SIBO - Treatment and Therapy
SIBO bacterial miscolonization
Very often in our diagnostics we now find impaired digestion as a result of bacterial overgrowth (SIBO) as the decisive cause of many abdominal and also other complaints.
This results in an overgrowth of the germ-poor small intestine with bacteria and microorganisms from the deeper sections of the intestine. These actually harmless bacteria are thus located in the wrong place and disrupt the body's own digestion, which is not yet complete at this point.
Breath tests with various sugar solutions are used in our practice as evidence of bacterial malabsorption; the standard test is performed with Glucose or a synthetic sugar.
Due to the significantly expanded treatment options for "SIBO" in recent years, here is an overview of principles of therapy for bacterial malocclusion.
Treatment strategy for SIBO
Various treatment strategies exist for the therapy of bacterial overgrowth of the small intestine/ SIBO.
Each strategy has 2 main goals:
1. Bacteria reduction
2. Support of digestion and healing of the damaged intestinal mucos
1. Treatment Goal For SIBO: Bacteria Reduction
There are basically four therapeutic options for reducing the bacteria detected in the small intestine:
1. Use of classical antibiotics
2. Use of herbal antibiotics/antimicrobial substances
3. Purely dietary treatment /food change
4. Elemental diet: starving the bacteria
1. use of classical antibiotics
Attempts are made to treat the bacterial overgrowth in the small intestine directly and quickly with antibiotics. For many gastroenterologists and SIBO therapists, this is the first choice.
Studies conducted with various antibiotics show up to 91% success in bacterial elimination (measured by hydrogen breath tests) and up to 94% improvement in patient symptoms.
Which antibiotics are recommended?
2. herbal antibiotics
As with pharmaceutical antibiotics, an attempt is made to attack the overgrowth of bacteria directly and quickly with herbal antibiotics/antimicrobials. This approach is the first choice for most naturopathic physicians and many alternative practitioners and is often preferred by patients. Studies show response rates of herbal therapy comparable to those of rifaximin with a similar safety profile.
Accordingly, many SIBO physicians and therapists have been using herbal antibiotics for many years. Consistently, they are found to be often as effective as pharmaceutical antibiotics in relieving symptoms and reducing gas levels in breath tests.
The use of herbal antibiotics can therefore be recommended as an alternative to classical antibiotics according to current knowledge. However, the side effects that occur due to the sometimes necessary high dosage must be taken into account and can sometimes even exceed the side effects of classic antibiotics. Therefore, a gradual dosage is always recommended.
Which herbal antibiotics are used?
Numerous herbs and essential oils exhibit antibiotic activity, but as with any condition for which antibiotics are used, it is critical to find the right remedy or combination of medications, as well as the appropriate dosage. A variety of medications are used.
Examples of pre-made herbal combination formulas (may be difficult to obtain):
Biotics FC Cidal
Often, a combination of these products will also be required to achieve successful and safe treatment of the bacterial malocclusion.
An individual combination usually consists of one to three of the following herbal antibiotics/essential oils:
Allicin from the garlic bulb (the most commonly used product is "Allimed").
Oregano oil - in capsules or as oil
Berberine - found in plants such as Goldenseal, Oregon Grape, Barberry, Coptis, Phellodendron, available in concentrated form in capsules.
Neem - extract from the Indian Niem tree, available in capsules.
Cinnamon - concentrated available in capsules
As a rule, take 2-3 times a day according to the instructions on the product packaging. In some cases, however, higher dosages are necessary. In individual cases, other herbal antimicrobial substances or essential oils may also be used.
Furthermore, the administration of additional active ingredients can improve the success of treatment, especially in difficult cases with strong gas formation (indication of strong bacterial colonization) or in relapse patients.
These include active ingredients such as partially hydrolyzed guar gum, biofilm solvents or the administration of bile acid preparations.
We strongly advise against simply "trying out" these drugs, which are often highly potent despite being freely available, without a reliable diagnosis and without consulting a therapist experienced in the treatment of bacterial colonization. This applies in particular to combination therapies and higher dosages.
3. dietary treatment / dietary change
Our diet has a significant impact on our gut bacteria population because our gut bacteria feed on what we eat as much as we do. And bacteria mainly eat carbohydrates in the process.
The only carbohydrate that bacteria do not eat much of is insoluble fiber. These are not "fermentable. "Fermentable" accordingly means that a food can be digested by bacteria.
Accordingly, all diets recommended for treatment and symptom reduction in SIBO reduce fermentable carbohydrates. Thus, an attempt is made to reduce the bacteria and the gas they produce by restricting their food supply. Ideally, the diet succeeds in providing enough food for the person being treated, but starving the bacteria.
Specifically, all dietary treatment approaches for therapy and symptom reduction in SIBO reduce the following fermentable carbohydrates / saccharides (sugar compounds):
Sugar (in all forms)
Prebiotics (inulin, fructo-oligosaccharides, galacto-oligosaccharides, arabinogalactan)
Typical sources of such fermentable carbohydrates / saccharides are:
Starch - cereals (pasta, bread, cereals...), beans, starchy vegetables
Resistant starch - whole grains, seeds, legumes.
Soluble fibers - again cereals, beans, nuts / seeds, vegetables, fruits
Sugar - fruits, sweeteners, juices, sweetened beverages
Prebiotics - agave, beans, vegetables, roots / herbs, supplements / prebiotics with inulin or oligosaccharides.
Some carbohydrates are absorbed so quickly that they may not have time to be fermented. These are the "simple sugars" glucose and fructose. These only occur in honey as a sole combination, but in all other foods they are combined with fermentable carbohydrates. Then they are absorbed correspondingly slower and can also serve bacteria as food. That is why glucose and fructose are usually limited or not allowed.
Ripe fruits, non-starchy vegetables, and nuts are allowed in many SIBO diets to ensure adequate nutrition and not overly restrict the food palette, even though they contain fermentable carbohydrates.
How to use dietary treatments/nutritional changes for SIBO:
As (sole) "main treatment" - without antibiotics or other therapy. Here, diet or dietary changes alone may provide sufficient symptom relief that no other treatment is needed or desired. However, long-term dietary changes will likely be required for long-term symptom control. In cases of massive malabsorption, with possible additional presence of malabsorption or "leaky gut" syndrome, more extensive treatment is usually necessary.
In combination with antibiotics or herbal antibiotics for symptomatic relief of symptoms and to support the success of the therapy performed.
As a supportive therapy during and after drug treatment, to support the healing of the mucous membrane in the gastrointestinal tract, which may have been attacked by the bacteria or also the antibiotic therapy.
It may take some time for the gastrointestinal mucosa to regain its full integrity, for the intestinal barrier function to be fully intact again, and for all foods to be properly digested again. Therefore, a SIBO-specific dietary change should be continued for at least one month beyond the end of drug therapy.
In the context of relapse prevention, the aim is to prevent recurrence of colonization of the small intestine after the end of drug therapy. This is clearly supported by possibly also maintaining a diet reduced in fermentable carbohydrates in the long term.
In the course, however, the range of foods consumed should be (cautiously) expanded to ensure an adequate supply of nutrients and to (regain) quality of life.
The so-called "meal spacing" should be maintained, i.e. the observance of meals for food intake while avoiding "snacking" as completely as possible. This allows the intestine sufficient rest periods, which it can use to cleanse itself of any bacteria that may reappear.
Examples of established SIBO Specific dietary changes/diets:
Specific carbohydrate diet (SCD)
"Gut and Psychology Syndrome Diet" (GAPS diet)
Low FODMAP Diet (LFD)
SIBO-Specific Food Guide (Dr. Siebecker)
SIBO Bi-Phasic Diet (Dr. Jacobi)
Simpler versions also include the "fast track diet for IBS (irritable bowel syndrome) or various forms of Paleo diets.
4. elementary diet
By feeding a pure liquid diet completely without fiber for 2 weeks, an attempt is made to "starve out" the bacteria present in the small intestine and reduce them in this way, without having to use additional antibiotic or antimicrobial drugs.
In the first meter of the approx. 4-6 meter long small intestine, a very hostile environment is found due to the mixture of stomach acid, digestive enzymes from the pancreas and bile from the liver. Therefore, no or hardly any bacteria are found there.
Due to the rapid absorption of nutrients as part of the "elemental diet" within this first meter of the small intestine, there is no nutrient supply left for the "bacterial lawn" behind it and the bacteria "starve to death".
The elemental diet is the only way to treat bacterial overgrowth purely by dietary means. In studies, this form of SIBO treatment has a success rate of over 80 percent with good overall tolerability by patients and hardly any side effects.
Many SIBO therapists use the elemental diet approach especially in cases of strong gas development (visible by high values in the SIBO breath test), as otherwise several rounds of antibiotic/ antimicrobial therapy are often necessary.
As a rule, a liquid diet consisting of sugar (glucose or honey), fat (vegetable oils) and an amino acid mixture is drunk 3-5 times a day, together with additional minerals and vitamins but completely without fiber.
Intake should be slow and in small sips so as not to overload the intestine's absorption capacity and leave no food for bacteria.
In order to ensure the supply of all necessary nutrients as well as a sufficient amount of calories, "ready-made drinks" are usually used.
In general, to ensure adequate nutrition and avoid weight loss, it is essential to consult with a nutritionist or therapist experienced in this form of treatment for bacterial malabsorption prior to the two-week course of treatment.
2. Treatment Goal if SIBO: Support digestion and healing of the damaged intestinal mucosa
Proper nutrition and adherence to a "food culture" are the most important measures to relieve the bowel, support digestion, and heal any damaged intestinal mucosa.
In addition, special medications and nutritional supplements are used depending on the patient's findings and previous illnesses.
The various diets and nutritional forms to prevent and support the treatment of SIBO have already been discussed above. In general and in the long term, it makes sense to reduce the amount of gluten and sugar in the diet to relieve the bowel and digestion. Sugary drinks should be avoided if possible (or consumed at most once a day as part of a meal).
The most important aspects of the eating culture are, in particular, the observance of meal spacing, i.e., the avoidance of "snacking" between meals, as well as sufficient mechanical disintegration of the food already in the mouth by adequate chewing (without constant drinking!).
It seems essential to allow sufficient time for each meal.
Typical supportive medications improve digestion
Bulking agents such as psyllium husks or Optifibre (partially hydrolyzed guar gum)
Apple Cider Vinegar
Dextrorotatory lactic acid (RMS)
Daosin / Daozyme
Mucosal healing / Leaky gut treatment:
Humic acids (Activomin)
Treatment of bacterial imbalance in the colon (in addition to dietary changes and digestive improvement):