SIBO (small intestinal overgrowth of bacterial) is a relapsing, permanent condition that could be affecting up to 10 percent of the population. The main characteristic that characterizes SIBO is when the small intestine is colonized by normal gut flora. The small intestine is usually free of any bacterial colonisation however changes in the environment inside the small bowel could cause an overgrowth of bacteria, which manifests with various symptoms that are characteristic of SIBO.
Signs and symptoms
When a patient is diagnosed with SIBO they might be afflicted with a variety of symptoms that include bloating, gas, abdominal discomfort, diarrhoea, fatigue and numerous other symptoms. For a long time, patients suffering from SIBO manifestations have been identified and classified as having IBS. This is mainly due to the fact that there isn’t any agreement and consensus internationally on the underlying causes of the disease and the best method of diagnosing it and an absence of solid evidence on the best treatment strategy for patients suffering from SIBO.
The small intestine isn’t usually colonised by bacteria. In SIBO the bacteria that are normally found in the large bowel begin to develop within the bowel of the small. They feed on small molecule sugars and fermentable carbohydrates that are ingested by us. The resulting gas production in SIBO may cause problems with digestion, absorption and absorption of food, and can damage the membranes that line the intestinal lining which can cause symptoms.
Risk Factors
A variety of potential risk factors are being identified to cause SIBO. In addition, it may occur in healthy individuals, but certain individuals may be suffering from anatomical problems, for example, prior small bowel resection surgeries and gastric bypass. A number of medications reduce the ability of the gut to move like narcotic painkillers and anti-diarrhoeal medications. These may cause an overgrowth of bacterial. Some patients who use acid suppressing medication like proton pump inhibitors that decrease amounts of acids that goes through the small bowel may have bacterial growth but this isn’t confirmed. People with connective tissue diseases such as Ehlers-Danlos syndrome, fibromyalgia and rheumatoid arthritis could be more likely to experience chronic symptoms of small intestine overgrowth of bacterial.
Diagnosis
The diagnosis of bacterial growth is still a subject of debate, with a variety of methods being suggested. There is no universally-acceptable gold standard test for SIBO and the use of the lactulose breath test has become extremely common over the past few years. The goal of this test is to attempt to replicate the environment inside the bowels of the small that could be present on a daily basis for patients suffering from small intestinal bacterial growth and monitor the gas production that result from the bowel’s small intestine to determine whether there’s SIBO. Quantification of methane and hydrogen gases in breath sample is one of the cheapest non-invasive, non-invasive, and possibly the most commonly used test to diagnose bacteria overgrowth in the United Kingdom. The gases found in breath of humans represent the process of fermentation of carbohydrates found in the bowel’s small. It’s not certain how beneficial it is to repeat the breath test after treatment is.
Treatments
SIBO treatment includes three methods. The first is to induce an end-of-life of SIBO then keep the remission going and stop SIBO becoming recurrent, and thirdly and perhaps most importantly, is to alter or treat the cause of SIBO or other factors that lead to the growth of SIBO.
The treatment for bacterial overgrowth Although it’s controversial, the treatment is still primarily focused on reducing the amount and size of bacteria within the bowel. In this regard, antibiotics remain the primary treatment currently. The selection, dosage and duration of treatment is not yet completely understood since there are only a few studies of a high standard that provide guidance to clinicians on the best antibiotics to use. In the near future we will see more focused on more individualized treatments that target specific areas of the microbiome. They aren’t yet available. We typically provide Rifaximin which is among the most researched antibiotics used in patients suffering from any type of functional bowel diseases. Studies have shown that it is efficient and safe to treat SIBO. It is especially effective for patients suffering from hydrogen overproduction as well as diarrhoea and bloating symptoms. The issue with it in the United Kingdom is that it is approved only to treat diarrhoea caused by travellers, but is also prescribed for patients suffering from liver disease so its usage in small intestinal bacterial overgrowths is usually challenging, since a lot of clinics or hospitals don’t prescribe it, and patients typically have to be charged for a 2 week treatment of antibiotics. Alternatives include doxycycline that is a lot less expensive but does not have the same scientific backing for its usage.
M-SIBO – Production of Methane
It should also be noted that when we perform breath tests to determine SIBO we also check to detect methane-gas production. There is evidence, which was presented in Digestive Disease Weekly in Chicago 2017 that indicates methane production can cause slower transit and motility in the gut. These patients frequently do not respond well to Rifaximin by itself and require an additional antibiotic. Neomycin is a non-toxic antibiotic that is used in a variety of other diseases and has been demonstrated to increase methane overproduction in patients. Pro-kinetics are a method of enhancing the efficacy of this particular group of patients like a small dose of a substance known as prucalopride could enhance the effectiveness of the antibiotics in boosting gut motility and increase the effectiveness for the medication.
Herbal Antibiotics
For some patients, there is the option of using herbal antibiotics.
Maintenance
Remission maintenance is extremely crucial because SIBO is a chronic illness that can recur in a variety of patients. In some studies, as much as one third of patients are likely to experience an occurrence of small intestinal bacteria and a close eye is required for patients following the induction of remission SIBO to determine that if symptoms are persistent, that treatment is commenced early. A lot of practices employ the following methods to prevent SIBO from recurring. One of the factors a patient must consider is eating habits. By limiting the amount of fermentable carbohydrates, and following a diet like one that is low FODMAP diet will ensure that the surrounding environment is exposed to less fermentable food items and make sure that there is an environment that is less favorable for any remaining bacteria to grow. Research has shown that in certain patients, the low FODMAP diet can lead to an improvement in patients suffering from an overgrowth of bacteria. In addition, the mobility and movement in the small bowel need to be improved by making use of pro-kinetic drugs. Prokinetics in stimulating and stimulate the MMC (migrating motor complex) of the small intestine in order to stop the recurrence of infections and recolonization. I advise patients to take them once they’ve finished their initial course of antibiotic therapy, we are able to look at prokinetics. These fall under herbal alternatives like iberogast drops, which are a good option to take at night or pharmacological treatments, such as an infrequent dosage of Resolor (prucalopride) in the evening. I also suggest patients look into the use of digestive and pancreatic enzymes while striving to improve the bowel’s environment following treatment to avoid SIBO from recurring.
Diabetic Control for SIBO
In a few patients where the above strategies haven’t resulted in success, it is possible to think about more strict dietetic elimination, such as an elemental diet. We must admit that this option is only available for those suffering from persistent symptoms that are not resolved despite three or more cycles of antibiotics and the failing to make a test of the lower FODMAP diet. In simplest terms, the term “elemental” diet refers to a type of diet consisting of a liquid that is made up of digested carbohydrate, proteins and fats. It’s been used for a number of years to treat illnesses like Crohn’s disease. The reason for the elemental diet is that these nutrients are taken in very fast through the digestive system. This can be beneficial for patients suffering from an overgrowth of bacterial organisms as there is no need for food items to remain in the small intestines which could be used to generate gas for the unwelcome overgrowth of bacteria. The elemental diet is the ability to provide nutrition to the patient, while also squeezing out the bacterial. Implementing the diet for elemental health is generally performed under the supervision of one of our skilled dieticians. Patients are advised to drink a formula in place of their normal meals for up to two weeks based on the nature of their symptoms as well as their medical history. It is important to note that there aren’t any high-quality research about the benefits of the elemental diet, but there are studies that have demonstrated that in certain patients following fourteen days on the diet, there’s an 80% response and a breath tests that are negative following treatment. There are obviously some drawbacks to this. The most significant one is the degree of compliance. It can be extremely difficult to limit diet to just the intake of liquids for a period of 2 weeks.
Probiotics
There has been an increase in concern about the importance of prebiotics and probiotics over the past 10 years and I am often asked by patients if they play a part in treating the overgrowth of bacterial. The exact function of probiotics in managing of SIBO is still unclear and needs to be established. It is evident that replacing harmful bacteria with beneficial bacteria, which is essentially having positive effects on patients. However, I would recommend caution when using of probiotics in the treatment of bacteria overgrowth because it could in certain patients cause the problem to be somewhat worse over the course of a short time.