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Small Intestinal Bacterial Overgrowth

What is SIBO?

SIBO stands for small intestinal bacterial overgrowth. Normally, the small intestine has few bacteria.  Most intestinal bacteria are contained in the large intestine. When there are too many, or they are the wrong type of bacteria in the small intestine, it is called SIBO.

Don’t we need bacteria in our intestine?

We do.  Bacteria are important for our immune system, digestion, vitamin production and more. But, when SIBO is present, there are too many bacteria and they are in the wrong place. This can cause malabsorption, inflammation, and some or many of the symptoms below.

What are some of the symptoms of SIBO?


Stomach pain


Weight loss



Nutrient deficiencies and their associated symptoms: Vitamin B12, A, D, E, iron, other B vitamins, fat, protein and carbohydrate malabsorption

Carbohydrate intolerance-symptoms such as bloating/pain/gas fatigue after eating


Joint pain


What causes SIBO?

To keep bacteria counts at a healthy low level in the small intestine, your body must have normal levels of stomach acid; properly functioning pancreas and gall bladder; normal intestinal motility (ability to move food through the digestive tract); normal mucosa (lining of the digestive tract); and structurally normal valves.


These medical conditions and treatments that affect one of the factors above can predispose someone to SIBO:


Liver or pancreas disease

Celiac Disease/Non-celiac GS

Inflammatory Bowel Disease



Chronic Constipation


Chronic Antibiotic Use

Immune suppressed states i.e. AIDS, Cancer, chronic steroid use

Other chronic diseases

Chronic use of acid blocking medication


Is SIBO associated with any other illnesses?

In addition to the diseases that predispose someone to SIBO, it is also seen more commonly in people with rosacea, restless leg syndrome, interstitial cystitis and cirrhosis.


How do you test for it?

It is typically diagnosed using a breath test in which the patient drinks a sugar-containing drink and exhaled gases are measured. If there are too many bacteria, excess gases (hydrogen, methane or both) will be produced. It should be noted that the reliability of this test is less than ideal and many cases will be missed. Some physicians will treat based on symptoms

How is SIBO related to Celiac Disease and Non-Celiac Gluten Sensitivity?

People with celiac disease have a higher incidence of SIBO. A 2003 paper found there was a high incidence of SIBO in celiac patients on a gluten-free diet with ongoing symptoms. Anecdotally, there is a higher incidence of SIBO in non-celiac gluten sensitivity (NCGS) patients, but due to the lack of data surrounding NCGS, the science is that arena is still to come.

What is the connection to IBS?

Irritable bowel syndrome (IBS) is a common condition. A person with IBS typically has symptoms such as bloating, cramping, abdominal pain, diarrhea and/ or constipation. There is no definitive test or diagnostic marker at this time (although one is under development), so diagnosis is based on symptoms and history. Until we have a better understanding of IBS, there will be debate on its cause and treatment. Some studies say that up to 50-60% of people with IBS may have SIBO and that by treating the SIBO you will get resolution of the IBS symptoms.

So, are some cases of IBS actually SIBO?  A recent review paper addressed the use of Rifaxamin, an antibiotic used to treat SIBO, as a treatment for IBS patients. Many of the studies showed improvement or resolution of IBS symptoms if the IBS patients were diagnosed with SIBO. Another recent study in children found that 66% of children diagnosed with IBS had SIBO. Treating the SIBO resolved the IBS symptoms.

How do you treat it?

The underlying cause of the SIBO must be addressed first or treatment will not be effective. For example, if SIBO is due to celiac disease it will never get better without first adhering to a strict gluten-free diet. After treating the underlying cause, the subsequent therapy will depend on a traditional or integrative approach.

Traditional SIBO treatment:

Antibiotics are the mainstay of therapy and are often used in conjunction with motility agents to prevent “build up” of bacteria by moving things through the intestinal tract. Some physicians will also prescribe a low sugar diet. In severe cases, elemental diets are used. These are liquid diets in which all of the nutrients are broken down and don’t require digestion. The nutrients are absorbed so quickly that the bacteria don’t have time to act on them and produce symptoms. This is done for a short duration to effectively “starve” the bacteria.

Integrative SIBO treatment:

As mentioned above, the underlying cause must first be treated. From there, the following integrative therapies may be used:




Diet/nutritional interventions

Motility agents

Digestive Enzymes


Elimination Diets


Relaxation Techniques

Stress Reduction

Addressing sleep disorders

Herbal antibiotics

Elemental Diets


Are there special diets for SIBO?

Many diets are used to treat SIBO. Which diet is used depends on the clinical scenario and the practitioner. Most of the diets have the same goal of reducing sugars that the bacteria would consume. Commonly used diets are, SCD, GAPS, Candida, FODMAPS, Paleo or a general low sugar diet.

Once you treat it, is it gone forever?

Long term outcome varies, but recurrence is common.

How do you best prevent recurrence?

You may be able to prevent or minimize the risk of recurrence by eating a “clean diet” of primarily plant-based whole foods; minimizing processed foods and sugar; reducing stress; exercising; taking probiotics; and adopting good sleep habits. Some people will use a less restricted form of one of the above-mentioned diets on a long term basis; each person is different.

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“I have always been a very active person and enjoyed a full life, however, I had various health problems for more than 11 years that began taking their toll on my body. I sought help from many health care professionals during that time. I went from Medical Doctors (including a Gastroenterologist), Osteopaths, Acupuncturists, Chiropractors, Physical Therapists to Massage Therapist’s and no one was able to provide me with a correct diagnosis. Nor did they go beyond treating my symptoms and search for the etiology of my illnesses. It wasn’t until I met Dr. Amy Burkhart that my road to wellness began. 5 years ago, I was diagnosed with Celiac Disease after Dr. Burkhart suggested I be tested. I was told by the Gastroenterologist to adopt a gluten free diet and offered an appointment with a dietician. For me, this wasn’t sufficient. I went on a strict gluten free diet and my symptoms and health improved, but I still wasn’t well. I had developed multiple food sensitivities from years of damaging my gut with gluten. Dr. Burkhart put together a comprehensive individualized program that put me on the path to wellness. She helped me discover my food sensitivities, replenish lost vitamins and minerals with high quality supplements and was available to see me through this process. Through her care, I became healthy again, resumed and surpassed all physical activities I had enjoyed many years earlier.”

6 months ago

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