5 Facts About SIBO the Internet Keeps Getting Wrong

·8 min read

Small intestinal bacterial overgrowth -- commonly referred to as SIBO -- can be thought of as a four-letter word for bloating, excess gas, abrupt changes in your bowel patterns and general digestive misery. Because the condition is often mistaken for irritable bowel syndrome, or IBS, people can suffer with SIBO for months -- if not years -- before the condition is properly diagnosed and treated.

With each passing year, I see more and more patients affected by this condition, and I've noticed that many of them arrive in my office with similar misconceptions about it.

Much of the misinformation is being fueled by a veritable "cottage industry" of SIBO-related products and services that seem to be regard this miserable -- but usually treatable -- condition as a chronic condition, lifestyle or identity. So allow me to set the record straight.

[READ: Stomach Bloating: How to Relieve Your Tight, Round Belly.]

5 Facts About SIBO

1. SIBO is not an infection, and it's generally associated with an underlying condition.
There's a popular misconception that SIBO is an intestinal bacterial infection -- something you can catch in a way similar to food poisoning or come down with as the result of having too much "bad bacteria" in your digestive tract. Or that SIBO is something you develop as the result of poor diet, stress or lack of sleep. It is none of these things.

SIBO typically develops as the result of something else gone awry in your system that renders your small intestine too hospitable to the normal, sometimes even friendly bacteria that typically stay put in your large intestine (colon) where they belong.

In other words, SIBO is a case of having too many benign bacteria living in the wrong neighborhood of your gut. Therefore, if you have developed SIBO, you'll want to talk to your doctor about identifying and, when possible, treating the underlying cause. If you can treat the thing that's making your small bowel so hospitable to bacteria in the first place, you can prevent the condition from coming back.

2. SIBO can absolutely be cured.
One particularly troubling myth about SIBO is that it always comes back, even when treated with antibiotics, so there's no point in even taking medication. In reality, SIBO is routinely cured and often stays away for prolonged periods of time, if not for good.

It's true that there are a few predisposing factors for SIBO for which no remedy is available, and the unlucky people with these risk factors are at high risk for chronic recurrence. But many risk factors for SIBO can be addressed, meaning that recurrence is not a given if the underlying cause can be corrected.

But what about recurrent SIBO, you ask? Indeed, many people suffer from it, and I have a few guesses as to why -- and none of them are because the condition isn't treatable. First, not everyone responds to the first antibiotic medication their doctor prescribes, and often, these patients aren't offered another course of antibiotics. Among patients who are offered another course of antibiotics, it's often the same drug that didn't work the first time. This means the initial overgrowth was never fully treated, and it persists over time.

Second, some organisms implicated in SIBO are not bacteria but methane gas-producing critters called archaea, and they do not respond particularly well to the most common antibiotic used to treat SIBO -- rifaximin. Research shows that people with methanogenic (methane-producing) SIBO typically fare better when treated with a cocktail of two complementary antibiotics that target different types of organisms rather than rifaximin alone.

Third, many doctors don't follow through with the diagnostic detective work to identify and resolve SIBO's underlying risk factor, making recurrence likely. And finally, many people choose to take bacterial probiotic supplements for SIBO under the mistaken impression that their condition resulted from an imbalance of "good versus bad" bacteria. In theory, these probiotics could actually be what's causing SIBO to recur.

[Read: What Is Gut Health?]

3. Probiotics for SIBO may be part of the problem -- not part of the solution.
There is no research-based answer as to whether probiotics for SIBO are helpful. But despite this lack of evidence, the internet is full of self-proclaimed experts advising all manner of probiotic supplement protocols claiming to treat or prevent SIBO. Consider this: If SIBO represents an overgrowth of normal (aka benign or "good") bacteria in a neighborhood that's too hospitable to bacteria, isn't it possible -- and even likely -- that these supplements are actually "seeding" the recurrence by delivering concentrated doses of bacteria day after day?

At the gastroenterology practice I work, my colleagues and I have come to believe this may be the case for many of our patients with SIBO, particularly those whose SIBO results from having low stomach acid or slow motility in their small intestines.

For this reason, patients in our practice who have a history of SIBO are advised to limit probiotic use to yeast-based strains like Saccharomyces boulardii (commonly marketed as Florastor) that cannot overgrow in the small bowel.

[READ: 10 Reasons Your Stomach May Be Hurting.]

4. Diet hasn't been shown to cause or cure SIBO.
Patients who are medication-averse are often looking for natural treatments for SIBO and routinely ask me how to cure SIBO with diet. I wish I could say that there's evidence for a SIBO diet that cures or prevents the condition, but to date, there isn't. The role of diet for SIBO is to help manage your symptoms until you are able to be treated -- and a few diets are generally quite effective at doing so.

The low-FODMAP diet, for one, is arguably the least restrictive way to get maximum symptom control -- or the best bang for your dieting buck. It's the approach I recommend in my clinical practice.

So-called elemental diets -- or diets consisting exclusively of powders or drinks that contain pre-digested nutrients -- are also effective at symptom control, but they are extremely costly and incredibly unpleasant to drink. You may feel relief while limiting your diet to these powders, but you'll tire of them quickly, and as soon as you resume a normal diet, the SIBO symptoms will be back in short order.

The idea circulating online that restricting your diet when you have SIBO can somehow "starve" the bacteria and cure SIBO naturally has not been demonstrated in scientific studies. You can certainly suppress bacterial populations in all segments of the gut -- small intestine and colon alike -- to a modest extent with diet restriction, but you'll never come close to eradicating them.

Furthermore, staying on these restricted diets once your SIBO has been treated has not been demonstrated to be an effective strategy for prevention of recurrence -- at least not to date. Be aware that diet restriction affects all bacterial communities in the gut; its effects cannot be limited to those communities overgrowing in the small intestine alone. For this reason, prolonged adherence to a highly restricted diet could have unintended adverse effects on the healthy diversity and balance of your colon's microbiota.

5. "Herbal antibiotics" aren't an evidence-based cure for SIBO.
The game of Internet telephone has spread the idea of so-called "herbal antibiotics" -- sometimes referred to as the Johns Hopkins Protocol -- so far and wide that it's easy for a SIBO newbie to assume that these are standard, well-studied, known-to-be-effective treatments for SIBO.

The entire basis for this belief is one single study published in 2014 involving 104 people -- only 37 of whom were given herbal products and only 17 of whom seemed to have a favorable response. Its title misleadingly implies that herbal therapy is equivalent to the antibiotic rifaximin in treating SIBO, though those of us who've actually read the study have noted its design was so flawed and results so flimsy that its bombastic title is hardly supported by the actual data findings.

For one, the researchers used lax diagnostic criteria for SIBO that aren't consistent with widely accepted standards, meaning that it's not even clear how many people in this study even had true SIBO to begin with. Secondly, the rifaximin dose used in this study was lower than the standard dose used to treat SIBO. In other words, the patients given rifaximin were under-medicated compared to how SIBO patients are normally treated.

Lastly and most importantly: The results of the comparison between herbal remedies and rifaximin that found them to be comparable weren't even statistically significant. When results in a small study like this aren't statistically significant, it means that the relationship observed in this study is not likely to be observed in the population at large.

Now don't get me wrong: I have no particular affinity for a prescription antibiotic that costs some people over a thousand dollars for a two week course, and I would like nothing more than to have an economical, herbal remedy that could eradicate SIBO gently and effectively. But as far as I can tell, there's no actual evidence to support commonly touted herbal regimens as effective cures for SIBO, nor have any of their key ingredients -- oregano oil, thyme oil, mint oil, ginger and other herbal extracts -- ever even been demonstrated to have an antibiotic/antimicrobial effect in the guts of live human beings ( in vivo).

And while these herbal supplements may be cheaper than rifaximin, they're not actually cheap; each product typically costs $50 or more per bottle, and patients are often kept on cocktails of them for months at a time. To justify the hundreds of dollars and months spent on these supplements, I'd like to see a study in which more than just 17 people seemed to respond positively to treatment, wouldn't you?