Complete Guide to SIBO: Symptoms, Testing & Treatment

SIBO
THE COMPLETE GUIDE

EVERYTHING YOU NEED TO KNOW
ABOUT SMALL INTESTINAL BACTERIAL OVERGROWTH
BYRON HERBALIST
SIBO In this guide we will be

covering everything you need to
know about small intestinal bacterial
overgrowth. This complete guide to
SIBO, in all it’s 10,000 plus words glory,
covers the key points on SIBO including
testing options, conventional and
alternative treatments and the common
underlying causes of this gut disorder.
WRITER: Todd Mansfield
Small intestinal bacterial overgrowth,
also known as SIBO, is a digestive
disorder that is becoming more widely Herbal medicine practitioner, lover
recognised in the digestive health of plants and explorer of the gut
community. It is associated with a microbiome. Todd holds a Bachelor
wide range of health issues such of Health Science majoring in
as nutrient deficiencies, intestinal Western Herbal Medicine. Todd
hyperpermeability (aka leaky gut) and spends his time consulting with
even liver damage. patients and digging deep into
the cutting edge research in gut
Read on to learn more about this health, digestive issues and the
digestive imbalance or if you know impact of the gut microbiota on
what you are looking for you can use health and disease.
the table of contents below.
2 W: byronherbalist.com.au SIBO The Complete Guide

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Table Of Contents
What is SIBO.............................................................................................................................................. 5
Why is SIBO an Issue?........................................................................................................................... 6
Symptoms of SIBO.................................................................................................................................. 7
Different Types of SIBO?....................................................................................................................... 8

Hydrogen Dominant SIBO........................................................................................................................................... 8
Methane Dominant SIBO............................................................................................................................................. 9
Mixed SIBO............................................................................................................................................................................. 9
Hydrogen Sulfide Dominant SIBO......................................................................................................................10
Fungal SIBO, or Should we Say SIFO?...............................................................................................................11
Underlying Causes of SIBO............................................................................................................... 13

SIBO Causes: Disorders of protective antibacterial mechanisms............................................... 13
Low stomach acid................................................................................................................................................. 13
Exocrine pancreatic insuficiency............................................................................................................... 14
Immunodeficiency syndromes................................................................................................................... 14
SIBO Causes: Anatomical Abnormalities........................................................................................................ 15
Ilecocecal valve pressure............................................................................................................................... 15
SIBO Causes: Motility Disorders............................................................................................................................ 16
Post Infectious SIBO............................................................................................................................................ 16
Comorbidities Associated with SIBO............................................................................................18

Intestinal permability..................................................................................................................................................... 19
Cirrosis/Liver damage................................................................................................................................................. 19
Malnutrition...........................................................................................................................................................................21
Inflammatory Bowel Disease...................................................................................................................................21
Irritable Bowle Syndrome.........................................................................................................................................22
Diabetes..................................................................................................................................................................................23
Rosacea...................................................................................................................................................................................23
Diverticular Disease.......................................................................................................................................................24
Bacteria Found in SIBO Patients....................................................................................................25
Testing for SIBO......................................................................................................................................29

Specificty and Sensitivity in Testing ..................................................................................................................29
The Gold Standard Test..............................................................................................................................................30
SIBO The Complete Guide W: byronherbalist.com.au 3

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Breath Testing......................................................................................................................................... 31
The North American Consensus on SIBO Breath Testing.................................................................32
Glucose...................................................................................................................................................................................32
Positive Glucose Breath Test........................................................................................................................33
Pros of Glucose Breath Testing..................................................................................................................33
Cons of Glucose Breath Testing.................................................................................................................33
Lactulose...............................................................................................................................................................................34
Positive Lactulose Breath Testing............................................................................................................36
Issues with Lactulose Breath Testing.....................................................................................................36
Pros of Lactulose SIBO Testing...................................................................................................................37
Cons of Lactulose SIBO Testing.................................................................................................................37
Fructose..................................................................................................................................................................................37
Pros of Fructose SIBO Breath Testing....................................................................................................38
Cons of Fructose SIBO BreathTesting...................................................................................................38
Which Test is Best When Screening for SIBO?.........................................................................................38
Sibo Diets................................................................................................................................................. 40
The Low Fodmap Diet................................................................................................................................................. 40
Risks with the Low Fodmap Diet.......................................................................................................................... 41
Conventional Treatment for SIBO..................................................................................................42

Antibiotics in SIBO...........................................................................................................................................................42
Pros of Rifaximin Over Other Antiobiotics.....................................................................................................42
Prokinetic Drugs...............................................................................................................................................................44
Natural Treatments for SIBO............................................................................................................45

Herbal Antimicrobials...................................................................................................................................................45
Herbs to Avoid....................................................................................................................................................................48
Tailored Herbs for Specific SIBO Types..........................................................................................................49
Herbs to Treat the Underlying Cause of SIBO.......................................................................................... 50
Probiotics in SIBO........................................................................................................................................................... 50
Prebiotics in SIBO............................................................................................................................................................52
Elemental Diet........................................................................................................................................54
The Issues with the Elemental Diet...................................................................................................................54
Why Does My SIBO Coming Back..................................................................................................56
Preventing SIBO Recurrence...........................................................................................................57
Want More Help?...................................................................................................................................58
References and Resources...............................................................................................................59

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What is SIBO
First off, a definition is helpful.
Either way the definition stands.
More bacteria in the small intestine than there should be.
SIBO is much like it sounds. An overgrowth of bacteria in the small intestine. There
has been debate over what the exact cut off is for SIBO. The most widely held
definition is a growth of bacteria is greater than 1,000,000 (that’s 10 to the power
5) colony forming units per lm while some researchers are pushing to reduce that
number down to 10, 000 (10 to the power of 3) colony forming units (1).
SIBO
AN OVERGROWTH OF BACTERIA
IN THE SMALL INTESTINE
Originally the thinking was that the small intestine was sterile.
As our technology to assess microbes has improved we have learned that a healthy
small intestine has a microbial community. That said, the small intestine has far less
bacteria when compared to the large intestine due to a range of factors including the
flow of the contents (known as peristalsis – we will be coming back to this concept
later) as well as bactericidal substances such as bile acids keeping the level of
microbes low (2).

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Why is SIBO an Issue?

Small intestinal bacterial overgrowth is associated with a whole range of comorbidities
– additional conditions – as well as changes to the digestive tract structure and
function.
SIBO may be responsible for;
• Vitamin deficiencies
• Malabsorption
• Malnutrition
• Intestinal permeability (aka leaky gut)
• Liver damage
• Changes in bowel pattern
• Abdominal pain (and many other symptoms!)

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Symptoms of SIBO
Now that we have covered the different types of SIBO we can talk about the different
symptoms that digestive health clinicians should be familiar with. While no specific
symptom can determine whether SIBO is present the following symptoms should
raise some red flags and lead to SIBO testing.
Some of the following symptoms can be present in both methane dominant SIBO and
hydrogen dominant SIBO. Other symptoms are more common in one or the other.
But remember, symptoms aren’t enough to diagnose which type of SIBO you really
need to test if you suspect!
Symptoms (3).
• Bloating – common in methane and hydrogen dominant

• Flatulence – common in methane and hydrogen dominant
• Abdominal pain – common in methane and hydrogen dominant
• Tenderness – common in methane and hydrogen dominant
• Weight loss – common in methane and hydrogen dominant
• Steatorrhoea (aka fat in the stool due to poor fat digestion) – more common
in hydrogen dominant SIBO
• Diarrhea – more common in hydrogen dominant SIBO
• Constipation – more common in methane dominant SIBO

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Different Types of SIBO?

While the umbrella concept of SIBO is simple enough to understand – an overgrowth
of bacteria in the small intestine. The different forms of SIBO can make the picture
slightly more complicated. And what can make it slightly more complicated is the fact
that a number of different types of SIBO can be present at the same time.
Confused yet?
Don’t be.
We will take each different type of SIBO one at a time.
Hydrogen Dominant SIBO

In the human gut certain bacteria produce certain gases as a by product of their growth
and replication. Hydrogen production is common among bacteria that make up the
gut microbiota. In a healthy gut hydrogen producing bacteria reside mainly in the large
bowel. However, in the context of SIBO, certain hydrogen producing bacteria can take
up residence in the small bowel and become what we call hydrogen dominant small
intestinal bacterial overgrowth (4).

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The testing section of this guide will outline how to test for hydrogen dominant SIBO
by using certain sugars that these particular bacteria use as a food source.
Methane Dominant SIBO

Moving onto the second form of SIBO we come to methane dominant SIBO.
Where hydrogen production in the human gut can come from a wide variety of bacteria,
methane production is limited to just a few. These are known as methanogens, and
are technically not bacteria, but archaea. The most common methane producer in the
human gut is known as Methanobrevibacter smithii. Methanobrevibacter smithii (and
other less commonly found methane producers) use hydrogen – remember hydrogen
is in good supply in the gut – to make methane or CH4 (4).
The number one symptom of methane dominant SIBO is constipation (5).
If a patient is presenting with bloating, abdominal distention after meals and constipation
I would immediately be thinking methane dominant SIBO. The next step her, after
a thorough intake and history, would be ordering a SIBO breath test to confirm this
suspicion. More on that soon!
Image taken from: Methane Production During Lactulose Breath Test Is Associated
with Gastrointestinal Disease Presentation showing the prevalence of constipation
and methane production in patients with SIBO.
Mixed SIBO
The third type of SIBO is what is known as mixed type SIBO.
I’m sure that some of you have already put two and two together. If methane producers
use hydrogen to make methane then there must be hydrogen producing bacteria
present as well.
When we test for SIBO using SIBO breath tests there is the possibility that both
methane and hydrogen producers are found in the small bowel leading to the mixed
SIBO diagnosis.
It is also possible for the methane producing archaea to be using all of the hydrogen
(produced by the hydrogen bacteria). It is common to test for and find methane

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dominant SIBO, treat the methane producers successfully, then retest and find
hydrogen dominant SIBO.
What has happened here, most likely, is the methane producers have hidden the
hydrogen producers by using up all of their byproduct – hydrogen.
Hydrogen Sulfide Dominant SIBO

A final form of small intestinal bacterial overgrowth is called hydrogen sulfide dominant
SIBO.
We have covered hydrogen sulfide production in the large bowel before by covering
the different bacteria that form hydrogen (Desulfovibrio and Bilophila) as well as their
implication in leaky gut and inflammatory bowel disease.
Now let’s talk about hydrogen sulfide production in the small intestines.
The main problem with diagnosing hydrogen sulfide dominant SIBO is that there is,
currently speaking, no test available that screens for this gas. Our best people are
working on that as we speak.
The lack of testing for hydrogen sulfide SIBO is problematic to say the least.
In one recent study the researchers found that screening for hydrogen sulfide was
better correlated with patient symptoms. Patients with higher levels of hydrogen
sulfide had more diarrhea, constipation, abdominal pain and even fatigue (6).
Image taken from: Measurement of Hydrogen Sulfide during Breath Testing Correlates
to Patient Symptoms.
Below is an image that shows some of the clinical associations between the different
gases and the possible mechanisms – i.e. how they affect the body.

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Image taken from: Gas and the Microbiome showing different gases and their
implication in gastrointestinal disorders.
Fungal SIBO, or Should we Say SIFO?

This may be an article for a different time.
Small intestinal fungal overgrowth (such as Candida) is not commonly talked about.
The idea that bacteria can take up residence in the small bowel should be a clear sign
that fungal overgrowth can occur as well (7).
If this is the case then proper fungal treatments may be necessary when addressing
SIBO cases.

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Image taken from: Small Intestinal Fungal Overgrowth showing the budding of Candida
from a harmless unicellular yeast into a pseudohyphal fungal overgrowth.

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Underlying Causes of SIBO

What sets the stage for bacterial overgrowth in the small intestine? The answers can
be numerous and much like the different types of SIBO a number of underlying causes
can be present at the same time.
As SIBO is relatively recent to the game (remember back when all gut issues were
Candida infections?) the underlying causes don’t seem to be addressed by many
people that treat SIBO. Many times it is simply antimicrobial herbs, possibly followed
by probiotics and you’re done.
As the underlying causes that led to SIBO are often not addressed with this approach
the relapse rates can be high.
These causes for SIBO can be broken down loosely into three categories including
disorders of protective antibacterial mechanisms, anatomical abnormalities and
motility disorders. Remember there may be one or many predisposing factors that
can encourage small intestinal bacterial overgrowth (8).
Let’s cover each category one by one.
SIBO Causes: Disorders of protective antibacterial mechanisms

Low stomach acid
Known in the medical world as achlorhydria may lead to SIBO. A healthy stomach is
acidic. Damn acidic! This helps to kill off many of the microbes that are present in your
food, on your pets (think of a dog’s love for licking your face), in unfiltered water (beaver
fever is usually Giardia, contracted from river and pond water) and many, many other
places.
So low stomach acid can cause SIBO, but what causes low stomach acid?
The first offender are pharmaceutical drugs known as proton pump inhibitors – or
PPIs. These drugs effectively shut off the production of acid in the stomach. Originally
this class of drugs were prescription and only intended for short term use. Now many
of them are available over the counter and are commonly taken long term.
PPIs are associated with small intestinal overgrowth and there is high quality science
to back this up, including two meta analyses (one from 2013 and one from 2017).

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PPIs are also associated with other non SIBO related issues (seen in the image below)
including magnesium and vitamin B12 deficiencies and possibly even Clostridioides
difficile (previously Clostridium difficile), chronic kidney disease and dementia (11).
While there may be a place and time for these commonly used drugs they, much like
antibiotics, may be overprescribed.
Image taken from: Proton Pump Inhibitors: Review of Emerging Concerns
This is a less clear underlying cause of SIBO but worth covering anyway.
Exocrine pancreatic insuficiency

SIBO appears to be more common in patients with chronic pancreatitis (12). The
thinking here is, due to the reduced function of the pancreas and it’s antibacterial
proteolytic enzymes, bacteria is permitted to grow in the small intestine (8).
There would be other symptoms associated with chronic pancreatitis that a primary
care physician would be well aware of and capable of managing.
Immunodeficiency syndromes
Finally immunodeficiency syndromes including IgA deficiency and even AIDS can
predispose one to SIBO (13, 14).

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Narrowing in on the selective IgA deficiency we can see that it is one of the more
common primary immunodeficiencies, which may predispose one to mucosal
infections (SIBO would fit in here) as well as atopy and even autoimmune diseases (15,
16).
SIBO Causes: Anatomical Abnormalities

Moving onto the second category of conditions we can see that anatomical abnormalities
can predispose one to small intestinal bacterial overgrowth. These conditions include
small intestinal obstruction, diverticula, fistulae, surgical blind loop and previous ileo
caecal resections (8).
This is a fairly simple concept to understand but one that is often overlooked. Anything
that impairs the flow through the small intestinal lumen will lead to stagnation and
bacterial overgrowth.
Often these conditions are associated with previous surgeries (17).
One anatomical abnormality that is not necessarily associated with previous surgeries
is diverticular disease. Diverticular disease is associated with slower oral coecal transit
time – remember anything that slows down the flow through the intestines may
predispose you to SIBO (18).
One study found that transit time was delayed in 74.44% of patients with diverticulitis
and that 58.88% of patients from the trial had SIBO diagnosed by a lactulose breath
test (19).
Ilecocecal valve pressure

The ileocecal valve connects the end of the small bowel to the start of the large bowel.
For quite some time, poor ileocecal valve function it has been theorised to be involved
in SIBO. As our technology to assess what is actually happening in the gastrointestinal
tract develops we are started to get a clearer picture of how important the ileocecal
valve is in health and disease.
We know that the large bowel has significantly (let’s say exponentially!) more microbes
when compared to the small intestine. The ileocecal valve keeps the microbes from
being refluxed from the large bowel back into the small bowel. You can think of it as a
gatekeeper. It allows contents to flow in one direction only.

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SIBO patients were shown to have lower ileocecal valve pressure, leading to a ‘lazy’
ileocecal valve and the possibility that microbes could make it back into the small
intestine. These microbes, if given the right environment, could then overgrow into a
case of SIBO (20).
SIBO Causes: Motility Disorders

The third category of SIBO causes include a range of gastrointestinal motility disorders.
Again we can see the same pattern emerge here with poor flow through the small
intestine leading to bacterial overgrowth.
These conditions include:
• Scleroderma
• Autonomic neuropathy in diabetes mellitus
• Post radiation enteropathy
• Vagal nerve dysfunction
• Migrating motor complex dysfunction
Post Infectious SIBO

Irritable bowel syndrome can be broken down into a number of different sub categories
(constipated, diarrheal, mixed and post infectious) but the idea that infections could
predispose you to SIBO is rather new and still needs to be worked out by the scientific
community.
Still, I felt it was worth including in this SIBO guide because it makes so much sense.
How many people have developed SIBO after acute gastroenteritis. Maybe it was
during a trip to a third world country or maybe (as in my experience) it was from
consuming contaminated drinking water.
So what does the literature say on this concept?
First off, there has been new developments in diagnosing post infectious IBS.
After being exposed to any number of different bacterial infections including

Campylobacter jejuni, Salmonella, Escherichia coli and Shigella different toxins have
been found including cytolethal distending toxin A, B and C. Our body then produces
antibodies against these toxins.

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It all makes sense so far right?
Then, possibly due to the molecular mimicry model of autoimmunity, there is some
cross reactivity and the antibodies start targeting a very important protein found in the
gut called vinculin.
Vinculin has a number of key roles in the gut. It is involved in neuronal cell motility, and
gut wall formation (21).
This is pretty big news.
Infections by certain common bacteria can predispose you to poor gut motility, a hall
mark of SIBO!

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Comorbidities Associated with SIBO

Small intestinal bacterial overgrowth is associated with a long list of other health
issues. Some may be caused by SIBO, some may be caused by the same thing that
caused SIBO (a bit of a tongue twister there).
The image below lists some of the more common conditions associated with SIBO.
Image taken from: Breath Testing for Small Intestinal Bacterial Overgrowth: Maximizing
Test Accuracy outlining some of the conditions associated with small intestinal
bacterial overgrowth.
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Intestinal permability
Intestinal hyper permeability (aka leaky gut) is associated with small intestinal bacterial
overgrowth.
In fact, SIBO may be causing leaky gut in certain people.
One small study found that clearing the bacterial overgrowth in SIBO patients improved
their leaky gut.
Plus, increased intestinal permeability – leaky gut – is associated with a number of

commonly seen issues in SIBO such as food intolerances and histamine sensitivity.
Cirrosis/Liver damage
Liver damage may not be the first thing you think of when you think of SIBO but the
connection between the gut and liver is well documented.
Seeing as the liver is connected to the gut via the portal vein, and receives a continuous
supply of nutrient and microbe laden blood, this should be fairly obvious.

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Image taken from: Review article: the gut microbiome as a therapeutic target in the
pathogenesis and treatment of chronic liver disease showing a healthy gut on the left
and a dysbiotic gut on the right and their association with inflammation, liver function
and damage.
In cases of SIBO and leaky gut the liver takes on an extra load of endotoxin (also
known as lipopolysaccharide or LPS) laden bacteria which can promote localized
inflammation, liver cell damage and even body wide inflammation (24).
A recent systemic review with meta analysis, published in the European Journal of
Gastroenterology & Hepatology, concluded that there was a ‘significant association
between NAFLD (non alcoholic fatty liver disease) and SIBO was observed in this
metaLanalysis’

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Malnutrition
Both fat soluble vitamins including vitamin D, vitamin E and possibly even vitamin A
may be deficient in SIBO cases whereas vitamin K levels may be normal or even raised.
This vitamin is synthesised by bacteria so this makes sense when you think about it.
Other nutrients which may be low in SIBO cases include vitamin B12 (keep an eye
out for megaloblastic anaemia and the associated polyneuropathy) as well as iron
deficiency which may lead to microcytic anaemia.
There are a few reasons to explain these possible nutrient deficiencies associated
with SIBO including bacterial metabolism, the damage that SIBO can cause to the
mucosa of the small intestine and even the restricted diets that many people use to
either treat their SIBO or minimise their symptoms. Finally chronic diarrhea and fat
malabsorption may lead to nutrient deficiencies (26).
Inflammatory Bowel Disease

Are inflammatory bowel disease (IBD) and SIBO connected in any way?
We know that IBD, including Crohn’s disease and ulcerative colitis, have an altered
microbiota in the large bowel that could be driving the disease (more here and here).
We also know that SIBO is a condition of an altered microbiota in the small intestine.
But is there an overlap?
One systemic review with meta analysis (very high level science) found that SIBO
was present in 22.3% of patients with inflammatory bowel disease. Looking into the
subtypes of IBD they found that SIBO positive Crohn’s patients did not have elevated
CDAI (Crohn’s disease activity index) compared to Crohn’s disease patients without
SIBO. One study included in the review found that there was significantly higher levels
of calprotectin (which can be tested by your doctor and is also found on the GI MAP)
in SIBO patients with Crohn’s disease compared to SIBO negative Crohn’s disease
patients.
So what do we make of this?
It is early days in the SIBO and IBD world. The study covered above was published
this year (2019) and only included 1175 IBD patients. The second issue here is that the
studies included only used one type of sugar in their SIBO breath test (we’ll cover why
that is an issue later on) so they may be underreporting the incidence of SIBO in IBD.

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For now I think it is worth keeping in mind that if you have IBD then it is possible that
SIBO is also present as well. Treating your SIBO (if present) may improve some of your
gut symptoms but current thinking is that it is not a driver of IBD.
Again this may change as we learn more.
Irritable Bowle Syndrome

Irritable bowel syndrome has been correlated with SIBO for quite some time now. It is
quite common for patients that had originally been diagnosed to have SIBO and, when
treated, many of their symptoms improve.
The question is, how common is SIBO in IBS and if someone has SIBO do they still
have IBS?
The answer to the first question varies depending on which study you read.
• One of the most recent systemic review with meta analysis found SIBO to be
present in over ⅓ of the patients with IBS
• Another, older systemic review with meta analysis found that SIBO was
present in 54% of IBS patients when using a glucose or lactulose breath test
but only 4% when using the gold standard SIBO test, aspirate and culture.
The list of papers linking IBS to SIBO could go on and on.
I’ll leave it to the researchers to work out exactly how strong the connection is between
the two gut disorders. For now it’s worth pointing out that if you have been diagnosed
with IBS and fit the symptom picture of SIBO it may be worth getting tested to rule it
out.

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Image taken from: Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome:
A Bridge between Functional Organic Dichotomy
Diabetes
Diabetes, both type 1 and type 2, are possible comorbidities associated with SIBO.
In type 2 diabetes, the more common of the two, the poor blood sugar control (both
hyperglycaemia and hypoglycaemia) can alter the gut motility. Type 2 diabetes have
been shown to have slower oral cecal transit time and higher rates of SIBO (31).
Rosacea
Does SIBO cause rosacea or are they simple correlated?
One study found that SIBO was much higher in patients with rosacea. Plus when they
treated and cleared the SIBO the skin condition cleared or greatly improved in over
90% of the patients.

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True it was a small study and there is not much science to confirm these results but
it does make you wonder. The gut skin axis may be the driver in at least some people
with rosacea.
We have covered that particular study in more depth here for your to read at your
convenience.
Diverticular Disease
Most people would think that diverticulitis is associated with a low fiber diet and
much of the research is confirming that suspicion. While there is very little research
connecting diverticulitis and SIBO, other predisposing factors for diverticular disease
such as motility disorders (slowed transit time through the intestines) is a major factor
that leads to SIBO in the first place (as we discuss here).
One study looking into the connection between SIBO and diverticulitis found that
58.88% of patients with diverticulitis had SIBO using the lactulose breath test – don’t
forget here that the lactulose breath test can miss some cases of small intestinal
bacterial overgrowth as we covered in the testing section.
The same study also found that treating SIBO in patients with diverticulitis resulted in
significantly improved symptoms.
Image taken from: Gastrointestinal bacterial overgrowth: pathogenesis and clinical

significance.

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Bacteria Found in SIBO Patients

So we now know that SIBO is an overgrowth of bacteria in the small intestine but what
types of bacteria are responsible?
This question is harder to answer than you might think.
A number of bacteria have been found in SIBO cases via duodenal aspirate and
culturing including;
• Streptococcus • Klebsiella
• Enterococcus • E. coli
For SIFO it was predominantly Candida species of fungus (34).
Other bacteria include gram positive, aerobic or facultative anaerobic bacteria such
as;
• Staphylococcus • Corynebacterium
• Micrococcus • Bifidobacterium
• Lactobacillus
Gram positive anaerobic bacteria;
• Fusobacterium
• Peptostreptococcus
Gram negative, aerobic or facultative anaerobic bacteria;
• Proteus • Neisseria
• Acinetobacter • Citrobacter
• Enterobacter
Gram negative, anaerobic bacteria;
• Bacteroides
• Clostridium

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References for bacteria found in SIBO (35, 36).
This list of bacteria associated with SIBO was put together from microbes found using
the culture and microscopy techniques – basically sampling the small intestine and
trying to grow what you have sampled.
The real problem here is that not every microbe can be cultured!
The percentage of microbes that cannot be cultured ranges from paper to paper
(from 20 60% all the way up to 80%) although this number changers as our culture
techniques improve (39).
To date there has only been a few studies using DNA based (non culturable)
assessments of the microbiota in SIBO patients.
One study sampled the jejunum (the middle section of the small intestine) from 20
patients which was then cultured to diagnose SIBO (remember over approximately 10
to the 5th factor – 10 to the 7th factor would indicate an overgrowth). They also assessed
the samples using a common DNA based assessment known as 16S ribosomal RNA
– I think of this almost as a unique fingerprint that each bacterial genera has. A great
way to assess bacteria without culturing.
The most abundant microbes were similar to bacteria found in the mouth including;
• Streptococcus (28%) • Actinomyces (3%)

• Prevotella (13%) • Rothia (2%)
• Veillonella (7%) • Leptotrichia (2%)
• Fusobacterium (6%) • Gemella (2%)
• Haemophilus (5%) • Neisseria (2%).
As well as other bacteria including a few from the Proteobacteria phylum which we
have covered before including;
• Escherichia (7%) • Enterobacter (1%)

• Klebsiella (2%), • Bacteroides (1%)
• Citrobacter (2%) • Lachnoclostridium (1%)
• Actinobacillus (1%)

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The study concluded that few to no colonic bacteria were found in the jejunum in
patients with SIBO. We will circle back to this when we talk about different causes for
SIBO.
Image taken from: Jejunal Flora of Patients with Small Intestinal Bacterial Overgrowth:
DNA Sequencing Provides no Evidence for a Migration of Colonic Microbes.
From this study 12 out of 20 patients were diagnosed with SIBO due to excessive
bacterial counts from the aspirate taken from their small intestine.
Another recent DNA based study found an increase in the Proteobacteria phylum in
SIBO patients and a decrease in the Firmicutes phylum. They also found a decrease in
bacterial diversity in SIBO patients as well.
The image below shows DNA based assessment of patients without SIBO (the 0’s
along the x axis) as well as upper aerodigestive tract SIBO (the 1’s) and coliform SIBO
(the 2’s).

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Image taken from: Characterization of Proximal Small Intestinal Microbiota in Patients

With Suspected Small Intestinal Bacterial Overgrowth: A Cross Sectional Study

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Testing for SIBO

Testing for SIBO is complicated.
To date there is not one test that is as specific and sensitive as many clinicians (myself
included) would like. Each and every one of the SIBO tests available are unreliable in
their own special way.
Before we get into the different testing options let’s cover exactly what I mean by
specific and sensitive.
Specificty and Sensitivity in Testing

Specific testing. A test that is highly specific means that there is a very low chance
of what it known as a false positive. A false positive in the pathology world is when a
test comes back positive for a marker (in this case we are talking about SIBO) but it is
wrong.
Definitely not what we want.
With tests that have low specificity we get these false positive test results. In the case
of SIBO if the testing came back with a false positive you might end up treating SIBO
when in fact there was no SIBO!
Sensitive testing. On the other hand there is the concept of the sensitivity of a test.
Tests that are highly sensitive rarely miss. Highly sensitive testing means there is a low
chance of a false negative (a false negative is when the test says there is no infection
when in fact there is). In the case of SIBO a highly sensitive test would catch SIBO
every time. On the other hand testing that has poor sensitivity (meaning it has low
sensitivity) would miss SIBO even when it was there!
Again not what we want.
So circling back to the point above, currently we don’t have one readily available test
that is both highly specific and highly sensitive. Let’s cover what we do have and the
best way to get around this massive problem in SIBO testing and diagnosis.

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Image taken from: Gastrointestinal bacterial overgrowth: pathogenesis and clinical

significance.
The Gold Standard Test

The gold standard test used to diagnose SIBO is what is known as a small bowel
aspirate and culture. The small bowel is sampled and then cultured. If the cultured
microbes reach a certain threshold it is considered small intestinal overgrowth (22).
A few issues have been raised around this invasive and costly procedure;
• Where the sample was taken in the small bowel (the bacterial overgrowth
may have been missed).
• Sample handling and culturing techniques vary
• How much is considered an overgrowth?
• Many bacteria sampled cannot be cultured
These issues and more have led researchers and gut health clinicians to look for better
alternatives in assessing someone for small intestinal bacterial overgrowth.
Introducing the SIBO breath test with all of its pros and cons!

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Breath Testing
An overview of the concept of breath testing is shown in the image below.
Image taken from: Breath Tests for Gastrointestinal Disease: The Real Deal or Just a
Lot of Hot Air?
Sugar is consumed. If there is sufficient bacteria in the small intestines then they will
ferment the sugar and produce hydrogen and/or methane and carbon dioxide. Excess
hydrogen and methane gas makes their way into the bloodstream and out of the body
via the lungs which is then captured and assessed.
A sufficient rise in either one or both, within a given time, would indicate SIBO.
there is a significant rise beyond the given time this indicates that the sugar has passed
through the small intestines and into the large bowel where it has been fermented by
the bacteria there.
In 2017 a paper was published in the American Journal of Gastroenterology outlining

a panel of SIBO researchers consensus on SIBO breath testing. Did I mention it was
complicated? The paper outlined a number of key points that you need to be aware of
when considering which SIBO breath test is best and how to interpret it.

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The North American Consensus on SIBO Breath Testing

Key points from the paper include the following;
1 void antibiotics for at least 4 weeks prior to SIBO breath testing.

A
Stopping prebiotics and probiotics was unclear, some say yes some were
uncertain.
2 Stopping promotility and laxative agents for 1 week prior to SIBO
3 Avoiding fermentable foods (complex carbohydrates, FODMAPS etc.) should

be avoided for 1 day prior to SIBO breath testing.
4 Fasting for 8 12 hours before the SIBO breath testing was recommended.
5 Patients should avoid smoking and exercising before the SIBO breath test.
Each SIBO breath testing provider will have their own approach and best practices for
getting the most from the test. It is best to follow their recommendations (or the health
clinician you are working with) to the letter. The worst scenario would be a user error
which normally means you have to pay for another test.
Glucose
Glucose is a very well studied sugar used in SIBO breath testing. It is considered very
specific but not very sensitive.
When glucose is used as a breath testing sugar to diagnose SIBO there are very little
chances of it saying you have SIBO when in fact you do not (only when the proper pre
test diet is followed as outlined above). However, there is a higher chance of a glucose
breath test saying you do not have SIBO when in fact you do!
Here is why.
Glucose is very easily absorbed in the upper small intestine. Why is that important? If
the intestinal overgrowth is located further down in the small intestine (what is known
as distal in medicine speak) then the glucose may not be available (as in it has already

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been absorbed into the bloodstream) to be fermented by the bacteria and produce a
rise in gas levels as seen in the image below (44).
Image taken from: Is It Useful to Administer Probiotics Together With Proton Pump
Inhibitors in Children With Gastroesophageal Reflux? showing no significant increase
in hydrogen (left) indicating no SIBO and a significant increase (right) showing SIBO.
Quality breath tests will also record methane levels simultaneously.
Positive Glucose Breath Test

For hydrogen dominant SIBO a rise of 20ppm of hydrogen over baseline in the first
90 minutes is thought to be a positive reading. This conclusion was drawn by the The
North American Consensus paper on SIBO breath testing paper.
Methane dominant SIBO is less precise. The The North American Consensus paper
on SIBO breath testing agreed that a level equal to or greater than 10ppm of methane
was indicative of SIBO. Here there is the issue of methane production in the large
bowel. Some clinicians would want to see a rise in methane of 10ppm or more within
the first 90 minutes to help distinguish between large bowel methane production and
methane dominant SIBO.
Pros of Glucose Breath Testing

Glucose breath testing is highly specific. If there is a significant rise in gas production
(and you have followed the proper test prep instructions) then SIBO is probable.
Cons of Glucose Breath Testing

Glucose breath testing is not very sensitive. If there is no rise in gas production then
you may still have SIBO.

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Lactulose
Moving onto the darling sugar used in SIBO breath testing we come to lactulose. It has
been getting a ton of press lately for reasons that I will outline below.
First off what is lactulose?
Lactulose is a semi synthetic disaccharide formed from lactose. It acts as a prebiotic,

meaning it reaches the large intestine undigested and can be fermented and
consumed by beneficial bacteria (45).
Image taken from: Medical, nutritional and technological properties of lactulose. An

update.
When consumed as a sugar for a SIBO breath test lactulose makes its way through the small
intestine and into the large intestine where it is fermented by colonic bacteria, resulting in
the production of hydrogen and possibly methane (if methanogens are present). If there
is an overgrowth of bacteria in the small intestine – if SIBO is present – then there will be a
rise in hydrogen and/or methane before the lactulose reaches the colon (46).
There have been a range of different interpretations proposed for the interpretation of a
positive lactulose breath test ranging from the ‘double peak’ – the thinking here is that
the first peak signifies bacterial fermentation in the small bowel and the second peak

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signifies bacterial fermentation in the large bowel – and the ‘early rise’ – a rise in hydrogen
above 20 ppm over baseline within 90 minutes – (both seen in the image below)
In the The North American Consensus paper on SIBO breath testing they agreed that
the ‘early peak’ was a better indication of a SIBO positive patient and that the ‘double
peak’ was not necessary for a positive result.
Image taken from: The diagnosis of small intestinal bacterial overgrowth: Two steps
forward, one step backwards? Showing the ‘double peak’ and the ‘early rise’ of
hydrogen on a lactulose SIBO breath test. Both of these diagnostic criteria have been
called into question.

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Positive Lactulose Breath Testing

This is much the same as the glucose breath test taking into account the issues with
lactulose breath testing outlined below.
For hydrogen dominant SIBO a rise of 20ppm of hydrogen over baseline in the first
90 minutes is thought to be a positive reading. This conclusion was drawn by the The
North American Consensus paper on SIBO breath testing paper.
Methane dominant SIBO is less precise. The The North American Consensus paper
on SIBO breath testing agreed that a level equal to or greater than 10ppm of methane
was indicative of SIBO. Here there is the issue of methane production in the large
bowel. Some clinicians would want to see a rise in methane of 10ppm or more within
the first 90 minutes to help distinguish between large bowel methane production and
methane dominant SIBO.
Issues with Lactulose Breath Testing

As with every other SIBO test available lactulose breath testing does have its own
issues.
First off we have patients with fast oral cecal transit time. This is common in people
suffering from diarrhea – a common SIBO symptom. Secondly lactulose is commonly
used as a laxative and has been shown to speed up transit time! With a faster transit
time an early rise in gas production could mean that the lactulose has reached the
colon – here we could suffer from a false positive diagnosis of SIBO (22).
The last issue, and one that many clinicians miss, is the fact that lactulose is very
selective in which bacteria it feeds. This is why it has commonly been used as a
prebiotic. Certain bacteria cannot use lactulose as a food source. If these bugs were
making up the small intestinal overgrowth there is a high chance of getting a false
negative.

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Image taken from: Small intestinal bacterial overgrowth showing differing results for
sensitivity and specificity of both the glucose SIBO breath test and the lactulose SIBO
breath test.
Pros of Lactulose SIBO Testing

It is a commonly used SIBO breath test sugar, is widely available and is relatively
affordable.
Cons of Lactulose SIBO Testing

Lactulose SIBO breath testing may miss certain cases of SIBO due to the selectivity of
the sugar. Using it may also result in false positives due to the increased transit time.
Fructose
A third sugar, very rarely used in clinical and research settings to identify SIBO, is
fructose. Commonly this sugar is used to identify fructose malabsorption issues. In
a healthy small intestine fructose should at least partly be absorbed. When there is
fructose malabsorption the sugar makes its way down to the large bowel where it can
cause issues such as bloating, nausea and even diarrhoea.
Fructose malabsorption is such a common issue that some researchers are even
considering it as one of the issues causing irritable bowel syndrome (47).
The image below shows fructose malabsorption leading to excessive fructose reaching
the colon and the classic symptoms of fructose malabsorption being produced. What
is not shown in the image below, and what few gut health professionals are aware of,
is the possibility of the malabsorbed fructose being fermented in the small intestine

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even before it reaches the large intestine. If there is an early rise of gases on a fructose
SIBO breath test then, you guessed it, you could be dealing with SIBO.
Image taken from: Fructose malabsorption.
Pros of Fructose SIBO Breath Testing

Including the fructose SIBO breath test covers more area when testing for SIBO.
Often times SIBO patients have trouble absorbing fructose in the small intestine due to
the damage done to the microvilli. If this is the case then the poorly absorbed fructose
will be fermented in the small bowel and turn up as a positive SIBO breath test.
Cons of Fructose SIBO BreathTesting

Fructose is not a commonly used sugar for detecting SIBO.
There is very little research available and no consensus on proper interpretation

guidelines. As such it is best used in combination with other breath tests (glucose or
lactulose)
Which Test is Best When Screening for SIBO?

And now the million dollar question. Which test is best for proper SIBO diagnosis?
Seeing as each test, from the aspirate and culture to everyone of the three breath test
sugars (glucose, lactulose and fructose) all have their issues and proper diagnosis

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of SIBO is so important before any microbiome restoration can happen in the large
bowel we need to use a combination of tests to be sure.
The best practice, as outlined by Dr Jason Hawrelak, one of the top gut health
practitioners here in Australia, is to use multiple breath tests each with a different sugar.
Screening for small intestinal bacterial overgrowth using glucose, fructose and lactulose
(each on different days) makes up for each of the different sugars shortcomings. Plus
noting which sugar is fermented in the small bowel and which isn’t can help when it
comes to the treatment of SIBO.

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Sibo Diets
The approaches to dietary interventions for SIBO vary depending on who you speak
to. A few of the top diets for SIBO include the low FODMAP (stands for fermentable
oligosaccharide, disaccharide, monosaccharide and polyol) diet, the SCD (specific
carbohydrate) diet and the GAPS (gut and psychology syndrome) diet.
Below is a short snapshot of the low FODMAP diet which is commonly used to minimise
the symptoms associated with SIBO.
The Low Fodmap Diet

The low FODMAP diet is the most frequently diet used to manage symptoms associated
with SIBO.
First off what is a low FODMAP diet?
The quick answer here is that it is a very restrictive diet.
The low FODMAP diet restricts a whole range of carbohydrates that can be fermented
by the bacteria that reside in your gastrointestinal tract including;
• Fructose (particularly in excess of glucose)

• Oligosaccharides found in many foods including wheat and onions
• Galacto oligosaccharides – found in legumes
• Sugar polyols – sorbitol and mannitol
• Lactose – particularly if it is poorly absorbed
The idea around this diet stems from the idea of limiting poorly absorbed short chain
carbohydrates, thus limiting fermentation and gas production which is associated with
symptoms of SIBO such as bloating and distention (49).
It has been commonly prescribed for patients with IBS and has shown good success
in reducing their symptoms (50).
Remember when we covered the connection between SIBO and IBS? Due to the
overlap, many things that improve IBS symptoms may also improve SIBO symptoms.

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It is important to note that a low FODMAP diet is not a no FODMAP diet. The particular
approach involved restricting these foods, noting whether symptoms have improved,
then reintroducing different types of FODMAPs one at a time and finally customising
your personal low FODMAP diet (51).
Risks with the Low Fodmap Diet

The low FODMAP diet does come with a few possible downsides as listed in a 2017
review paper Controversies and Recent Developments of the Low FODMAP Diet;
1. Using the low FODMAP diet to ‘diagnose’ IBS is used by some clinicians. This
is considered poor practice and proper diagnostic procedures are much
better suited. An example here would be using the ROME criteria for IBS and
excluding other pathologies like SIBO, gluten sensitivities and large bowel
dysbiosis.
2. Disordered eating. As with many restrictive diets the low FODMAP diet can
lead to eating disorders in certain predisposed people.
3. Altered gastrointestinal microbiota. This may be the top offender when it
comes to issues with the low FODMAP diet. Many FODMAPs, due to their
fermentable nature, have prebiotic like effects on the gut microbiota. Low
FODMAP diets have been shown to reduce levels of beneficial bacteria in
the large bowel. Other possible negatives of the low FODMAP on the gut
microbiome include a reduction in the butyrate producing beneficial bacteria.
Due to these issues it is best to limit the low FODMAP diet to the treatment phase and
begin to reintroduce fermentable carbohydrates as quickly as possible.

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Conventional Treatment for SIBO

Conventional treatment for SIBO is antibiotics. The thinking here is that if there is a
bacterial overgrowth then the treatment is to remove the bacteria that are overgrowing.
Pretty straight forward right?
Antibiotics in SIBO
Commonly used antibiotics include;
• Clindamycin • Rifaximin
• Metronidazole • Tetracycline
• Neomycin
Each of these different antibiotics have different success rates with successful
interventions ranging from 35% up to 100% (53).
Rifaximin appears to be the antibiotic of choice for hydrogen dominant SIBO. The
archaea involved in methane dominant SIBO (Methanobrevibacter smithii) appear to be
more antibiotic resistant. When methane dominant SIBO is present the most common
conventional approach appears to be a combination of both neomycin and rifaximin (54).
Pros of Rifaximin Over Other Antiobiotics

As a herbalist and a microbiome explorer and admirer I am not a huge fan of antibiotics
and their overuse. The rise of resistant microbes and the negative impact on the gut
microbiota puts me off antibiotics unless absolutely necessary. More on that here.
With that out of the way rifaximin appears to be safer than most other antibiotics.
First off it is effective against both anaerobic and aerobic bacteria plus it is very poorly
absorbed into circulation. Rifaximin seems to be well tolerated with few adverse
events noted (55).
One in vitro study even showed some prebiotic effects of rifaximin on the large bowel
gut microbiota. An increase in Bifidobacteria and Faecalibacterium prausnitzii were
observed in a colonic like simulation (56).
These prebiotic effects on the colonic gut microbiota have been seen in a number of
other studies (shown in the table below).

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Image taken from: Eubiotic properties of rifaximin: Disruption of the traditional concepts
in gut microbiota modulation
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While it seems that rifaximin is better tolerated than most other antibiotics and that
it does not appear to cause microbiome damage and disruption in the large bowel it
does not treat the underlying cause in many patients who eventually relapse (8).
Prokinetic Drugs
Prokinetic pharmaceuticals are often used in conventional medicine to encourage
healthy movement through the small bowel in SIBO patients post antibiotic treatment.
These mainly include one of three drugs although others may be used (54).
• Erythromycin
• Domperidone
• Prucalopride
Erythromycin is actually an antibiotic, and although it is only used in small amounts as

a prokinetic drug, it is still worth knowing that it’s primary use is to kill bacteria.

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Natural Treatments for SIBO
Herbal Antimicrobials
Herbal medicine can be very effective in treating SIBO.
In fact, one particular study compared the use of herbal antimicrobials against rifaximin
(a popular antibiotic for SIBO). They found that the herbal antimicrobials were actually
more effective at treating SIBO than the antibiotic (58).
The study does have a few inconsistencies, mainly the smaller than recommended
dose for rifaximin as well as the timing of the intervention. Either way it does show that
herbs can be used to successfully treat SIBO.
Different herbs that are commonly used include ones high in different active
constituents including those high in;
• Berberine
• Tannins
• Volatile oils
Berberine rich herbs include;
• Philodendron
• Coptis chinensis
• Goldenseal
• Oregon grape root
• Barberry

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There may be an overemphasis on berberine at the moment when treating different

gut infections and overgrowths. There has even been talk about berberine resistance.
Plants rich in polyphenols are often a suitable alternative to berberine rich herbs.
Some of these herbs are also rich in volatile oils (a major win!).
These include among many many others;
• Pomegranate husk
• Propolis
• Cloves
• Oregano leaf (not oil as it may be too damaging to the gut ecosystem)

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Finally volatile oils from selective herbs have been used in the treatment of SIBO.
These include;
• Oregano oil
• Thyme oil
• Clove oil
• Peppermint oil

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There is some concern around the damage to the gut microbiota composition when
using such strong herbal oils. Many of these oils can almost be seen as broad spectrum
as antibiotics.
As a clinical herbalist I would only recommend taking the whole plant, often in tincture
form, instead of the isolated plant oils.
Here we are still getting the oils (although at lower concentrations) along with all of
the other active constituents that would be missed by going the oil only route.
Herbs to Avoid
Apart from the long term use of herbal oils and berberine rich herbs there is one other
herb that should be absolutely avoided.
Grapefruit seed extract, often used as a potent herbal antibiotic, has been shown
again and again to be a contaminated product spiked chemicals like benzethonium
chloride and triclosan.

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Some preliminary (and unfortunately unpublished data) has shown that it has broad
spectrum and devastating effects on the gut microbiota, possibly as bad as broad
spectrum antibiotics.
Grapefruit seed extract, often used as a potent herbal antibiotic, has been shown
again and again to be a contaminated product spiked chemicals like benzethonium
chloride and triclosan.
Tailored Herbs for Specific SIBO Types

When it comes down to it you really need to know which type of SIBO you are treating.
Then the herbal formula can be specifically tailored to treat the specific bacterial
overgrowth.
Just throwing herbs and supplements at SIBO generally won’t get you very far.
Best case scenario you may clear the overgrowth, worse case scenario you will be
throwing money away and prolonging your healing journey.

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Herbs to Treat the Underlying Cause of SIBO

Specific herbal medicines can be used to treat the different underlying causes of SIBO.
If the underlying cause for your specific case of SIBO was low stomach acid then bitter
herbs can be used to increase stomach acid production and digestive flow.
If poor gut motility was the underlying cause then prokinetic herbs such as ginger can
be used.
The herbal formulation is very much dictated on each individual person’s needs.
Probiotics in SIBO
Here we are venturing into controversial territory.
Are probiotics helpful when treating SIBO?
It very much comes down, once again, to the type of SIBO and the type of probiotic.
Thanks to all the hard work that Dr. Jason Hawrelak has done in educating naturopaths
on probiotics it seems clear that probiotic strains come are key here (61).
Some probiotics may be helpful in reducing methane dominant SIBO (Lactobacillus

reuteri stands out here) and some may help to speed gut transit time.
Working with a healthcare provider that really and truly understands probiotics and
their appropriate use is important here. They may be hard to find and in high demand
but don’t let that stop you from looking!
One study assessed a probiotic in the treatment of SIBO in patients with chronic liver
disease.
They found that the probiotic group, taking a product called Duolac Gold resulted in
SIBO symptom alleviation in 24% of the treatment group (it wasn’t clear whether they
retested)
The probiotic contained the following strains and was given at a dose of 2 capsules
daily for 4 weeks.
• Bifidobacterium bifidum (KCTC 12199BP)

• Bifidobacterium lactis (KCTC 11904BP)

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• Bifidobacterium longum (KCTC 12200BP)

• Lactobacillus acidophilus (KCTC 11906BP)
• Lactobacillus rhamnosus (KCTC 12202BP)
• Streptococcus thermophilus (KCTC 11870BP)
Image taken from: Short term probiotic therapy alleviates small intestinal bacterial
overgrowth, but does not improve intestinal permeability in chronic liver disease
In another study probiotics were assessed for the treatment of SIBO in a Chinese group
of patients with gastric or colorectal cancer.
They found that taking a certain probiotic called Bifidobacterium triple viable capsule
was effective in treating SIBO in 81% of the probiotic group.
The major issues with this study includes;
1. The diagnostic testing issues to determine SIBO. They used a glucose breath
test and a cutoff of only 12 ppm of hydrogen increase over baseline. Now it is
considered 20 ppm

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2. The authors did not describe what probiotics were Bifidobacterium triple
viable capsule product so we don’t know what type were used!
Just from these two studies it should be clear that probiotics are a possible treatment
option for SIBO. Combining them with herbal antimicrobials may very well improve
their effects.
Prebiotics in SIBO
Again very controversial territory. Prebiotics in SIBO?
The use of prebiotics in SIBO treatment is a hotly debated topic. Many clinicians would
advise against prebiotics when treating SIBO. After all, the low FODMAP diet, which
restricts prebiotics, can be helpful for improving SIBO symptoms.
The real art and science of prebiotic prescribing for SIBO comes down to determining
which specific bacteria are overgrown in the small intestine. Seeing as we don’t
have the technology to determine this educated guesses can be made. The second
crucial part of this is symptom improvement or worsening by the patient when certain
prebiotics are introduced.
Personal note here.

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I have found that fructo oligosaccharides are generally not well tolerated in SIBO
patients. Things like FOS and inulin are best avoided *personal opinion here* until after
the SIBO has been cleared.
Other prebiotics seem to be better tolerated depending on the patient.
One study found that combining a prebiotic, in this case partially hydrolysed guar gum,
with antibiotics significantly improved eradication rates compared to the antibiotic
alone.
The debate goes on between clinicians and researchers that believe that this is due
to the prebiotic feeding up the bacteria so that they were happy and rapidly dividing
(thus more exposed to the antibiotic treatment) and the other side who believe that
this particular prebiotic helped to modulate and rebalance the small intestinal gut
microbiota.
Other than that specific study there are very few papers available looking at prebiotics
and SIBO.
One fascinating paper (which we have covered here) outlined an interesting case
study where a patient, suffering from long term IBS, was treated successfully with a
prebiotic called lactulose.
Lactulose shouldn’t be used in certain SIBO cases, mainly the ones that have been
diagnosed with a lactulose breath test. That makes perfect sense when you think it
through. If a lactulose SIBO breath test has shown that there are bacteria in the small
intestine that can utilise lactulose as a food source you wouldn’t want to be feeding
them up.

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Elemental Diet
Finally the elemental diet is commonly used in difficult to treat SIBO cases.
The elemental diet is a specifically formulated diet which is absorbed in the proximal
small bowel. Basically the nutrients in this liquid diet are completely absorbed quickly
before they can be used as food by the bacterial overgrowth.
The success rate of the elemental diet is approximately 80% for a two week diet. At
two weeks if the SIBO breath test is still positive an additional week of the elemental
diet bumps the success rate up to about 85% (66).
Image taken from: A 14 day elemental diet is highly effective in normalizing the lactulose
breath test showing the before (dotted lines) and after (straight line) of patients on an
elemental diet.
The Issues with the Elemental Diet

1. Cost. The elemental diet can be quite costly. That said, you are eliminating
your shopping bill for the time that you are on the elemental diet so that
needs to be factored in.

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2. Palatability. The elemental diet is reported to taste terrible for some people.
3. Weight loss. It can be difficult to maintain weight on the elemental diet.
The pros and cons of the elemental diet (67) needs to be weighed up for each SIBO
patient.

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Why Does My SIBO Coming Back

SIBO relapse is common. Very common.
It may be the one issue that few clinicians know how to address when treating SIBO.
For some patients it may be next to impossible to address the relapse issue.
One paper found that SIBO recurrence was upwards of 40% in a 9 month follow up of
successfully treated patients.
Another study found that in patients who had cleared SIBO with antibiotics it returned
in 13% in 3 months, 28% in 6 months and 44% in 9 months (68).
Treating the SIBO overgrowth in the first place is straightforward enough for most
cases. True there are very tough to treat cases but with proper diagnosis (is it hydrogen
dominant SIBO, methane dominant SIBO or both?) and targeted therapy most SIBO
cases can be successfully cleared.
Preventing a relapse is another thing.
Getting to the bottom of why you had SIBO in the first place is key to working towards
prevention of relapse.

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Preventing SIBO Recurrence

Maintaining remission in treated SIBO patients means addressing the original issue
that led to the overgrowth in the first place.
Motility agents may be required long term to keep the flow through the intestines and
prevent stasis, stagnation and an overgrowth of bacteria.
Conventional approaches rely on prokinetic drugs. Alternative practitioners

(naturopaths, herbalists) rely on prokinetic herbs.
One approach is to limit your food intake to windows of the day. The fasted state encourages
the migrating motor complex in the intestinal tract to sweep through and keep things
moving along. That is akin to the grumbling of your stomach when you are hungry.
In the table below we can see the approach taken by modern medicine to treat the
underlying cause of SIBO.
Image taken from: How to Test and Treat Small Intestinal Bacterial Overgrowth: an
Evidence Based Approach

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Want More Help?

As you have now learned small intestinal bacterial overgrowth can be more complicated
than simply treating the bacterial overgrowth in the small bowel. There are high rates
of relapse and underlying causes that are often not addressed.
If you suspect you have SIBO and would like to organise a consultation with me here
at Byron Herbalist then <head over to our appointments page> to organise a suitable
time.
I use targeted herbal medicine, prebiotics, probiotics and microbiome restoration

techniques to address the bacterial overgrowth and ensure that the underlying causes
for your SIBO have not been neglected. Here at Byron Herbalist I focus my time on
digging deep into the scientific research and the historical use of herbal medicine
from the wisdom traditions of the world. It is a fine line to walk. Currently I think we are
leaning too far towards the reductionist science and forgetting that the plant medicine
that we use has depth that science can’t determine.
I take what science has to offer but always keep in

the back of my mind the principles of true grass-roots
herbalism. Focusing on building a person’s vitality and
health, supporting their physical, emotional and mental
health is all possible using herbal medicine.
Todd Mansfield
Byron Herbalist

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References and Resources

1. Small Intestinal Bacterial Overgrowth: A Primary Care Review
2. The small intestine microbiota, nutritional modulation and relevance for health
3. Review article: small intestinal bacterial overgrowth – prevalence, clinical
features, current and developing diagnostic tests, and treatment
4. Gas and the Microbiome
5. Methane Production During Lactulose Breath Test Is Associated with
Gastrointestinal Disease Presentation
6. Measurement of Hydrogen Sulfide during Breath Testing Correlates to Patient
Symptoms
7. Small Intestinal Fungal Overgrowth
8. Small intestinal bacterial overgrowth syndrome
9. Proton Pump Inhibitor Use and the Risk of Small Intestinal Bacterial Overgrowth:
A Meta analysis
10. Meta analysis: proton pump inhibitors moderately increase the risk of small
intestinal bacterial overgrowth.
11. Proton Pump Inhibitors: Review of Emerging Concerns
12. Intestinal Bacterial Overgrowth During Chronic Pancreatitis
13. Association of gastric hypoacidity with opportunistic enteric infections in patients
with AIDS.
14. Jejunal bacterial overgrowth and intestinal permeability in children with
immunodeficiency syndromes
15. The Epidemiology and Clinical Manifestations of Autoimmunity in Selective IgA
Deficiency
16. Selective IgA deficiency: Epidemiology, Pathogenesis, Clinical Phenotype,
Diagnosis, Prognosis and Management
17. Small Intestinal Bacterial Overgrowth in Patients With Lower Gastrointestinal
Symptoms and a History of Previous Abdominal Surgery
18. Interaction between rifaximin and dietary fibre in patients with diverticular
disease
19. Assessment of small intestinal bacterial overgrowth in uncomplicated acute
diverticulitis of the colon
20. A Prospective Evaluation of Ileocecal Valve Dysfunction and Intestinal Motility
Derangements in Small Intestinal Bacterial Overgrowth
21. Assessment of Anti vinculin and Anti cytolethal Distending Toxin B Antibodies in
Subtypes of Irritable Bowel Syndrome
22. Breath Testing for Small Intestinal Bacterial Overgrowth: Maximizing Test
Accuracy

BYRON HERBALIST
23. Small intestinal bacterial overgrowth and intestinal permeability

24. Review article: the gut microbiome as a therapeutic target in the pathogenesis
and treatment of chronic liver disease.
25. Small intestinal bacterial overgrowth and nonalcoholic fatty liver disease: a
systematic review and meta analysis
26. Gastrointestinal bacterial overgrowth: pathogenesis and clinical significance
27. Systematic review and meta analysis: the prevalence of small intestinal bacterial
overgrowth in inflammatory bowel disease
28. Prevalence and predictors of small intestinal bacterial overgrowth in irritable
bowel syndrome: a systematic review and metaanalysis
29. Small Intestinal Bacterial Overgrowth in Irritable Bowel Syndrome: Systematic
Review and Meta analysis
30. Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge
between Functional Organic Dichotomy
31. Malabsorption, Orocecal Transit Time and Small Intestinal Bacterial Overgrowth
in Type 2 Diabetic Patients: A Connection
32. Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its
eradication.
33. Assessment of small intestinal bacterial overgrowth in uncomplicated acute
diverticulitis of the colon
34. Dysmotility and ppi use are independent risk factors for small intestinal bacterial
and/or fungal overgrowth
35. Diagnosis and Management of Small Intestinal Bacterial Overgrowth
36. Small Intestinal Bacterial Overgrowth: Roles of Antibiotics, Prebiotics, and
Probiotics
37. Characteristics of gut microbiota in adult patients with type 1 and type 2 diabetes
based on next-generation sequencing of the 16S rRNA gene fragment
38. Culturing the human microbiota and culturomics
39. Functions of the Microbiota for the Physiology of Animal Metaorganisms
40. Jejunal Flora of Patients with Small Intestinal Bacterial Overgrowth: DNA
Sequencing Provides no Evidence for a Migration of Colonic Microbes
41. First Large Scale Study Defining the Characteristic Microbiome Signatures
of Small Intestinal Bacterial Overgrowth (SIBO): Detailed Analysis from the
Reimagine Study
42. Characterization of Proximal Small Intestinal Microbiota in Patients With
Suspected Small Intestinal Bacterial Overgrowth: A Cross Sectional Study
43. Breath Tests for Gastrointestinal Disease: The Real Deal or Just a Lot of Hot Air?
Hydrogen and Methane Based Breath Testing in Gastrointestinal Disorders: The
North American Consensus

BYRON HERBALIST
44. Is It Useful to Administer Probiotics Together With Proton Pump Inhibitors in

Children With Gastroesophageal Reflux?
45. Medical, nutritional and technological properties of lactulose. An update
46. The diagnosis of small intestinal bacterial overgrowth: Two steps forward, one
step backwards?
47. Is Fructose Malabsorption a Cause of Irritable Bowel Syndrome?
48. Fructose malabsorption
49. Does a diet low in FODMAPs reduce symptoms associated with functional
gastrointestinal disorders? A comprehensive systematic review and meta-
analysis
50. Does a diet low in FODMAPs reduce symptoms associated with functional
gastrointestinal disorders? A comprehensive systematic review and meta-
analysis
51. The low FODMAP diet in the management of irritable bowel syndrome:
an evidence based review of FODMAP restriction, reintroduction and
personalisation in clinical practice
52. Controversies and Recent Developments of the Low FODMAP Diet
53. A Systematic Review of Diagnostic Tests for Small Intestinal Bacterial Overgrowth
54. How to Test and Treat Small Intestinal Bacterial Overgrowth: an Evidence Based
Approach
55. Rifaximin dose finding study for the treatment of small intestinal bacterial
overgrowth
56. Rifaximin modulates the colonic microbiota of patients with Crohn’s disease: an in
vitro approach using a continuous culture colonic model system
57. Eubiotic properties of rifaximin: Disruption of the traditional concepts in gut
microbiota modulation
58. Herbal Therapy is Equivalent to Rifaximin for the Treatment of Small Intestinal
Bacterial Overgrowth
59. Simultaneous identification and quantification by liquid chromatography of
benzethonium chloride, methyl paraben and triclosan in commercial products
labeled as grapefruit seed extract
60. Development and Validation of an HPLC/UV/MS Method for Simultaneous
Determination of 18 Preservatives in Grapefruit Seed Extract
61. Probiotics: Choosing The Right One For Your Needs
62. Short term probiotic therapy alleviates small intestinal bacterial overgrowth, but
does not improve intestinal permeability in chronic liver disease
63. Effect of probiotics on small intestinal bacterial overgrowth in patients with
gastric and colorectal cancer

BYRON HERBALIST
64. Clinical trial: the combination of rifaximin with partially hydrolysed guar gum
is more effective than rifaximin alone in eradicating small intestinal bacterial
overgrowth
65. Culture proven small intestinal bacterial overgrowth as a cause of irritable bowel
syndrome: response to lactulose but not broad spectrum antibiotics
66. A 14 day elemental diet is highly effective in normalizing the lactulose breath test
67. Diagnosis of small intestinal bacterial overgrowth in the clinical practice
68. Small intestinal bacterial overgrowth recurrence after antibiotic therapy

Complete Guide to SIBO: Symptoms, Testing & Treatment

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SIBO

THE COMPLETE GUIDE

SIBO In this guide we will be

2 W: byronherbalist.com.au SIBO The Complete Guide

Why is SIBO an Issue?........................................................................................................................... 6

Different Types of SIBO?....................................................................................................................... 8

Underlying Causes of SIBO............................................................................................................... 13

Comorbidities Associated with SIBO............................................................................................18

Bacteria Found in SIBO Patients....................................................................................................25

Testing for SIBO......................................................................................................................................29

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Conventional Treatment for SIBO..................................................................................................42

Natural Treatments for SIBO............................................................................................................45

Why Does My SIBO Coming Back..................................................................................................56

Preventing SIBO Recurrence...........................................................................................................57

Want More Help?...................................................................................................................................58

References and Resources...............................................................................................................59

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Either way the definition stands.

More bacteria in the small intestine than there should be.

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Why is SIBO an Issue?

SIBO may be responsible for;

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• Bloating – common in methane and hydrogen dominant

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Different Types of SIBO?

We will take each different type of SIBO one at a time.

Hydrogen Dominant SIBO

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Methane Dominant SIBO

The number one symptom of methane dominant SIBO is constipation (5).

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Hydrogen Sulfide Dominant SIBO

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Fungal SIBO, or Should we Say SIFO?

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Underlying Causes of SIBO

Let’s cover each category one by one.

SIBO Causes: Disorders of protective antibacterial mechanisms

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Image taken from: Proton Pump Inhibitors: Review of Emerging Concerns

Exocrine pancreatic insuficiency

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SIBO Causes: Anatomical Abnormalities

Often these conditions are associated with previous surgeries (17).

Ilecocecal valve pressure

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SIBO Causes: Motility Disorders

These conditions include:

Post Infectious SIBO

So what does the literature say on this concept?

After being exposed to any number of different bacterial infections including

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It all makes sense so far right?

This is pretty big news.

SIBO The Complete Guide W: byronherbalist.com.au 17

Comorbidities Associated with SIBO

In fact, SIBO may be causing leaky gut in certain people.

Plus, increased intestinal permeability – leaky gut – is associated with a number of

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1 void antibiotics for at least 4 weeks prior to SIBO breath testing.

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