Bloating, constipation, loose bowel movements, cramping, fatigue—these broad symptoms have many potential underlying causes. One such cause that is becoming better understood and more commonly suspected is SIBO, or small intestinal bacterial overgrowth.

SIBO is a condition where bacteria overwhelm the small intestine. The microbiome thrives on balance; too much or too little of even the 'good bugs,' or finding them in the wrong place, can create digestive and body-wide symptoms.

It’s a stubborn and relatively common issue for the general population, and it deserves attention as a crucial topic in gut health! The more you know, the more you can hopefully feel empowered around this and other topics related to the microbiome. Let’s explore all about SIBO!

What Is SIBO?

For this discussion, it's important to note the order that food passes through our major organs. First food enters the stomach, is released into the small intestine, and lastly the large intestine.

In a normal, balanced microbiome, most microbes are found living in the large intestine—not the small intestine. Though there are a few microbes native to the small intestine, when we consider the microbiome we are generally interested in the variety and growth within the large intestine.

Small intestinal bacterial overgrowth (SIBO) occurs when bacteria, whether “good” or “bad”, invade and multiply within the small intestine. Normally, adequate bile, the quick passage of digested food, and the high acidity of the contents from stomach acid keep most microbes out of the small intestine.

Disordered function or lifestyle factors that affect the normal environment of the small intestine can make way for SIBO to occur. It may be gradual or happen relatively quickly if the triggers are strong enough. These non-native microbes are then free to exert their effects which leads to the many potential symptoms of SIBO.

Symptoms of SIBO

Similar to leaky gut, SIBO symptoms can manifest both in the digestive tract and throughout the body. This makes it difficult to reliably identify in a clinical situation because body symptoms like fatigue and brain fog don’t conventionally make us think “gut”! But you’ll see this is a common theme emerging the more we learn about gut health and the microbiome!

Bacteria play many roles and release many byproducts of their own life processes, including hydrogen and sulfur-containing gasses and fatty acids. Again, when functioning normally, balanced, and in the right location, we can handle living with these mutually beneficial microbes. When overgrown, this can lead to the following symptoms:

Digestive Symptoms:

• Bloating
• Constipation
• Loose stool or diarrhea
• Abdominal pain or cramping
• Gas
• Indigestion or “upset stomach”
• Nausea
• Acid reflux or “heartburn”

Non-Digestive Symptoms:

• Fatigue
• Brain fog and difficulty concentrating
• Joint pain
• Skin problems
• Mental health concerns, including depression and anxiety
• Nutritional deficiencies because of poor absorption function in the small intestine
• Weight maintenance issues

What Causes SIBO?

Low Stomach Acid

We require enough stomach acid to properly break down proteins, kill unwanted microbes that enter the gut through the food, and maintain microbial balance in the small intestine. Too little stomach acid can create the perfect opportunity for SIBO.

Whether from acid reducing medications, the presence of H. Pylori, or poor eating habits like eating while stressed or on the go can all contribute to underproduction of stomach acid. It makes you wonder about the flip side to long-term use ever since these common acid-reducing medications became over-the-counter.

Certain Medications

In addition to acid reducing medications like proton pump inhibitors (PPI’s), there are many other medications that directly affect the balance of the microbiome. The usage of antibiotics, especially broad-spectrum antibiotics, is associated with imbalances that can lead to SIBO. Painkillers such as opioids are also associated with increased risk of developing SIBO.

Decreased Bowel Motility

When the digestive ability slows down, and you experience constipation, this leads to relative stagnation of the digestive products in the small intestine. This slower transit creates the perfect environment for bacteria to settle and feed in an area that would normally be limited by the normal transit of broken-down food.

Common causes of slower bowel function include chronic stress, a diet low in plant fiber, lack of physical activity, irritable bowel syndrome, pregnancy, and some autoimmune conditions. Regardless of the reason, it’s the slower transit that is responsible for giving bacteria the opportunity to overgrow in SIBO.

Inadequate Bile Production and Secretion

Just as stomach acid maintains the ideal environment in the small intestine, bile, which is created in the liver and stored in the gallbladder, is just as important. Bile helps to remove unwanted pathogens and bacteria in the small intestine in addition to playing a key role in fat digestion and fat-soluble vitamin absorption!

Bile production and secretion can be affected by many conditions and environmental factors. These include liver and gallbladder conditions, some medications, genetic conditions, and overwhelm of the liver’s detoxification capacity. Alcohol, medications, environmental toxins, and low antioxidant intake to support liver detox pathways are just a few examples.

Inadequate Digestive Enzyme Production and Activation

In addition to managing blood sugar balance, the pancreas is the organ responsible for producing and delivering enzymes that help us chemically break our food (fats, carbs, and proteins) in the small intestine. If this function is impaired, undigested food may linger in the small intestine for too long, encouraging bacterial growth. Additionally, pancreatic fluid has antibacterial properties.

What Other Factors or Conditions Are Related to SIBO?

There are other factors that are related to SIBO that aren’t necessarily causes for developing SIBO. Some of these may increase the risk of SIBO or contribute to its persistence if it’s already present.

Dietary Factors

Our microbiome shifts in reaction to the foods that we consume. Though diet isn’t a direct cause of SIBO, certain foods do encourage the growth of certain bacteria that are commonly overgrown or opportunistic species! Sugar, starches, and dairy products are favorite foods of some of these microbes and can lead to a flare up of symptoms.

Dysbiosis

Dysbiosis is the term used to describe a microbiome that is out of balance and that causes disease and dysfunction. Simply having an imbalanced microbiome, such as overgrowths and opportunistic growth of less favorable bacteria in the large intestine, can set the stage for SIBO.

Stress

Short-term and long-term stress can contribute to SIBO. Emotional, environmental, or physical stress activates our 'fight or flight' nervous system. Our digestive function falls under the opposing nervous system, our “rest and digest” nervous system.

When there is imbalance between these two systems, both our digestive function and immune system strength can become suboptimal and further set the stage for SIBO to take hold.

Risk Factors and Related Conditions to SIBO

Other conditions that affect digestive function or the physical digestive tract are associated with promoting or perpetuating small intestinal bacterial overgrowth. These include:

• Inflammatory bowel diseases such as Chron’s and ulcerative colitis
• Irritable bowel syndrome (IBS)
• Acute and chronic pancreatitis
• Hypothyroidism
• Autoimmune conditions such as celiac and lupus
• Diabetes
• Liver or kidney disease
• Restless leg syndrome
• Colon cancer

Lastly, there are two similar conditions that can appear separately or together with SIBO - SIFO and IMO.

• Small intestinal fungal overgrowth (SIFO) - when fungi, also called yeasts, invade and overgrow in the small intestine
• Intestinal methanogen overgrowth (IMO) - when methanogens (from the archaea domain, not bacteria) invade and overgrow within the small intestine.

Diagnosing SIBO

SIBO may not be the first condition a healthcare practitioner considers.. The symptoms overlap with many other conditions of the digestive tract. However, the awareness of SIBO is ever-growing, clinically and in the research as well!

The SIBO Breath Test

Remember, SIBO is a situation of bacteria overgrowing. Their numbers increase their activity and waste generated in the forms of gasses (hydrogen, methane, and hydrogen sulfide). This is exactly what is tested for through a breath test. A patient drinks a carbohydrate solution, the bacteria break down the sugars, produce their gaseous waste, and the collected breath is analyzed for overproduction of gasses!

Other Tests for SIBO and Its Effects

• Comprehensive Stool Testing - Though stool testing doesn’t directly test the small intestinal environment, expert lab interpretation can identify patterns that are suggestive of SIBO in addition to noting other related functional digestive issues.
• Micronutrient Testing - Since a spectrum of malabsorption can be associated with SIBO, micronutrient testing can help to identify nutritional deficiencies that can underlie many other widespread issues in the body.
• Conventional Blood Test and Imaging - Assess for any underlying conditions or those related to SIBO discussed above, including autoimmunity, hypothyroidism, diabetes, liver disease, and more.

Treatments for SIBO

SIBO is a notoriously stubborn condition to treat because it has a tendency to come back after treatment. This is especially true if the underlying cause of the SIBO is not found in addition to treating the bacterial overgrowth itself.

Antibiotic & Herbal Treatment

Though antibiotics can also cause SIBO, targeted antibiotic therapy is the standard treatment of choice from a conventional perspective. Herbal treatment of SIBO is also considered effective and has been shown to be just as effective as antibiotic therapy. Reaching therapeutic doses for antimicrobial herbs such as oregano oil with a qualified herbalist is crucial for their efficacy.

Diet & Lifestyle Treatment

In addition to antibiotic or herbal therapy, there are supportive lifestyle and behavioral patterns used to target SIBO. If there are nutrient deficiencies from poor absorption arising from the SIBO, nutrient replacement is also a common intervention.

There are also several therapeutic diets that have shown some efficacy in supporting treatment of SIBO. These are the elemental diet and low-FODMAP diet.

• The elemental diet attempts to go back to the “elements” of what is needed in a diet and removes all potential allergens and supplies only “predigested,” bioavailable nutrients.
• The low-FODMAP diet attempts to eliminate the complex carbs that many of these bacterial culprits feed on to essentially “starve them out.”

Tips for Prevention and Long-Term Management of SIBO

Prevention is the best medicine, but of course long-term management and minimizing the risk of recurrence is key after treating SIBO. Here are some tips for navigating the sometimes stubborn terrain that is SIBO.

1. First and foremost, identify the underlying cause or causes of SIBO. Take a detailed look at medication and alcohol usage or make sure there isn’t any physical cause of SIBO through advanced imaging.
2. Support your gut balance through diet and little to no alcohol consumption.
3. Whether you choose low-FODMAP while you’re actively treating SIBO or switching to a low-inflammatory diet such as a Mediterranean pattern to support balance, there are many approaches to explore.
4. Stress management - Prioritizing stress management is also pivotal. Not only because of the direct effects that stress plays on gut motility, but increasing our resilience to stress can also support the strength of the gut immune system!
5. Tend to your bowel movements - Remember, bowel movements represent a zoomed-out view of our body’s ability to detox properly and regularly. It also supports balance within the gut. Aim for 1-3 bowel movements every day, usually after meals.
6. Consider supplements such as the digestive enzymes and ginger in Cielo’s Horizon to support adequate breakdown and absorption of nutrients.
7. Consult with a healthcare professional or team of professionals to help assess and treat SIBO. It’s ideal to tackle this condition strategically.

Conclusion

Understanding SIBO and its widespread effects is crucial for anyone struggling with gut health issues. By recognizing the symptoms, underlying causes, and effective treatment strategies, you can take empowered steps toward better digestive health.

Remember, balance is key to maintaining a healthy microbiome.

For more insights and personalized advice, feel free to reach out with questions. Follow Cielo and Dr. Kenny on social media for ongoing tips and updates.

Together, we can navigate the complexities of gut health and achieve lasting wellness!