I’ll never forget the frustration I felt when I thought I had found the answer to my health struggles – whether it was finding out I had Celiac and starting a gluten-free diet, or being diagnosed with a parasite and starting treatment – only to have my health fall apart again.
It wasn’t because I didn’t want to get better. It wasn’t because I wasn’t trying hard enough.
The real issue is that gut health can be incredibly complicated. And SIBO (small intestine bacterial overgrowth) may be one of THE most complex gut conditions out there.
If you have SIBO, but you’re not getting better, I have something for you today.
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Meet Brie Wieselman – she is a dear friend of mine and an absolute expert on SIBO and gut health.
Brie is one of our recommended practitioners and someone I would trust my own health with.
She’s been generous enough to share this powerful blog post answering one of the questions we get all the time: “Why isn’t my SIBO clearing up?”
When Cara came to see me, she had just fired her 6th doctor.
She had struggled with painful bloating, constipation, and hemorrhoids for the last 10 years. Figuring out what to eat felt like trying to find her way out of a maze with her ever-increasing food reactions.
Being 26 years old with chronic acne and yeast infections didn’t make her eager to get out there and date, despite wishing she had a partner. But the worst part was the debilitating depression and panic attacks that got worse each time her digestive symptoms flared.
Her last practitioner had given her a Lactulose breath test to check for Small Intestine Bacterial Overgrowth (SIBO), and it had come back positive – with very high levels of both hydrogen and methane.
A SIBO diagnosis made sense to Cara – she knew that her symptoms had first appeared after several years of taking antibiotics for teenage acne, and had snowballed after a bad bout of food poisoning.
She was overwhelmed with relief to finally have a diagnosis and a treatment plan.
Cara started the supplement protocol her practitioner recommended right away. At first, she felt better. But by the time the protocol was done, her symptoms were just as bad as before starting.
That’s when Cara came to see me.
She was feeling the way so many of my clients with SIBO do: doubtful that she ever would get better.
Do You Relate To This SIBO Story?
When you learned that you had SIBO, you probably felt a mixed sense of frustration and relief.
Relief, because all of your symptoms finally made sense. Frustration, because you’d heard how difficult treating SIBO could be. Diet changes… herbs… antibiotics… prokinetics… it is a lot to learn about, put into action, and manage!
You started a low FODMAP diet. Maybe you even found a practitioner, and they started you on a protocol of herbs and supplements.
Taking action helped you to feel empowered and you even start to feel better!
Your symptoms were improving, and may even have resolved. This was the best you’ve felt in ages! But then, the symptoms gradually return, and you feel like you’re back to square one, defeated.
You (and Cara) did everything “right.” You took the supplements, followed the diet… so why aren’t you healing from SIBO?
When You’re Doing Everything Right, But Not Healing from SIBO
I’ve spent the last several years working one-on-one with clients who have stubborn SIBO. I’ve learned that if you’re doing things “right” but not getting better, it’s likely one of these reasons:
# 1: You’re Not Treating For Long Enough
There is no one-size-fits-all treatment time for SIBO. The most important factor for deciding how long you should treat is what levels of hydrogen and methane gases were found on your lactulose breath test, prior to the 120-minute mark. (This is why sample collection is timed!) Standard protocols have a treatment length of 2 – 4 weeks. This can be effective in some cases, but more severe SIBO may require 8 – 12 weeks of continuous antimicrobial treatment to fully resolve.
#2: You’re Using The Wrong Herbal Treatment
A quick Google search will produce dozens of natural protocols that have been used to treat SIBO. But, it is important to know the type of SIBO you have (methane or hydrogen dominant, hydrogen sulfide, or mixed type), in order to treat it properly with herbs. This is why testing and proper interpretation is imperative. Using the proper dosage of each supplement is also critical to success, and this information is not always listed online.
#3: You’re Not Looking At All The Options (Rx Meds)
At this point, it is well known that prescription drugs, and especially antibiotics, may contribute to causing or worsening digestive symptoms, and other medical conditions, including SIBO. Understandably, you may be reluctant to use them.
However, it is important to know that everything is a toxin, taken in the right dose. Even water can be toxic if you drink too much of it at once.
Rifaximin is the most common prescription drug used to treat SIBO. It is an antibiotic with several unique properties. It is not absorbed into systemic circulation – it stays inside the intestines. This means that you cannot use Rifaximin to treat an ear infection; it would never get to the inner ear. Rifaximin is largely inactive by the time it makes it through the small intestine and into the colon. (This also means that it doesn’t upset the beneficial flora in the large intestine, leaving our good bacteria intact.)
To put it another way, Rifaximin is not associated with many of the negative side effects a normal antibiotic can cause. Dr Mark Pimentel, associate professor of medicine at Cedars-Sinai Medical Center, and a leading researcher in the area of IBS and SIBO diagnosis and treatment, says that he sees Rifaximin be effective in at least 70% of patients who have SIBO.
It certainly is not a magic bullet, but it may be worth a second look, especially if you have been leery of antibiotics in general. It could be a valuable treatment option.
#4: You’re Not Using Probiotics
You may have been told NOT to take probiotics while you’re treating for SIBO. If you’ve taken probiotics in the past, you may have even felt that they made your symptoms worse. (Especially true of d-lactate forming strains like acidophilus, which can actually aggravate pre-existing SIBO in certain people.) But some strains of probiotics are shown to be more effective at treating SIBO than prescription antibiotics! Stick to soil based organisms, spore based probiotics, or Bifidus strains to be safe.
#5: You’re Not Testing For Co-Infections
Many people with SIBO either haven’t had their stool tested for parasites and yeast, or have used panels that weren’t good enough to detect them. If you have one or more parasites and are living with yeast in your GI tract, you will generally not get a full response to your SIBO treatments. You will need to have these properly tested and treated to assist in the clearing of your SIBO.
#6: You’re Not Considering SIFO (Small Intestine Fungal Overgrowth)
SIFO (or small intestine fungal overgrowth) is commonly caused by Candida albicans or similar yeast/fungal species. A common scenario is to have a mixed pattern of Candida or other fungal overgrowth alongside of SIBO. It is possible to have identical symptoms while having one or the other, or a mixed overgrowth. While there is some overlap, fungal/yeast overgrowth tends to respond to different herbs, supplements, and prescriptions than are used to treat bacterial conditions. Since yeast feeds on sugars, using a high-glycemic elemental diet to treat SIBO will almost always worsen the yeast/fungal overgrowth aspect. Sometimes a more broad spectrum treatment is called for to treat the bacteria and yeasts that are causing symptoms to persist.
#7: You’re Following The Right Diet At The Wrong Time
In many people with SIBO, a low-FODMAP diet can definitely be a helpful way to manage symptoms. But eating low-FODMAP, or even just too low-carb, while treating the condition with antimicrobial agents can actually be counterproductive!
Studies show that using Rifaximin plus Partially Hydrolyzed Guar Gum (PHGG) is more effective at clearing SIBO than Rifaximin used alone. PHGG is a prebiotic, which means that it feeds bacteria. You would think that it would worsen SIBO by feeding the bacteria in the small intestine. But, the fact is that if you do not feed the bacteria or yeast while treating it, the organisms will go into “spore form” or dig deep into tissues where they cannot be treated properly. Feeding the bacteria causes them to reproduce. If you “feed the bacteria” while simultaneously using an agent that targets bacteria that are in their replicative phase, you’ll kill the bacteria off in much higher numbers.
In this way, prebiotics often improve the outcome of the treatment. Feeding the bacteria (either with a prebiotic like PHGG, or by including small quantities of better tolerated FODMAP foods) can be a good idea while taking herbs or prescriptions to treat SIBO.
#8: You’re Not Looking For Structural Issues
Why do some people get SIBO and others don’t? There are lots of reasons, but a big (and often ignored one) is anatomical differences in their intestines. Structural concerns are not the most common cause of SIBO, but they do exist. And you can’t tell if you have them by looking at the results of SIBO Breath Testing.
It is important to consider this as a potential contributing factor when a case of SIBO will not resolve after several attempts. Changes in the intestine, like strictures, a blind-loop resulting from a GI tract surgery, or problems with the ileocecal valve provide an ideal environment for bacterial colonization and overgrowth.
#9: You Think Clearing SIBO Is Just “Killing The Bad Guys”
This is the most common reason behind stubborn SIBO that just won’t go away. Many treatments for SIBO treat it like they would a parasite: they just want to kill the bad guys. But treatments that only consist of killing the overgrowth are incomplete and neglect to take in the body as a whole.
To unpack this a bit, we have to recognize that SIBO isn’t an infection that we “pick up” from somewhere out in the world, but rather a situation that arises because the terrain of the gut has changed so that it has become a place where bacteria are now able to thrive.
While our GI tract is designed to house trillions of beneficial bacteria in the large intestine, the small intestine is supposed to be relatively sterile. This balance is kept by several body functions. If one of them is not working properly, it can lead to changes in the terrain that will allow SIBO to develop.
Any of these issues can be either root causes of SIBO or unaddressed factors that are preventing you from long-term healing, even when you kill the bad guys:
Insufficient digestive secretions (bile, stomach acid, and pancreatic enzymes). Pancreatic enzyme insufficiency and inadequate stomach acid or bile production all set the stage for less-digested proteins, carbohydrates, and fats moving from the stomach into the intestinal tract. This means less nutrition for you, but is also more fermentable matter for the bacteria to help them proliferate.
Dysfunction in the Migrating Motor Complex (MMC). The MMC is responsible for cleaning the small intestine, specifically between meals. It functions like a broom or conveyor belt, sweeping bacteria, undigested carbohydrates and fibers that might feed bacteria, out of the small intestine and into the colon where they belong. If the MMC isn’t functioning correctly, undigested particles stay in the small intestine, becoming more food for bacteria.
Re-establishing proper motility and MMC activity is critical to your recovery from SIBO, as well as for preventing it from recurring. There are many ways to encourage the proper pattern of gut motility. Using either an herbal or prescription prokinetic agent during or after SIBO treatment is standard. But many therapies (like abdominal massage, acupuncture, and neurological chiropractic) can enhance the benefits.
Weak vagal tone. The vagus nerve is the main controller of the MMC. When it becomes “weak” (from trauma or stress, commonly) the function of the MMC is compromised. Physiologic approaches (like probiotics, prokinetics, abdominal massage, pelvic floor therapy, biofeedback, acupuncture, gargling, or chanting) are often helpful in restoring vagal tone.
But sometimes it is more important to find ways to gently face into the underlying mind-body issue that may be perpetuating the infection. Therapy, hypnosis, MBSR (mindfulness based stress reduction) and other approaches that address trauma and support the mind-body connection can prove to be indispensable in these situations. Oftentimes, the experience of having SIBO can provide an opportunity for deeper exploration of what is living in our hearts, minds, and spirit that is unresolved.
HPA-Axis Dysregulation (aka Adrenal Fatigue). Dysregulation of the HPA-Axis leads to imbalanced stress-hormone levels (especially cortisol). Having cortisol levels that are chronically either too high or too low can lead to reduced levels of immune secretions in the gut. Dysregulated cortisol can alter digestive secretions, compounding any infection. It can also slow down repair of the tissues that make up our stomach and intestinal lining, leading to leaky gut. It is important not to jump into treating HPA dysregulation without testing, as symptoms can be confusing and overlap.
Compromised immune system. A major cause of SIBO is digestive immunity that is compromised. Almost 90% of your total body immunity is located in the GI tract. Anything that suppresses or alters this immune activity can leave you more vulnerable to fostering bacterial growth where it shouldn’t be — in your small intestine!
Sympathetic dominance (constant state of “fight or flight”). If you are constantly in “fight or flight,” your gut is at a disadvantage. Chronic stress can stimulate the sympathetic branch of the nervous system (like having your foot constantly on the gas pedal), and suppress the parasympathetic branch (which is like the brakes).
We need both sympathetic and parasympathetic activity, in balance. The job of the sympathetic branch is to make sure you have the energy to get to a safe place. It prioritizes immediate survival and puts long-term building projects on hold.
Sympathetic dominance is known to slow motility; digesting the nutrients you’ll need tomorrow simply isn’t a priority if you’re running to save your butt, NOW! It also shuts down digestive secretions, and suppresses immune activity, while up-regulating inflammatory compounds. Not a good look when trying to maintain a well-functioning gut with a healthy microbiome!
Excess sympathetic nervous system activity will also suppress the parasympathetic branch of the nervous system. This side is the “feeding and breeding” side that promotes digestive and absorptive function and allows for repair and maintenance of the cells that form the mucous membrane of the gut lining.
Digestive-focused hypnosis, Heart-rate variability training, acupuncture, and meditation techniques, such as Mindfulness Based Stress Reduction, are a great way to give input to the nervous system and retrain it to kick off its shoes and relax a little.
Healing SIBO Is Complicated
Even if you know the experiences you have had that triggered your SIBO, the factors allowing it to persist are really the perfect storm. Optimizing the environment of the intestines, clearing out co-infections, personalizing your diet, enhancing motility, and promoting a healthy microbiome are all critical steps to fully resolving SIBO, for good!
Most of the above issues just require specific testing or some detailed detective work to diagnose. Addressing these underlying issues can make or break the success of your treatment.
If this article resonates with you and you need more help to get rid of SIBO for good, please contact my office to set up a FREE 15-minute consultation.
Many thanks to Brie for sharing her expertise on SIBO with us.
Healing SIBO is really complex – and it’s much easier with the guidance of a true pro like Brie.
If you’re ready to get the kind of one-on-one, targeted healing only a skilled practitioner can provide, find out how you can work with Brie here.
P.S. Did you enjoy this guest post from one of our recommended practitioners? What else would you like our recommended practitioners to write about?