ahs13 allison siebecker — small intestine bacterial overgrowth

Small Intestine Bacterial Overgrowth

Dr Allison SiebeckerAHS, August 2013

www.siboinfo.com

copyright Dr Allison Siebecker 2013


SIBO Symptoms: GI & Systemic

• Bloating/ abdominal Gas– Belching, flatulence

• Abdominal Pain, Cramps

• Constipation, Diarrhea, both

• Heartburn/ GERD

• Nausea• Leaky Gut/SI Sx- any Systemic sx: food

sensitivities, h/a, joint P, respiratory, skin, brain

• Malabsorption Sx- steatorrhea, anemia

IBS

SIBO= Underlying Cause of IBS

• Drs Pimentel/Lin/ Chow: 2000

• Tx’ed thousands of IBS pt’s successfully with SIBO protocol

• 84% IBS test+ SIBO• 75% of those whose

breath tests normalized after tx, had improvement in sx’s (Am J Gastroenterology 2003)

copyright Dr Allison Siebecker

Prevalence:SIBO is extremely common

• IBS alone effects up to 20% of US= 62,782,808– Up to 84% of people w/ IBS have SIBO= 52,737,558

– Not all studies show rates that high= 60% avg

= 37,669,684

• Then we have to factor in all the other dz that occur with SIBO (35+ so far), either as 1. a cause, 2. a comorbidity, or 3. a result. – It’s possible that 35%-50% of US has SIBO

=109,869,914- 156,957,020 people


SIBO Associated Conditions & Risk Factors

Study links on www.siboinfo.com: About SIBO; Assoc Dz AcneAcne RosaceaAcromegalyAlcohol Consumption (moderate intake)AnemiaAutismCeliac Disease/ Tropical SprueChronic Fatigue SyndromeCLL (Chronic Lymphocytic Leukemia)Cystic FibrosisDiabetesDiverticulitisDyspepsiaElderly AgeErosive EsophagitisGallstonesGastroparesisFibromyalgiaGERD Hepatic Encephalopathy (Minimal)H pylori InfectionHypochlorhydria

Hypothyroid/ Hashimoto's Thyroiditis

IBD (Crohn's, Ulcerative Colitis)IBS Interstitial CystitisLeaky GutLiver CirrhosisLymeMedications: Proton Pump Inhibitors,

OpiatesMuscular Dystrophy (myotonic Type 1)NASH /NAFLD (non-alcoholic:

steatohepatitis/fatty liver disease)ObesityPancreatitisParkinson's Prostatitis (chronic)Restless Leg SyndromeRheumatoid ArthritisSclerodermaSurgery: Post-Gastrectomy


http://www.siboinfo.com/

Dr Allison Siebecker

Small Intestine Review

What is SIBO?

• Bacterial Colonization of the SI– SI should have low Bacterial counts (101-2/top)– LI is the place for Bacterial colonization (1010-11)

• SIBO= Damage SI structure & function– SI compartment not designed for colonization– SI bact coloniz intereferes w/ digest & absorb

• Protective measures keep bact low in SI– St acid, Bile, Enz, Galt, Migrating Motor Complex

• SIBO= normal GIT bacteria, not pathogenic


Etiology (Cause)Anything that allows bacteria to back

up in the Small Intestine

1. Slowed motility in the SI ( MMC)•Dz: Gastroenteritis, Diabetes, Hypothyroid, Musc Dystrophy, Sclerosis, SLE, Br/Spinal Injury, IG• Drugs: Opiates Test subjects given morphine (which

inhibits MMC) develop SIBO

• Surgery: nerve damage, scarring, adhesions• Stress: Increased CRF inhibits MMC & HCl


2. Obstruction of the SI•Dz: Cancer: tumors, IBD-strictures, Cystic Fibrosis- xs mucus •Surgery: strictures, adhesions•Congenital: malrotation, atresia

3. Non draining pockets/sections of SI•Dz: SI Diverticulitis•Surgery: Blind loops


Etiology (Cause)Anything that allows bacteria to back up in SI

Gastroenteritis (GE)Post-infectious IBS/SIBO Pimentel

• 7-31% (50%) gastroenteritis > PI-IBS/SIBO

• bact secrete a toxin>disrupt musc & nerve connections, inactivating MMC> colonization

• Cdt b looks like something on our SI nerves, IS attacks SI nerves while attacking cdt b= damaging our nerves> MMC> SIBO

• MOA: Cx rx/molecular mimicry= AI mediated

• #, severity, tx, weakness, can go unnoticedcopyright Dr Allison Siebecker

2013

Etiology (Cause)

• SIBO is a disease that recurs often b/c underlying cause either can’t be corrected or unknown how

– Scarring=scleroderma: progressive, incurable– MMC dt nerve dmg from acute GE (perm?)• How Most Get SIBO= Combo of factors, ea

adding up until breaking point.

– hx GE + hypothyroid + period of stress (2wks)

– hx GE + hx occ mild IBS + opioids

• Thought= evolving ruminant digestion?copyright Dr Allison Siebecker

2013

Pathophysiology



SIBO Pathophysiology #1Bacteria compete for & steal our Food

SI Bacterial OvergrowthSI Bacterial Overgrowth

Bacteria Eat Our FoodBacteria Eat Our Food

Gas Gas GI Sx bloating, pain GI Sx bloating, pain constipation/diarrhea constipation/diarrhea

Premature Bacterial Exposure to Host’s Food

Fermentation

Food = Growth


Bacterial GasHydrogen, Methane, Hydrogen Sulfide

• Hydrogen, Methane not made by humans– Certain bacteria convert H M or HS

• Gas Causes Abdominal Sx of IBS– Bloating/distention= physical swelling– Pain= GIT sensitive to pressure, musc

contract against gas, Visc Hypersens in IBS– Eructation, flatulence= gas exiting– GERD/Nausea= gas back pressure – Altered BM’s = H>diarrhea/ M>constipation

Fiber/ Prebiotcs (Prebx)

• Indigestible to us= no enz break bonds • Digestible to bact= have enz

– Fiber exclusively feeds bact= Prebx (food for bact)

• Soluble Fiber: Inulin, psyllium, flax, chia, hemp, gums (guar, xanthan, locust bean, acacia/arabic,

mastic), beta glucan (oat bran/mushroom), alginate, glucomanan (konjac mannan), carrageenan, agar agar, arabinogalactan, pectin

• Oligosaccharides: FOS, GOS, MOS


Key Point

• In the case of SIBO, non-prebiotic carbs, carbs that we should be able to digest & absorb= become Prebx (feeding them, not us)

– feed bact in the SI- just b/c bact are there

• Starch from Grains & Tubers

• Lactose (only digestible to some- genes) – Worse lactose intolerance in SIBO

• Sucrose & sometimes Fructose & Glucose



SIBO Pathophysiology #2Damage= GI & Systemic Sx

SI Bacterial OvergrowthSI Bacterial Overgrowth

DisaccharidasesDisaccharidases(-) Carb Transporters(-) Carb TransportersBlunted Villi Blunted Villi GI Sx’sGI Sx’sElongated Crypt DepthElongated Crypt DepthIntestinal Permeability Intestinal Permeability Systemic Sx’sSystemic Sx’s

Hydrogen, Methane GasHydrogen, Methane GasGI Sx’s: GI Sx’s: Bloating Bloating Constipation/ DiarrheaConstipation/ Diarrhea Pain Pain

Inflammatory cytokinesInflammatory cytokinesDigest Brush BorderDigest Brush BorderBile Deconjugation Bile Deconjugation steatorrheasteatorrhea fat sol vit deficiencyfat sol vit deficiency A, D, E, KA, D, E, K

Bacterial Actions

Fermentation ofUnabsorbed Carbohydrate Damage the Brush Border

Bacterial Growth

Diagnosis/Testing



When to consider SIBO?

• If the symptoms (sx) of IBS are present– Bloating, constipation/diarrhea, abdom pain

• If one of the associated diseases along with digestive symptoms is present

• If a key indicator is present– See your notes

Key Indicators

• Antibiotics (Abx) improve GI sx • Prebiotics (Prebx) worsen GI sx (in Pbx)

• Fiber worsens constipation (& other GI sx’s)

• Carbs worsen GI sx (grains/veg/beans)

• GI sx start after opiate use (dt surgery)

• Chronic low ferritin with no other cause

• Gluten-free diet fails to improve Celiac pt

• Pancreas obscured by gas bubble on CT copyright Dr Allison Siebecker

2013


• Challenge test: lactulose=prebx meant to feed bact>gas. Sx/dz may increase/aggr

• Measures gas that only bacteria produce, (H,M) which indirectly shows their presence – collections every 15-20 min x 2 or 3 hrs= it’s the

timing that reflects the SI= avg 2 hrs – 1/5 H/M in SI diffuses across Brush Border>

blood> lungs= expired

• Performed at home with mail-in kits or in a facility with a machine (lab/hospital/office)

Testing- Lactulose Breath Test (LBT)


SIBO Breath Testing- LBT

• Stool tests reflect the LI, not the SI– Stool dx LIBO, not SIBO (dx:fat malabsorption)

• Other Breath tests: Urea-H pylori, CHO intol (lactose, fructose, sucrose, mannitol)

• Glucose can be used dx duodenal SIBO

• SIBO Testing is controversial- much debate – Gluc vs Lact, (+) criteria, timing, sen/spec stats– Indirect, imperfect, future options limited– I find it reliable. Simple/detailed/non-invas/inexpensive

Treatment


SIBO Treatment Protocol Variation of the Cedars-Sinai Protocol (Pimentel 2006)

Drs Siebecker & Sandberg-Lewis (2010)

SIBO Suspected

Hx GI/Extra GI, Meds, Dz

Antibiotic Elemental Diet

x 2-3 wks

Diet SCD, GAPS x 1.5+ years

1. Rifaximin: Diarrhea/Mixed 550mg tid x 10-14 days 2. Rifaximin + Neomycin: Constipation 550mg tid + 500mg bid x 10-14 days or Rif + Metronidazole 250mg tid x 10-14 d Optional: Probiotic, Antifungal

SIBO Lactulose Breath Test Or: GBT, Organic Acid Test

SIBO Breath Re-Test

Feel Better- 90%

Partial Improvement/ Not Better Re-Assess within 2 weeks

Prevention

1. Diet (SCD/Gaps, C-SD, Fodmap) 2. Prokinetic x 3 mo+ :Prucalopride 1-4mg hs :Erythromycin 50mg hs :LDN 2.5-5mg hs Optional: Probiotic, HCl/bitters, BB healing supplements Re-Treat

SIBO (+) SIBO (-)

Consider other Dx

Treat SIBO 4 options

Hx

Herbal Antibiotics

1. Berberine Herbs 2. Garlic/Allicin (methane) 3. Oregano 4. Cinnamon 1-3 caps 2-3 x day x 4 weeks Optional: Probiotic, Antifungal

Relapse

Treatment

• Algorithm + Key Tx Points – Tx takes time to master & SIBO takes time to tx

• Bacteria are sensitive to diff killing agents– No sensitivity testing for SI bact– May not get result you hoped for= try st else

• Adults often need more than Diet for Tx– Diet= insufficient sx relief -Diet=underweight– Diet= severly limited to get any sx relief– My opinion:Diet is not enough to dislodge SIBO



Key SIBO Tx Points for Success

• Test (3 hour Lactulose Breath Test)– dx, severity, gas type, methodical approach

• Successive Tx Rounds (Abx/HAbx) needed– If gas is above 35-45 ppm – Because avg gas dec from Abx/HAbx=25-35 ppm

• Methane &/or constipation cases are harder to treat

• Double Abx Tx or Allicin needed for methane/constipation cases

• Vary tx method as needed (Abx, HAbx, ED)

Key SIBO Tx Points for Success

• Re-Test to assess results

• Both Prokinetic & Diet for prevention

• Diet must be customized to the individual through their own trial & error – There’s no one “diet” that is perfect for anyone – There’s no test to find one’s perfect diet


Diet



Dietary Treatments for SIBO

1. Specific Carbohydrate Diet (SCD)

2. Gut And Psychology Syndrome Diet (GAPS)

3. Modified Low Fodmap diet (Modfod)

– no grains, tubers, sgr & combined w/ SCD/Gaps

For prevention only, after SIBO gone– Diet may expand as tolerated= grains/tubers/sgr– Cedars-Sinai Diet, Low Fodmap Diet, Less Strict

Paleo/Primal Diets• Don’t remove polysacch’s/go far enough for tx

Key Points of SIBO Diets

• Decrease CHO: poly/oligo/di-saccharides – Avoids Grains, Starch, Starchy Veggies, some Beans,

Sugar & most sweeteners, Lactose, Fiber/Prebx foods

• Allow monosac= glucose/fructose as honey

• Intro Diet to decrease bact, aid tiss healing• Progressive- easier to digest foods at 1st

– no raw fruit or veg, nuts or beans at 1st – fruit & veg= peel, de-seed, cook & puree at 1st

• Like Paleo focused on digestioncopyright Dr Allison Siebecker

2013

SIBO Diets: AllowStricter Paleo: Not allowedNot allowed

• Dairy- as lactose free, esp HM ygt

• Legumes- later in diet & only certain types

• Winter squash, beets, rutabagas

• Fruit juice- Scd: not from conc, Gaps: HM

• Honey- esp clover (sm= stevia)

• Alcohol/wine: later, sm amts, certain types

• Coffee: later, weak

• SCD (not Gaps):Vegetable oil, Saccharinecopyright Dr Allison Siebecker

2013

Lactose Free Dairy Points

• SCD= nutrition/calories/Pbx (HM ygt)

• Many w/ SIBO tolerate it & do better with it– Increased energy, stabilize weight loss, helps

digestion (ygt), increases food pleasure– Surprising! Dairy= bad? Not for many w/SIBO

• Key prob for Dairy Paleo= Store bought yogurt is not lactose free– Most fermented for 4 hours = 30% reduction

in lactose, LcF versions= pectincopyright Dr Allison Siebecker

2013

SCDLactose Free Dairy Foods

• Homemade 24 hr yogurt/sour cream

• Aged cheese, Dry Curd Cottage Cheese

• Ghee/butter

• Lactase enzyme treated cream in small amts

• Commercial lactose-free dairy (LcF milk discouraged on SCD, pectin often in LcF ygt)


SIBO Diets: Don’t AllowPaleo: AllowedAllowed (per version)

• Raw vegetables (salads)- at start

• Vegetable seed/skins- at start

• Raw fruit- at start (except v ripe banana)

• Fiber food/supps: chia/hemp/psyllium

• Tubers (pot/sw pot/yam)

• White Rice

• Cocoa/chocolate/cacao (even w/out sgr)

• Sugars other than honey/sacch/steviacopyright Dr Allison Siebecker

2013

• Dairy* Yes:Lc Free No or Yes• Grains No No or Yes• Legumes No:1st/Yes:later No (or Yes)• Veg: tubers No No or Yes• Veg: raw, skins No:1st/Yes:later Yes• Fruit: raw/juice* Mb:later/Yes Yes/No• Fiber foods No Yes• Sweeteners* Yes:Hny/stv/sacc No or Yes• Alcohol Mb:later No or Yes• Chocolate No No or Yes• Coffee* Yes:weak No or Yes*individually based


SIBO diets vs Paleo dietsFood SIBO Paleo

Summary

• SIBO is common

• Sx are the same as IBS

• Bacteria ferment carbs into gas> GI sx

• Dx= Lactulose Breath Test

• Tx= 4 options, 3=quick killing & Diet

• Prevention= Diet + Prokinetics

• Diet= Scd/Gaps/Modfod very similar Paleo

• Paleo w/SIBO= reduce listed carbscopyright Dr Allison Siebecker

2013

Diet Summary for Paleo folks with SIBO

• Consider: Lactose free dairy, esp HM ygt

• Avoid: starchy tubers, beans, raw vegetables & fruit, fiber/Prebx foods, sweeteners other than honey, grains

• May need to avoid certain veggies (see Fodmaps), high amt’s of veggies (dose matters), fruit, nuts/seeds


Announcement:Upcoming SIBO Symposium!

• Drs Pimentel, Weinstock, Siebecker and Sandberg-Lewis= speakers

• In Portland, Or

• Live webinar for distance viewers

• Recorded webinar may be purchased after

• Jan 17,18 2014

• Visit www.ncnm.edu/sibo-conference


http://www.ncnm.edu/sibo-conference

Resources

See www.siboinfo.com under:•‘Resources’ for:

– Labs -Books– Websites -Cookbooks– MMC videos -you tubes/classes

•‘Treatment’: ‘Diet’, for more diet info•For (+) test criteria, see ‘About’: ‘Testing’ or my Townsend article (‘Contact’: ‘Bio’)


http://www.siboinfo.com/

ahs13 allison siebecker — small intestine bacterial overgrowth

Health & Medicine