Small Intestinal Bacterial Overgrowth (SIBO)
By Steven Horne, RH (AHG) & Kimberly Balas, ND
See also Belching, Gas and Bloating, Gastritis and Leaky Gut Syndrome

Intestinal microflora, also called friendly flora or probiotics, play a role in regulating the immune system and keeping the colon healthy. However, most of the bacteria in your intestines should be in your colon or large intestines, not your small intestines.

When abnormally large numbers of bacteria (even friendly bacteria) start growing in the small intestines, they actually cause problems with your health. Small Intestinal Bacterial Overgrowth (SIBO) is a condition where abnormally large numbers of bacteria are present in the small intestines.

These bacteria feed off of sugars and starches in the diet (both refined sugars and natural sugars) and produce methane and hydrogen gas. They also inhibit the enzymes in the small intestines that break down starches into simple sugars for absorption. This can result in abdominal bloating, belching and/or flatulence (intestinal gas), especially when you eat grains and other complex carbohydrates. The gases produced by these bacteria can also cause abdominal pain, intestinal cramping, and IBS with constipation and/or diarrhea.

Gas pressure in the small intestines can push upwards against the stomach, contributing to the dcwelopment of a hiatal hernia and causing heartburn, acid reflux (GERD GastroEsophageal Reflux Disease ) and nausea.

SIBO increases a hormone called zonulin, causing an increase in small intestinal permeability (aka leaky gut
syndrome), which results in the intestines absorbing large molecules they should shoukld not. The bacteria also like to gobble up essential nutrients like fats, iron and vitamin B-12. The nutrient deficiencies from SIBO along with the absorption of large protein molecules can cause problems with the immune system and contribute to allergies, asthma, autoimmune disorders, and a general decline in health.

SIBO has wide ranging implications and may be a cause or a major factor in many diseases. GERD (or acid reflux), gas and bloating, and frequent belching are clues that SIBO may be a problem.

Other clues include having better bowel movements after taking antibiotics and bowel problems getting worse when taking probiotics or fiber. If bowel problems began after using opiates for pain, this is another clue that SIBO may be a factor.

Diagnosing SIBO
Experts in SIBO have estimated that about 35-50% of the general public has this problem. Unfortunately, it is not widely understood and hence, is not properly diagnosed. Many people who have SIBO think they have a candida or yeast infection. However, while yeast overgrowth can occur with or without SIBO, candida is often over diagnosed and SIBO is under diagnosed.

Medical diagnosis of SIBO is difficult because it is hard to get a culture from the small intestines. There are tests involving collecting breath samples from patients that drink either glucose or lactulose. Lactulose test is the most accurate. These tests must be ordered by a physician.

However, you can also assess this condition fairly accurately by symptoms. If you have an autoimmune disorder, pain in multiple joints, chronic allergies, chronic skin conditions, chronic fatigue or depression, or general malaise (just don't feel good) you may have leaky gut. When you have symptoms of leaky gut coupled with chronic diarrhea or constipation, regular abdominal pain, IBS, bloating or belching after meals, GERD and/or regular indigestion, you may have SIBO.

What Causes SIBO?
There are several major factors that contribute to the development of SIBO. The first is a lack of hydrochloric acid (HCL) in the stomach. HCL helps the body digest proteins, but it also helps to kill bacteria in the food we eat and prevent them from colonizing the small intestines.

A second factor is a lack of intestinal motility. In between meals migrating motor complexes (MMCs) sweep down the intestines, helping to rush bacteria. These movements of the small intestine are responsible for what we call hunger pains, the "rumblings" we feel in our gut when we have not eaten in a while. These MMCs may be damaged by surgery, intestinal scarring, various diseases, intestinal infections and certain drugs. Medications that can inhibit these intestinal movements include antibiotics, proton pump inhibitors, antacids and opiates (pain killers) like morphine.

Stress can be a factor in both low hydrochloric acid and the lack of intestinal motility, as the sympathetic nervous system (responsible for the fight or flight response) inhibits both digestive secretion and intestinal motility. When we are relaxed, the parasympathetic nervous system is more active and digestion and intestinal motility are enhanced. Unfortunately, many people in our society are eating on the run and do not take time to relax, chew their food thooughly and enjoy their meals.

A final factor in SIBO is a malfunctioning ileocecal valve. This valve lies between the small and large intestines and is designed to prevent back flow (that is, to keep material in the large intestine from migrating back into the small intestine). When this valve is not shutting properly, intestinal bacteria migrate from the colon into the small intestine causing gas, bloating and general weakness and malaise.

Natural Therapy for SIBO
Here are seven things you can do to overcome SIBO. Many of these things are also done for leaky gut.

1. Remove food and chemical irritants
Dietary adjustments are essential to overcoming both SIBO and leaky gut. It is absolutely essential to eliminate all refined sugars from the diet and most starchy foods. At the least one should eliminate grains containing gluten (wheat, rye, barley), but eliminating all grains may be required.

Dairy may also be problematie because the bacteria love feast on lactose, the sugar in dairy.
Goat milk products and cultured dairy foods can be beneficial for some people, yet other people may have to eliminate all dairy foods.

Fermented foods are generally helpful for SIBO. These are discussed under Step Six: Restore beneficial bacteria.

There are three dietary programs that may be helpful, depending on the severity of the problem. These are the Specific Carbohydrate Diet (SCD), the Gut and Psychology Syndrome (GAPS) diet and the Paleo diet.

2. Stimulate production of and/or supplement stomach acid and enzymes
There are two ways to increase stomach acid and enzymes. One is to rake supplements and the other is to take herbs and nutrients that stimulate their production. With SIBO it is normally necessary to do both.
To determine how much Betaine Hydrochloric Acid (HCI) you need, you can do a hydrochloric acid challenge test.
Note: do not perform this test if you have an active ulcer or a history of ulcers.

To do the test, take a capsule of PDA prior to a meal. If you notice no burning, increase to two capsules the next meal. Proceed until you notice a mild burning sensation, then immediately reduce your dose to the number of capsules that preceded the burning or heat sensation. Most people find a comfortable dose between 2-4 capsules.

If one or two capsules causes burning, you either don't have low stomach acid or your reflux is so severe that you won't be able to take HCI until you get it under control. Also, remember that the more protein you eat with a meal, the greater the need for HCI, so you can vary the dose with the size and content of your meals. Also, if you have severe digestive problems, you may also wish to take a complete food enzyme that has HCI and pancreatic enzymes.

Within 3-6 months most people feel a warmth in their stomach with the same dose they have been taking. When this happens it is time to decrease your dose and start weaning off of the PDA.

You can also mix one capsule of goldenseal powder with one teaspoon of Digestive Bitters and take this 15-20 minutes prior to meals with one to two glasses of water. A small pinch of a natural salt can also be taken at the same time, as this also helps stimulate HCI production by providing chloride.

Bitters are contraindicated if you have digestive atrophy. So, if you have dry mucus membranes, as evidenced by a dry and withered (or shriveled) looking tongue, don't take bitters because they dry the mucus membranes. Try Spleen Activator instead.

A lack of HCI may also be due to a lack of the following nutrients: chloride (low serum levels), zinc and thiamine. These are primary nutritional factors required for the synthesis of hydrochloric acid.

3. Improve intestinal motility (if necessary)
With SIBO it is also important to make certain that there is good intestinal motility between meals to flush the intestines and clear out bacteria. One way to do this is to allow adequate time between meals. Depending on the efficiency of your digestion, you need three to five hours between meals. Ideally, you should wait until you get stomach rumblings indicating your digestive tract is clear before eating the next meal.

If motility is slow there are some supplements that may be helpful. All carminatives increase digestive motility, and many people find that a cup of ginger tea is most helpful. You can also try taking 5-HTP Power twice daily. Gentle Move may also be helpful.

4. Close the ileocecal valve (if necessary)
If there is severe gas and bloating, you probably need to work on the ileocecal valve. This is done by massaging the valve to reduce swelling and inflammation and get it to close properly. This is demonstrated in Steven's video on techniques for self-correction of a hiatal hernia on Youtube.com.

5. Reduce bacteria
If a person has signs of SIBO, they will need to take some supplements to reduce bacterial overgrowth in the small intestines. This can be done with pharmaceutical antibiotics or herbal antibacterial agents. Agents that may be helpful include goldenseal, GastroHealth and Chinese Anti-Gas.
Garlic is another possible antimicrobial agent, but if friendly lacto bacteria are overpopulating the small intestines, it won't work. Use raw garlic or High Potency Garlic only.

6. Restore beneficial bacteria
People with SIBO often do not do well on probiotic supplements, especially if they contain prebiotics which feed the small intestinal bacteria as well as friendly flora. Cultured foods usually work better. Cultured vegetables in particular are very valuable in treating SIBO and leaky gut.
You can make your own cultured vegetables or you can purchase them from a health food store or some supermarkets. Making your own cultured vegetables is quite easy. Recipes for making cultured vegetables can be found in the book Nourishing Traditions by Sally Fallon.

7. Repair gut integrity
Since SIBO always causes leaky gut, it is important to rebuild the integrity of the intestinal membranes. One of the best ways to do this is by using the Bone Broth therapy.
Bone broth is high in glutamine and glycine, both of which are essential in healing the gut. They are emphasized in both the SCD and GAPS diet. Drink 1-4 cups of bone broth daily. You can also use it to make soups. Recipes for bone broth can be found in Nourishing Traditions.
If you can't take the bone broth, you can use L-glutamine, which can also be used along with bone broth. Other remedies that help heal the gut include chamomile tea (one cup three times daily), ATC concentrated licorice (1 three times daily) and colostrum powder.

Below is a list of suggested products. Those in bold are key products for the health issue explained on this page.
For details and ordering simply copy a product's name in the search box above or click on the bold name.

Therapies: Aromatherapy and Bone Broth

Herbs: Garlic, Ginger, Golden Seal and Pau d 'Arco

Herbal Formulas: Digestive Bitters Tonic, Echinacea/Golden Seal, Gastro Health and Una De Gato

Nutrients: L-Glutamine and Probiotics

Nutraceuticals: 5-HTP Power, Colostrum With Immune Factors, Food Enzymes, Melatonin Extra, PDA Combination and Small Intestine Detox

Essential Oils: Cinnamon and Peppermint