June 19, 2014

SIBO, small intestine bacterial overgrowth, is a hot topic right now. It is thought that most suffering from IBS and possibly even fibromyalgia, actually have SIBO. The current treatment for SIBO is an antibiotic called Rifaximin. I have been to at least four conferences where this treatment has been presented and one thing that the presenter always says is, ‘this antibiotic is okay because it is not well absorbed and only affects the small intestine.’ This seems to satisfy most of the practitioner’s fears that we are prescribing yet another antibiotic and now that we know that it doesn’t affect the large intestine, it is okay… but is it?

From time to time I hear incorrect assumptions about the small intestine versus large intestine, when it comes to gut flora. If you have read any articles about the flora in your gut, it is almost always referring to the large intestine.

A quick anatomy lesson – your stomach, which is up behind your ribs, empties into the small intestine – there are three sections in the small intestine – the first section is called the duodenum, the middle small intestines is the jejunum and the third section of the small intestines is the ilium. The ilium junctures with the large intestine right by your upper right hip. The large intestine moves up your right side (ascending colon), goes straight across your body to your left side (transverse colon) and then moves down your left side into your bowels (the descending colon).

It is true that in the large intestine, at this juncture point where the small intestine meets the large intestine, that we find the largest amounts of gut flora. This is where you recycle digestive enzymes, assimilate and absorb fat soluble vitamins… you could call this the last stage of digestion. Here’s an interesting fact, your bowel movement is 50% gut flora by mass. Think about how much turnover these flora must have to keep their colony levels up.

The point here, the small intestine is definitely not sterile. Let’s talk about the small intestine for a minute – this is where the majority of the immune system operates, the mucosal lining that protects your body from the outside world is one cell layer deep, this is the site of critical nutrient digestion and absorption and this is where food sensitivities are triggered. Matter moves through this area fast, so we don’t see huge colonies of flora here like we do in the large intestine, where matter moves through much more slowly.

Remember the three sections in the small intestine? In the duodenum, there are 1,000-100,000 cfu (colony forming units) of bacteria present per gram, in the jejunum there are 100,000-10 million cfu/ g and in the ileum there are 10-100 million cfu/ g (this is per gram – this is definitely not an insignificant amount of flora). In the small intestine we see bacteria present in the millions. When we look at the large intestine we see bacteria present in the billions. So you can see why there is an emphasis on the large intestine when discussing gut flora.

In the small intestine, Lactobacilli are the dominant flora in the duodenum and jejunum, and bifidobacteria is the dominant flora in the ileum.

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The consequences of SIBO are that gas producing organisms take up residence in the small intestine and cause inflammation, systemic immune responses, digestive unrest and simply unpleasant gut reactions pretty much every time the person eats. SIBO organics are gas producing –hydrogen gas producing, methane producing or hydrogen sulfide producing. For those with methane producing issues, this isn’t a bacteria overgrowth, in fact the organism isn’t a member of the bacteria family at all; it is another species called Archaea group called a methanogen.

SIBO treatment does not often include probiotics. The common assumption is that this is a bacteria overgrowth and that you will need to take an antibiotic to knock it out. So why would you take a probiotic and risk putting more flora in that area??

Here’s why – SIBO becomes an issue because of stress, antacid use, low stomach acids and dysbiosis (an imbalance of gut flora) in the small intestine. If there is no biofilm layer of lactobacillus in the duodenum, then the preferred pH of 6.5 – 7.5 will not be obtained. The surface will become more acidic and this will lower the body’s defenses.

Now, I do not recommend massive dose probiotics (really larger doses of probiotics do not mean that the probiotic will work better), I don’t recommend spore forming soil probiotics either, as these have the ability to turn pathogenic. Feed the gut what it prefers to have in this area to heal the area and address the inflammation that SIBO created. This will only be corrected and prevented from reoccurring when the dysbiosis is addressed. If this is not addressed and antibiotics are used without a replenishment phase, then what this will do is further damage the small intestine and it will open the door to everything that we see with chronic gut inflammation – immune dysfunction, food sensitivities, metabolic conditions and autoimmune conditions, if genetically susceptible.

SIBO is present because of dysbiosis and a dysfunctional gut lining in the small intestine. Replenishing lactobacilli and bifidobacteria has to be part of the treatment. This should be free of FOS (prebiotics) – simply lactobacilli and bifidobacteria. I prefer a powdered probiotic that I titrate up slowly. If there is a gut reaction from taking these probiotics, this is simply shedding light on the fact that there is dysbiosis present and this has to be addressed.

I have heard SIBO being referred to as a chronic condition and frankly, I am not buying it. You can treat SIBO by bringing you digestion back into balance from the top down, addressing stomach acid levels, digestive enzymes, rebalancing gut flora and of course, addressing your eating and lifestyle habits. Stress is a big contributor to SIBO and SIBO reoccurrence. By treating the whole body, SIBO can be knocked out for good.

Angela Pifer is a Functional Medicine practitioner and licensed Certified Nutritionist. Seattle’s go to nutritionist, Angela, has been in private practice for a decade. Work one on one with Angela through her private practice www.NutritionNorthwest.com.

 

To leave comments on this post, please visit Angela’s new site that exclusively speaks to SIBO treatment SIBOGuru.com: http://siboguru.com/sibo-why-probiotics-are-a-necessary-part-of-treatment/

 

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Comments

from 67 people

Angela

A new article has been added at my site SIBO Guru - please visit: http://siboguru.com/should-probiotics-be-part-of-sibo-treatment/
Should probiotics be a part of treatment? Yes! I also discuss which probiotics you should not include (those that will do more harm than good). I look forward to your comments!

Angela | March 26, 2015

Angela

COMMENTS ON THIS POST ARE CLOSED. To leave comments on this post, please visit Angela's new site that exclusively speaks to SIBO treatment SIBOGuru.com
http://siboguru.com/sibo-why-probiotics-are-a-necessary-part-of-treatment/

Angela | March 25, 2015

Angela

Hi Michelle,

I can't tell you how many times I hear - 'I was perfectly healthy one day, and then it seems like everything went sideways' - SIBO causes issues on a daily basis. Left unchecked it can really reek a lot of havoc. If your adrenals are taxed, I recommend first addressing your adrenals, detox pathways and nutritional status. THEN you can start to address SIBO to a deeper level. From your post I am reading adrenal fatigue and hashimotos (autoimmune thyroid) - so you'll need to first get your body into better balance before you go deeper with SIBO treatment. Otherwise, SIBO treatment will further tax your system. Healing the gut pulls a lot of energy from the system. I realize that this is a catch 22 - if no SIBO, then the rest of the body wouldn't be reacting this way, yet - there is really a hierarchy of treatment, when it comes to addressing SIBO.

http://siboguru.com/when-your-mucosal-defenses-are-down-secretory-iga-and-treating-sibo
Angela

Angela | March 23, 2015

Hi Angela,
Thank you for replying to my questions. My doc thinks maybe all the anti-microbials and licorice root woke up a dormant virus. I am feeling a bit better, still really exhausted. Your suggestion of a low FODMAP diet is what I may be going to next. Currently, my diet is so limited, that to place me on a low FODMAP diet would give me few options. but I'm willing to try it! I am pre-diabetic (HbA1c 5.8/fasting BS high 90's-low 100's); Adrenal Exhaustion (low cortisol/DHEA); low T3 with normal thyroid levels and normal antibody levels. My weight is still up, which he believes is due to my insulin resistance. It's so weird because I've always worked out, lifted weights, taken very good care of myself. I went Paleo 4 1/2 years ago, and spent about 3 yrs intermittent fasting several times a week for 16-18 hours a day. I really think the IFing over stressed my body in ways I can't even imagine. I use to fast on bike rides that were 50 to 60 miles long, just drinking coconut water mixed with a scoop of whey protein powder. I thought I was doing myself so much good! What an idiot I am! What is the link to your article on Sig1A? Thanks so much for your input!
Michelle

Michelle | March 17, 2015

Angela

Hi Chris,

High S IgA means that there is chronic inflammation going on in your gut, that hasn't been addressed. This could be leaky gut, SIBO, dysbiosis, parasite, celiac... could be a combination of these as well. To address this, the root cause will need to be determined. If SIBO (and not the rest), then you'll need to address SIBO (I prefer to do this with herbs and diet) and then you would start the process of gut healing (l-glutamine would be part of this) and addressing flora balance (lactobacillus, bifido and s. boulardii are all part of this - but we need to focus on the right strains). Large doses of l-glutamine won't heal leaky gut. This is part of the equation, but this can only be addressed when the root cause for why leaky gut is present is also addressed.
Angela

Angela | March 23, 2015

Sorry for the typing errors my phone is auto correcting to what it wants to put lol my siga levels were very high. And would l glutamine bring my siga levels down??

Chris | March 16, 2015

Thanks for the reply Angela my siga levels from my stool test were very My guess is inflammation from the bacterial overgrowth (leaky gut). Would taking high levels of l glutamine bring my diva levels down as it repairs the gut lining. And would bringing my lactobacillus levels back in range possibly reverse my sibo???

Chris | March 16, 2015

Angela

Hi Lea,
I am sorry to hear about your struggles! I was carrying a higher than normal patient load since the start of the year and that took me away from having time to respond to comments on my posts. I hope that you have found a practitioner to work with. If you have not, I will help you. Please contact scheduling@siboguru.com and Sophie will help you arrange an appointment with me.

Angela

Angela | November 7, 2015

Hello Angela, Have been going thru heck the last 8 years. Finally diagnosed with sibo, did 2 rounds of Rifaxamin it seemed to work some, but now all the constipation and incomplete bm's are starting all over again. Along with some bloating and about 10 lb weight gain. I think from what i been reading that i have methane gas, but they only tested for hydrogen gas. I need help. There is so much I cannot eat for years because I get bloated or feel like i am short of breath, I have went to lots of doctors, please help. Lea

Lea | March 16, 2015

Cd da stool assessment

Chris | March 16, 2015

Angela

Hi Chris, Stress and lack of Lactobacillus are both big contributors to SIBO. If you don't have healthy colonies of flora, then you won't be able to keep the balance/ gut homeostasis.

Did you have the breath test to identify SIBO?

On the stool test, was your Secretory IgA low or high? I just did a post on this regarding its implications with SIBO. With such low Lactobacillus, it wouldn't surprise me if these was low.

Angela

Angela | March 16, 2015

So I finally got diagnosed with sibo I am in the military and this condition developed over seas during deployment high stress long working hours I have always had good digestion until 9 months ago I am working with an ND and my navel gastro my ND had me order a cuss stool assessment and sibo test revealing I had sibo but I also have a no growth of lactobacillus species could this no growth with the stress of military life be the root cause of my sibo and once I adress my lactobacillus count should I see remission along with a modified diet?

Chris | March 16, 2015

Angela

Hi Kenny,

I am sorry for what you are going through. While you actively have gastritis, I don't recommend HCL betaine/ pepsin or taking a digestive enzyme that has either of these in it. I don't dispense medical advice over email or through a blog post. What I would say to a patient who came to see me with gastritis, is to take 10-20 grams of l-glutamine (powder) in a liter of filtered water and sip this in between meals. This is one thing that I use to help heal gastritis - as well as being assessed for h. pylori, pull known irritant foods (coffee, caffeine, tomato, citrus). Love slippery elm and DGL licorice (Gastric Repair by Biogenesis is a good product)...

With regards to you having a strong reaction each time you try to 'treat' SIBO, whether probiotic or botanicals - you will definitely need a more targeted and gentle approach to treating this. The first goal when treating SIBO is to stabilize the body and then we would start to slowly and methodically treat SIBO. If you would like to learn more about how I work, programs and fees, please take a look at the new site that I just launched: www.SIBOGuru.com

Warmly,
Angela

Angela | March 16, 2015

Hi Angela

I found your article while looking specifically into 'archea' species and Sibo, as It's what I suspect I'm mostly dealing with due to the fact I have more problems on the constipation side, that isn't to say I don't go enough, usually three to five times every morning with painful gas/cramps preceding and following, usually becoming steadily worse as the day continues. This has been the case for a year, having become steadily worse since it began in 2012. I was tested for Sibo last year, tested positive, numerous antibiotic treatments, none of which lasted if they helped at all. I turned to natural antimicrobials and only ended up feeling worse from those, so had to discontinue. Have tried probiotics, I recently tried a bifido specific mix, and just ended up making things worse, tried for two weeks and just couldn't handle it. Recently had an endoscopy and found gastritis, prescribed rifaxamin, have not taken due to worrying over further worsening things, as well prescribed nexium. I want to see a naturopath doctor but can't afford right now as the initial visit is really really expensive. I've tried other probiotics but they never seem to really help, including align and a lacto bifido mix, very frustrated and tired of living from day to day having to deal with these issues that consume every waking moment, I never have any ambition to do anything and some days don't even want to get out of bed. I'm just not sure what to do, I've been taking slippery elm to help stomach heal, I have dgl licorice, sugar and stevia free but am afraid to start, I've tried using betain and digestive enzymes but only aggravate stomach, suspect they caused the gastritis. I'm just seeking advice, or curious about your consolation prices, as I'm just out of ideas on what to do to treat myself, I barely eat and have lost so much weight, no matter how healthy or little or much I eat I still struggle with painful gas and cramping. Any help is appreciated.

Kenny | March 14, 2015

Angela

Hi Michelle, That this was such a recent diagnosis and you are treating this with herbs and trying to rebalance the gut, really increases the likelihood of you being able to cure this for good. Regarding your weight - I wonder what set SIBO up in the first place? Stress, illness... etc, and if is just your body reacting to the increased immune reactions (added stress) going on in your system. From the foods you are listing you are still including a lot of fermentable sources of carbohydrates (that would feed these organisms). I would look more into low FODMAPs while treating this, but I go beyond this - none of the specialized diets were created to address SIBO. We really need to adapt them further...

I wouldn't expect the herbs or probiotics to trigger weight gain. I would talk with your doctor about your current symptoms - yes, these can be 'die off' and then can be something else. Check back with them since they know your case well. I don't find that everyone feels die off on the protocol - in fact, some people feel better taking it - BUT everyone is different. SIBO is a condition that warrants consistent support to really tease all the variables out.

Thanks for reading!

Angela

Angela | March 12, 2015

Hi Angela, I'm really enjoying your content. You seem more in line with my practitioner then other blogs I've read. I especially liked your take on SIBO that it does not have to be recurring and can be cured. That gave me a lot of hope. I was just diagnosed with SIBO in February. I'm on a strong anti-microbial (200mg oregeno oil 3xday) as well as a probiotic with 2 types lactobacillus and bifdobacterium breve. He started me on Sac B yesterday. My question for you: I have gained about 4 lbs that will not come off since starting this protocol. Is this normal? I am not a heavy person, but I was already at my top weight when I started the protocol. My diet is mostly grass fed beef, fish, organic chicken, lots of vegetables especially kale, broccoli, Brussels; sweet potatoes for carbs; berries and maybe an occasional Apple. No eggs, nuts, dairy, grains, nightshades, caffeine, alcohol, or sugar. I drink a ton of water, some green tea and a lot of herbal teas. My second question: I have felt awful for the last week. Am I experiencing "die off"? Or is it the large amounts of anti-microbials and probiotics I'm taking? I have no energy and no motivation. Is this normal at the beginning of a protocol in your experience? Thank you, Angela. I really appreciate your blog.

Michelle | March 11, 2015

Angela

Hi Ruthann,

My goodness - I am sorry for where you are at right now! Are you working with a health care provider on the protocol that you listed out or using info off the web to try to figure this out on your own (with respect - I understand that you are trying to figure this out because you aren't finding the help that you need)?

I would say, if you walked into my office, the first thing that I would work with you on is getting you stable - stopping the weight loss, making sure that your adrenals and detox pathways are supported and then we would start a protocol to address SIBO. The protocols need to be done in a specific way - the right dosages and timing, etc... but at the same time, we can't 'attack' SIBO if you are losing weight and if you aren't feeling stable right now. Gut rebalancing takes a lot of energy from the body.

As for the antidepressant drug - I think that some doctors don't know what to do with the symptom set of SIBO. How this can change by the hour... this really isn't in the diagnose and medicate realm. What you really need is to work with someone to get stable and then start the systematic process of addressing SIBO. This will take months to address, but you would feel more stable from the start and this would feel doable to you. Is it the holistic doctor that isn't taking your calls? Is there anyone else in your area? I do work long distance - if you can't find someone, I am happy to work with you.

Angela

Angela | March 12, 2015

Angela, I have been diagnosed with sibo. Trying to attract it from every end. Sadly I am getting nowhere. Taking digestive enzymes, Hcl, herbal antibiotics. Took xifaxan for two weeks,it did nothing. Taking a biofilm buster, interface plus. Changed probiotics,taking prescript assist.without probiotics I don't go to the bathroom. Following a scd diet. Eating basically protein and veg. I am five two ninth four lbs and going down. I am in constant pain. Trying to see if motility issues are the cause. Scheduled for atest called the smart pill. Found out the test has gluten in it. I am celiac. The dr. Has not returned my calls. Working with a holistic dr, and had hoped for some results. So far none. Was told an antidepressant drug may help. I am desperate. I have no life. This is consuming me twenty four seven. Help

ruthann | March 10, 2015

Angela

Hi Kristin,

I would look at a few things -to start, pick a probiotic that doesn't have any prebiotics (no 'FOS' 'MOS' etc). Then I would start with S. Boulardii. Open up the capsule and take 1/4 dose for a week and see how you do... move to 1/2 dose and so on. Once this dose is established, then I would add in a bifido (not lacto) probiotic first, following the same dosage suggestions. Choose a probiotic in the millions and not in the billions. Then, add in a lacto probiotic, but not one that forms d-lactate. You gut doesn't have the balance right now to handle this (all lacto probiotics produce lactic acid - two forms, l-lactate or d-lactate).

There is a lot to do beyond this, but hopefully this will get you started.

Angela

Angela | March 9, 2015

Hi Angela. I have SIBO and high levels of candida due to years of prescription antiobiotics and natural antibiotics. However, whenever I try any probiotics, either the capsules or in yogurt or kombucha, I get terrible brain fog and the worst depression from the fog. I can't think straight or concentrate, and whenever I cut the probiotics out the brain problems and depression go away. I also get extremely irritable and angry on probiotics, even very small amounts. Do you have any advise?
Thanks! Kristin

Kristin | March 8, 2015

Angela

Hi Rita,

Having to pull thiols definitely can make this a bit harder to address, but it is doable. Have you seen this site/ list? It is fairly robust:http://www.livingnetwork.co.za/chelationnetwork/food/high-sulfur-sulphur-food-list/ For SIBO, you wouldn't be emphasizing sulfur producing foods, so these two plans would mesh well. What I caution against, is that you are getting backed into a corner with very few foods choices. Overemphasizing only a few foods in your diet will create, over time, sensitivities to these foods. The underlying mechanisms still need to be addressed, healed and rebalanced.

Angela

Angela | March 9, 2015

Dear Angela,
I am desperately in need of help. Not only do I have SIBO I also am highly sulfur sensitive (sulfur producing thiols). I also have MCS with all sorts of accompanying food and chemical reactions. One doc told me I have candida, another did a blood test that came back neg. Right now I am living on chicken, turkey, Jasmine rice, millet, (both 1/4 c. raw) carrots, beets, bone broth, and some vegetable juices (cuke, carrot, beet, celery, ginger). I throw in a buffalo burger once in a while for variety. I had very high levels of mercury which I am told are now down to normal. I question that testing as it was not done by hair testing. Both docs I am seeing right now are discouraging me from taking supplements that would help with the detoxing such as selenium and molybdnum. That is a brief history. I really need ideas of what to eat. Am hoping you can give suggestions or other places to try. All of the diets I have looked at so far emphasize much in the way of sulfur (thiol producing foods) which leave me about where I am now. Thank you for any help you can offer

Rita | March 7, 2015

Angela

Hi Ankit,

I hope you have found some relief from your symptoms!! Cipro can be really harsh on the gut. There is a lot to do here to treat, rebalance and address your gut symptoms. If you are still in need of support, please feel free to reach out through scheduling: http://siboguru.com/contact/

Warmly
Angela

Angela | July 23, 2016

Hello Angela..Its Ankit from India.. In october 2013 I had an endoscopy n helicobacter pylori and antral gastritis were detected.. then I was on rabeprazole and levosulphiride for about 10 ..then I had diarrhoea.. I took a lot of antibiotics without prescription.. I felt vary good after each course but symptins reoccur.. in september 2014 when I was taking cipro I had diarrhoea continuously.. from that day I still have lots of discomfort.. also took xifaxan but not much improvement.. m suffrring with leaky gut.. undigested food particles in stool.. I think I have bacterial imbalance.. please help me.. kindly provide me your email id for personal treatment

Ankit | March 4, 2015

Angela

Hi Izzy,

I recommend starting with Saccharomyces Boulardii first and then shifting into other probiotics - no prebiotics now, non soil organism probiotics and stay away from lactobacilli strains that have the propensity to form D-lactate instead of L-lactate. I am offering suggestions here to chat with your health care provider about. I can't offer exact protocols over email or in this comment section - each SIBO patient that I work with is complex and my approach is different with each one. It is best to work with a health care provider to get targeted support. I usually run a digestive stool test to look at beneficial/ unbeneficial flora levels as well as assessing the mucosal immune response...etc. Assess past and current factors, conditions, symptoms... this is a complex issue that needs to have targeted therapy to successfully address.
Angela

Angela | February 27, 2015

Hi Anglela, thank you for your reply! I'm still a bit confused as to what I should be taking if I really want balance the levels of gut flora? Also what are herbs specifically?I've been taking Probio 7 which do contain FOS. Thanks, Izzy

Izzy | February 27, 2015

Angela

Hi Jen,

Wow - they really came at the skin condition with all they had. Sometimes antibiotics are necessary - I am definitely not anti- antibiotics. I simply want to keep them handy for the scary stuff and not for things like SIBO. Were you also on steroids? It is possible that the antibiotics shifted your gut flora to a large degree, but I would expect you to see changes in your health over time from this and not within one year. I wonder what else changed for you at the time? It may have been the stress of the situation, strong antibiotic use, plus? that triggered this.

SIBO tests are always good to try, but it everything else has been ruled out and you still have classic SIBO symptoms (even with a negative SIBO test - these are not affective on everybody) then I would work with your health care provider to treat this empirically. That said PLEASE do not look to address this with more antibiotics. Antibiotics do not cure SIBO. They never have. We have to look at this as an extreme imbalance that needs to be rebalanced and not an infection that is wiped out by an antibiotic.

I you don't find the support that you need to address this, I work long distance.
Best of luck to you!
Angela

Angela | February 26, 2015

Hello,

Thank you for your work. I was wondering if it is possible to gain a lot of weight (after an intense five day treatment for a skin infection with SIX antibiotics) I was always 110 and have gained 20 lbs in a year eating the same or less a times. I have tested negative for SIBO but my functional DR. thinks I do have it. I eat only meat and fat and some veggies. Any fiber seems to do me in pretty rapidly (W/in two hours). I am feeling fat and hopeless at this point.

Jen | February 25, 2015

Angela

Hi Izzy - do the probiotics that you are taking, have prebiotics in them? Do they have FOS, MOS or DOS or inulin or list an 'added fiber'? I would start with Saccharomyces Boulardii - one of my favorites is by Klaire Labs.

If probiotics make symptoms worse and/ or if added fiber makes symptoms worse, these are two telltale signs that SIBO has not been fully addressed. I would get evaluated to see if SIBO is still present and then put a plan in place to address the with herbs, rebalance the gut, address the factors that set this up in the first place and rebalance flora. Antibiotics never balance gut flora. Never. They will knock things down and often times, make things worse. To the degree that SIBO will be harder to address long term and that it will be harder to balance the flora after their use. That said, probiotics will not fix 95% of SIBO cases. The small intestine houses a delicate ecosystem that needs to be addressed on many levels.

Warmly,
Angela

Angela | February 26, 2015

Hi Angela, I'm an 18 year old student and in the last 5 months I've been experiencing symptoms including bloating and gas and have started taking probiotics to try and balance the gut flora. I found this video very helpful and interesting but I have a couple of follow up questions. I've been taking them for about 3 weeks now and my bloating seems to be getting worse. My first question was, is it possible that it is getting worse because the probiotics are working, and if so how long will it take to see positive effects? and my second question is, is it necessary to have antibiotics to balance the gut flora or can it be done solely using probiotics?

Izzy | February 25, 2015

Also have lost a lot of weight and can't seem to gain. All tests (Endoscopy, EUS, Tumor markers) all come back just fine.

Mary | February 20, 2015

Angela

Hi Mary, I am sorry to hear about your symptoms. Though many people with SIBO feel better while on antibiotics, antibiotics do not cure SIBO. They may knock down the overgrowth, but they don't do anything to address why SIBO was set up in the first place, they don't help to rebalance the gut and heal this system and what I find is that antibiotic use actually makes rebalancing the system harder in the long run (meaning that once you start antibiotics to treat SIBO it is likely that SIBO will reoccur more often over the lifetime). Cipro is not an effective antibiotic to knock SIBO down. Xifaxan is - yet, it is also really expensive (if not covered by insurance) so I have seen some doctors use Cipro instead - but this is going to make things worse in the long run. I greatly appreciate your doctor's stance - that the doctor doesn't want to overuse antibiotics.

SIBO is a dynamic condition that takes time to heal with a multiphase approach to addressing SIBO, addressing diet, supporting digestion, addressing deficiencies with digestion and nutrition, gut healing, addressing immune shifts that occur at the mucosal level and rebalancing gut flora. This approach has to be customized to each patient. At least half of my current patient load is working with me to address SIBO. I work with this extensively. If you would like further one on one support I am happy to team up with your doctor to support you.

Warmly,
Angela

Angela | February 20, 2015

Breath test for SIBO was positive. Was put on Flagyl and Cipro for 10 days. Felt better while I was on the antibiotics but now am having a lot of stomach discomfort. No appetite and nausea. Pill for nausea helps somewhat. Quality of life is greatly diminished. Take one probiotic capsule a day and also eat Activia. Dr. doesn't want to "overuse" antibiotics. Help!

Mary | February 20, 2015

Angela

Hi Elizabeth,
You are welcome - thank you for your post! I am currently working on a 16 video series (because it takes that many videos!!) on SIBO. Stay tuned!

Angela

Angela | February 20, 2015

I just found you today! Thank you for telling us something I, for one, did not know: that more [probiotics] is not automatically better. Countless thanks, Angela. - Elizabeth

Elizabeth | February 20, 2015

Angela

Wow. You have definitely tried to address this from many angles and even a fecal transplant - was this from your mother or a sibling (this is the only source of innate flora that would support your gut flora - you get your flora from your mom + environmental impact over a lifetime). I wouldn't expect Cipro to address SIBO. I would expect it to make addressing SIBO more difficult. Part of SIBO's ability to take hold is the gut already being in an imbalanced state. Cipro would add to this imbalanced state. FODMAP was not designed to treat SIBO (really none of the specialty diets were - they need to be further modified to pull fermentable compounds.

I would not try any more antibiotics or medications at this point (unless an acute diagnosis that needs immediate medical attention - simply stating that antibiotics and antifungals do not 'cure' SIBO and they may make it more difficult to knock out).

I respect what you have tried and the long process that this has been for you. I would try a more gentle approach of addressing symptoms and starting the healing process with the gut. Have you tried any of the prokinetics? What have you done to address gut motility?

Angela

Angela | February 8, 2015

Cipro x 2 round, xyfaxan x 4 rounds, metrinidazol x1 round, norofloxan X 1 round, 3 positive H2 breath tests, FodMap, elimination, low/no carb, every probiotic available to humankind, the entire healthfood store's herbals, accupuncture, yogo, Balinese healer, many doctors, fecal transplant... yeast treatments, fluconazole, nystatin, and the many varied herbal antifungals..

20 years now...

And you would suggest?

another desperate soul | February 7, 2015

Angela

Hi Amber,

That is young to get SIBO and it is absolutely possible. I agree with a slow approach AND this needs to be addressed. This will not go away on its own, anytime soon. I don't recommend antibiotics or herbal antimicrobials, or any prebiotics... instead, look at rebalancing the gut, pulling known food sensitivities (sounds like she starting to react when you reintroduced food, so this may be a sensitivity, it may be a lack of... innate digestive support and it may be both) and focusing on a low fermentable diet. I am not sure if you have already been looking at SIBO diets - FODMAPs wasn't designed to treat SIBO. It still has fibers in the plan, that will ferment. There are specific probiotics that work well that will start to rebalance the gut

I disagree with the GI doctor. Is the other doctor your primary care doctor? I am happy to work with you, but, with her age, I need to team up with another doctor that will be continuing primary care and support the protocol that we lay down. I'll reach out privately to connect with you via email.

Warmly,
Angela

Angela | February 5, 2015

Hi, my daughter Tatum is three and she has all the symptoms of SIBO. I have been to her pediatrician who diagnosed her with SIBO and then her GI that said this was something that every other person has and downplayed it. I am so frustrated!! I have one Dr telling me to change everything in her diet and give her supplements and the GI dr saying to not worry about diet and give her probiotics and prebiotics. The pediatrician says no prebiotics. Her tummy starts out flat and by the end of the day it looks like it's going to pop!! She has never had a normal bowel movement since I stoped breast feeding her at one. She lives in a loving stress free home, what do you think is causing this? I am so at a loss. Amber :(

Amber Williams | February 5, 2015

Angela

Hi Natalie,

I definitely hear your frustration. Thank you for sharing this with me. I am happy to set up a consultation to help you get to the bottom of this. I am looking forward to hearing more about your history and what you have tried - and when you did, what degree, if any, symptoms were addressed. I'll email you directly to schedule a consultation.

Warmly,
Angela

Angela | January 23, 2015

Hi Angela, I have spent two years battling SIBO after testing positive to a hydrogen breath test. I am 35, otherwise in perfect health, 120lbs and exercise regularly. I have spent hundreds of hours reading everything available online & in bookstores, been to 5 separate Gastroenterologists and tried almost every GI-prescribed antibiotic and probiotic (including Align & VSL3) with no reduction in symptoms, including Rifaximin & Metronidazole. I have a big plastic crate filled with herbal supplements & digestive emzymes that have done nothing. My GI even prescribed Tetracyclic antidepressants, which did nothing except give me a very dry mouth. The only drug I have not tried is Neomycin, as the often-permanent side-effects of hearing loss & kidney damage look scary. Fructose & wine seems to make symptoms worse so I avoid all fruit/ wine & follow a low FODMAP diet but foods I can tolerate one day causes massive bloating the next. I am 'lucky' in that extreme bloating is my only symptom (no pain, diarrhea or constipation). I wake with only minor to moderate bloating, but I can go up 2 jeans sizes in 20 mins after breakfast after eating a boiled egg with a glass of plain warm water. By diner-time every single day I have a pronounced '5 month's pregnant' pot belly which looks ridiculous on my slim frame. I am getting married soon and the only way I'll be able to fit onto a wedding dress is by going on a water fast for 3 days beforehand. I'd love to book a private email or phone consultation with you if you are available. Thank you so much for reading this.

Natalie | January 23, 2015

Angela

Hi Jason,

I'll follow up with you offline - thank you for your thanks!

Angela

Angela | January 16, 2015

Hi Angela,

I just wanted to say thanks for everything that you do. I actually have some questions about SIBO and I would like to ask you some questions offline.

Jason | January 16, 2015

Angela

Hi Mary,

I list out the probiotics that I use here, so you may reference these and discuss them with your doctor: http://siboguru.com/product-category/probiotics/

Angela

Angela | July 23, 2016

Hi,
Where do I purchase the powdered probiotics -- lactobacilli or bifidobacteria?

Mary | January 9, 2015

I am not a doctor or an English professor, but the third section of the small intestine is the ileum, not ilium,

Max | January 2, 2015

Also, I do not take PPI's at all. I felt they hurt more than they help. I have not taken PPI's for over 1 1/2 - 2 1/2 weeks. I think I took them in a grand total including both the nexium and prolisec (not together but seperately taking 1 then just nexium when it was prescribed to take over the prollisec) of 8-10 days

Jeb | December 14, 2014

Angela

Hi Jeb,
Symptoms really vary - I look for restless leg syndrome, IBS symptoms (which run the gamut), dis-ease after garlic, onions, apples... high FODMAP foods, sometimes chronic fatigue - look at the history - any food poisoning/ travelers diarrhea, stress... burping, acid reflux, there are a collection of symptoms that can point towards SIBO and it is definitely something that you should get tested for. Make sure you find a doctor (whether MD, ND or GI specialist) that will run a 'lactulose breath test for SIBO - to test both hydrogen and methane.' I prefer Common Wealth's Lactulose breath test and not Genova's test (the latter runs a 2 hour test and I want to see a 3 hour test).

I second your choice to come off the PPI. No need to mask a symptom. Let's figure out what is causing this. Let me know how the test comes out...
Angela

Angela | December 14, 2014

What are the red flag signs of SIBO? Like what can I check off to confirm it? My parents haven't taken me to a g.i My most consistent symptoms If you will are 1.twitching in my legs and sometimes in my jaws (for the last month) 2. Very slight, feint but noticeable headaches 3. Just as I lay down to sleep or right as I wake up, lots of stomach rumbling and sometimes gas. 4. Lots of gas at those 2 points of the day. I was diagnosed with ibs and was put on prolisec the went to personal doctor and also said ibs and put me on nexium. I stopped using the nexium because I noticed I felt the absolute worse when I took it. I take a brand of Probiotics now, now called Nature Probiotics. My mother wants me to take it daily. It could be a placebo but I feel there is improvement since I started taking it. But I still have problems.

Jeb | December 14, 2014

Angela

Hi Shanon,

Thank you for reaching out - I can appreciate how much discomfort you are in. The diet (low FODMAP, SCD or a combo) need to be done in unison with the antibiotic treatment. The goal is to remove fermentable (food) particles that the organisms feed off of and we need to look at why this was set up in the first place - stress, low stomach acid, migrating motor complex inhibition... this all needs to be addressed to truly knock this out. I would look to see how much recovery you did get from the first round of antibiotics - this would be done with another test. Antibiotics and herbal treatments usually knock down the organisms by 30ppm/ per 14 day and one month treatment, respectively. If you did the breath test, did it look at both hydrogen and methane producing organisms? You may be treating for hydrogen producing organisms only and still have a methane issue - both antibiotics should have been done simultaneously. I do appreciate budgeting - I can work with you on a payment plan, but I don't work on a sliding scale. If interested - send me an email: angela@nutritionnorthwest.com

Angela | December 9, 2014

For approximately two years ive been experiencing massive bloating, gas, and "noisy" gut. I feel like im walking around in someone else's body. I have no control over my gut and how it feels. I can go days without eating and still be bloated as if i'm four months pregnant or ate an entire Thanksgiving turkey by myself. I had a hydrogen breath test which indicated I have sibo. I took riflaximin first which did nothing. I am currently taking doxycycline hyclate. My GI suggested a low FODMAP diet if this antibiotic doesn't work. I am halfway through the antibiotic and feel no different. I've been researching low FODMAP diet restrictions. But I feel as if no one can tell me why I have sibo and how to prevent it. Should I be on a probiotic after my antibiotic?! I want to see a nutritionist, but that is not covered under my ins of course. Money is extremely tight. Any advice on probiotics or FODMAP or SIBO would be so ver appreciated. I cannot live this way. It's so uncomfortable.
Thank you for your time.

Shanon Dean | December 8, 2014

Angela

Hi Innesa,

I am happy to set up a consultation with you. I can help you, very quickly, address SIBO and your symptoms and work to bring your gut back into balance. This is important during breastfeeding and for your baby. Some antibiotic is passed through the breast milk. Antibiotics are necessary sometimes - they save lives. They also wreak a lot of havoc. I will email you directly from my private practice email - right now.
Warmly,
Angela

Angela | December 1, 2014

I'm interested in a consultation with you. Dealing with horrible SIBO issues. Still breastfeeding. I think I know the root of my issue. Multiple Antiboitic rounds after recurring breast infections in one year. 8 to be exact!

Innesa | November 30, 2014

Angela

Hi Anne, Cipro and Flagyl are not commonly used to treat SIBO. You definitely do need to follow these with probiotics, but that won't 'fix' this. Getting at the root cause to address why SIBO was set up in the first place is the necessary step that may be missing. SIBO doesn't just happen. Something(s) caused it. Dietary changes are in order, as well as retesting (make sure that they SIBO was knocked out - methane should be under 3ppm and hydrogen under 20ppm). If the antibiotics did not take these numbers down enough (and I doubt that they did) then you will need another option to treat SIBO.

Bifidobacterium probiotics have been shown beneficial to prevention. Nothing with FOS, MOS, DOS in it - just Bifido and Lactobacillus blend. I wouldn't get this at the drug store. Go with a health care providers line to address this.

SIBO is incredibly difficult to treat and knock out for good. If you need further support, reach out. I can help.

Angela

Angela | November 20, 2014

Hello,
Can you give a recommendation for a good probiotic? I was diagnosed with SIBO and was put on Cipro and Flagyl and ws told to follow the treatment with a Probiotic but there are so many.

Thank you!

Ann | November 20, 2014

Angela

Hi Isaac,

The upper 2/3 of the intestine has gut flora present - it isn't sterile. The dominant flora present is lactobacillus. We need this present to keep the balance and we need this present in an area that sets up food sensitivities, allergies and can tip the balance with an autoimmune condition. Probiotics are part of the recovery phase of SIBO treatment.

Lack of balance of gut flora, is one reason SIBO was set up in the first place. Treating SIBO and then not replenishing this, isn't a good idea. You can find SCD compliant probiotics.

If you are guessing that peristalsis is one contributing factor, then you will also need to look at what is inhibiting the vagal nerve and inhibition on the migrating motor complex. Today's post speaks to issues with the Migrating Motor Complex. http://www.cleanandleanrevolution.com/when-your-stomach-growls-it-isnt-telling-you-it-is-hungry/#post-top

Warmly, Angela

Angela | November 6, 2014

Hello Angela,

I've heard conflicting things about SIBO and it's difficult to decide who to listen to when it comes to something like my health.

I was under the impression that even too much lactobacilli or bifidobacteria can overgrow in the SI? This is just what I've read from forums like Mark's Daily Apple and such, so i doubt it's that accurate...

I believe my SIBO originated from weak peristalsis, so I feel like no amount of antibiotics or probiotics will stop it from coming back.

Great video by the way.

Isaac | November 6, 2014

Angela

There are a lot of factors involved in creating a reoccurring condition. TO answer your question regarding which probiotics - seek out a SCD compliant probiotic. This will help, but this won't 'fix' things. There is more at play here. I do work long distance - if you find the you want help figuring this out, contact me: angela@nutritionnorthwest.com
Warmly,
Angela

Angela | November 6, 2014

I have been battling methane-type SIBO with numerous rounds of antibiotics and natural antibiotics for a year. After fearing taking probiotics for a long time, I now feel that probiotics are the missing link to my healing. You mentioned a probiotic powder would be a good option. Can you let me know more specifics about obtaining this type of probiotic please?

K | November 5, 2014

Angela

Hi Joyce,

I would want to know which type of SIBO you have - hydrogen producing or methane producing. Probiotics should be used as part of the regimen, but there are also antimicrobial herbs and supplements that will help address this (as well as figuring out what set this up in the first place and addressing that too - low stomach acid, for example). Insurance companies are more likely to cover this if prescribed twice daily for three weeks than three times daily for two weeks (then take it three times daily for two weeks). Again, this depends on your body, type of SIBO and additional symptoms. You are right that his comment was very vague. I would not recommend this, unless with very specific probiotics. You may cause a lot of unrest if you don't use the right ones. I am happy to work with you through my private practice: www.nutritionnorthwest.com

Angela

Angela | September 29, 2014

So glad I found this! Last week my doctor diagnosed me with SIBO. My insurance won't cover Riflaximin and it would be over $900 out of pocket, so I've been told to try the antibiotic Neomycin instead. My doctor said I should continue taking probiotics, but up my dose to 6 times what I normally take for 30 days, then go back down to my regular dose. She said this is the current theory of thought for SIBO treatment. But I'm confused by that because how do the doctors know what anyone's "regular" dose is? Does that sound rational to you that I should multiply my current dose by 6 (spread throughout the day)?

Joyce | September 28, 2014

Angela

Hi Jacqueline, thank you for reaching out and sharing all of this with me. YES, I can help!! Let's plan some time to get together to figure this out. This could be SIBO, a parasite/ traveler's bug or a big imbalance in your gut flora. I'll reach out to your privately to discuss this further.
Warmly,
Angela

Angela | September 23, 2014

Hello Angela,

I found you through Chriss Kresser's site. I am a devote of his and truly respect his research and advice.

I have had what I call "IBS" for my whole life. It has been a life altering problem. I have had to withdraw from many social opportunities and could never take any group classes because of this problem. The biggest symptom of my IBS is debilitating gas. I mean, clear the room, 4th of July fireworks noisy gas & constipation.

Of course, certain foods make it worse ie: whey protein and things like cabbage, broccoli etc... (insoluble fibre makes it worse) but it can last weeks and keep me house bound carrying air freshener with me and blaming the dog. I joke, but actually it's been a horrible experience. I can't go dancing, I often took enema's so I could go on a date, I would often not eat just so I wouldn't be noisy and smelly, I'd eat nothing but rice and chicken broth and egg whites some days ... I'd call in sick to work b/c I was just unable to walk or stand up without it bursting out of me.

Now that I have read a few articles on SIBO, I'm wondering if this is what I have been dealing with for over 30 years? I'd like to get to the bottom of this problem so I can have a full life and not live it wondering when my "IBS will flare up" again and if I can be apart of any group activities ever again.

IS this something you feel you could help me with and we could actually cure?

Jacqueline from Niagara-on-the-Lake, Ontario Canada

Jacqueline | September 23, 2014

Angela

Hi Alexander,
Thank you for watching! VSL#3 is a well studied commercially available probiotic. This is recommended by a lot of MDs because of this, but it is not a product that goes far enough in addressing digestive issues. The dose and duration AND type/ strain to take depends on the condition you are addressing, what you are trying to recover and what part of the digestive tract you are addressing. Small intestinal flora colonies are in the thousands to million (latter as it approaches the large intestine) and the large intestine carries flora colonies in the billions. You can and do evoke a change in the small intestine by taking moderate doses. Commercially, the average person usually chooses the probiotic bottle that has more listed on the label. This isn't a correct way to choose this supplement. More is not better.

Warmly,
Angela

Angela | September 1, 2014

This video was very interesting- I have been hearing for years now that probiotics should be avoided at all costs, but I always seemed to improve slowly but surely after using VSL #3. Quick question though: why not megadose with probiotics? And what do you consider a megadose? Thank you for your time.

Alexander | September 1, 2014