as a quick way to repopulate your gut with beneficial organisms.
As I mentioned in the first post in this series, yeast overgrowth is likely also part of SIBO. Not for everyone, but for a sizeable number. When beneficial gut flora populations are disordered, not only is there an overgrowth of pathogenic bacteria, it’s also not unusual for resident yeast populations to overgrow as well.
If you have genital yeast issues (vaginal yeast in woman, jock itch in men) or a white coating on your tongue (thrush), alert your doctor so that an appropriate anti-fungal is made part of your treatment protocol.
Probiotics and Prebiotics
SIBO is impossible without disruption to our beneficial gut flora; disruptions caused by many things like licit and illicit drug use, binge drinking, stress, diet, viral and bacterial infections, etc.
So the interest in using probiotics and prebiotics for treating SIBO is growing but is it scientifically valid?
In the case of prebiotics, scientific evidence for its beneficial use is scanty at best. There currently are no large randomized controlled trials in the literature to answer this question but hopefully this will soon change.
As you may recall from my post on prebiotics, I consider them fertilizer for Bifidobacterium in the colon. By feeding your friendly colonic bacteria, they grow and outcompete other colonic pathogens. However, the main locus of action for prebiotics is in the colon, not the small intestine.
Nevertheless, many cases of SIBO are due to gram-negative bacteria migrating from the colon. So I can see a definite benefit in encouraging the growth of bifidobacteria to control the spread of these pathogens. But whether encouraging these colonic species can help correct an existing case of SIBO is still unresolved.
The research on probiotics is far more promising. I’ve covered many of the functions of beneficial bacteria here but let me quickly recap.
As in the colon, beneficial bacteria outcompete pathogens for both food and attachment sites. Unlike the colon, however, the predominant species in the small intestine is Lactobacillus.
Lactobacillus strains, like Bifidobacterium, produce lactic acid to make the small intestine inhospitable to pathogens. They also produce antimicrobials that directly target harmful bacteria. They strengthen the gut’s immune response to infection by communicating with the structures that form the gut-associated lymphoid tissue or GALT system. They strengthen the gut wall preventing translocation of pathogens to systemic circulation. They exert a strong anti-inflammatory effect along the gut wall. And since they regulate the growth cycle of the absorptive cells that line the small intestine, they are absolutely essential to digestive health and your eventual recovery through diet.
This doesn’t exhaust all their vital function, but it’s enough for the purposes of this post.
In one small randomized clinical trial among 12 patients, administering Lactobacillus casei and Lactobacillus acidophilus proved effective against bacterial overgrowth that resulted in chronic diarrhea. However, Lactobacillus fermentum proved ineffective. Just like antibiotics, probiotic strains differ in their actions against harmful bacteria.
Speaking from personal experience, probiotics and prebiotics along with eliminating gluten went a long way in reducing my IBS symptoms. Unfortunately, I still had lingering issues. This was well before I developed Syontix Probiotics Ultra, however.
This could have been because the brand of probiotics I took came in enteric-coated capsules. There’s a real question about how effective these types of capsules are in protecting probiotic bacteria from stomach acid. That is the reason I didn’t rely on enteric coating for Syontix probiotics.
It’s also possible that the probiotics I purchased were mostly dead by the time I took them even though they were nicely shelved in a refrigerated case in the store. When buying probiotics requiring refrigeration, the consumer has absolutely no way of knowing whether they were properly handled once they left the manufacturer.
Finally, it could be that probiotics are not effective against an existing intestinal infection once it’s established.
If anyone out there has successfully treated their SIBO using only probiotics or prebiotics or fermented probiotic-rich food, I would love to read your story in the comments section.
Garlic
As many of you already know, I was never officially diagnosed with SIBO, “just” irritable bowel syndrome. My doctors–yes there was more than one–ordered many tests that led to my diagnoses of IBS but no one ever thought to test me for SIBO. I certainly had never heard of SIBO so I didn’t know to ask to be tested. As previously mentioned, not being screened for SIBO when diagnosed with IBS is all too common in this country.
So with nothing but a newly minted IBS diagnosis to my name, I began my search for answers, first online and afterwards at the local university science library. It was then that I discovered I had all the classic signs of someone suffering from a small intestinal bacterial overgrowth.
I considered calling my physician and requesting a referral to a gastroenterologist for a hydrogen breath test, but by this point I was so tired and discouraged with the medical system, I decided to try garlic instead.
Why garlic? Because of its well-known antibacterial, antiviral, antifungal and antiparasitic properties. I figured if I did have SIBO and a yeast overgrowth why not give it a shot? If it didn’t work, I could always make the request to see a gastroenterologist later.
*****ALERT*****
THIS IS IN NO WAY A RECOMMENDATION THAT YOU DO THE SAME.
Let me be crystal clear and say this is what I felt was right for me at the time, not what I’m recommending to anyone reading this blog. As the disclaimer statement to the right reads, I’m not a medical doctor nor do I play one on the internet.
I also didn’t attempt this until after I had been given a series of tests by my doctor(s) that ruled out a lot of other conditions, including parasites. It was only after they told me that I had IBS, but was given no other advice other than to watch my stress levels and eat plenty of fiber (?!?!?), that I embarked on this experiment.
So what follows is my experience using raw-organic garlic to treat my IBS and what I believe was SIBO and yeast overgrowth.
During the first week, I took a garlic supplement but apart from some bad breath, I didn’t notice anything different other than that my wallet was lighter than before. So I decided to try the real deal. Another benefit of raw garlic is that it has inulin, and I figured it would at least feed my bifidobacteria if nothing else.
I had read that imported garlic was likely irradiated by the USDA at the border. Unfortunately, irradiation kills the enzyme allinase and it’s this enzyme that is responsible for forming the active ingredient allicin when a clove of garlic is crushed or chopped. So I was careful to use only organic garlic that I sourced from a local health-food store or farmer’s market.
I knew I had to eat it raw to derive any benefit but wasn’t looking forward to it. I love garlic but eating it raw can be a bit much, but unfortunately, there was no way around this. I used a garlic press to crush one to two cloves into a glass, added plain water and waited for a minimum of 15 minutes before swallowing to allow the allicin time to strengthen.
Please note that a clove is one small piece of a garlic bulb. I once told this story to someone who will remain anonymous, and they went home and tried to eat a whole bulb of garlic instead. Mother of God! Are you crazy I exclaimed? I’m shocked they could get most of it down without vomiting!
I soon learned it was best to take this garlic “juice” on a full stomach or risk nausea. I did this after each meal, including breakfast, if you can imagine, for about seven days. So what happened?
Well, at first I felt a lot of stomach discomfort and rumbling. Then the need to go to the bathroom became overwhelming. It was not unusual to experience cramping as well. And what showed up in the toilet was like nothing I had ever seen before or since. I can only describe it as fudge-like in consistency with a very reddish-brown hue. I’ll leave it at that.
This went on for several days until my stools returned to normal. By then all of my IBS symptoms totally disappeared. I was shocked to say the least as nothing else had worked until then. What the garlic killed is still a mystery to me. Was it bacterial or fungal or both? I don’t know or really care. I was just happy it, whatever “it” was, was finally gone. I have not seen a doctor for anything other than a physical in the last two years.
Nonetheless, there were some definite unpleasant side effects.
The lingering garlic taste in my mouth and strong garlic body odor was a big issue. I noticed people giving me a wide berth when they approached me. Heck, even my dog Tahoe was less likely to get near me, and she can’t stand being alone! On the plus side there wasn’t a chance in hell a flea or vampire was going to suck my blood during this garlic fest.
As with any herbal medicine, there’s no way of knowing how much of the active ingredient you’re actually getting. I noticed that my reaction would vary with cloves from different bulbs. Some bulbs would be stronger than others. No doubt this is due to differences in how they were grown and the time since harvest. Unlike a prescription drug, there is just no way to control for this.
As mentioned there was stomach upset, cramping and unpredictable visits to the bathroom. Lucky for me, I work out of my home, but if I didn’t, I don’t think I would have chanced it, at least not during the work week.
The amount of inulin in garlic is also unpredictable so at times gas produced in the colon due to fermentation was made worse.
I also learned to not take it anywhere near bedtime or the rumbling/cramping/bathroom dashing would keep me up for part of the night.
Garlic is also a broad-spectrum antibiotic and like any broad-spectrum antibiotic, there may be risks in developing resistant bacteria or harming beneficial gut flora with long-term use although some debate this. However, I only took it for about a week, and to avoid any possible harm to my gut flora I continued taking probiotics.
So that, dear reader, was my experience with taking garlic for my IBS. As I said, I’m not recommending you try this only that it was the treatment option that worked for me.
(I’ve posted a new article on garlic here – 3/14/13)
Prognosis
Once a case of SIBO is successfully treated, how permanent is the treatment?
Sorry to say the figures aren’t encouraging as relapse rates are high. In one study that followed 80 patients prescribed rifaximan, 35 people or 44% had a recurrence of SIBO within nine months after successful treatment. God only knows how many had a recurrence after nine months.
These figures are even worse if you’re older, have had an appendectomy, have short-bowel syndrome or continue taking proton-pump inhibitors. No doubt diet plays a huge factor in relapse so if you haven’t read my posts on dietary causes predisposing to SIBO please do so. You can read them here, here and here.
Final Words
Those who’ve suffered with IBS or SIBO know it’s no walk in the park. Whether you stay free of SIBO once cured will largely come down to staying away from those factors that impair gastric barrier function, slow intestinal peristalsis and harm your beneficial gut flora. Not all of these factors are within your control. Previous surgical operations, radiation therapy, AIDS and cystic fibrosis are just some examples of this.
Nevertheless, many of the predisposing factors I’ve outlined in this series are within your control. I credit changes to my diet and staying away from these non-dietary causes for remaining IBS free for over two years. I hope sharing my experience and knowledge with you leads you to the same place.
To your health!
References:
Bergner, P. (1996). The Healing Power of Garlic. USA: Prima Health.
Bures J., Cyrany J., Kohoutova D., et al. (2010) Small intestinal bacterial overgrowth syndrome. World Journal of Gastroenterology, 16(24): 2978-90.
Quigley E. M. M., Quera R. (2006). Small Intestinal Bacterial Overgrowth: Roles of Antibiotics, Prebiotics and Probiotics. Gastroenterology, 130: S78-S90.
I’ve been slowly reading through all of your articles on SIBO, very informative and big thanks!
Having learned more about SIBO in the last few months, it seems to make the most sense as to what’s causing my health issues. Despite being the healthiest eater I know, I still have IBS and really poor, dry skin (keratosis pilaris -KP). Taking supplements like zinc & vitamin A help slightly, but I know things aren’t getting absorbed like they should. Interestingly, I’m the only one if my family with a “bad case” of KP, and also happen to be the one that received the most antibiotics (for ear infections) as a child. They seemed to have had a pretty negative effect on my gut flora and it’s never recovered.
Thanks for commenting. Hopefully you can find something in this series of posts to help you. As I mentioned, I too was eating a nutrient-dense diet along the lines of one recommended by the Weston A. Price Foundation but still had many issues. At the end of the day, if you can’t digest your food properly, nutrient density or supplements will only take you so far.
Your dry skin screams fat malabsorption to me. That was a big issue for me as well and no dermatologist I ever saw ever considered fat malabsorption as a possible cause.
Those digestive cells in the small intestine need to be free of pathogens, especially gram-negative bacteria, in order to work like they are supposed to. And once clear of the infection, it’s Lactobacillus bacteria that keeps them healthy in the absence of predisposing dietary factors.
My guess is like me, you were afflicted with gut dysbiosis at a very early age and paid the price with repeated ear and other infections. The problem was further compounded by repeated courses of antibiotics and diet.
If you do have SIBO, your goal is to get rid of it and find out what in your diet may be predisposing you to it so that clearing up the infection is not in vain. Of the dietary factors I blogged about, the two biggest culprits are gluten grains and binge drinking.
SIBO and IBS can be beat. I’m now 52 and have never felt better or more nourished in my life.
Good luck!
I used to often ask about fat malabsorption on forums, but no one was ever able to give me a good explanation & they usually recommended I eat more of the fat-soluable vitamins (which I was and still am doing.) Also, every time I eat too much fat it goes right though me & I’m very thin. I know many people would love to have the issue of not being able to gain fat, but having poor skin is definitely a negative.
I look forward to reading through the rest of your articles and learning more. I’ve had extensive testing done in the last few months which didn’t reveal much except IBS. Also have been gluten-free for several years, very rarely ever drink (wine), no industrial oils, avoid gmos, etc….but not much improvement.
Dr. Dahlman has a protocol for SIBO with 2 different supplements that kill the overgrowth. I may go with that and then look into taking your probiotics.
I wish you much good luck and hope Dr. Dahlman’s protocol works for you.
Yes, garlic is not for everyone which is why I was careful to note that while it worked for me it may not be right for anyone else. Just make sure you add probiotics and prebiotics to your routine. Correcting gut dysbiosis is pretty much impossible without nurturing your friendly gut flora.
I wish you luck and look forward to hearing how your recovery progresses.
Ray
Thanks for all the information on your website. Its been very helpful. So I’ve been struggling to get a diagnosis for my digestive issues and my docs have no idea what is wrong with me. In the meantime, I am unable to tolerate any food but bone broth and some boiled meat. I was thinking of trying the garlic treatment. What diet would you recommend while doing the garlic?
Thanks
RS
Short answer: a non-toxic one which yours appears to be although much too low in carbs to heal that gut of yours and prevent feeding yeast.
Long answer: I think the best nutritional book on the market today is Perfect Health Diet by Paul Jaminet and Shou-Ching Jaminet. Their website is here: http://perfecthealthdiet.com and their book is available on Amazon here: http://www.amazon.com/Perfect-Health-Diet-Youthful-Vitality/dp/0982720904/ref=pd_bxgy_b_img_y
Just make sure you stay away from gluten, vegetable oils, high fiber meals, nightshades and alcohol until you get this under control. At least try adding white rice or rice noodles to your diet. Vietnamese pho with gelatinous bits is a wonderfully nourishing and healing soup
You may want to add some digestive enzymes to every meal you eat. That at least can help breakdown your food so it doesn’t end up fermenting in your colon causing gas and bloating. I’ve had good results with this formula: http://www.amazon.com/MRM-Digest-All-Condition-Vegetarian-100-Count/dp/B000GG5K3U/ref=sr_1_1?ie=UTF8&qid=1353456178&sr=8-1&keywords=digestall
Don’t forget the prebiotics and probiotics.
The thing I like about organic garlic is that it kills not only pathogenic bacteria but yeast and parasites as well. If you can get over the side effects it’s truly a miraculous herb. I’m planning on devoting an entire post to it in the future.
There is hope. I was there once but I’ve never felt better than I do now.
Good Luck!
If one needs to take antibiotics, Doxy for a month, beside probiotics, do you think Inulin is a must as well?
I have your probiotics already, can I take it 3 times a day while on Doxy?
Thanks.
Yes, I think prebiotics are essential. You want to provide bifidobacteria in your colon with their preferred food so they can grow and produce three vitally important short-chain fatty acids: butyrate, acetate and propionate. Of the three, butyrate will nourish intestinal cells to prevent translocation of gut pathogens to systemic circulation, aka endotoxemia. My latest post details how acetate and propionate are important for blood pressure regulation.
As for the probioitcs, twice a day should be sufficient. Just make sure to take the probiotics away from your antibiotic dose. If you antibiotic dose is 8 hours apart, take the probiotic 4 hours after and 4 hours before your next antiobiotic pill.
If you are not currently on anti-fungal medication, I would strongly advise taking one diced clove of raw, organic garlic in water daily as I described in this post to prevent a fungal overgrowth. Candida overgrowth is a typically unfortunate side effect of antibiotic use.
did you have bloating that was cured when you did the raw garlic remedy? Have you had symptoms return?
thanks
I had bloating, constipation alternating with diarrhea, dry skin, and insomnia. The garlic was the only thing that worked for me coupled with probiotics and prebiotics.
Symptoms have never returned. I’m still taking prebiotics daily and probiotics during the cold/flu season, when I travel or if I’m under a lot of stress. I consume one clove of raw garlic in water daily to prevent problems.
I’m also gluten-free. While not a celiac, I’m very gluten sensitive so I avoid wheat flour like the plaque. I advise the same for anyone with gastrointestinal issues.
May I ask how long after you took the garlic until your insomnia and bloating were normal?
(what type/how severe was your insomnia?).
Was your skin so dry that your heals cracked and peeled? This is very odd symptom to me.
thank you!