Simplifying SIBO
My name is Dr. Joe Mather. I’m a board certified physician who has been treating patients with SIBO for a decade using tools from both natural and conventional medicine.
After doing this work for years, it’s clear to me that SIBO is one of the most underdiagnosed, poorly understood, and mistreated conditions in all of medicine. We see this in the millions of Americans who can’t find relief to their IBS symptoms, and I see this regularly in the patients who come to work with me. Most of these patients are still hurting despite working with multiple GI specialists and integrative practitioners.
This is a shame, because there are so many tools and treatments that can help you feel better. Both conventional and natural medicine offer treatments that can help, but the real secret is to treat SIBO step by step.
I hope the information on this site helps you to finally heal from SIBO and get back to your life!
-Dr. Joe
I created this page to share with you a simple way to find relief from GI symptoms caused by SIBO.
What is SIBO?
Small Intestinal Bacterial Overgrowth (SIBO) is a condition where bacteria grow near the beginning of your digestive tract in the small intestine - rather than the large intestine, where large numbers of bacteria are supposed to be.
Normally, the stomach, and upper small intestines normally contain only a small amount of bacteria. This is because stomach acid, bile and digestive enzymes all help to clean the upper GI tract of microorganisms. One study looked at samples of intestinal fluid in different parts of the intestine to see how many bacteria were present. They estimated that the uppermost part of the GI tract only contains about 100,000 counts of bacteria per sample, a small amount. Moving downward to the lower part of the small intestine, the count increased a thousand fold - to 1,000,000,000 counts of bacterial per sample. Finally, when researchers took a sample from the large intestines they found that the count had increased an additional thousand times to 1,000,000,000,000.
All of this is to say that bacteria in the gut is highly concentrated in the large intestine, while the small intestine is relatively sterile in contrast.
All of this means that while the body is normally used to dealing with massive amounts of bacteria in the lower GI tract, the upper part is not.
When bacteria start to grow where they aren’t supposed to be, they cause a variety of GI symptoms: bloating after meals, diarrhea, constipation, and abdominal pain.
Going one step farther, as the small intestine is protected by dense collections of immune tissue. Bacterial imbalances in the small intestine can trigger these immune tissues which can lead to problems in other parts of the body. This is why so many patients with SIBO struggle with brain fog, fatigue, joint pain and skin conditions like rosacea or acne.
Most cases of SIBO are fixed using a straight forward, three-step process.
Treat SIBO Step by Step.
Approaching SIBO one step at a time allows you to evaluate what is helping and what is not. It gives time for the diet or probiotics or other treatment to do their work. Doing things one step at a time will save you time and money, and increase the chances that you get rid of SIBO once and for all.
Over the years, I’ve seen many patients who felt better after they were given a prescription antibiotic by their GI doctor - only to feel completely dismayed when their symptoms came back in a week or so.
What went wrong?
First, these doctors missed out on the opportunity to fix lifestyle problems. They never asked their patients about their sleep habits. They didn’t take the time to evaluate if their diet was contributing to their GI problems, and they didn’t help them lower stress or get off PPIs.
Second, these doctors didn’t set up their patients for success by giving them probiotics. They didn’t do a good enough job getting their patient’s GI system healthy before giving the antibiotic. This is why as soon as the antibiotic was stopped, SIBO came right back.
This is why it is so important to treat SIBO one step at a time.
My patients start with any of the dietary or lifestyle problems that lead to SIBO. Then if they aren’t better, we add probiotics. Finally if they are still struggling, we add in further treatments.
This approach works for the vast majority of cases of SIBO. It helps patients avoid having to take too many supplements and it helps save money in unneeded testing.
The first step in getting rid of SIBO is to look for root causes of bacterial overgrowth.
Why do bacteria overgrow?
Our modern lifestyle plus the inappropriate use of medications cause most cases of SIBO.
If you are serious about healing SIBO, then focus on your lifestyle and basics first.
In fact, the single most common reason for treatment failures in SIBO is that your doctor didn’t do enough to help you improve your sleep, stress levels or diet.
For most patients, lifestyle change is the only way to get at the root cause of bacterial overgrowth, and the most common reason for SIBO treatment failure is that your doctor didn’t do enough to help you understand just how critical it is that you take a look at these factors.
Read more about the causes of SIBO here.
Lifestyle changes usually sound completely overwhelming to many patients. However, I’ve found that patients don’t need to be perfect as long as you they are addressing the factors that are driving SIBO in their life rather than simply going on what they read online. I’ve also seen that small changes can make a big difference, and there is no need for complicated diets or unrealistic treatment programs. A good doctor will be working to meet you where you are, and to figure out which lifestyle changes are right for you
If you’ve been struggling with symptoms of SIBO then I’d recommend you take a look at the most common causes of SIBO in the link below and work with your practitioner to figure out exactly what changes to make.
If you’ve cleaned up your diet and lifestyle but are still hurting, then it’s time to add probiotics.
Probiotics and SIBO
Too many patients suffering with SIBO have been told incorrectly that they cannot take probiotics.
The truth is that probiotics dramatically help most patients with SIBO.
The mistaken idea that probiotics don’t help SIBO comes from multiple places. It comes from GI doctors who haven’t had the the time to read the relevant medicalliterature. It also comes from the integrative practitioners who have been incorrectly taught that giving probiotics will make their patients worse, or that they can only give probiotics after they’ve finished several treatment phases of an unnecessarily complicated protocol.
This is incredibly unfortunate because probiotics alone can resolve SIBO, and is the most commonly missed treatment by doctors.
My average SIBO patient comes to see me after having failed multiple treatments from different practitioners, and most of these of patients tell me that they have tried probiotics, but didn’t see a big difference. The problem is quite simple: they either haven’t taken a high enough dose, haven’t taken a broad enough number of species, or just didn’t stick with probiotics long enough to see a difference.
I frequently start my patients on three different types of probiotics:
The vast majority start feeling better right away. They tell me that their bloating, gas and abdominal pain after meals is better. Those with diarrhea report fewer loose stools, and those with constipation report that they are having more regular bowel movements. Many tell me that they have noticed that their brain fog has lifted, they are having less joint pain, and their skin is clearer.
Different patients need different doses, and I typically have patients start at a smaller dose, working up to higher doses over a period of 1-2 weeks.
You can learn more about why probiotics are so important in managing and healing SIBO by following the link below.
If you’ve done a good job with diet, lifestyle and probiotics, but still have symptoms - then it’s time to add extra treatment.
Additional Treatments
SIBO is not fun.
Because of how miserable SIBO can make you feel, it’s the most natural thing in the world to want to skip straight toward the “more powerful” antibacterial treatments in hopes of clearing SIBO out as quickly as possible. There are several reasons why this isn’t usually the best plan.
The most important reason is that when you slip diet, lifestyle and probiotics you increase the chance that SIBO comes right back as soon as you stop the antibacterial treatment. Another reason is that these treatments cost more and in my practice I routinely hear horror stories from patients who have spent thousands of dollars and years of their life trying to get rid of SIBO. (One of the main reason I created this site.) As a result, I try to emphasize simple, proven strategies with my patients to keep the cost of getting healthy to a minimum. Lastly, although they are generally well tolerated antibiotics, herbs and elemental diets have a greater chance of side effects than fixing the problem directly using lifestyle and probiotics.
So, what are the go-to treatments for cases of SIBO that don’t respond to probiotics and lifestyle work? They are prescription antibiotics, antimicrobials herbs and nutraceuticals and a nutritional powder called an Elemental Diet. Prescription antibiotics and herbs act directly to kill problematic bacteria, while Elemental Diets work by starving out bacterial populations and causing your body to release bile and other secretions that clear out bacteria.
Most patients only need to pick and follow through with one of the three options below. However, in more severe or treatment resistant cases your doctor may ask you to combine therapies.
Medications like rifaximin typically work the fastest in reducing symptoms and have shorter treatment courses compared to herbals. Unfortunately they can be very expensive when not covered by insurance. Prescriptions are great when the problem is bacterial, but they don’t have any effect against yeast or other organisms that can cause problems in the small intestine.
Most of my patients prefer to use herbal treatments to manage and treat SIBO. Although herbal therapies generally takes a little longer than prescription medications, they have broader action than antibiotics and can kill off other organisms like yeasts or amoebas that can mimic SIBO symptoms.
An elemental diet isn’t really a diet, because there’s no food involved. Elemental Diets are nutritional formulas where all of the carbs protein, fats are broken down into highly absorbable components. This means that your nutrition is absorbed in the first several feet of your small intestine, which effectively starves the bacteria hanging out lower in your digestive tract.
How long does it take?
Let’s look at an example of how how treatment is sequenced to get an idea for a timeline.
Lifestyle: 2-4 weeks, then add probiotics.
Probiotics + Lifestyle: 2-4 weeks, then add treatment if needed.
Probiotics + Lifestyle + Treatment: 4 weeks, repeat if symptoms not completely gone.
When approached step by step, most patients get significant relief within weeks to months, depending on their individual reasons for developing SIBO, their underlying health, and their ability to follow the plan step by step. If someone hasn’t found significant relief by 3 months then something has been missed.
The critical component is not rushing through and blending all the steps together. Adding too many treatments at once makes it impossible to learn what is helping and what is not.
Doing things one step at a time will save you time and money, and increase the chances that you get rid of SIBO once and for all. Each step done properly and for enough time makes increases the chance that the next step will give you symptom relief.
Remember, an experienced physician will be able to guide you how to combine or move through these treatments faster than on your own. If you are stuck, then reach out to a doctor who is comfortable treating SIBO.
Putting it all together.
We start with diet because sometimes making a simple dietary adjustment is enough to completely get rid of your bloating and abdominal pain - and sometimes is enough to normalize a positive breath test. For example, you might start one of the diets that commonly help with SIBO, and notice that after a week your symptoms are roughly 25% better.
Although this is a step in the right direction, you still aren’t feeling all the way better. This doesn’t mean that the diet failed, it just means you need to further treatment.
You would move to the second step and add probiotics. Patients with SIBO almost always find additional relief combining probiotics and diet - these treatments work better together. In mild cases of SIBO this approach is often enough to get someone back on track. You would maintain the diet and probiotics together for a few months, then expand expand the diet and lower the probiotic doses.
The more severe the case, the more likely it is that you’ll need a final step. This step involves picking from herbal antimicrobials, prescription antibiotics or elemental diets. One or more of these treatments are added onto the lifestyle and probiotics. Again, once symptoms have been reduced to their lowest level, we work to wean off the supplements, the medications and broaden your diet.