The SIBO Saga: Part 2

sibo2Disclaimer:  As I have said in the past, I’m not a research blogger.  I’m here to mix “data with soul” and give you useful info, but only in the context of my real, human experience.  That is not to say that citation on my part and proper follow-up on your part are not important.  Everything I wrote about in this blog was presented by Dr. Mark Pimentel at the SIBO Symposium during January 2014 and you can pay to have access to those presentations through the National College of Natural Medicine’s website.

As I sit down to write this blog I feel exactly like I felt writing the previous SIBO blog.  Basically . . . wow.  This is NOT just a tummy ache situation here, folks.  SIBO is serious and all the complex ins and outs are sorta’ mind-blowing.  Today I was going to focus on Hydrogen-Dominant SIBO, but I found that it tends to be much more straight-forward than Methane-Dominant SIBO.  I decided to cover the gist of it, but then move on to a few other topics that don’t readily fit into the other posts I have planned for this series.  They are such interesting tid-bits I figured I’d just squish them into one blog.

As you all know, in the past, I have posted on my Facebook page about the two kinds of organisms that lead to SIBO:  hydrogen producers and methane producers.  We covered methane producers last time.  Hydrogen producers are bacteria that lead to SIBO with diarrhea.  My understanding is that just as the methane causes muscle movement to slow down in SIBO with constipation, hydrogen causes it to speed up in SIBO with diarrhea.  A patient with Hydrogen-Dominant SIBO may even be acutely aware of this when they do a Lactulose Breath Test, as the test may cause them to immediately have serious diarrhea.  The treatment for Hydrogen-Dominant SIBO recommended by all the doctors, seemed to be the antibiotic Rifaximin.  Dr. Pimentel discussed the use of Neomycin only, but stated that drug resistance can easily and quickly develop to Neomycin (although, interestingly, if it is combined with Rifaximin it is less likely to occur).  Pimentel also discussed the misuse of anti-diarrhea medications for this form of SIBO.  He referred to it as a “bandaid” that should only be used to make a patient comfortable until they can see their doctor, not for the long-term, as it is not addressing the underlying cause of the SIBO.

There was alot of interesting and new, for me, discussion about breath testing during the Symposium.  As I’ve written before, the dominance of either hydrogen or methane is detected during a Lactulose Breath Test.  The patient must do a careful prep starting 24 hours before the test and the machine measuring the gases must be carefully calibrated for the best results.  Despite so much being dependent on the patient & machine for the most accurate results, Dr. Mark Pimentel highly favors the Lactulose Breath Test for SIBO testing.  His reason for this is that it has less chance to be absorbed too early in the test (as a glucose test would be, for instance) and therefore gives a better snapshot of the all the bacteria involved in a possible overgrowth.  I found this valuable since so many people come to me with the assumption that breath testing is unreliable.

There are also breath testing kits that you can order and do at home to detect possible SIBO.  Previously, I didn’t think these kits were likely to be very accurate and did not encourage people to use them.  However, to my surprise, Dr. Pimentel explained that his team tested their accuracy and found them to be 97% accurate.  He recommended the test offered by Commonwealth Laboratories and advised that patients watch their instructional YouTube video on taking the test to ensure the best results.  Dr. Pimentel routinely uses this test with his remote patients.

Back to SIBO itself . . . Pimentel explained his team’s hypothesis for IBS (a term that he used pretty interchangeably with SIBO), stating that they believe a toxin, called CdtB, from a “destructive event” (most likely some form of food poisoning) creates autoimmunity to a protein called vinculin.  This autoimmune reaction causes damage to nerves in the gut, especially the small intestine, which changes the natural movement of the digestive system.  This leads to SIBO, which leads to IBS.  For all of you that swear your SIBO started after that special meal during your first ever trip to exotic Honduras . . . it is totally possible.  This was personally interesting for me, because some of my worst symptoms of SIBO first appeared after my family and I arrived in W. Africa.  Travel to these developing locations does seem to increase the risk for succumbing to SIBO.  However, that bad plate of chicken salad at the local deli might do it too.

Dr. Pimentel also stated that he does not use SIBO as a diagnostic term, since SIBO is only an indication of other problems in the GI system.  For instance, it could be the autoimmune reaction described above or a pancreatic disease or a bowel obstruction, etc.  He stressed that if a patient is having very rapid recurrence of SIBO after treatment, less than three to four weeks, it is important to look carefully for underlying conditions.  There are cases where the underlying condition was actually much more serious than SIBO itself.

A final, and very fascinating tid-bit is the role of the “cleansing wave” in SIBO.  The migrating motor complex (MMC) is the movement of our GI track to sweep everything clean, moving debris and bacteria out.  The movement naturally occurs every 90 minutes when a person is NOT eating, obviously the greatest period of cleansing is during sleep.  However, as much as 70% of SIBO patients experience disruption of the appropriate rhythm.  Dr. Pimentel underlined the importance of SIBO patients having periods of “fasting” between meals and not constantly snacking throughout the day, in order to let the cleansing action occur.  If you have food, it immediately shuts down the wave.  He also stated that many will need help stimulating the MMC, which can be done with a number of prokinetic (pro movement) drugs.  Erythromycin, an antibiotic, can be used at a very, very low dose.  This dose does not seem to cause other problems or lead to resistance.  Low Dose Naltrexone (a drug often advocated by Chris Kresser, as well) and other drugs can also be used.  Generally, these prokinetics are given before bed on an empty stomach, to stimulate the most cleansing action during sleep.  Some patients will need this for a short time, while others may require it long term, depending on damage from SIBO itself, other diseases, or injury to the gut.  There are also some probiotics that can help stimulate the MMC, which Pimentel touched on.

Okay, that’s it for today in the SIBO saga people!  I will be writing about Herbal Antibiotics, Diet for SIBO, and also other health issues that are connected with SIBO in the coming weeks, so stay tuned.  As before, there is alot to cover, but I it is worth it, since SIBO & AI are often pals.

You can find Part 3 of the SIBO series here.

About Angie Alt

Angie Alt is a co-founder here at Autoimmune Wellness. She helps others take charge of their health the same way she took charge of her own after suffering with celiac disease, endometriosis, and lichen sclerosis; one nutritious step at a time. Her special focus is on mixing “data with soul” by looking at the honest heart of the autoimmune journey (which sometimes includes curse words). She is a Certified Health Coach through the Institute for Integrative Nutrition, Nutritional Therapy Consultant through The Nutritional Therapy Association and author of The Alternative Autoimmune Cookbook: Eating for All Phases of the Paleo Autoimmune Protocol and The Autoimmune Wellness Handbook. You can also find her on Instagram.


  • […] SIBO Saga:  Part 2 can now be found HERE, at Autoimmune Paleo, where I and my blog partner, Mickey Trescott, now blog.  Thanks for […]

  • […] You can find Part 2 of the SIBO series here. […]

  • Cubby says

    Great post, Angie! Thank you so much for writing it! I hope to attend the SIBO conference in Portland one of these years.

    I was diagnosed with SIBO last spring and thankfully, was able to get rid of it using antibiotics (Rifaximin) and a SIBO diet that was like a very restricted Paleo diet. I had the hydrogen-dominant SIBO and had diarrhea every few weeks for about 30 years. After I healed from the SIBO, I had no more diarrhea. As of this post, I haven’t had a bout of diarrhea in almost a year. This is mind-blowing for me. To no longer have chronic pain in my ab region after nearly 30 years is like a miracle.

    After nearly six months of the SIBO diet, I started adding in lots of foods that used to be restricted. Things got worse and I wondered why I was so bloated all the time. By consulting Dr. Google, I figured out that I can’t tolerate FODMAPS. So, I went on a low FODMAP diet and in just a few weeks, I’m feeling a lot better. Thanks again for writing posts like this and educating others about SIBO!

    • Angie Alt says

      You are so welcome Cubby! Awesome work figuring out how to beat your SIBO!!

  • Danica says

    You mentioned that Dr. Pimentel touched on there being probiotics that help stimulate the MMC. Do you know which those are or how to find out?

  • Iatrogenia says

    Did Dr. Pimentel mention LDN as a prokinetic for IBS? I haven’t been able to find any references to that anywhere, other than the naturopathic doctors.

    I would also like to know of any herbs that stimulate the MMC. I am already using fresh ginger for motility, but have been unable to find out if it has an effect on the MMC.

    Thank you.

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