|Battling bacteria w/ more bacteria. Sounds odd, but works like a charm.|
More common and obvious complaints of SIBO patients include gastrointestinal discomforts and malabsorption. Eventually, the on-going bacterial overgrowth can yet also have systemic inflammatory effects and the translocation of bacteria into the gut stream displays a persistent risk factor for sepsis (Quigley 2006).
Unfortunately, the not exactly abundant currently available research indicates, as Zhong et al. write in their latest paper in the Journal of Clinical Gastroenterology that "antibiotics alone may be inadequate for SIBO decontamination" (Zhang 2017). This is bad news because, as previously hinted at, ...
Next to the well-known localized bowel-related consequences, SIBO can also trigger weight loss as well as vitamin and mineral deficiencies due to defective nutrient uptake. In this context the following nutrients are particularly worth mentioning (Dukowicz 2007):
"[...] the delicate balance between host and environment is central to intestinal homeostasis. The intestinal epithelium is exposed on a daily basis to the bacterial antigens of the commensal microflora that in turn induce a state of controlled inflammation. This physiologic response to bacterial antigens is not harmful to the host and generates both the induction of immune tolerance and the secretion of immunoglobulin A (IgA). [...] In disease states, a proinflammatory response to these same luminal antigens leads to the development of such disorders as celiac sprue and inflammatory bowel disease" (Quigley 2017)
Figure 1: Bacterial flora along the gastrointestinal tract; relative concentrations of bacteria at various points in the adult human intestine. Note these concentrations apply only to species that can and have been cultured (Quigley 2006).
- fat-soluble vitamins A, D, E, K, as well as vitamin B12, and iron
- dietary protein (high risk of hypoalbuminemia)
Proton pump inhibitors do not cause SIBO, but they sign. increase your risk of developing it: Even though Ratuapli et al. write in their 2012 study that "[i]n [their] large, adequately powered equivalence study, PPI use was not found to be significantly associated with the presence of SIBO as determined by the GHBT", studies using more accurate measures of SIBO than the glucose hydrogen breath test (e.g. duodenal or jejunal aspirate culture) suggest that it clearly predisposes to the development of SIBO - with PPI users being 7-8-fold more likely to develop SIBO than non-users (Lo 2013) - to which extent this may be thwarted by primary diseases, the type of PPI (older studies show much higher SIBO rates) and the administration frequency is unfortunately not addressed in either Lo's meta-analysis or the individual studies.In observational studies, SIBO has even been linked to Parkison's disease (Gabrielli 2011; Fasano 2013), cirrhosis (=liver disease | Gupta 2010), fibromyalgia (Pimentel 2001) and other diseases and syndromes. For all of them, however, the links are putative and a causal involvement of SIBO has yet to be demonstrated.
- Do probiotics prevent the occurrence of SIBO? Six studies investigated the occurrence of SIBO in patients with probiotics use. The pooled analysis of all studies suggested that patients using probiotics exhibited a slight predisposition toward a decreased incidence of SIBO when compared with those not using probiotics, but without statistical significance (RR=0.63; 95% CI, 0.29-1.36; P=0.24) (Fig. 2). Also, high heterogeneity was presented (I2=84.4%, P<0.05).
Figure 2: FIGURE 2. Forest plot showing the incidence of SIBO for probiotic users compared with the nonprobiotic users. CI indicates confidence interval; RR, relative risk; SIBO, small intestinal bacterial overgrowth (Zhang 2017).
- Do probiotics help with SIBO eradication? The pooled decontamination rate from studies using either probiotics alone and studies using probiotics + antibiotics was 62.8% (51.5% to 72.8%), with high heterogeneity (I2=71.1%, P<0.05).
Figure 3: Pooled SIBO decontamination rate, grouped by probiotics alone or probiotics plus antibiotics. CI indicates confidence interval; SIBO, small intestinal bacterial overgrowth (Zhang 2017)
A different image emerges when we compare antibiotics, alone, vs. antibiotics + probiotic trials. Here, Zhang's results suggested that patients with SIBO using probiotics have a significantly higher SIBO decontamination rate compared with the nonprobiotic users (RR=1.61; 95% CI, 1.19-2.17; P<0.05), and a lower level of heterogeneity (I2=25.7%, P=0.25).
Furthermore, their chronic use may, as the data in Figure 2 indicates, protect you from developing SIBO - in particular if you belong to one of the SIBO risk groups because of structural/anatomic features such as small intestine diverticula, small intestine strictures, surgically created blind loops, resection of ileocecal valve, etc., motility disorders such as gastroparesis, small bowel dysmotility, celiac disease, etc., IBS or metabolic disorders such as diabetes, or hypochlorhydria, organ system dysfunction, including, cirrhosis, renal failure, pancreatitis, etc., or medications such as antibiotics and drugs that suppress the gastric acid production.
- Barrett, Jacqueline S., et al. "Probiotic effects on intestinal fermentation patterns in patients with irritable bowel syndrome." World J Gastroenterol 14.32 (2008): 5020-5024.
- Camilo, Ermalinda, et al. "Folate synthesized by bacteria in the human upper small intestine is assimilated by the host." Gastroenterology 110.4 (1996): 991-998.
- Dukowicz, Andrew C., Brian E. Lacy, and Gary M. Levine. "Small intestinal bacterial overgrowth: a comprehensive review." Gastroenterol Hepatol (NY) 3.2 (2007): 112-22.
- Fasano, Alfonso, et al. "The role of small intestinal bacterial overgrowth in Parkinson's disease." Movement Disorders 28.9 (2013): 1241-1249.
- Gabrielli, Maurizio, et al. "Bacillus clausii as a treatment of small intestinal bacterial overgrowth." The American journal of gastroenterology 104.5 (2009): 1327.
- Gabrielli, Maurizio, et al. "Prevalence of small intestinal bacterial overgrowth in Parkinson's disease." Movement Disorders 26.5 (2011): 889-892.
- Gupta, Ankur, et al. "Role of small intestinal bacterial overgrowth and delayed gastrointestinal transit time in cirrhotic patients with minimal hepatic encephalopathy." Journal of hepatology 53.5 (2010): 849-855.
- Kwak, Dong Shin, et al. "Short-term probiotic therapy alleviates small intestinal bacterial overgrowth, but does not improve intestinal permeability in chronic liver disease." European journal of gastroenterology & hepatology 26.12 (2014): 1353-1359.
- Lauritano, Ernesto Cristiano, et al. "Rifaximin dose‐finding study for the treatment of small intestinal bacterial overgrowth." Alimentary pharmacology & therapeutics 22.1 (2005): 31-35.
- Lo, Wai–Kit, and Walter W. Chan. "Proton pump inhibitor use and the risk of small intestinal bacterial overgrowth: a meta-analysis." Clinical Gastroenterology and Hepatology 11.5 (2013): 483-490.
- Lunia, Manish Kumar, et al. "Probiotics prevent hepatic encephalopathy in patients with cirrhosis: a randomized controlled trial." Clinical Gastroenterology and Hepatology 12.6 (2014): 1003-1008.
- Ockeloen, L. E., and J. M. Deckers-Kocken. "Short-and long-term effects of a lactose-restricted diet and probiotics in children with chronic abdominal pain: a retrospective study." Complementary therapies in clinical practice 18.2 (2012): 81-84.
- Pimentel, Mark, et al. "Small intestinal bacterial overgrowth: a possible association with fibromyalgia." Journal of Musculoskeletal Pain 9.3 (2001): 105-113.
- Ponziani, et al. "Subclinical atherosclerosis is linked to small intestinal bacterial overgrowth via vitamin K2-dependent mechanisms." World J Gastroenterol. 2017 Feb 21;23(7):1241-1249. doi: 10.3748/wjg.v23.i7.1241.
- Quigley, Eamonn MM, and Rodrigo Quera. "Small intestinal bacterial overgrowth: roles of antibiotics, prebiotics, and probiotics." Gastroenterology 130.2 (2006): S78-S90.
- Ratuapli, Shiva K., et al. "Proton pump inhibitor therapy use does not predispose to small intestinal bacterial overgrowth." The American journal of gastroenterology 107.5 (2012): 730-735.
- Scarpellini, E., et al. "Bacillus clausii treatment of small intestinal bacterial overgrowth in patients with irritable bowel syndrome." Digestive and Liver Disease 38 (2006): S32.
- Soifer, L. O., et al. "Comparative clinical efficacy of a probiotic vs. an antibiotic in the treatment of patients with intestinal bacterial overgrowth and chronic abdominal functional distension: a pilot study." Acta gastroenterologica Latinoamericana 40.4 (2010): 323-327.
- Zhang, et al. "Probiotics for Preventing and Treating Small Intestinal Bacterial Overgrowth: A Meta-Analysis and Systematic Review of Current Evidence." Journal of Clinical Gastroenterology: April 2017 - Volume 51 - Issue 4 - p 300–311 doi: 10.1097/MCG.0000000000000814.