SIBO

Small intestinal bacterial overgrowth (SIBO)

10 alarming SIBO symptoms (and not just IBS)

abdominal pain, bloated, bloating, constipation, cramping, diarrhea, discomfort, fiber, fodmap, gas, IBS, irritable bowel syndrome, low-fodmap, malabsorption, probiotics, reflux, rosacea, SIBO, SIBO test, skin rashes

SIBO symptoms?

You cannot fit into your jeans anymore because you feel so bloated? You wake up with a flat belly in the morning, and in the evening, you look like six months pregnant? These may sound a bit extreme, but they are not exceptional cases. Many clients experience constant gas or bloating, and some of them already have the popular diagnosis of IBS.

I want to emphasize that bloating is not normal, especially when it happens constantly. It is always a sign of gut inflammation and irritation and is one of the leading SIBO symptoms.

What is SIBO?

SIBO stands for Small Intestinal Bacterial Overgrowth. It means an increase in the number of bacteria and/or changes in the types of bacteria present in the small intestine. SIBO symptoms and SIBO are commonly caused by an overgrowth of various bacteria that should generally be found in the large intestine. (1)

Classic SIBO symptoms are similar to IBS symptoms (Irritable Bowel Syndrome). These include abdominal pain, discomfort, cramping, gas, bloating, reflux, diarrhea, and/or constipation.

According to studies, 84 % of IBS cases are caused by SIBO. (2)

10 typical SIBO symptoms:

You have constant bloating and gas – you may have difficulty figuring out which foods cause flatulence because you are bloated all the time, or bloating just increases as the day goes on.
You have persistent diarrhea or constipation – hydrogen-dominant SIBO usually causes diarrhea, while "methane-dominant SIBO" (or precisely IMO- Intestinal Methanogen Overgrowth) mostly causes constipation, but this is also not always true! Mixed types are also common. (3)
Your symptoms get worse when you eat fiber – You may have heard that the daily value for fiber is around 25 grams per day on a 2,000-calorie diet for adults (4). You still try to complete this challenge, but your symptoms have gotten worse. In that case, SIBO can be the culprit. Typically, a healthy gut needs fiber to feed the good bacteria and support normal function. However, your symptoms get worse if you feed the overpopulated bacteria.
You have several food intolerances, such as gluten, lactose, fructose, and histamine intolerance. – You lack enzymes, which are needed to break down certain foods, triggering a digestive response. (5)(6)
You are already diagnosed with IBS – the majority of IBS patients have SIBO symptoms – you should not be satisfied with the IBS diagnosis; dig deeper!
You feel worse after eating – You get full quickly after eating a normal-sized meal, which can happen when you have low stomach acid. (7) Slow stomach emptying when the food stays in your stomach for long hours, causing nausea, can contribute to SIBO. Damage to the migrating motor complex (MMC), which is usually responsible for sweeping food and bacteria through the digestive tract and gets activated when you don’t eat, is one of the most common underlying causes of SIBO. (8)
You don’t do well with probiotics—do you get abdominal pain and cramping after eating fermented foods such as kefir, sauerkraut, and kimchi? Maybe you tried random multi-strain probiotics that just made everything worse. These could also be a sign of SIBO.
You have chronic illnesses such as chronic fatigue syndrome and autoimmune diseases - Leaky gut can also be a culprit if your gut remains “leaky,” and food particles, among others, can get into your bloodstream. These will activate your immune system, which will begin attacking foreign invaders, triggering inflammation. A long-term defense can lead to damage to your organs and food intolerances, as these foreign invaders may look similar to your own body’s cells, and the immune system gets confused, overloaded, and starts attacking your tissues. (9)
You suffer from skin rashes and rosacea – an impaired gut (SIBO symptoms) can also cause skin problems.
You have malabsorption issues, such as fat (which can also cause floating stools) and/or vitamin and mineral deficiencies, especially fat-soluble vitamins (D, E, K, A).

You can read more about SIBO symptoms and the SIBO testing options in my previous blog post.

This post is only for informational purposes and is not meant to diagnose, treat, or cure any disease. I recommend always consulting with your healthcare practitioner before trying any treatment or dietary changes.

References

1. Ness-Jensen, E., Hveem, K., El-Serag, H., & Lagergren, J. (2016). Lifestyle Intervention in Gastroesophageal Reflux Disease. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 14(2), 175–82.e823. https://doi.org/10.1016/j.cgh.2015.04.176
2. Acid Reflux (GER & GERD) in Adults". National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults
3. "Gastroesophageal reflux disease (GERD)". Mayo Foundation for Medical Education and Research. 1998-2022. https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940?p=1
4. Antunes C, Aleem A, Curtis SA. Gastroesophageal Reflux Disease. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441938/
5. Hornby, P. J., & Abrahams, T. P. (2000). Central control of lower esophageal sphincter relaxation. The American journal of medicine, 108 Suppl 4a, 90S–98S. https://doi.org/10.1016/s0002-9343(99)00345-9
6. Inhibition of gastric acid secretion by stress: A protective reflex mediated by cerebral nitric oxide J. V. Esplugues, M. D. Barrachina, B. Beltrán, S. Calatayud, B. J. R. Whittle, S. Moncada Proceedings of the National Academy of Sciences Dec 1996, 93 (25) 14839-14844; DOI: 10.1073/pnas.93.25.14839, https://doi.org/10.1073/pnas.93.25.14839
7. JAMES L. SMITH; The Role of Gastric Acid in Preventing Foodborne Disease and How Bacteria Overcome Acid Conditions. J Food Prot 1 July 2003; 66 (7): 1292–1303. doi: https://doi.org/10.4315/0362-028X-66.7.1292
8. Wu, M. L., & Lewin, K. J. (2001). Understanding Helicobacter pylori. Human pathology, 32(3), 247–249. https://doi.org/10.1053/hupa.2001.22898
9. Britton, E., & McLaughlin, J. (2013). Ageing and the gut. Proceedings of the Nutrition Society, 72(1), 173-177. doi:10.1017/S0029665112002807 https://doi.org/10.1017/S0029665112002807
10. Avinash K. Nehra, Jeffrey A. Alexander, Conor G. Loftus,Vandana Nehra, Proton Pump Inhibitors: Review of Emerging Concerns. Concise review for clinicians| volume 93. issue 2. p240-246. february 01, 2018. DOI: https://doi.org/10.1016/j.mayocp.2017.10.022
11. . 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. https://doi.org/10.3748/wjg.v16.i24.2978
12. Reddymasu, S.C., Sostarich, S. & McCallum, R.W. Small intestinal bacterial overgrowth in irritable bowel syndrome: are there any predictors?. BMC Gastroenterol 10, 23 (2010). doi.org/10.1186/1471-230X-10-23
13. Kim, K. M., Kim, B. T., Lee, D. J., Park, S. B., Joo, N. S., Kim, Y. S., & Kim, K. N. (2012). Erosive esophagitis may be related to small intestinal bacterial overgrowth. Scandinavian journal of gastroenterology, 47(5), 493–498. https://doi.org/10.3109/00365521.2012.668932
14. Lombardo, L., Foti, M., Ruggia, O., & Chiecchio, A. (2010). Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 8(6), 504–508. https://doi.org/10.1016/j.cgh.2009.12.022
15. Haworth, J. J., Boyle, N., Vales, A., & Hobson, A. R. (2021). The prevalence of intestinal dysbiosis in patients referred for antireflux surgery. Surgical endoscopy, 35(12), 7112–7119. https://doi.org/10.1007/s00464-020-08229-5
16. Smith, K. J., O'Brien, S. M., Smithers, B. M., Gotley, D. C., Webb, P. M., Green, A. C., & Whiteman, D. C. (2005). Interactions among smoking, obesity, and symptoms of acid reflux in Barrett's esophagus. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology, 14(11 Pt 1), 2481–2486. https://doi.org/10.1158/1055-9965.EPI-05-0370
17. Pan, J., Cen, L., Chen, W., Yu, C., Li, Y., & Shen, Z. (2019). Alcohol Consumption and the Risk of Gastroesophageal Reflux Disease: A Systematic Review and Meta-analysis. Alcohol and alcoholism (Oxford, Oxfordshire), 54(1), 62–69. https://doi.org/10.1093/alcalc/agy063
18. Smith, R. E., & Shahjehan, R. D. (2021). Hiatal Hernia. In StatPearls. StatPearls Publishing.
19. Noar, M. D., & Noar, E. (2008). Gastroparesis associated with gastroesophageal reflux disease and corresponding reflux symptoms may be corrected by radiofrequency ablation of the cardia and esophagogastric junction. Surgical endoscopy, 22(11), 2440–2444. https://doi.org/10.1007/s00464-008-9873-4
20. Dağlı, Ü., & Kalkan, İ. H. (2017). The role of lifestyle changes in gastroesophageal reflux diseases treatment. The Turkish journal of gastroenterology : the official journal of Turkish Society of Gastroenterology, 28(Suppl 1), S33–S37. https://doi.org/10.5152/tjg.2017.10
21. Surdea-Blaga, T., Negrutiu, D. E., Palage, M., & Dumitrascu, D. L. (2019). Food and Gastroesophageal Reflux Disease. Current medicinal chemistry, 26(19), 3497–3511. https://doi.org/10.2174/0929867324666170515123807

10 alarming SIBO symptoms (and not just IBS) Read More »

Consider SIBO testing if you suffer from constant bloating

bacterial overgrowth, bloating, breath test, breath testing, chronic fatigue, constipation, diarrhea, dysbiosis, glucose breath test, gut healing, Gut Health, IBS, ibs smart test, lactulose, leaky gut, reizdarm, SIBO, sibo breath test, sibo practitioner, SIBO test, small intestine

SIBO testing

What is SIBO & SIBO testing?

First of all, what is SIBO? SIBO stands for Small Intestinal Bacterial Overgrowth. It is defined as the presence of excessive bacteria in the small intestine. The problem is that there are too much bacteria and/or the wrong type of bacteria present in the wrong place.

Symptoms can be excess/trapped gas, bloating, diarrhea and/or constipation, abdominal pain or cramping, food sensitivities, chronic fatigue, brain fog, and the list goes on. (1)(2)

Before getting tested

Before getting to SIBO testing, many people try different methods to relieve their symptoms. These approaches may include lifestyle changes (e.g., reducing sugar/junk and processed food consumption; stress; getting more sleep) or eating more fiber, prebiotic foods, and herbs. However, if these changes don’t bring the expected results or make the current symptoms worsen, then it might be time to visit the GI doctor to have some tests.

Although having the symptoms mentioned above doesn’t mean that you have 100% SIBO. It is crucial to rule out other diseases (like endometriosis, Crohn’s/ Colitis) and get a proper diagnosis by your healthcare practitioner. There can be many different diseases, which could cause the same symptoms.

Suppose you have already been diagnosed with IBS (Irritable Bowel Syndrome). In that case, it is definitely worth getting SIBO testing because, according to a study, up to 84% of patients with IBS actually have SIBO. (3)

It may also happen that a person thought SIBO was causing the symptoms, but then the culprit turned out to be Celiac disease. (4) If you start using an antimicrobial treatment for assumed SIBO without any proper diagnoses, then it may cause more harm than good. So testing is essential, which can help define the treatment plan.

SIBO testing method #1: SIBO breath test

The three-hour lactulose or glucose breath test is generally used for diagnosing SIBO, which detects the different types of gases that bacteria produce in the small intestine. It checks for hydrogen and methane gas. (5) There is now a new test available in the US: the TrioSmart test that can detect the third type of gas: hydrogen sulfide. (6) I wrote about the different types of SIBO.

The bacteria in our intestines ferment specific carbohydrates, and they produce gases as a byproduct. The breath test involves drinking a sugar solution (lactulose or glucose, a type of carbohydrate) that feeds the bacteria in the gut, and they start making gases. Then these gases are absorbed in the intestines and get into our blood, from where the gases are delivered to our lungs and exhaled in our breath. That is what the breath test intended to capture.

The breath test is done for 3 hours, while breath samples are taken at 20-minute intervals. The first two hours represent the small intestine, and the last hour is usually the large intestine. Measuring the level of those gases is also important to determine how severe the bacterial overgrowth is and what treatment would suit the best.
Be aware that a prep diet is required to be followed before SIBO testing. It involves following a low-fiber diet and fasting for 14 hours. (When you order a test, you should receive instruction on the prep diet). (7)

A hydrogen breath test is also used for testing carbohydrate malabsorption issues when dietary sugars are not absorbed well, such as lactose (sugar in milk), fructose (sugar in fruit), sorbitol, and sucrose. (8)

Can you trust the SIBO breath tests?

While the breath test is considered the most practical SIBO testing method, it certainly has its limitations.
A meta-analysis of the breath test accuracy showed that lactulose substrate might provide a higher number of false-positive results than the glucose test. Glucose breath test seems to work better than lactulose breath test for diagnosing SIBO. It seems glucose testing has better sensitivity and specificity. (9) (10) In this case, clinicians may need to evaluate the results more carefully before giving out a diagnosis, and it would be worth doing a test for both types of substrates.

Other problems can be:
• the missing consensus on the interpretation of breath test results
• Individual’s motility can influence the test results – transit time may differ from person to person (11)

Other types of tests

If you have IBS-D or IBS-M/SIBO-D, you experience mainly diarrhea symptoms; then an IBS-SMART test is available to diagnose post-infectious IBS (PI-IBS). It is a blood test that looks for the markers of food poisoning (one of the leading causes of SIBO), which is the result of auto-antibodies forming in a lot of people and starting an auto-immune process. The antibodies measured in the blood are anti-CdtB toxin and anti-vinculin. These antibodies can attack the nerves of the gut and impair the cleaning wave, the Migrating Motor Complex. (12)(13)

What tests are not suitable to diagnose SIBO?

Stool tests because the results represent mainly the end of the large intestine, although they might indicate some issues in the small intestine but cannot diagnose SIBO. Overgrowth of bacteria in a stool can show dysbiosis.
Organic Acid Tests (OAT) check the urine for byproducts of yeast or bacteria in the small intestine, which can be very useful but cannot tell whether your SIBO is hydrogen/ hydrogen-sulfide or methane-dominant. (14)

Conclusions

Using SIBO testing (a breath test) has its advantages and disadvantages, but it can still be the most practical approach to diagnosing SIBO. Metanalysis showed that a glucose breath test might provide a more accurate diagnosis than a lactulose breath test. Having a SIBO diagnosis can be crucial as it can define the best treatment options (each type of gas requires different strategies).

Bear in mind that diagnosing SIBO might be just the first step because it will not tell you what caused SIBO in the first place. However, finding the underlying cause is crucial to prevent relapsing.

If you have questions regarding SIBO or need help finding out your root cause and support on your healing journey, then feel free to 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.

References

Dukowicz, A. C., Lacy, B. E., & Levine, G. M. (2007). Small intestinal bacterial overgrowth: a comprehensive review. Gastroenterology & hepatology, 3(2), 112–122.
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
Ghoshal, U. C., Shukla, R., & Ghoshal, U. (2017). Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge between Functional Organic Dichotomy. Gut and liver, 11(2), 196–208. doi.org/10.5009/gnl16126
Atay, O. (2021). 49- Other Diseases of the Small Intestine and Colon. (J. S. Robert Wyllie, Ed.) Pediatric Gastrointestinal and Liver Disease (Sixth Edition), Pages 534-540.e3. doi:doi.org/10.1016/B978-0-323-67293-1.00049-9.
Simrén, M., & Stotzer, P. O. (2006). Use and abuse of hydrogen breath tests. Gut, 55(3), 297–303.doi.org/10.1136/gut.2005.075127
(TrioSmart, n.d.) https://www.triosmartbreath.com/
Camilleri, M., & Szarka, L. A. (2021). Every Breath Test You Take: Practical Advice on Breath Testing Used to Detect Small Intestinal Bacterial Overgrowth. Digestive diseases and sciences, 66(2), 331–333. doi.org/10.1007/s10620-020-06776-4
Rana, S. V., & Malik, A. (2014). Hydrogen breath tests in gastrointestinal diseases. Indian journal of clinical biochemistry : IJCB, 29(4), 398–405. doi.org/10.1007/s12291-014-0426-4
Losurdo, G., Leandro, G., Ierardi, E., Perri, F., Barone, M., Principi, M., & Leo, A. D. (2020). Breath Tests for the Non-invasive Diagnosis of Small Intestinal Bacterial Overgrowth: A Systematic Review With Meta-analysis. Journal of neurogastroenterology and motility, 26(1), 16–28. doi.org/10.5056/jnm19113
Rana, S. V., Sharma, S., Kaur, J., Sinha, S. K., & Singh, K. (2012). Comparison of lactulose and glucose breath test for diagnosis of small intestinal bacterial overgrowth in patients with irritable bowel syndrome. Digestion, 85(3), 243–247. doi.org/10.1159/000336174
Simrén, M., & Stotzer, P. O. (2006). Use and abuse of hydrogen breath tests. Gut, 55(3), 297–303. doi.org/10.1136/gut.2005.075127
Definitive tests for irritable bowel syndrome developed at Cedars-Sinai. Cedars-Sinai website. https://www.cedars-sinai.org/newsroom/definitive-tests-for-irritable-bowel-syndrome-developed-at-cedars-sinai/. Published May 14, 2015. Accessed June 21, 2019.
Morales W, Rezaie A, Weitsman S, Barlow G, Pimentel M. Sa1680 — second generation anti-CdtB and anti-vinculin testing produces greater diagnostic accuracy for IBS-D compared to IBD. Gastroenterology. 2019;156(6 Suppl 1):S-364.
Lord, R. S., & Bralley, J. A. (2008). Clinical applications of urinary organic acids. Part 2. Dysbiosis markers. Alternative medicine review : a journal of clinical therapeutic, 13(4), 292–306.

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