Home / BTHCP: 017 SIBO: A Hidden Cause of IBS, IBD, GERD and Much More!

BTHCP: 017 SIBO: A Hidden Cause of IBS, IBD, GERD and Much More!

Welcome to the Back to Health Chiropractic Podcast 

I’m your host Dr. Marc Dupuis on this show we discuss tips, tools and strategies to improve the health & wellness of you and your family!

Today we are going to shed some light on a hot topic in functional medicine; SIBO or Small Intestine Bacteria Overgrowth.  

SIBO is a condition in which abnormally large numbers of bacteria are present in the small intestine leading to problems with digestion and absorption of nutrients and for many, increased intestinal permeability or “Leaky Gut”.  Technically speaking SIBO is defined when small intestinal bacteria levels rise above 10(3)bacteria/ml. Let’s talk for a moment about the small intestine

There are a number of factors that are supposed to keep bacteria levels lower in the small intestine compared to the large intestine.  The major factors are: the presence of digestive HCL, bile, and other digestive enzymes, the presence of gut associated lymphatic tissue (GALT) and the action of the migratory muscle complex (MMC).  We will cover how these factors influence small intestine bacteria levels in a moment. The average small intestine is about 20 feet in length (compared to the large intestine which on average is about 5 feet in length).  

The complete digestive tract is a highly specialized structure that is connected to and influenced by both the central nervous system and the enteric nervous system and contains over 100 trillion bacteria.  Over our lifetimes we will put literally TONS of foods, fake foods, preservatives, chemicals and more into our mouths, therefore it should come as no surprise that diet is one of the major causes of SIBO, more on that later.

Because of the numerous bodily processes that are reliant on a properly functioning digestive system, there are a number of Diseases Associated with SIBO.  The most common ones are: IBS (irritable bowel syndrome), IBD(irritable bowel diseases such as Crohn’s disease & Ulcerative Colitis), GERD, Celiac & Gluten Sensitivity, Autism, Fibromyalgia & Chronic Pain Syndrome, Interstitial Cystitis, Diabetes, Scleroderma, Cirrhosis & Hepatic Encephalopathy, Hypothyrodism and Diverticulitis.

Symptoms of SIBO
The most common Signs & Symptoms of SIBO are:

  1. Abdominal Gas & bloating, with or without pain and or discomfort.  This is due to an excess of hydrogen and methane gases being produced by the overpopulated bacteria in the small intestine.  Because excess methane gas often causes constipation and excessive hydrogen gas often causes diarrhea this explains the second major sign/symptom of SIBO
  2. Abnormal bowel function.  What is normal? One should have a bowel movement at least once per day, the consistency of your stool should be similar in consistency to that of a ripe banana.
  3. Excessive burping and excessive flatulence
  4. Reflux
  5. Nausea
  6. Fatigue
  7. Other systemic symptoms that come after eating food, three such examples are headaches, joint pain and a sense of “crashing after eating”.
  8. As mentioned earlier If left untreated SIBO can lead to leaky gut (increased intestinal permeability) which can then cause food sensitivities, headaches, respiratory problems and even neurological disorders such as depression, anxiety and more…

Some of the most common clinical finding related to SIBO which are likely to be missed by health-care providers not trained in functional medicine are:

  1. Anemia
  2. B12 deficiency
  3. Fat malabsorption
  4. low body weight combined with inability to put on weight
  5. Fat soluble vitamin deficiency (ADEK)


The most common causes of SIBO are:

  1. Long course utilization of broad spectrum antibiotics
  2. Proton pump inhibiting drugs (anti-acid drugs)
  3. Opioid drugs
  4. Food poisoning
  5. Significant life stress
  6. Other significant infections
  7. Food Allergies/Sensitivities

Fortunately our bodies do have multiple, natural ways to prevent SIBO: Many of our digestive enzymes help to keep bacterial populations in balance.  The gut associated lymphatic tissue (GALT) within our small intestine tissues works to regulate commensal or friendly bacteria and identifies and fights intestinal pathogens, the ileocecal valve (one way valve) helps to encourage normal flow of intestinal contents and the Migratory Motor Complex or MMC plays a tremendous role in preventing SIBO.  Let’s talk about the migrating motor complex: It is activated by enteric nervous system, (ENS (gut brain/2nd brain)) operates between meals, every 90 min MMC performs one full peristaltic sweep from stomach to ileum encouraging proper clearance of continents from the small intestine into the large intestine. The MMC stops when eating resumes.  Knowledge of how the MMC works should give pause to those that are trying diets that encourage eating every 1-2 hours as this could result in becoming more susceptible to developing SIBO.

Risk factors: There are some known risk factors for developing SIBO and they include: having an atypical small intestine loop or loops, having diverticuli present, have a sluggish or suppressed Migratory Motor Complex. and diabetes.

How do you know if you have SIBO?  This takes us to the next part of our discussion, Testing for SIBO.

There are a few challenges to testing this specialized region of the intestine. Due to its length, location and given the fact that the small intestine is far from the rectum, stool cultures are not at all effective in determining its contents.  The best way to currently asses if one has SIBO is to perform a lactulose SIBO breath test. For this test a patient drinks a lactulose solution and then over the period of at least two hours has their breath tested to see how much Hydrogen & methane gas is exhaled.   Because the bacteria in the small intestine acts upon the lactulose solution, producing hydrogen & methane gases, this test can accurately tell what is going on in this part of the intestine. This test can also be performed with the patient drinking a glucose solution, however, lactulose is preferred since it is a synthetic sugar which unlike glucose is non-digestible by the patient, yet is digestible by intestinal bacteria.  Now, it is important to know that many health-care providers are familiar with an H-pylori breath test due to the long term knowledge of H-pylori’s association with stomach ulcers and pernicous anemia, however, many are unfamiliar with the SIBO breath test. Therefore if you ask your health-care provider for a SIBO breath test, the wrong test may be ordered, just a heads up.

Sources do vary on what criteria is required to consider a test positive, however, for the most part a positive test is considered if any of the following occurs within the first 2 hours of the test:

  1. a rise in Hydrogen gas of 20 ppm over lowest preceding level
  2. a rise in Methane gas of 12 ppm over lowest preceding level
  3. a combined rise in Hydrogen gas & Methane gas of 15 ppm over lowest preceding level

Now that we reviewed how to test for SIBO, more importantly, what are the treatments for SIBO?

Currently there are four major major methods of treatment available.  What someone will need in regards to which treatment or which combination of treatments depends on a number of different factors some of which are age, underlying health, severity of symptoms, previous treatment.  Treatment often requires multiple rounds due to the high rate of recurrences or relapses.

  1. General Dietary modification:  This method of treatment is designed to be ongoing,  it will not likely be effective if done for just a one or two or three weeks.  The main goals are to (1) lower the patient’s carbohydrate intake which will limit growth in the overpopulated species of bacteria and (2) consume foods that encourage proper gut motility which helps to clear bacteria populations from the small intestine (the latter goal is to follow what is considered to be a prokinetic diet).   Research has shown that the AMOUNT of FOOD one eats per meal IS Important. Eating smaller amounts per meal will aid in the recovery of SIBO. Obviously if you regularly consume large portions, much of what you will not be able to absorb only serves as additional fuel for the already overpopulated small intestinal bacteria! Another general rule of thumb; Space meals out at least 4 hours apart to allow for maximal Migratory Motor Complex activity, remember it takes 90 minutes after eating for just one wave of motility from the stomach through small intestine.  1b. Specific Diets:  There are six specific diets that have been shown to be useful in the treatment of SIBO. They are:
    1. Specific Carbohydrate Diet
    2. GAPS (Gut and psychology syndrome diet)
    3. Low FODMAP diet (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols, short chain carbohydrates & sugar alcohols that are poorly absorbed by the body but readily available as food for intestinal bacteria)
    4. Cedars-Sinai Low Fermentation Diet (C-SLFD). Easiest to follow
    5. SIBO Specific Food Guide (SSFG). Most restrictive, however, seems to result in the most symptomatic relief
    6. Paleo Diet  
      You can easily Google any of these diets to learn more about them.

Prokinetic foods: These are low FODMAP foods that are rich in calcium & magnesium which play a major role in smooth muscle contraction/relaxation, thereby increasing Migratory Motor Complex activity.  Some examples are ripe bananas, almonds & quinoa. Some of the most commonly used prokinetic supplements are Iberogast (I-bureau-gast) which contains a mixture of 9 herbs, MotilPro which contains ginger, vitamin B6, acetyl-l-carnitine and 5-HTP.  A number of health-care providers will use ginger on its own as a supplement to improve gut motility.

  1. Elemental diet: Treatment duration 2-3 wks: Use of a powder that is mixed with fluid and drank that contains pre-digested nutrients, therefore it is easily digested without placing much stress on the GI and is designed to replace ALL meals for 2-3 weeks.  The success comes from essentially starving the overgrown bacteria populations while still providing nutrients to the patient. Research has shown that the elemental diet can be AS effective as prescription antibiotics! the down side, it is a difficult diet to adhere to due to poor taste, and restriction of all solid foods, which is also often emotionally very difficult for the patient.  Other downsides to this diet are possibility of excessive weight loss and Yeast overgrowth.
  2. Herbal antibiotics Treatment duration 4 – 6 wks: Research has shown that the following herbs & herb derived compounds are AS effective as prescription antibiotics; Allicin (Ally-sin), Berberine, Neem, Oregano & Cinnamon.  Avoid whole garlic due to pre-biotic fiber content which supports bacteria growth
  3. Antibiotics Treatment duration 2 wks: Most commonly use drugs are Rifaximin (Re-fax-a-min), Neomycin and Metronidazole (Metro-Nye-di-zol)

One of the main challenges that can arise during treatment for SIBO is a poorly tolerated “Die off”, which is a temporary worsening of symptoms related to toxins being released from bacteria being killed off.  The most common symptoms of die off include flu like symptoms, increased gas/bloating or a worsening of whatever initial symptoms they first presented with. Symptoms from die off can last as long as 3-4 wks and is a major reason why it is so important to work with a qualified health-care professional who can help to modify the treatment plan, if needed, to help make the die off phase more manageable.  The good news is this: despite research saying die off symptoms can last as long as 3-4 wks, it is not that common. Im my experience, these symptoms typically last only 1 to 2 wks, provided that the patient is compliant in making the modifications to their treatment plan that I recommend.

This wraps up our conversation on small intestine bacteria overgrowth or SIBO.  I hope this helped to explain what exactly SIBO is, the most common symptoms of SIBO, most common diseases associated, how to test for it and most importantly, how to treat it.  I will put links to some of the information we touched upon today, they can be found on our show notes page that is located at www.backtohealthchiropractcposdcast.com.

This concludes today’s episode of The Back to Health Chiropractic Podcast, where we discuss tips, tools & strategies to improve the health and wellness of you & your family!  Please SUBSCRIBE to this podcast so that you never miss a future episode, also PLEASE SHARE this podcast with ANYONE you feel may benefit from what we covered today.

Finally, Thank you very much listening and until next time, have a Fantastic Day!


Excellent website for an overview of SIBO

Dr. Mullin’s work showing herbal therapy is equal to prescription antibiotics for the treatment of SIBO

Genova Diagnostics SIBO Breath Test