Below please find a living document that summarizes the key information around Small Intestinal Bacterial Overgrowth ("SIBO"). Please comment with any additional information or research for inclusion consideration. Version 1.0 is summary material; I will be adding more details and citations for specific studies.
SIBO, as the name implies, occurs when bacteria overgrow the small intestine. The small intestine should have a low concentration of bacteria due to the presence of stomach acids and peristalsis, the wave-like muscle movement in the intestines. For context, stomach and proximal small intestine would typically have about 103/mL of bacteria, while the terminal ileum (end of the small bowel as it gets close to the colon) about 109/mL (or 1,000,000 times more), and the colon about 1012/mL (or 1,000,000,000 times more).
The overgrowth of this bacteria will present with a number of symptoms:
Bloating after eating ("postprandial") - most common symptom
Flatulence, often malodorous
Loose, watery stools (more common in Hydrogen-dominant SIBO)
Constipation (more common in Methane-dominant SIBO)
Absorption problems
Weight loss / inability to gain weight
Fat and fat-soluble vitamin deficiencies, particularly Vitamins A, D, and K
Floating stools (from fat malabsorption)
Vitamin B12 malabsorpiton
Protein and Carbohydrate malabsorption
Systemic problems
Overgrowth of bacteria in the small intestine can increase production of toxins and intestinal permeability
This has been less studied, but less serious effects include:
brain fog
confusion
anxiety
depression
More serious complications can include
hepatic encephalopathy
D-lactic acidosis
nonalcoholic fatty liver disease
Various conditions have increased correlations, including
Rosacea
Eczema
Food intolerances
I will split this section into practical steps and clinical diagnosis.
Practically, a gastroenterologist will typically rule out other conditions first:
Physical exam
Colonoscopy and Endoscopy
Abdomen ultrasound
Stool test for parasites
At that time, if your symptoms match SIBO, your doctor may go directly to treatment. But otherwise these are the clinical tests:
BREATH TEST
This is the most common diagnostic method due to its low cost and limited invasiveness. Unfortunately, studies have been mixed on the sensitivity and specificity, with ranges between 30% and 75% -- hence why some doctors skip the test and go directly to treatment.
There are a number of preparations:
Antibiotics avoided for four weeks prior
Prokinetic drugs and laxatives avoided for one week prior
Complex carbs avoided for 12 hours prior
Exercise and smoking avoided day-of
For the actual test, you'll measure hydrogen and methane levels at baseline. Then drink either 10g lactulose or 75g glucose with one cup of water. Then your breath is measured every 15 minutes for 120 minutes.
There's some art to identifying a positive test; one semi-official criteria is:
methane level of >= 10ppm at any time during the test; or
hydrogen that increases >= 20ppm above the baseline level
Recently, new research has been investigating another typo of SIBO, that's dominated by Hydrogen Sulfide. Unfortunately, traditional breath tests cannot identify this gas, and someone with "flat-line" Hydrogen and Methane symptoms could be suffering from Hydrogen Sulfide SIBO. This version is typically characterized by "rotten egg" smelling gas, and may be worsened by eating high sulfur foods.
CULTURE
Historically a jejunal aspirate was done and concentration of bacterial colonies were measured, with an elevated level of > 103/mL being positive for SIBO. There are a number of issues with this:
overgrowth may be patchy, and a single sample may miss it
not all SIBO bacteria can be cultured/identified
samples can be contaminated during/after sampling
Antibiotics
The current best practice prescription treatment is:
Hydrogen-dominant: Xifaxan, typically 550mg x 3 times daily, for 10-14 days. Studies have shown Xifaxan alone can be 50-65% effective, but Xifaxan + 5g daily of Partially Hydrolyzed Guar Gum can be 80%+ effective.
Methane-dominant: Xifaxan (550mg x 3 daily) plus Neomycin (500mg x 2 daily) for 10-14 days. The use of PHGG for methane-dominant has not been evaluated, but it's likely to be beneficial.
Mod's note-- personally, if your doctor is onboard, I think dosing with Xifaxan + Neomycin + PHGG is the best way to "cover your bases". The best place to find PHGG: https://sunfiber.com/products/
Important: because these antibiotics only operate selectively in the GI tract, and are NOT absorbed by the body, they are unlikely to cause the systemic issues associated with antibiotic use, making them safer. Additionally, Xifaxan crystallizes before it gets to the large intestine, meaning it should not affect the all-important microbiome.
Herbal Therapy
Additionally, studies have shown similar levels of success with over-the-counter "herbal" treatments. Two options; I believe each are two capsules twice daily for four weeks, but please confirm:
Dysbiocide and FC Cidal (Biotics Research Laboratories, Rosenberg, Texas)
Candibactin-AR and Candibactin-BR (Metagenics, Inc, Aliso Viejo, California)
Remission
Unfortunately, SIBO has very high rates of recurrence. Some possible ways to reduce recurrence chances:
Switch to a low FODMAP diet for 6 weeks after treatment, to starve any remaining bacteria and prevent regrowth
Incorporate a prokinetic, such as low dose Naltroxene, erithromycin, or even over-the-counter products such as Iberogast
Many people can avoid symptoms of their SIBO by switching to special diets, sometimes very restrictive ones. This is not a cure, but simply symptom management. A true cure addresses the underlying cause of the SIBO, and lets the patient eat "normally" without any effects (short of unrelated intolerances).
Hopefully this helps people, and I look forward to updating this and cleaning it up over time!
-nyc-reddit
The past 2 years, SIBO (Small Intestinal Bacterial Overgrowth) caused chronic inflammation throughout my body which led to a host of other issues that I am still dealing with. I read so many books, took dozens of Labs, bought so many health supplements, and dealt with severe depression and anxiety on my 2-year journey of trial and error to try and heal my gut...
After 2-years and over $13,000 spent, I finally tested Negative for SIBO and I decided to make a video about how I beat it. For the first time in 2-years, I feel pretty freaking good. If you or your friend is having IBS/Gut issues, I hope this video helps some of you heal fast. Much Love💙 - Ian https://www.youtube.com/watch?v=bpNJdnRQInw&feature=youtu.be
Oh man, this really hits close to home for me.
Started off as relatively minor digestive issues (gas, occasional diarrhea) that I attributed to overtraining. Eventually, it got so bad that I had a hard time even going to the grocery store without feeling like I was going to have a panic attack. My joints were so unbearably sore, I had insane fatigue and so on and so on…
Luckily the low FODMAP diet and herbal antibiotics have drastically reduced my symptoms to the point that I’d consider life changing. But thanks to your video, I’m now thinking of diving in on 2-3 weeks of the elemental diet to hopefully entirely kill this shit off and feel 100% for the first time in years. Cheers for the great, informative video! 👍🏻
Should be changed to:
Loose, watery stools (more common in Hydrogen-dominant SIBO)
Constipation (more common in Methane-dominant SIBO)
Source: I'm someone with Hydrogen dominant and constipation, we're out here.
Noted. What were your breath tests results like, if I may ask? (baseline and peaks)
Hi canige, I specifically referenced only the herbal remedies that I have read about that were successful in peer reviewed studies. Notably: https://www.ncbi.nlm.nih.gov/pubmed/24891990
I'm sure people have anecdotal evidence, but I haven't seen studies showing the effectiveness of any of those substances. In fact, searching PubMed shows 0 results for "SIBO" and any of those three items you mentioned. So proceed at your own risk.
A brief sentence explaining the difference between remission and cured might be helpful - I was initially confused by why the section on remission would start with "unfortunately." Maybe high rates of recurrence is more accurate? I'm not sure.
Whoops, complete brain fart while rushing. Will correct tonight!
Really helpful of you to put this together. Thank you. My suggestion for the future would be to mention Hydrogen Sulfide SiBo somewhere, it can be part of the puzzle. Thanks again.
Noted, and added. I just read some more about it; that's such an unfortunate additional manifestation, given the inability to detect it. Do you have any experience with it?
Does the guar gum need to be partially hydrolysed? What does that mean?
Yes, it does. Studies have used the "SunFiber" formulation, which has a list of products here: https://sunfiber.com/products/
Hey! Thanks for this, just made a post 5 days ago with my breath test results showing high hydrogen and methane levels (also had a HIDA scan the day before which showed low gallbladder function). My doctor FINALLY got back to me and his email just states he wants me to go on Docycyline for 2 weeks and that's it.... Nothing about further testing/labs, lifestyle/diet changes, supplements, etc. I've had stomach pain for over a decade, and the strange thing is I was on Doxy from ages 16-22 for acne and have been on/off and taking it for 1-6 months at a time from ages 22-26 but haven't taken it since (now 29). Doxy made me throw-up and I would always be nauseous for an hour after taking it, it did help my acne since they stated I have bacterial/inflammatory acne. My dermatologist has suggested going back on Doxy but I have held off.
Do you think it's worth replying asking about Xifaxan + Neomycin + PHGG or trying to find a new doctor at this point?
It's always worth asking! I'd link him/her here when you do that: https://www.ncbi.nlm.nih.gov/pubmed/19996983/
Do you know anywhere I can find information about the percentage risk of hearing loss when taking this dose of neomycin?
I haven't seen a specific number, but the usual precaution is not to use it "for too long with too high of a dose," and since it's used for other conditions with much higher dosage (4-12 g/day), I felt comfortable with the smaller dosage for the limited time period.
It's pretty much zero since it's not absorbed like traditonal aminoglycosides.
A couple dumb questions ;
Do you have to take all four herbal remedies at the same time? And is it for the same 14 days as the antibiotics? Are they effective for both hydrogen and methane?
Does the bacteria treated with the herbal method have the same reoccurance rate as you would have if treated with antibiotics?
Is a really bloated area under the belly button that juts out all weird looking a sign of SOBO? Also everytime I burp it seems my stomach just fills right back up with gas. Is that a symptom of SIBO?
thanks
Typically you’d take one pair or the other. So Dysbiocide + FC Cidal OR Candibactin-BR + Candibactin-AR.
There isn’t much research on reoccurrence rate when it comes to the herbals. However, in this study, the herbals actually did work better at initially killing off the SIBO: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030608/
Yes, abdominal distension, bloating and cramping can all be present when suffering from SIBO. That said, you’ll want to get one of the tests to confirm.
So glad you’re putting this together. This may be a dumb question, but why the different bacteria estimations in the large intestine and colon? I thought they were the same body part.
Not a dumb question-- that was carelessness on my part! It should be 103 in the stomach and proximal small intestine; 109 in the terminal ileum (end of the small bowel as it gets close to the colon); and 1012 in the colon. I will make those edits later. Thank you!
hi NYC, great post, thank you for taking the time to compile it and share it with the community.
I had one question regarding the current best options for methane dominant SIBO. I read an excellent post on Medium - https://medium.com/@stkirsch/insights-from-mark-pimentel-on-the-treatment-of-sibo-c091bb5aa00
This post claims that the current best practise for m-dominant SIBO is actually Rifaximin + Flagyl, not Rifaximin + Neomycin. Do you have any idea on whether that is still accurate?
I'm going based on this article, which was co-authored by Pimentel himself, and is clearly titled, "A combination of rifaximin and neomycin is most effective in treating irritable bowel syndrome patients with methane on lactulose breath test"
It's been a while since I wrote this sticky, so I don't recall off the top of my head any studies with Rifaximin + Flagyl. If you have them, could you send them over? Even though Dr. Pimentel is an incredible doctor, unless he can point to double blind placebo controlled studies for his treatment regimen, I'll have to assume it's just like any other doctors'-- a bit of intuition.
Hello, i've been diagnosed with sibo and now i'm on a rifaximin treatment that shouls last 2 weeks. After one initial episode of watery diarrhea, i started to feel better and now i can eat more fruits/insoluble fibers but i'm still having trouble to digest fatty foods. My question is: will my body start producing more enzymes to digest fats as time goes by, or do i have to get something to "train" it release them? (i'm already taking digestive enzymes but without hcl)
Hi, thanks so much for this! I also recently found this, which may be helpful: https://kresserinstitute.com/prebiotics-probiotics-kids-sibo/
It describes using pre and probiotics right after the administration of antibiotics.
I'm wondering if you'd read anything about a clear liquid cleanse being useful pre-antibiotics? I guess I'm wondering what I might be able to do to boost the effectiveness of them when I finally take them. I'm searching around but coming up with little, and my doctor doesn't know (my gynecologist actually got me the prescriptions).
What if I only have 1 symptom: Bloating?
Other possible symptoms I might have:(I am not sure if this is a symptom or something else) Strength weakness, muscle gains almost non-existent, brain fog, concentration problems, looinsg hair.
Since then I don't eat dairy, my stool isn't fat/watery/slimy. According to a study, people who take isotretinoin to fight acne, are more likely to get digestive issues. Does this mean: Isotretinoin -> LI -> SIBO?
Great slide deck with detailed overview from Siebecker, although about 2.5 years dated. Info still seems pretty up to date.
Here's another good data source https://sites.google.com/view/sibo-notes/
Do any of you folks have a good protein powder that you would recommend that doesn’t make you bloat like crazy?
I’ve dealt with hydrogen SIBO off and on for the last few years - I treat it and it always seems to come back despite prokinetics etc... At the moment I’m managing my symptoms mostly through diet and I’m eating a modified low fermentable diet for the most part.
I’m sensitive to gluten, cow dairy, and eggs. I’m using hemp seed protein right now and it seems ok for my system but it’s not all that high in protein. I’m a weightlifter and looking to up my protein intake as I train more. Any recommendations out there?
A year ago in acute stress I developed gastritis and then bloating and bowel issues with horrendous insomnia and hot flashes.
It’s waxed and waned and I tested positive on breath tests for methane and hydrogen levels being high.
Xifaxan did nothing. Then I tried ceftin 6 mos later with some help as well as motegriry.
I did random microbials like oregano oil Allicin and Berberine too.
Where I’m dumb possibly and I’m concert with the two gastros is there was ZERO effort paid to diet.
Fast forward to now and my insomnia and stress are the worst it’s been my entire life and bloating as come back and despite not being constipates this round my stools alternate from well formed to floating (probably from excess gas).
Clearly the culprit is stress/trauma but the physical gastro issues are causing insomnia and I’m thinking it’s time to do low fodmap. I sent recent bloodwork to a dietitian and meeting with her Monday.
What should I expect and ask for? If I can reduce bloating and stool issues I believe insomnia will abate and thus I’ll be able to build better habits to manage stress.
I’m dumb for never trying this. Thoughts?
Just started. My ND couldn’t give me an average of when it starts to work for most people because everyone has different reactions. Thought I’d ask here.
Side note, thanks to everyone here who encouraged me to leave the GI MD who said prokinetics were “way too radical for someone your age”. Took two rounds of antibiotics that worked amazingly well but after a month of feeling great the SIBO always came back because the underlying issue was never resolved. She said antibiotics and laxatives are “the standard protocol” and sent me on my way. So grateful for everyone here telling me I’m not crazy to look elsewhere.
I’m trying to make a grocery list and really want to start planning my meals to heal and keep my gut healthy. Any recommendations or sources for plans? I struggle a lot with brain fog and low energy/anxiety alternating so I know protein is important. I can’t eat eggs. What foods/brands do you suggest for a well rounded diet?
Sooo weird. Does anybody experience this? It’s not like hunger per say it’s like a feeling like I didn’t just eat. I just had chicken and potatoes for dinner, should be filling, I should feel full. But I don’t. But if I eat until I FEEL full I’d be eating way too much. Am I just crazy?! Lol
I saw a GI doctor at Tufts medical last week who told me to get citrucel to help regulate my bowel movements. Right now I’m doing candibactin AR and BR and take triphala+magnesium to help with motility but still have a feeling of incomplete bowel movement and severe bloating. Sometimes I drink coffee to help me use the bathroom in the morning and then end up going from normal poops to diarrhea. I just don’t know if anyone has tried and had success with this fiber supplement?
Hi all, since Xifaxan + Neomycin or Atrantil didn’t work for me AT ALL. Has anybody tried Biotics method on getting rid of SIBO?
This is the protocol on their page:
Today we discussed our primary protocol for supporting those with SIBO (Small Intestinal Bacterial Overgrowth)! To support those with SIBO its best to think of this as two separate protocols that we switch between. One is for rebuilding gut bacteria and the other is for killing. To receive maximum benefit, it's best to switch between the two protocols every week.
Kill Protocol: ADP™: (3) 3x each day Dyscbiocide™: (2) 3x each day FC-Cidal™: (2) 3x each day
Rebuild Protocol: Lactozyme™ (2) 3x each day
SIBO is quite simply an imbalance of gut flora. To balance it is best to kill off excessive “bad” bacteria and work on promoting healthy bacteria. It typically take 2-3 rotations of this protocol to bring relief. So we are looking at around a month and a half protocol. We have many more protocols located on our Facebook Page as well as on the Biotics NW webpage. Hope you enjoy the day and keep healing the world!
Would this be enough for methane dominant?
Willing to do anything at this point...
No doctor is even willing to consider SIBO.
Feeling hopeless :(
Thinking about trying out a round of berberine before I start an herbal formula (dysbiocide + fc cidal). Any succcess stories with it?
My doctor emailed the other day to say my latest SIBO's (hydrogen) test came back negative. Great news, right? I was so excited until today when I got the actual numbers. So according to the document anything less then 20 is considered ok, I blew a 23. Now I know it's only 3 points over but considering how often SIBOs comes back and how hard it is to keep away, I am very nervous about it.
Since my doctor referred to it as negative I assume she is fine with it and just wants me to move on and continue the low-fodmap diet. But part of me wants to call her out and say she is wrong. I don't want to go back on Xfaxian but my numbers have gone down by about 30 each time I did it, so maybe one more round would clear it for good.
Any advice on what I should do?
Anyone else belch (and I stress BELCH) from deep within, almost a hydraulic adjustment? What causes this? While I had IBS for 15+ years, I never had these belches until after amoxicillin, which lead to my SIBO dx. Is this part of SIBO? Or something else?
My understanding was that archaea created gas that was expelled through the lungs. Is extra gas expelled through the belches? I have very little wind.
I'm on day 11 of neomycin+rifaximin. My bowel habits are much better, but the belching and bloating is just as bad as ever. It's making me wonder if it's not from SIBO/archaea/dysbiosis. And if not—what causes these gnarly growling belches? Candida/SIFO?
FWIW, I was negative on the IBS Smart Check, so I shouldn't have altered motility from food poisoning (amazing, since I had hemorrhagic e coli). I also had a pretty unremarkable GI-Map—just showed a bacillus overgrowth, heightened zonulin, lowered iGA, and low lactobacilli.
They REALLY get going when I get hungry, which is even weirder.
I wrote down on a piece of paper how much I burp during the day. I wake up burp. Drink water burp. Burp while eating and after eating. I’m bloated, constipated and over it. I calculated what I wrote down for the day and I burped over 100+ times. I tested negative for h.pylori, celiac, crohns. Negative antibodies in blood test. Awaiting results to see if it’s a parasite. The only thing I didn’t test for yet is SIBO. Curious to see if others experience the same pain and discomfort. I’m curious on what your journey is. I would love to read what your symptoms were and how did you find out/treat it.
I’ve been on omeprazole since I was 18. I tapered off of my omeprazole at 26, and then started taking Pepcid 20 mg morning and evening. For the last 6 months I’ve been having intense nausea, mostly in the morning. I started getting intense gnawing stomach pain that felt like gastritis about two months ago. I’ve also been experiencing migraines around once a week. I used to only have them about once per month or every other month. I saw a gastroenterologist for these issues and they had me do an abdominal ultrasound. Results came back mostly normal. They told me I had a bit of sludge in my gallbladder. Has anyone experienced any issues similar to this? I’m not sure if this is GERD related, long term PPI use, or SIBO. I’ve seen a naturopath and they think it’s SIBO. I also took a blood test and they told me I had a gluten, dairy, and egg sensitivity. Which is weird because I’ve never had any issues with these foods in the past. But I’ve been gluten, dairy, and egg free for two months. I feel no better. Any ideas?
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