What is SIBO?
Small Intestinal Bacterial Overgrowth or shortly SIBO is a digestive disorder when an increased amount of bacteria present in the small intestines. Bacteria start fermenting carbohydrates, starches, fibers and produce byproducts, gases, which can cause damage to the small intestines’ wall and lead to different symptoms. (1)
These symptoms could be: bloating and gas, diarrhea and/or constipation, abdominal pain, nausea, belching, reflux, rashes, food intolerances, and many more. The whole process would be normal if it occurred in the large intestine, where it is supposed to happen. (2)
While looking at the symptoms, we can’t say certainly which type of SIBO someone has, although you can guess.
Doing a SIBO lactulose or glucose breath test is one of the best and practical ways to identify it. (3) So test, don’t guess!
SIBO is categorized into different subtypes:
• Hydrogen Dominant SIBO
• Methane Dominant SIBO
• Hydrogen Sulfide Dominant SIBO
The main difference between these three types of SIBO is the gases produced by the bacteria residing in the small bowel. It is also possible that someone has a Mixed Type of SIBO, meaning multiple types of gases present simultaneously.
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Hydrogen Dominant SIBO
The most common symptoms with the Hydrogen type of SIBO are diarrhea/loose stools, abdominal cramping, pain, bloating. Normal commensal bacteria in our intestines produce hydrogen gases through carbohydrate fermentation. Hydrogen could be a substrate for other gas production such as methane, acetate, and hydrogen sulfide. (2)(4)
The conventional approach for hydrogen-dominant SIBO includes antibiotics such as Rifaximin (Xifaxan). Rifaximin is a nonsystemic antibiotic, which has an effect on the small intestine. (5)(6)
A natural protocol uses single herbs or herbal complexes such as Berberine, Neem, Oregano.
Methane dominant SIBO / Intestinal methanogen overgrowth
It is more likely associated with constipation, nausea because methane slows down the intestinal transit, the way the food passes through the intestines and also causing retrograde motility (8). It is most commonly caused by Methanobrevibacter smithii (M. Smithii), which belongs to ancient archaea, single-celled organisms, and not bacteria. The higher amount of M. Smithii you have, the higher the chances you will have symptoms. Methanogens create methane in the body, and to do that, they require hydrogen and carbon dioxide. (7)
Methane dominant SIBO patients are mostly less reactive to foods than hydrogen dominant SIBO patients, although they respond to treatment much slower.
Not everyone with constipation or IBS-C has methane overgrowth.
Conventional treatment of methane overgrowth requires different and additional medication next to Rifaximin, e.g., Neomycin or Metronidazole. (9) The natural antimicrobial next to the herbs, as mentioned earlier, would be Atrantil, Allicin (stabilized garlic extract).
Hydrogen Sulfide SIBO
This type of SIBO is associated with belching, flatulence with the foul odor of rotten eggs, nausea, diarrhea or constipation, abdominal pain, body/joint pain, even bladder pain. Hydrogen Sulfide (H2S) gas is produced by sulfate-reducing bacteria that feed on hydrogen. (10)
Testing Hydrogen sulfide SIBO can be tricky. The only test that can diagnose this type is the TrioSmart test that is only available in the US.
According to Dr. Nirala Jacobi, if you have been tested with the 3-hour breath test, and your results may show a true flatline, and you have diarrhea and other SIBO symptoms, then hydrogen sulfide dominant SIBO can be suspected. Sometimes, it is good to follow up with another type of test sugar, such as glucose or fructose.
Patients with hydrogen sulfide SIBO can react to sulfur-containing foods, so following a low-sulfur diet for a few weeks may help manage the symptoms. (Reducing meat, dairy, cruciferous vegetables, onions).
Conventionally the same antibiotic protocol is used (as in the case of methane dominant SIBO) combined with bismuth (11).
What is the best treatment option?
According to a study, herbal treatment can be as effective as Rifaximin. (12) The type of treatment should be evaluated by your practitioner to define the best-customized approach.
Besides using antibiotics and antimicrobials, there is a third type of treatment: the Elemental Diet. It is the only diet that can starve the bacteria with an 80-85% success rate (13).
Summary
If you are experiencing digestive problems and you suspect that SIBO can be the culprit of your symptoms, ask your practitioner to test you for SIBO. Knowing the type of your SIBO can determine the best treatment options.
It is still advisable to dig deeper to find your root causes. Dealing with SIBO requires a holistic approach, supplements/medication, and customized nutrition and lifestyle changes.
I know from my own experience that SIBO can be a super frustrating condition and may require a long journey, but it is possible to get rid of it as I did.
If you would like to get guidance on your SIBO journey, book a free consultation call.
*This post is only for informational purposes; and not meant to diagnose, or treat any disease. I advise consulting with your healthcare practitioner regarding any treatment options or dietary changes.
1. Dukowicz, A. C., Lacy, B. E., & Levine, G. M. (2007). Small intestinal bacterial overgrowth: a comprehensive review. Gastroenterology & hepatology, 3(2), 112–122.
2. Bures, J., Cyrany, J., Kohoutova, D., Förstl, M., Rejchrt, S., Kvetina, J., Vorisek, V., & Kopacova, M. (2010). Small intestinal bacterial overgrowth syndrome. World journal of gastroenterology, 16(24), 2978–2990. doi.org/10.3748/wjg.v16.i24.2978
3. Pimentel, M., Constantino, T., Kong, Y., Bajwa, M., Rezaei, A., & Park, S. (2004). A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Digestive diseases and sciences, 49(1), 73–77. doi.org/10.1023/b:ddas.0000011605.43979.e1
4. Majewski, M., & McCallum, R. W. (2007). Results of small intestinal bacterial overgrowth testing in irritable bowel syndrome patients: clinical profiles and effects of antibiotic trial. Advances in medical sciences, 52, 139–142.
5. Gerard L, Garey KW, DuPont HL. Rifaximin: a nonabsorbable rifamycin antibiotic for use in nonsystemic gastrointestinal infections. Expert Rev Anti Infect Ther. 2005 Apr;3(2):201-11. doi: 10.1586/14787210.3.2.201. PMID: 15918778.
6. Barkin, J. A., Keihanian, T., Barkin, J. S., Antequera, C. M., & Moshiree, B. (2019). Preferential usage of rifaximin for the treatment of hydrogen-positive smallintestinal bacterial overgrowth. Preferential usage of rifaximin for the treatment of hydrogen-positive smallintestinal bacterial overgrowth. Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru, 39(2), 111–115.
7. Pimentel M, Gunsalus RP, Rao SS, Zhang H. Methanogens in Human Health and Disease. Am. J. Gastroenterol. Suppl. 2012;1(1):28–33. Available at: http://www.nature.com/doifinder/10.1038/ajgsup.2012.6.
8. Pimentel, M., Lin, H. C., Enayati, P., van den Burg, B., Lee, H. R., Chen, J. H., Park, S., Kong, Y., & Conklin, J. (2006). Methane, a gas produced by enteric bacteria, slows intestinal transit and augments small intestinal contractile activity. American journal of physiology. Gastrointestinal and liver physiology, 290(6), G1089–G1095. doi.org/10.1152/ajpgi.00574.2004
9. Low, K., Hwang, L., Hua, J., Zhu, A., Morales, W., & Pimentel, M. (2010). A combination of rifaximin and neomycin is most effective in treating irritable bowel syndrome patients with methane on lactulose breath test. Journal of clinical gastroenterology, 44(8), 547–550. doi.org/10.1097/MCG.0b013e3181c64c90
10. Banik GD, De A, Som S, et al. Hydrogen sulphide in exhaled breath: A potential biomarker for small intestinal bacterial overgrowth in IBS. J. Breath Res. 2016;10(2).
11. Ohge, H., Furne, J. K., Springfield, J., Sueda, T., Madoff, R. D., & Levitt, M. D. (2003). The effect of antibiotics and bismuth on fecal hydrogen sulfide and sulfate-reducing bacteria in the rat. FEMS microbiology letters, 228(1), 137–142. doi.org/10.1016/S0378-1097(03)00748-1
12. Chedid V, Dhalla S, Clarke JO, Roland BC, Dunbar KB, Koh J, Justino E, Tomakin E, Mullin GE. Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth. Glob Adv Health Med. 2014 May;3(3):16-24. doi: 10.7453/gahmj.2014.019. PMID: 24891990; PMCID: PMC4030608.
13. Pimentel, M., Constantino, T., Kong, Y., Bajwa, M., Rezaei, A., & Park, S. (2004). A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Digestive diseases and sciences, 49(1), 73–77. doi.org/10.1023/b:ddas.0000011605.43979.e1
Alexandra is a Functional Medicine Certified Health Coach & Holistic Nutritionist specializing in IBS, SIBO, and Gut Health. She helps her clients identify the root causes of their chronic gut issues with functional testing, supporting their bodies holistically and implementing the necessary lifestyle changes long-term to regain control of their bodies and enjoy food freedom. Book your FREE SIBO Assessment call now >>>
