SIBO (small intestinal overgrowth of bacterial) is a relapsing, chronic condition that can cause 10-15 percent of the population. The main characteristic for SIBO is when the small intestine gets filled with normal gut flora. The small intestine usually free of any bacterial colonisation however changes in the environment inside the small bowel could result in an increase in the number of bacteria, which manifests with various symptoms that are a hallmark of SIBO.
Signs and symptoms
If a patient develops SIBO they might suffer from a range of symptoms, including bloating gas, abdominal discomfort, diarrhoea, fatigue and many other. For a long time, patients suffering from SIBO signs have been identified and labeled with IBS. It is due to the fact that there is a lack agreement and consensus internationally on the underlying causes of the disease and the most effective method for diagnosing it and there is a lack of reliable information on the most effective SIBO treatment for these patients.
The small intestine isn’t usually colonised by bacteria. In SIBO the bacteria that are normally found in the large bowel begin to develop within the bowel of the small. They feed on small molecule fermentable carbohydrates and sugars we consume. The resulting gas production in SIBO could cause issues in digestion, absorption of food, and can damage the membranes that line the intestinal lining which can cause symptoms.
Risk Factors
A variety of risks have been listed as a risk factor for SIBO. It is important to note that it can happen in healthy individuals, but certain people might have anatomical problems, for example, prior small bowel surgery as well as gastric bypass. Certain medications can slow the gut’s motility like narcotic painkillers and anti-diarrhoeal medications. These may cause the growth of bacteria. Some individuals who are taking acid-suppressing medications like proton pump inhibitors that decrease levels of acid that goes through the small bowel may be affected by bacterial overgrowth but this isn’t confirmed. Patients suffering from connective tissue diseases such as Ehlers-Danlos syndrome, fibromyalgia and rheumatoid arthritis could be more susceptible to suffering from the symptoms that recur from small intestinal overgrowth of bacterial.
Diagnosis
The identification of bacterial overgrowth is a matter of debate, with a variety of methods being suggested. There is no universally-acceptable gold standard test for SIBO and the use of the lactulose breath test has become extremely common over the past few years. The goal of the test is to try to recreate an environment within the bowels of the small that could be present on a daily basis for patients suffering from small intestinal bacterial growth and monitor the gas production which result from the production of gases in the bowel’s small intestine to determine whether there’s SIBO. Quantification of methane and hydrogen gases in breath sample is one of the least expensive non-invasive, non-invasive, and possibly the most widely used test to determine the presence of bacteria overgrowth in the United Kingdom. The gasses in the human breath represent the process of fermentation of carbohydrates found in the bowel’s small. It’s not evident how important it is to take tests on breath after treatment.
Treatments
Treatment for SIBO is a combination of three strategies. First, it is to trigger the remission of SIBO and secondly, ensure that remission is maintained and stop SIBO from returning, and lastly and perhaps most importantly, is to address or alter the root cause or factors that lead to the growth of SIBO.
The treatment of bacterial growth Although it’s controversial, the treatment is still mostly focused on reducing the number and growth of bacteria within the bowel. Antibiotics remain the most effective treatment at present. The selection, dosage and duration of treatment aren’t well understood, as there are only a few studies of a high standard that provide guidance to clinicians on the best antibiotics to use. In the near future we will see more attention paid to more specific treatments targeted at specific components of the microbiome. There are no such treatments yet. We usually provide Rifaximin which is among the most researched antibiotics used in patients suffering from all kinds of functional bowel diseases. Research has proven it reliable and safe for treating SIBO. It is especially effective for patients suffering from hydrogen overproduction as well as diarrhoea and bloating symptoms. The issue for patients in United Kingdom is that it is approved only for use in patients suffering from diarrhoea in travelers, but it is also used for those suffering from liver diseases so its application in the small intestinal bacterial overgrowths is usually challenging, since a lot of doctors or hospitals do not prescribe it, and patients typically have to pay for a two-week treatment of antibiotics. ALternatives include doxycycline, which is less expensive, but it does not have the same scientific backing for its usage.
M-SIBO – Production of Methane
It is important to note that when we perform breath tests to determine SIBO we also test to detect methane-gas production. There is a solid evidence presented in Digestive Disease Weekly in Chicago 2017 that shows methane overproduction can result in slower transit and motility in the gut. These patients frequently do not respond well to Rifaximin on its own and require another antibiotic. Neomycin is an effective antibiotic that is used in many other conditions and has been demonstrated to reduce methane production in patients. Pro-kinetics used in this particular group of patients like a lower dose of a substance known as prucalopride may enhance the effects of antibiotics, which can increase the gut’s motility and increase the effectiveness for the medication.
Herbal Antibiotics
For some patients, there is the option of using herbal antibiotics.
Maintenance
Maintaining remission is crucial because SIBO is a chronic illness that can recur for a number of patients. In some studies, as much as 1/3 of patients may experience an incidence of small-intestinal bacteria and a close eye is required for patients following the induction of remission SIBO to determine that if symptoms are persistent, that prompt treatment is initiated. There are many practices that employ these methods to prevent SIBO from returning. One important aspect that patients should consider is first the diet. By limiting the amount of fermentable carbohydrates, and following a diet like those on the lower FODMAP diet will make sure that the ambiance is exposed to less fermentable food items and make sure that there is less of a favorable environment for the bacteria that remain to multiply. Research has shown that in certain patients, the low FODMAP diet alone may trigger an improvement in patients suffering from overgrowth of bacterial. In addition, the mobility and movement in the small bowel has to be improved by using prokinetics. Prokinetics in stimulating your MMC (migrating motor complex) of the small intestine, which helps prevent the recurrence of infections and recolonization. I advise patients to take them when they’ve finished their initial treatment with antibiotics, they may look into prokinetics. These fall under herbal alternatives like Iberogast drops that are a good option to take at night or pharmacological treatments, such as an infrequent amount of Resolor (prucalopride) in the evening. I also recommend patients look into the use of digestive and pancreatic enzymes while striving to improve the small bowel’s environment after treatment to avoid SIBO from recurring.
Diabetic Control for SIBO
In a few patients where these measures have not been effective, one could think about more strict dietetic elimination, such as eating the essential diet. We must admit that this option is reserved for those suffering from persistent symptoms that are not resolved despite three to four cycles of antibiotics and the inability to test the lower FODMAP diet. In its simplest form, it is one comprised of a liquid formulation which contains digested carbohydrate, proteins and fats. It’s been used for a number of years for treating illnesses like Crohn’s disease. The essence of the diet is that the above ingredients are taken in very fast through the digestive system. This can be beneficial for patients suffering from an overgrowth of bacterial organisms as there is no need for food items to remain in the small intestines in order to generate gas for the unwelcome overgrowth of bacteria. The elemental diet is the ability to provide nutrition to the patient while reducing the bacterial. The implementation of the elemental diet is usually carried out under the supervision by one of our experienced dieticians. Patients take a drink instead of their normal meals for 2 to 3 weeks, based on the nature of their symptoms as well as their medical history. It should be noted that there aren’t any high-quality research regarding the effectiveness of the elemental diet, but there are a few studies that have proven that in certain patients following fourteen days on the diet, there is an 80% response and a positive breath tests following treatment. There are obviously some drawbacks to this, and the main one is the issue of acceptance; it is very difficult to restrict one’s consumption of fluids for 2 weeks.
Probiotics
There is a great deal of concern about the importance of prebiotics and probiotics over the past 10 years and I am often asked by patients if they play a part in treating bacteria overgrowth. The exact function of probiotics in the treatment of SIBO is not clear and requires to be established. It is evident that replacing the unwanted bacteria with healthy bacteria which is essentially having an effect that is beneficial to patients. However, I recommend caution when using of probiotics in the treatment of an overgrowth of bacterial, as it may in certain patients cause the problem to be little bit worse over the course of a short time.
Copyright – Classicalnet