WHAT IS THE RELATIONSHIP BETWEEN SIBO (SMALL INTESTINAL BACTERIAL OVERGROWTH) AND IBS (IRRITABLE BOWEL SYNDROME)?

SIBO (SMALL INTESTINAL BACTERIAL OVERGROWTH)
AND IBS (IRRITABLE BOWEL SYNDROME)
WHAT'S THE RELATIONSHIP?

Wellcome Images V0010948

"In patients with SIBO, bacteria ferment ingested carbohydrates in the small intestine causing increased gas production. Accumulation of this gas in the intestine results in bloating and flatulence. Excessive luminal [intestinal] distension may even cause abdominal pain or discomfort. Bacteria in the intestine may produce toxic by-products after fermentation, which may damage the inner lining of the small intestine and colon."  From the March 2014 issue of the World Journal of Gastroenterology (Irritable Bowel Syndrome and Small Intestinal Bacterial Overgrowth: Meaningful Association or Unnecessary Hype?)

I've shown you in the past what SIBO is.  I've also shown you what IBS is (for those that were not aware, it's an AUTOIMMUNE DISEASE that many researchers believe to be a precursor to IBD).  What if I showed you that these two health issues are essentially the same --- or if not completely identical, so intimately related that untangling them from each other is all but impossible.  Follow along as we explore the numerous links between these two common problems.  How common?

The September issue of Therapeutic Advances in Chronic Diseases (Gastrointestinal Bacterial Overgrowth: Pathogenesis and Clinical Significance) said that, "Small intestinal bacterial overgrowth (SIBO) is defined as the presence of an abnormally high number of coliform bacteria [bacteria present in the large intestine and feces] in the small bowel. The most common symptoms associated with SIBO include diarrhea, flatulence, abdominal pain and bloating.  The prevalence of SIBO in IBS varies from 30 to 85% depending on the source used. The prevalence of SIBO in liver cirrhosis is 50% and in celiac disease, the prevalence of SIBO in some studies is also estimated to be 50%. Interestingly, in asymptomatic morbidly obese patients the prevalence of SIBO was noted to be 17%."  In other words, SIBO is far from uncommon.

As far as IBS is concerned, About IBS dot com says that, "Irritable bowel syndrome is the most common functional gastrointestinal disorder with worldwide prevalence rates in the area of 10–15%.  IBS is the most common disorder diagnosed by gastroenterologists and accounts for up to 12% of total visits to primary care providers.  There are between 2.4 and 3.5 million annual physician visits for IBS in the United States alone."  MedScape parrots these statistics, adding to it that "only 3.3% are medically diagnosed."  In essence, this means that these doctor visits are being driven by the very worst of the worst.  The others --- like many of you --- are just sucking it up and living with it.  BTW, I saw a major study from the past few months saying the international prevalence of IBS could be be over 20%.  That would be 1 in 5 or about 65,000,000 Americans and about 1,500,000,000 worldwide.

As for the gas --- one of the single most distinguishing characteristics of both SIBO and IBS --- it is both foul-smelling and toxic.  That's right; toxic.  Several studies actually discuss IBS/SIBO-associated health issues in relation to CDT's (Cytolethal Distending Toxins), about which Wikipedia says, "toxins produced by certain gram-negative bacteria that trigger cell cycle arrest, leading to the enlarged or distended cells for which these toxins are named.  Affected cell lines (including human fibroblasts, epithelial cells, endothelial cells, and keratinocytes) die by apoptosis [programmed cellular destruction].  CDT's are classified as AB toxins, with an active ("A") subunit that directly damages DNA.  Many of these bacteria infect humans. Bacteria that produce CDTs often persistently colonize their host."  In other words, not only are these creatures vile, they can be tough to get rid of as well.  We'll talk more about how that's done later in the post.  Oh, and don't ever underestimate the importance of the epithelial cells they mention (THE LEAKIES) or FIBROBLASTS.

Because the stomach is (OR AT LEAST SHOULD BE) extremely acidic, it acts as one of the defense mechanisms preventing bacteria from getting into the small intestine from the top of the GI tract (for an overview of digestion, ENDOGUT is the place to go).   At the beginning of the small intestine the relatively few bacteria found there will be gram positive and at the end of the GI tract, they'll be gram negative.  Due to the gas producing features of these bacteria, the bowel (large intestine) distends, compromising the doorway between small and large intestine (the illeocecal valve), thus allowing large amounts of gas to enter the small intestine.  Interestingly enough, these gasses can be easily tested for using various breath tests.  Hydrogen-based gases tend to cause diarrhea, while methane-based gases tend to cause constipation.  One of the hallmarks of IBS for many individuals is that they make both gasses, depending on what they eat --- one reason they have alternating diarrhea and constipation

Although there are some physicians and researchers who say that the relationship between IBS and SIBO is controversial (for instance, this month's issue of Current Opinion in Gastroenterology published a study called Small Intestinal Bacterial Overgrowth as A Cause for Irritable Bowel Syndrome: Guilty or Not Guilty?), my humble opinion is that peer-review is clear on the subject. Not only is there a relationship, the scientific literature shows it to be both robust and underestimated --- a thought echoed by the title of a study in the August 2015 issue of Neurogastroenterology and Motility (Possible Underestimation of SIBO in IBS Patients). 

Before we get into the nuts and bolts of the SIBO / IBS relationship, I want to show you a few things you need to at least thinking about.  Because IBS is autoimmune, and because autoimmune diseases tend to travel in packs, there are very specific health issues that have been associated with this problem.  Not surprisingly, it's been linked to INCREASED INTESTINAL PERMEABILITY in the large intestine (do not confuse this with diarrhea) as well as autoimmunity itself (HERE).  Other studies have linked things as seemingly unrelated as rosacea (facial redness) and RESTLESS LEG SYNDROME (both are autoimmune diseases) to both SIBO and IBS.  We'll get to the Depression / IBS / SIBO link shortly.

THE RELATIONSHIP BETWEEN SIBO AND IBS

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There are so many studies on this topic it can make your head spin.  Just realize that the link between IBS and SIBO, although not completely understood, is undeniable.  I could have used dozens upon dozens of studies to prove this point.  To keep things rolling along I only used a few that I thought had good overviews, one of them having to do with children.

• The March 2017 issue of Gut and Liver (Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge between Functional Organic Dichotomy) revealed who is most susceptible to the IBS / SIBO combo.  "Female gender, older age, diarrhea-predominant IBS, bloating and flatulence, proton pump inhibitor and narcotic intake, and low hemoglobin are associated with SIBO among IBS patients."  What should we take away from this?  Remember that ANEMIA is a deal-breaker as far as fixing any chronic issue is concerned.  Also, women are far more likely to develop autoimmunity than men.  I'll deal with PPI's later.  Furthermore, we see why the breath tests work so well.  "Eighty percent of the gases like hydrogen and methane are eliminated with the flatus and the remaining 20% are absorbed and exhaled by lung, which can be measured in breath."  Lastly we learn about the, "paradigm shift in understanding this disorder, hitherto thought to be predominantly psychogenic in nature."  In other words, even though the problem is FUNCTIONAL AND NOT PATHOLOGICAL, it's not simply in the patient's head as was believed for decades.

• Last June's issue of Gastroenterology Research and Practice (Small Intestinal Bacterial Overgrowth in Patients with Irritable Bowel Syndrome: Clinical Characteristics, Psychological Factors, and Peripheral Cytokines) dealt with the INFLAMMATION both created and caused by this issue, saying "Bacterial products, such as endotoxins, can affect gut motility.  Gut bacteria are also important for activating an immune response. Immune-mediated cytokines have multiple actions.  there is a large body of work demonstrating that patients with IBS have low-grade immune activation, and associations between psychological state and stress and immune activation have been detected in mucosa. Results from animal experiments suggest that low-grade gut inflammation can alter gastrointestinal tract motor function and that gut motility abnormalities can further predispose to bacterial overgrowth....  Previous studies have confirmed that anxiety and depression are more common in patients with functional gut and intestinal disorders than in the healthy population, particularly in patients with IBS, as confirmed here. Anxiety, depression, and life event stress were more prevalent in patients with IBS than in healthy controls." Inflammatory ENDOTOXINS (lipopolysaccharides) are commonly seen in the IBS / SIBO combo, while ANXIETY / DEPRESSION are both considered to be inflammatory disorders.

• Just so you are aware, this is not just an adult problem --- not by a long shot.  Back in 2009, the journal Pediatrics published a study called Prevalence of Small Intestinal Bacterial Overgrowth in Children with Irritable Bowel Syndrome.  The authors, seven gastroenterologists from Rome's University of Sacred Heart Gemelli Hospital, concluded that, "The prevalence of abnormal [breath test] results were significantly higher in patients with IBS (65%) with respect to control subjects (7%).  Results from this study suggest a significant epidemiologic association between SIBO and IBS in childhood."  What does this ultimately mean for your children?  Stick around to find out.

All of this is great information and important to know if you struggle with this problem.  But so far, I haven't covered much having to do with addressing / solving / fixing the problem.  This section is short folks, and is where the rubber meets the road as far as dealing with IBS and SIBO are concerned!  Oh; as far as diagnosis is concerned, you can do the breath tests, but honestly, if you have problems with gas coming from either end of your digestive tract after a meal, you have some degree of SIBO.

TREATMENT OF SIBO AND IBS WITH SOMETHING THAT CAUSES THE PROBLEM IN THE FIRST PLACE....   ANTIBIOTICS
ALTERNATIVE SOLUTIONS FOR IBS & SIBO

As you saw earlier, the IBS / SIBO combo is not only common, it is the number one reason people visit gastroenterologists (digestive specialists).  What's the average GI specialist doing for these patients?  You see it over and over again in the studies; they are prescribing antibiotics --- chiefly an antibiotic by the name of rifaximin; the same most commonly used to treat C. DIFF INFECTIONS.  The thing about C. Diff is that, like other GI infections / DYSBIOTIC CONDITIONS, the treatment (antibiotics) is at least a substantial part of the very thing that's likely causing the problem in the first place.  And even though study after study recommends rifaximin, saying it is about 75% or so effective for ten weeks, it creates dysbiosis. So regardless of how much antibiotic you take or how effective it is over the short haul, unless you radically change your diet (more on this momentarily), the problem will continue to come back over and over again.

A year ago in January, the World Journal of Gastroenterology asked a question via the title of a study --- Is Irritable Bowel Syndrome an Infectious Disease?  Listen to their own conclusions.  "Irritable bowel syndrome (IBS) is the most common of all gastroenterological diseases, with a worldwide prevalence of 7%-21%. The presence of small intestinal bowel overgrowth (SIBO) has been documented in patients with IBS and reductions in SIBO as determined by breath testing correlate with IBS symptom improvement in clinical trials. The incidence of new onset IBS symptoms following acute infectious gastroenteritis also suggests an infectious cause. Alterations in microbiota-host interactions may compromise epithelial barrier integrity, immune function, and the development and function of both central and enteric nervous systems explaining alterations in the brain-gut axis."  Not surprisingly the authors concluded that IBS is an infectious disease.

Don't, however, confuse infectious with communicable (at least in most cases).  Due to the pressure of the excess gas, the bacteria is being forced up the small intestine from the bottom via post-meal distension and bloating --- the most defining characteristic of IBS / SIBO.  This pressure opens the illeocecal valve, allowing both gas and bacteria into the small intestine.   But besides ANTIBIOTICS, which we know will automatically create more dysbiosis, what can be done?  For starters, let's look at a study done by nine gastroenterologists from the University of Pittsburgh's Department of Internal Medicine (Herbal Therapy Is Equivalent to Rifaximin for the Treatment of Small Intestinal Bacterial Overgrowth) and published in the May 2014 issue of Global Advances in Health and Medicine.

"SIBO is widely prevalent in a tertiary referral gastroenterology practice.  Patients with SIBO have chronic intestinal and extraintestinal symptomatology which adversely affects their quality of life. Present treatment of SIBO is limited to oral antibiotics with variable success. One hundred and four patients who tested positive for newly diagnosed SIBO by lactulose breath testing were offered either rifaximin 1200 mg daily vs herbal therapy for 4 weeks.  Of the 37 patients who received herbal therapy, 46% had a negative follow-up LBT compared to 34% of rifaximin users.  Adverse effects were reported among the rifaximin treated arm including 1 case of anaphylaxis, 2 cases of hives, 2 cases of diarrhea and 1 case of Clostridium difficile. Only one case of diarrhea was reported in the herbal therapy arm, which did not reach statistical significance.   Herbal therapies are at least as effective as rifaximin for resolution of SIBO. Herbals also appear to be as effective as triple antibiotic therapy for SIBO rescue therapy for rifaximin non-responders."

Did you catch that folks?  Nine GI specialists from a major medical institution said that HERBAL TREATMENT is not just as good as, but better than, the medical standard of care --- rifaximin. Furthermore, said herbal remedies are at least as effective as the triple antibiotic therapy given to those who don't respond to rifaximin.  Let the magnitude of these conclusions sink in for a moment.  Not surprisingly there are some very good herbal formulas out there.  There is also some total junk.  The bottom line, however, whether we are talking about antibiotics or herbs, there are other steps that must be taken if you hope to solve the SIBO / IBS combination over the long haul.

• CHANGE YOUR DIET:  Foods that produce gas (sugar -- especially fructose in the form of something called FODMAPS) must be eliminated.  I've dealt with FODMAPS extensively in the past.  FODMAPS also happen to mimic the GI portion of Gluten Sensitivity (HERE).  Also be aware that FIBER and many common PROBIOTICS have the potential to cause bloating and distension as well. For those of you with hardcore sugar / carb addictions, THESE POSTS might be right up your alley.  Bottom line is that you will need to be on a FODMAP-free, GLUTEN FREE, PALEO DIET that cuts all GRAINS and BEANS as well as DAIRY and many FRUITS.   You'll also want to focus on consuming GOOD FATS.  I always recommend an ELIMINATION DIET to figure out exactly what you are sensitive to.
  

 

• GET OFF THE ANTIBIOTICS:  I've shown you in the past why antibiotics are arguably the single most dangerous drugs that people are regularly prescribed from cradle to grave (HERE). Worse yet is that the more of them you take, the more you'll need because they hammer the bacteria that make up 80% OF YOUR IMMUNE SYSTEM. Antibiotics create all sorts of physiological vicious cycles that will sooner or later destroy your health (see first link in bullet).

 

• GET OFF THE PROTON PUMP INHIBITORS:  Without going into great deal here, suffice it to say that the acid-blocking drugs known as PPI'S are both extremely common and heavily associated with the double-headed monster known as IBS / SIBO.  BTW, the warning labels on these drugs say that you cannot be on them more than three times a year for more than two weeks at a time.

 

• ADDRESS MOTILITY ISSUES:  Based on the work of FUNCTIONAL NEUROLOGIST Dr Ted Carrick, there are exercises to address the motility issues by stimulating certain parts of your brain, your cranial nerves, or your enteric nervous system.  Some of these include gargling, gagging, and ENEMAS / COLONICS.  As your healthcare provider because all of them might not be right for your particular situation.

 

• ADDRESS GUT HEALTH:  Because many of those dealing with these sorts of issues can't do fermented foods or probiotics, it makes it tough to not only address their intestinal permeability issues, but their MICROBIOME as well.  Depending on what's feeding the problem or how severe it is, FMT might prove beneficial in some situations.

Every day there are people getting off the MEDICAL MERRY-GO-ROUND by creating their own EXIT STRATEGIES.  And while there are no one-size-fits-all "cures," there are steps to take that will help most of you not only understand what's wrong with you, but start successfully addressing it as well.