June 19, 2014

SIBO, small intestine bacterial overgrowth, is a hot topic right now. It is thought that most suffering from IBS and possibly even fibromyalgia, actually have SIBO. The current treatment for SIBO is an antibiotic called Rifaximin. I have been to at least four conferences where this treatment has been presented and one thing that the presenter always says is, ‘this antibiotic is okay because it is not well absorbed and only affects the small intestine.’ This seems to satisfy most of the practitioner’s fears that we are prescribing yet another antibiotic and now that we know that it doesn’t affect the large intestine, it is okay… but is it?

From time to time I hear incorrect assumptions about the small intestine versus large intestine, when it comes to gut flora. If you have read any articles about the flora in your gut, it is almost always referring to the large intestine.

A quick anatomy lesson - your stomach, which is up behind your ribs, empties into the small intestine – there are three sections in the small intestine - the first section is called the duodenum, the middle small intestines is the jejunum and the third section of the small intestines is the ilium. The ilium junctures with the large intestine right by your upper right hip. The large intestine moves up your right side (ascending colon), goes straight across your body to your left side (transverse colon) and then moves down your left side into your bowels (the descending colon).

It is true that in the large intestine, at this juncture point where the small intestine meets the large intestine, that we find the largest amounts of gut flora. This is where you recycle digestive enzymes, assimilate and absorb fat soluble vitamins… you could call this the last stage of digestion. Here’s an interesting fact, your bowel movement is 50% gut flora by mass. Think about how much turnover these flora must have to keep their colony levels up.

The point here, the small intestine is definitely not sterile. Let’s talk about the small intestine for a minute - this is where the majority of the immune system operates, the mucosal lining that protects your body from the outside world is one cell layer deep, this is the site of critical nutrient digestion and absorption and this is where food sensitivities are triggered. Matter moves through this area fast, so we don't see huge colonies of flora here like we do in the large intestine, where matter moves through much more slowly.

Remember the three sections in the small intestine? In the duodenum, there are 1,000-100,000 cfu (colony forming units) of bacteria present per gram, in the jejunum there are 100,000-10 million cfu/ g and in the ileum there are 10-100 million cfu/ g (this is per gram - this is definitely not an insignificant amount of flora). In the small intestine we see bacteria present in the millions. When we look at the large intestine we see bacteria present in the billions. So you can see why there is an emphasis on the large intestine when discussing gut flora.

In the small intestine, Lactobacilli are the dominant flora in the duodenum and jejunum, and bifidobacteria is the dominant flora in the ileum.

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The consequences of SIBO are that gas producing organisms take up residence in the small intestine and cause inflammation, systemic immune responses, digestive unrest and simply unpleasant gut reactions pretty much every time the person eats. SIBO organics are gas producing –hydrogen gas producing, methane producing or hydrogen sulfide producing. For those with methane producing issues, this isn’t a bacteria overgrowth, in fact the organism isn’t a member of the bacteria family at all; it is another species called Archaea group called a methanogen.

SIBO treatment does not often include probiotics. The common assumption is that this is a bacteria overgrowth and that you will need to take an antibiotic to knock it out. So why would you take a probiotic and risk putting more flora in that area??

Here’s why - SIBO becomes an issue because of stress, antacid use, low stomach acids and dysbiosis (an imbalance of gut flora) in the small intestine. If there is no biofilm layer of lactobacillus in the duodenum, then the preferred pH of 6.5 - 7.5 will not be obtained. The surface will become more acidic and this will lower the body’s defenses.

Now, I do not recommend massive dose probiotics (really larger doses of probiotics do not mean that the probiotic will work better). Feed the gut what it prefers to have in this area to heal the area and address the inflammation that SIBO created. This will only be corrected and prevented from reoccurring when the dysbiosis is addressed. If this is not addressed and antibiotics are used without a replenishment phase, then what this will do is further damage the small intestine and it will open the door to everything that we see with chronic gut inflammation - immune dysfunction, food sensitivities, metabolic conditions and autoimmune conditions, if genetically susceptible.

SIBO is present because of dysbiosis and a dysfunctional gut lining in the small intestine. Replenishing lactobacilli and bifidobacteria has to be part of the treatment. This should be free of FOS (prebiotics) – simply lactobacilli and bifidobacteria. I prefer a powdered probiotic that I titrate up slowly. If there is a gut reaction from taking these probiotics, this is simply shedding light on the fact that there is dysbiosis present and this has to be addressed.

I have heard SIBO being referred to as a chronic condition and frankly, I am not buying it. You can treat SIBO by bringing you digestion back into balance from the top down, addressing stomach acid levels, digestive enzymes, rebalancing gut flora and of course, addressing your eating and lifestyle habits. Stress is a big contributor to SIBO and SIBO reoccurrence. By treating the whole body, SIBO can be knocked out for good.

Angela Pifer is a Functional Medicine practitioner and licensed Certified Nutritionist. Seattle's go to nutritionist, Angela, has been in private practice for a decade. Work one on one with Angela through her private practice www.NutritionNorthwest.com.

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Comments

from 152 people

Angela Pifer

Hi Nina,

Yes, anyone can develop SIBO. Please work directly with your pediatrician on this. There are other conditions that share similar symptoms.

Warmly

Angela

Angela Pifer | October 5, 2016

Hi Angela- Can infants develop sibo? I ask because my 10 month old has had digestive issues. At 2 months there was some blood and mucus in her stool. At 5 months, I gave her 3 days worth of klaire labs infant probiotics with inulin base and things just got so bad after that, continuos blood and mucus, alternating diareaha and constipation... She is breastfed. I just wonder if the inulin and high dose 10 strain infant probiotic couldve overwhelmed her little system and the "good" bacteria could be causing a bad effect. Traditional md ped gi docs are not familiar with this and Im desperate for answers. Thank you.

Nina | September 29, 2016

Angela Pifer

Please post the study- happy to take a look. I haven't seen any studies saying this, and a few articles online where people are taking liberties with this topic. L-glutamine is the single most healing supplement we can use for the gut. Some people may not tolerate this well, but this has more to do with them having leaky brain as well, lacking B6 which is needed for conversion of glutamate to GABA (so glutamate levels increase and this can be excitatory) or it might increase detox reaction, so we always should go slow with the introduction.

Warmly
Angela

Angela Pifer | August 21, 2016

Hi

I saw some studies that showed that glutamine can increase bacterial overgrowth. Thoughts?

Mia | August 20, 2016

Angela Pifer

Hi Karen,

There are a few practitioners who will consult long distance with SIBO. You might want to seek one out to get some added help. Dr. Kelley Reis' office in Portland will also do a phone consult with you and will send you a SIBO breath test kit to test this, YET - SIBO is a secondary condition. So there is much, much more here to address. If you are tolerating the probiotic (you don't have a noticeable reaction 1-3 hours later) then it might be fine. I would get the test to confirm this and then find a practitioner to work with. Treating SIBO head on without addressing the underlying condition is going to likely going to lead to a recurring condition and you are (respectfully) very stuck on only a few foods at this point. BEST of luck to you!!

Warmly

Angela

Angela Pifer | August 21, 2016

Hi, I was diagnosed with IBS over 20 years ago. Currently, I am very limited to what I can eat: only meat and fish and some well cooked low FODMAP vegetables - very little fibre, no fruit, carbs, dairy or sugar. Even then, I still experience severe bowel cramping most days; otherwise I am very healthy and physically fit. I strongly suspect I have SIBO but because of where I live, I don't have access to health resources to confirm it. I start my day with a probiotic- (12 billion) and take 3 drops of oil of oregano after meals. Any suggestions?

Karen Gaudet | August 12, 2016

Thank you Again Angela,

I had the SIBO and Glucose breathe test and all that came out positive was Methane. I also had the stool test; all clear.


No hiatal hernia, PH Bravo test showed normal acid levels but with mild reflux and gastritis. Even after 6 days taking this antibiotic I do not have diarrhea or constipation. No need to reply, just adding info. Will take a look at your site and meanwhile have the Blood tests check for IgG, IgA, and IgM Candida antibodies in my blood but based on recent blood test I do not appear to have it.

Gracias
Jose

papote55 | July 13, 2016

Angela Pifer

No, the organisms will not spread to the lungs. I would seek out a visceral manipulation therapist to work on your diaphragm and digestive organs and I would also consider that this might be a small intestinal fungal overgrowth as well. The SIBO breath test is one test and though it may identify an issue, it is only one part of the equation. Even if you are not constipated, if you have methane dominant SIBO, xifaxan will not fix this. I would also work to heal the reflux (the therapist can see if you have a hiatal hernia) while you are taking the acid lowering medication, then work to get off that quickly. This will create more issues down the road. I just opened my practice again for new patient appointments. If you want to get in sooner - starting next week, reach out to scheduling@sg.siboguru.com. Warmly, Angela

Angela Pifer | July 13, 2016

Thank you Angela,

Sorry, just noticed you replied. ;-( He did have doubts because I did not have any of the regular symptoms for this like diarrhea,constipation or gas (just a little gas). I do have chest pressure all day long, breathing problems and muscle/rib cage pain. Do you think this bacteria can spread to the lungs and create a breathing problem? So I believe he just took it easy by not adding another antibiotic on top of Xifaxan. I'm also taking dixalant 60mg for the reflux which is not helping. Do you believe taking to much probiotics like 25 Billions can create this problem? I have been taking probiotics for 2 years up to 30 Billions. Sorry for the questions, but this is my 2nd GI in 2 years and so far they have not helped me so I just got a referral for Mayo Clinic in Jacksonville but I have to wait until Sep 1 to see them. ;-(

papote55 | July 13, 2016

Angela Pifer

Hello! Xifaxan alone will not treat methane SIBO. This needs to be either a combination antibiotic therapy for methane, or an herbal approach. There is no reason to do xifaxan for two weeks to 'see what happens.' I recommend calling your doctor now to get the full protocol - pairing this with neomycin or metronidazole. Otherwise, you will not knock down the methane and over time, I have seen this make the gut even more resistant to recovering. I can't recommend a specific probiotic to you over a blog post. I do list the probiotics that I work with under my shop on my site. Look through these and then discuss these with your health care provider.

Thank you for the compliments on the video!

Warmly, Angela

Angela Pifer | July 7, 2016

Hi Angela,

Great Video! I took the SIBO breathe test and came out with "Presence of Bacterial Overgrowth is Supported" Peak Methane (CH4) Production of 8ppm. GI gave me Xifaxan to take 3 times daily (550mg) for 2 weeks. He also said to take probiotics but he did not say how much or what kind. I have been taking probiotics for 2 years up to 30 Billions daily. I do not have diarrhea but I do fell full every time I eat even if they are small meals. I have lost 55 pounds and my stools are floating every day. The reason I see a GI is because I have mild reflux/gastritis and PPI's or H2 blockers don't work on me- They said I have GERD but I also believe I have LPR because it goes all the way up to my throat. My main symptoms which I had for over a year is chest pressure behind breast bone, rib-cage pain and lack of air from lungs and nasals. Cleared by Pulmo and Cardio. No heartburn and I feel 80-90% better when I lay back. Is all day long, starts easy and gets worse during the day and then at night it goes back down. Gets worse when I stand, walk, talk or eat. I was referred to Mayo Clinic at Jacksonville FL but have to wait until Sep 1 for my first visit. My main question is what probiotic you recommend and in what dose? I love your video and subscribed to get more information, I like your approach so I'm willing to take the extra step to get better. ;-)

papote55 | July 7, 2016

Angela Pifer

Hi Frank,
"I feel as if each individual is so unique that hard and fast rules are the most common mistake made in medicine full stop." - I couldn't agree with you more.

SIBO is an overgrowth of organisms in the small intestine. SIFO is a fungal overgrowth in the small intestine. Candida is a fungal overgrowth in the large intestine.

The right practitioner will assess your labs, symptoms and look at what you have tried - what worked, what hasn't and gleam some very relevant information from this and then create a customized ADAPTABLE plan that starts the treatment process. We need to constantly evaluate progress and be able to adapt the plan as we move forward. I have not used the same treatment protocol on any two of my patients. It really does have to be that customized and unique to the individual to work.

We really have to look to the underlying reasons that SIBO was set up. If these can fully be addressed, then I expect full recovery. If these need to be managed, then a modified plan might be in order. What we can't expect is SIBO diagnosis + SIBO treatment = SIBO full recovery. SIBO is much more complicated than this.

The 'SIBO diet' is only meant to help alleviate symptoms. The diet doesn't treat SIBO. Our goal with the diet is to keep as much variety as possible and to modify the fermentable 'load' only in people who need it. Treat correctly, then work on gut healing and immune modulation, then start to test and expand the diet. There is a very sensitive period after treating SIBO, where the diet needs to remain modified. Yet, after this, we really do have to start to expand the variety, so the patient isn't 'nutritionally challenged' by the diet. It may be Frank, that there is more to still address here for you. I appreciate your question. Best of luck to you!

Warmly,
Angela

Angela Pifer | July 23, 2016

Angela
Quick question about the differentiation between SIBO and Candida overgrowth. Interestingly a low FODMAP diet has seemed to help control my digestive issues more than just about anything else. Its has come to the point that I am now able to play my intestines as if they were an instrument. Unfortunately I feel the research with regard to probiotics, IBS, candida, SIBO, etc, etc is still far from conclusive. I feel as if each individual is so unique that hard and fast rules are the most common mistake made in medicine full stop. With that in mind how does one go about determining and isolating intestinal conditions without treating the entire digestive tract start to finish. Although it is possible to obtain progress, relapse is more common then most people would care to admit due to impractical dietary restrictions. At what point do you determine that a restrictive diet is for life despite an individuals best efforts to eat healthy foods that are actually hurting them. Thanks

Frank | June 16, 2016

Angela Pifer

Yes, here are studies:
http://www.ncbi.nlm.nih.gov/pubmed/21381407
http://www.ncbi.nlm.nih.gov/pubmed/18763284
http://www.ncbi.nlm.nih.gov/pubmed/23244247 this one shows lactobacillus used after antibiotic
http://www.ncbi.nlm.nih.gov/pubmed/25579140
http://www.ncbi.nlm.nih.gov/pubmed/25244414
http://www.ncbi.nlm.nih.gov/pubmed/23653934
http://www.ncbi.nlm.nih.gov/pubmed/17378388

Warmly,
Angela

Angela Pifer | July 23, 2016

"Replenishing lactobacilli and bifidobacteria has to be part of the treatment."

Is there anything on PubMed to back this up? I'm very interested but could not find much. Thanks!!

S | June 14, 2016

Angela Pifer

Hi Ondina,
VSL3 doesn't have any prebiotics in it. It is a high potency lactobacillus probiotic. Most all the probiotics that I use are listed under my shop http://siboguru.com/product-category/probiotics/ you don't need to purchase these from me. This is just a good reference so you see what I use with my patients.

Warmly,
Angela

Angela Pifer | July 23, 2016

In your article about probiotics for SIBO I'm curious what is the name of the powdered probiotic that you like to titrate up slowly? I have SIBO and have been taking VSL3 but not sure if this has prebiotics in it!

Thank you for taking the time to answer my queries...; ) Ondina

Ondina | June 12, 2016

Angela Pifer

Hi Bharat,

I am so sorry to hear about your situation. The symptoms can be so overwhelming and debilitating. I appreciate that you have been to a very good doctor and that you have identified that this is SIBO. There is much more to be done here to address your symptoms and to treat this. I do work long distance, both nationally and internationally. If you find that you would like further help with this, please reach out to scheduling: http://siboguru.com/contact/ You definitely can't live off cucumber water (I say this with empathy, I know how hard you are trying to not have symptoms).

I also appreciate all the research that you are done. There is a LOT out there. It is good to be educated, and you need to find someone to work with who really knows that and can help to treat you as an individual.

Warmly,

Angela

Angela Pifer | July 23, 2016

Hey Angela,
I have been reading about SIBO since the time I have got to know that I m one of its victim.there hasn't been any side or any medicine which I have not checked out or tried respectively.i am an aspiring model from India and I have a shoot coming up in 9 weeks.i have been diagnosed with SIBO after 9 months of struggle with my body and doctors.i have almost tried everything but it does go for 3-4 days and when I start feeling good about it,it shocks me by its symptoms on the 5th day.i am so depressed and feel helpless about it.it is so demotivating as an aspiring model because the bloat is really bad and u don't feel like doing anything.i have controlled my diet,infact sometimes I just drink water and sometimes cucumber juice with protein shake but it still comes back.i have been to the best doc of the town but nothing has gone my way till yet.i would really appreciate and don't know will do what all if u could help me with the same.nothing in this world is worse than SIBO.
Help me please!

Bharat | June 11, 2016

Angela Pifer

Hi Steph,

Yes, here are studies:
http://www.ncbi.nlm.nih.gov/pubmed/21381407http://www.ncbi.nlm.nih.gov/pubmed/21381407
http://www.ncbi.nlm.nih.gov/pubmed/18763284http://www.ncbi.nlm.nih.gov/pubmed/18763284
http://www.ncbi.nlm.nih.gov/pubmed/23244247http://www.ncbi.nlm.nih.gov/pubmed/23244247 this one shows lactobacillus used after antibiotic
http://www.ncbi.nlm.nih.gov/pubmed/25579140http://www.ncbi.nlm.nih.gov/pubmed/25579140
http://www.ncbi.nlm.nih.gov/pubmed/25244414http://www.ncbi.nlm.nih.gov/pubmed/25244414
http://www.ncbi.nlm.nih.gov/pubmed/23653934http://www.ncbi.nlm.nih.gov/pubmed/23653934
http://www.ncbi.nlm.nih.gov/pubmed/17378388http://www.ncbi.nlm.nih.gov/pubmed/17378388

And really common clinical sense, SIBO is set up because of an imbalance in the system - this is set up because of immune dysfunction (at the mucosal level), dysbiosis, motility dysfunction, etc. Probiotics help with immune modulation. This is really why we take them.

Warmly,
Angela

Angela Pifer | July 23, 2016

Hi Angela,

Thank you for the informative article! I'm interested in doing more research about SIBO and probiotics - would you mind suggesting some key studies that support your use of lactobacilli and bifidobacteria strains? I couldn't find much - have you come to this conclusion from experience only?

Steph | June 10, 2016

Angela Pifer

Hi Jennifer,

First, let me apologize here. Your question was a bit more timely here and I have been really busy this past month with my clinic. It may be that 1/8 pinch is your dose. If 1/4 doesn't work for you, but 1/8 did, then stick with 1/8 pinch longer. Once this sits well, then try 1/8 pinch twice a day. I definitely would not push through symptoms. I would evaluate why they are happening and make some adjustments.

If you find that the Sibiotica does not work at this time, set it aside (tightly sealed, in the refrigerator) and consider trying Bacillus coagulans next.

Warmly

Angela

Angela Pifer | July 23, 2016

Hi Angela,
Great information and blog! Under the direction of a great doctor, I feel like I am finally turning the corner in a long 3-year battle with severe SIBO. This year alone I have done elemental, antibiotics and 2 months of herbals. Once I started to feel better at the end of herbals, we started to introduce probiotics to see how I respond. Following your advice and knowing my long battle probably points to severe dysbiosis, I started with literally a pinch of Sibiotica each morning. I think if I measured it out, it would amount to about 1/8 of a capsule! I was hoping to work up to 1/4 of a capsule within a week. My gut reacted with gurgling and loose stool within a day of the first dose. As you mentioned in the video above, that is probably a sign that this is needed more than ever. The same symptoms have continued over the past few days of me taking the same dose, but has not gotten worse. What do you recommend people do in such a situation - power through it and it usually gets better in a few weeks, or wait and do more herbal treatment before trying again? Thanks!

Jennifer | June 7, 2016

Angela Pifer

Hi Melissa,

Thank you! Once a negative SIBO test is reached, people don't always feel immediately better. The next steps are gut healing, immune modulation and then working to rebalance the gut flora. You may need to be on a modified diet this entire time, then, after this (maybe 2-3 months after treatment) you may challenge some fermentable 'loads' to see what you can handle at that point. There are some supplements that might help with cramping (please discuss these with your health care provider - Iberogast, enteric coated peppermint, Gentian and Skullcap...)

It sounds like you know what this isn't - it isn't a parasite, fungal overgrowth that was missed and you don't see a level of pathogenic bacteria. I would look more at rebalancing the dysbiosis and healing up the gut. I also recommend visceral manipulation (type of body work) and biofeedback.

Warmly,

Angela

Angela Pifer | July 23, 2016

Hi Angela!

First, let me just say that I love your blog and have found these posts to be so, so helpful while navigating my SIBO journey. I would be so grateful if you took the time to answer one of my questions!

I recently managed to clear my overgrowth using a combination of a 3 week elemental diet plus herbs (yay!) but am unfortunately still experiencing classic SIBO symptoms (boo...) - plus cramping when eating foods that I used to tolerate. Is this something you typically see in your practice? I tested negative for pathogenic bacteria of the colon, parasites, h. pylori and yeast metabolic markers in the SI (via Organic Acids test) a few months ago.

Would love to know if I'm missing something obvious that could be causing the continued bloat and new, painful symptoms...

Thanks in advance!! :)

Melissa | June 6, 2016

Angela Pifer

Hi Stephanie,
You are using a probiotic that is much too strong. It also has FOS (fructooligosaccharides in it) which are prebiotics. They made a very wrong recommendation for you. I would pull these immediately and focus on a lower fermentable plan to calm your gut down.

Diflucan (anti-yeast medication) is a bit too strong for my liking. We do need a good yeast balance to keep the bacteria at bay (same can be said for the opposite - when an antibiotic is taken and this knocks down too much bacteria, then people can get a yeast overgrowth). This needs to be more of a balancing act and this is why I prefer herbal antimicrobials and antifungals. We can use herbs that exhibit both properties so we can address these (SIBO/ SIFO/ Candida) at one time. For a yeast issue, saccharomyces boulardii is a good probiotic to use.

Warmly,

Angela

Angela Pifer | July 23, 2016

Hi Angela-

Four years ago I was diagnosed with Hashimotos as well as hypothyroidism. To figure out what the real deal was, how it all could have possibly started, I found out that last year I also have SIBO. The doctor that diagnosed me told me that probiotics wouldn't really be beneficial. I've been a little leary of taking probiotics, but decided to start taking a month ago probiotics that were at 15 billion (the one that my other doctor suggest I use) I was doing fine, didn't notice anything different. Since my thyroid went out, I'm constantly fighting with candida, so I decided a week and a half ago to start my Diflucan treatment as well as taking a candida support. I went to GNC to get the candida support and they suggested that since I was killing off a lot of bad bacteria as well as good, that I go up to a 50 billion probiotic. Since then I have been super constipated, bloated and edgy. I was hoping that maybe my body would even itself out, but now I'm questioning it. I was more regular not taking a probiotic than I am now! Looking at what the probiotic contains, it has Lactobacillus acidophilus, bifidobacterium bifidum, bifidobacterium animalis subsp. lactis and fructooligosaccharides. I noticed the last one is an FOS, which I saw you said we shouldn't take in your article. What would your suggestion be on how I can get back to normal while including probiotics? Any advice would be much appreciated! Thanks!

Stephanie | June 6, 2016

Angela Pifer

Hi Tawnya,

Yes, the information is different for anyone who has had a bowel/ stomach surgery. It is likely that you have SIBO because of the surgery and that you are experiencing an overgrowth of your innate flora (flora that is supposed to be there, yet is there in too large of number). Since you have had a bowel/ stomach surgery, I recommend doing everything possible to avoid antibiotics. You are going to be more prone to a recurrence because of the surgical juncture that was made. Instead, look to treating this with herbs and addressing symptoms to best manage this long term. I say this because, I antibiotics should be a last resort and it isn't a good idea to use multiple rounds over the course of your lifetime. I do understand that symptoms can get so debilitating sometimes, that the antibiotics seem like the only option, yet there may be more to be done here to get you comfortable first, treat this more gently with herbs and then work on a maintenance plan over time.

The root cause here is complicated because of the surgery. I don't know your case personally, so I don't know if there are additional issues contributing here (sluggish thyroid adding to motility issue, past food poisoning, adhesions from the surgery).

If you haven't found the answers you are looking for, I am happy to work with you. Reach out through my scheduling: http://siboguru.com/contact/

Warmly,

Angela

Angela Pifer | July 23, 2016

I recently had the Glucose Hydrogen Breath Test done and tested positive. I have not yet started anti-biotic treatment, as I am trying to research my best options that are more related to having had gastric bypass surgery 13 yrs ago. I have read through the information on this website and watched a few videos and am wondering if any of this information might be different for someone who has had gastric bypass surgery. I have been experiencing severe bloating/gas, along with mostly constipation. I am looking to treat the bacteria but more importantly, the root cause. Should I be in search of a certain type of doctor or specialist, or is the altered structure of my intestines treated in the same way as the information provided on your website?

Tawnya | May 16, 2016

Angela Pifer

Hi Anne,

It sounds like there is still more here to address. That SIBO and possibly, the underlying condition, or possibly the dysbiosis after SIBO hasn't been addressed fully. The probiotics that I use in my practice are listed on my site: http://siboguru.com/product-category/probiotics/ this is a good reference to talk with your practitioner about. I find that a low fodmap plan is the best regroup diet, yet I only alter the diet to reduce symptoms (not as part of the treatment plan).

You may need further treatment, but since you are breastfeeding (please don't let this interrupt your plans for breastfeeding) you should wait until after you are done breastfeeding to treat this again. You could use a low fodmap plan to help make your symptoms manageable during this time.

I hope you feel better soon Anne!

Warmly

Angela

Angela Pifer | July 23, 2016

Hi Angela,

What specific probiotics? I have SIBO, and took two courses of xifaxan...I still have symptoms. Can you tell me which brand you recommend? And which diet (i.e. specific carb, FODMAPs, BRAT, etc). Help...I'm also breast feeding.

I was taking Renew Life critical care 50 billion flor and eating greek yogurt daily before the SIBO finding...now I stopped both back last Oct, did the two courses and nothing has changed. I'm still completely bloated and constipated all the time. Any advice???

Thanks!

Anne | April 19, 2016

Angela Pifer

Hi Joni,

I would look at two things - if there is a histamine issue present, and if you are having an immune reaction to some of the foods that you are eating. I would also look at blood sugar regulation and adrenals.

I find that some people have histamine reactions after having SIBO chronically and that once this is addressed, they can recover from this. I see that these reduced after addressing SIBO, yet there may have still been more dysbiosis to address and heal.

I would also look at a possible mold/ mycotoxin exposure to see if you are carrying a mycotoxin load that is affecting your system.

There are food sensitivity tests that I do not recommend and one that I do. Cyrex Array 10 has been right every time I've run it.

I hope that this helps Joni!
Warmly
Angela

Angela Pifer | July 23, 2016

Hi Angela,
I am wondering if you have ever experienced heart palpitations with SIBO. This past year I have been dealing with heart palpitations as soon as I start eating. I have been gluten-free for years. Multiple heart tests and the cardiologist said my heart is fine. Palps are being caused by something outside of my heart. I went on a severely restricted diet and then tested positive for SIBO last summer. I took herbals for 5 weeks and then rifaximin. Retest showed it was cleared completely. I continued to have periodic heart palpitations (although much less often & more mild). This past Fall/Winter I went through a significant amount of stress (medical issues of my husband & son) and ate more carbs/sugar than I should. I am pretty sure the SIBO is back as I have all my symptoms back (except the watery stools). I am getting tested again on Monday. I really want to get to the root of the gut/heart palpitation issue but no one seems to know. I have spend literally $1000's of $$ on doctors (N.D. & Functional Medicine doc). They were happy to take my money, but then after months of appointments and "protocols" they still had no idea what was causing my gut issues and palpitations. I have read a lot of your posts this past year. I know you can't diagnose me from my post, just curious if you know of anything relative a SIBO/general dysbiosis & heart palpitation correlation.

Joni | April 8, 2016

Angela Pifer

Hi Heather,

It really depends on the patient, SIBO, symptoms, additional conditions, if LOW diversity (seen on a stool test) etc., so unfortunately it is hard to answer this question as a yes or no.

I list the probiotics that I use with my patients in my shop – it is easiest to reference this and then to discuss these with your practitioner to find the right one. http://siboguru.com/product-category/probiotics/http://siboguru.com/product-category/probiotics/ You can open any probiotic and take a small amount of it to start. You don’t need to purchase a powder probiotic to start.

Warmly
Angela

Angela Pifer | July 23, 2016

Angela - Do you give the probiotic concurrently with the antibiotic/herbal treatment for SIBO? Or do you wait until after the treatment phase is over? What dose (CFUs)do you like to use and any preferred brands?

Heather | April 1, 2016

Angela Pifer

Hello, I would say that it is one person's view on what worked for them. They also mention yogurt and eating this and they feel that this added to their relapse. I do like the reply comment right below the post "HiI am afraid i TOTALLY disagree, I have been working with bacteria for more than 12 years in a professional capacity and know from first hand experience that reintroduction of targeted bacteria in to the GI tract as a whole is vital for the efficient treatment and recovery in the long term for SIBO of all kinds. telling people not to take probiotics and other supplements is extremely narrow minded and may prevent people from finding some relief." I completely agree with this.

Warmly
Angela

Angela Pifer | July 23, 2016

What do you have to say about this:
http://www.ibsgroup.org/forums/topic/102286-after-5-relapses-now-cured-heres-how/

Dharmendra Singh | March 2, 2016

Angela Pifer

Hi Kristen,
Do probiotics make him worse? I really wish I could help with further advice here, but this is an age group that I do not work with. Please seek out a pediatrician in your area.
Warmly
Angela

Angela Pifer | July 23, 2016

Hi Angela,
I suspect my infant is having gut issues related to a disturbance in his gut flora. He was IUGR (intra-uterine growth restricted), and was born smaller than average as a result. Also, he was born via emergency c-section. At only 1-week old, he was admitted to the ICU due to dehydration and a possible underlying infection. There, he was given 3 broad-spectrum antibiotics. Based on the fact that he was small/underdeveloped, born via c section, and given a boatload of antibiotics, I know his gut flora has been altered and is likely behind all of his symptoms (gas, diarrhea, often with mucus and sometimes blood). A milk (and other) allergies have been ruled out. What would you suggest as possible treatment for a 6-week old? I should note that my older son had similar issues and symptoms seemed to disappear when treated with an antibiotic for something unrelated. This has me wondering and reading about SIBO.... Thanks in advance for your help.

Kristen | February 26, 2016

Angela Pifer

Hi Mia,

I am going to repost a summary from Klaire Labs monograph on d-lactate - it is quite eye opening.

SUMMARY: Organic acid testing may reveal the presence of the isomer D(-)-lactate. Confusion exists among clinicians on how to interpret this result and what to do about it. Humans produce only very small amounts of D(-)-lactate, but normally metabolize this isomer efficiently. Microorganisms can make mostly D(-)-lactate, L(+)-lactate or a mix of the 2 isomers. Elevated urine D(-)-lactate levels are often confused with D(-)-lactic acidosis, an extremely rare condition occurring almost exclusively in patients with short-bowel syndrome and an overgrowth of certain Lactobacillus or Enterococcus species. D(-)-lactic acidosis has never occurred in a person with an anatomically intact bowel. Elevated urine D(-)-lactate levels may be due to a gastrointestinal microbiota predominated by species that produce high amounts of D(-)-lactate. Increased Enterococcus and Streptococcus populations are the most likely culprits. However,
elevated levels also imply a diminished mitochondrial capacity to metabolize D(-)-lactate. Factors that may impair metabolism of D(-)-actate include elevated acetyl-CoA levels, high oxalate concentrations, and thiamine deficiency as well as high intakes of high fructose corn syrup. When elevated urine D(-)-lactate levels are encountered the most effective approach is to resolve gut dysbiosis with pre- and probiotics, optimize digestion with enzymes, restrict excessive carbohydrate intake, provide nutritional mitochondrial support, and reduce elevated oxalate levels.

Angela Pifer | February 15, 2016

Hi Angela,
I react to d lactate producing probiotics and do have sibo. I see you now prefer sbo's?
Is this of possible use to sibo after adding s. Boulardii?
I have tried many probiotics and react more to acidophilus than I do to inulin.

Mia | January 23, 2016

Angela Pifer

Hi Brenda,

Yes I have seen this. Dyslipidemia (high cholesterol) is a results of oxidative stress, inflammation and/ or an autoimmune reaction. I have seen a few otherwise healthy people, with very high cholesterol and oxidative patterns that have been traced back to asymptomatic dysbiosis (some SIBO and some not) and once the gut was healed, the cholesterol recovered.

Angela

Angela Pifer | February 15, 2016

I do have a question. I have NOT been diagnosed with SIBO, but I do have a doctor's appt in a couple of weeks to get to the bottom of my digestive problems. My question is what is the correlation between HIGH cortisol and digestive problems? My cortisol has been tested twice (blood) and it's almost twice what it should be.

Thanks

Brenda | January 22, 2016

Angela Pifer

Hi Rachel,
I would work with her on learning how to blow into a tube -practice this with a straw and then take the test. I would not treat this without really knowing what you are treating. I also recommend using a lab that also measure CO2 at each interval (Common Wealth Labs do this) so you can make sure that the collection was done properly and you are getting an accurate reading. This might be SIBO and it might not. I would hate to treat these and then it turns out it is something else, she is so young. I know you understand this, otherwise you wouldn't be posting here and asking this question. Warmly, Angela

Angela Pifer | January 20, 2016

Hi there, my daughter began having tummy issues at age 3. She is now 4.5 yo, and we have narrowed down food intolerances (gluten and dairy protein). We have been the peds allergist (she has no allergies), the peds gastro doc, and he is baffled. All her blood work is Norma, negative celiac panel, negative for O &P, you name the test, we have done it (minus breath tests, since I was told that at such a young age this can be difficult to get an accurate reading).

At our last visit, peds gastro doc thinks it is SIBO and prescribed 7 day course of flagyl and VSL 3. I am an RN and am desperate for help.

Rachel | January 20, 2016

Angela Pifer

Hi Stephen,

I am so sorry to hear about your symptoms and continued health concerns. Have you been assessed for Lyme, mycotoxins, heavy metals... it definitely sounds like there is something else going on here than 'just' SIBO.

Here are some sleep support suggestions to discuss with your health care provider: 3 grams of glycine; Sleep Well Drops from Herban Wellness in Kirkland, WA (they will mail this to you, request their 'hawethorne' formula); 1 scoop of PurePaleo protein at bedtime (this is hydrolyzed beef protein/ no fermentable compounds); Magnesium Chelate, Designs for Health. Take all of these at bedtime. Also adrenal support and calming - I like Apex products for this. Epsom salt bath, sleep hygiene makeover.

You could add calcium-d-glucarate to indirectly lower the gut ammonia levels.

There is a lot more to do to this, but I hope that this helps!

Angela

Angela Pifer | February 15, 2016

Hi Angela,

I'm suffering with chronic insomnia, depression, anxiety, fatigue, brain fog and a lot of other issues. I have been using antimicrobials and probiotics for the past 5 months, things have gradually gotten worse for me and I got to the point where I had to stop the antimicrobials because my depression/insomnia was getting worse.

I've had a lot of tests done, and they showed:
- High cortisol
- High ammonia
- High oxalates
- Low glutathione
- Low B2, B6, biotin
- High succinate (Krebs cycle is basically broken)
- Streptoccous overgrowth, Citrobacter farmeri, no Lactobacillus/Bifidobacterium, Candida
- Immunology - lgA at 80.6
- Digestive markers were OK
- Thyroid - High Reverse T3, TSH is 0.69
- Neurotransmitters are all out of balance, low serotonin/gaba, higher glutamate
- No parasites (but doctor I was seeing only did a stool test x1, so not sure if parasites have been completely ruled out)
- May have CBS upregulation though not sure

I'm wondering what I can do to improve my sleep? Is it possible parasites could be an issue? I'm working on a protocol to detox with NAC, and Pure encapsulations GI Fortify, but know this is only a small part of getting detox going. This product has licorice root in it though, which I think is going to worsen my cortisol problems. I know this is only a small part of the picture, I'm not anemic as far as I know but I do feel cold in the hands/feet. I find a lot of supplements overstimulate me during the day, so I haven't been able to use B vitamins. It's very difficult to get off to sleep at night without a prescription sleeping tablet. I also wake up very early and unable to get back to sleep. Ammonia is a big problem I think, but not sure how to treat it. Ornithine makes me feel better for a short time but then it wears off. Anti inflammatories (Quercetin) help but haven't been using them on a regular basis.

Thanks

Stephen | December 25, 2015

Angela Pifer

Hi Olga,

I often use l-glutamine, slippery elm and DG licorice along with other supplements and compounded bismuth as adjunct care to address acid reflux. I find them highly effective!

warmly,
Angela

Angela Pifer | February 15, 2016

I have sibo and acid reflux. Dr gave dgl, aloe vera, S elm. And for sibo other suplements, probiotic and mucosagen. She recomended "breaking the vicious cycle" book and follow the diet for 3 months. The book said not to take aloe vera, dgl and s. Elm. It is ok to take mucosagen?
Thanks

Olga | December 10, 2015

What strains of probioics produce d-lactate or even both d and l lactate so I can avoid the buggers? I just went through two courses of xifaxan clearing much brain fog, then tried some probiotics to replenish my good guys and stave off c diff only to have the tying to think though mud can't remember recent information return.

i could cry.

or scream.

going to see my gi dr asap but in the mean time I am trying to learn what I can to talk to her about - and make sure she knows what she is talking about.

There is a real dearth of information on the internet or at least that I can find. My google fu has failed me.

jen | November 25, 2015

Hi Angela
Thank you very much for your response and helpful advice.
I think you are so right that detox pathways in particular need to be functioning well. In my case histamine metabolism also as I have read (not sure if accurate) that significant amounts of histamine can be released when killing off bad bugs.
When detox pathways and adrenals are in better shape and supported and it is deemed the right time to try a herbal anti microbial protocol do you tend to co-administer a probiotic from the outset of the program or do you introduce this later after an initial "cleansing period"? Do you always do a biofilm treatment at some point in the process?
Many thanks again
Paul

Paul | November 18, 2015

Angela Pifer

Hi Alyce,

I definitely recommend that you work with a qualified practitioner to help you determine the best course of action with your treatment. Once there has been a re-sectioning, this brings up new issues that need to be assessed and addressed. Depending on which sections are re-sectioned, adhesions (high risk after surgery), and how you are healing, you will be more prone to having an overgrowth of beneficial flora (like lactobacillus or bifidobacterium) - so taking a lactobacillus or bifidobacterium probiotic may not be the best approach for you. It is important to know what is contributing to SIBO (if SIBO) and formulate a plan that addresses this - the approach is different if lactobacillus overgrowth, something like klebsiella or methanogens (organisms that migrate up from the large intestine). One treatment does not treat SIBO - unfortunately.

Warmly,
Angela

Angela Pifer | February 15, 2016

Hello Angela,

Im always so confused on what Probiotic/ Prebiotic to take if I don't have a colon. I had my large intestine removed about 10 years ago, and since then I have taken different types of probiotics. Lately I have been experiencing the symptoms of SIBO when I don't take a probiotic and wanted to know if the treatment you suggest would be any different for someone in my situation.

Thanks in advance,
Alyce

Alyce | November 17, 2015

Angela,
Thanks for the great information on d-lactate. What do people take who are sensitive to the build up? Thanks so much for answering my question, I have also learned a lot from your responses to others.

Marie | November 15, 2015

Angela Pifer

Hi Elizabeth,

Yes, nausea is quite a common symptom. I see this with SIBO and I also see this with SIFO (fungal overgrowth). After you are done with the course of antibiotics, I would wait five days (no fiber, antibiotics or probiotics) and retest the breath test. See what level parts per million gas was knocked down with that round. I would also shift to herbals antimicrobials at that point - these are both antimicrobial and antifungal in property. If antibotics are not addressing symptoms and you almost feel worse, I would investigate the possibility of fungal and/ or that you may simply not be responsive to the antibiotics. Also look at diet - making adjustments to reduce your nausea.

Best of luck to you!
Angela

Angela Pifer | November 14, 2015

This was an enjoyable read with lots of great information. Just curious - have you ever seen people with Sibo that they're only symptom is extreme nausea? I tested positive in the hydrogen breath test, and I am on rifaximan now. It's making me quite sick though (just intensifying the nausea, no other symptoms), just like the initial antibiotic that I took that started all of my symptoms (augmenting). So again, I'm curious if you ever seen people with Sibo that they're only symptom is nausea. I tested positive in the hydrogen breath test, and I'm on day 3 of the rifaximan. It's making me quite sick though, just like the initial antibiotic that I took that started my nausea in the first place. I spent four months trying various probiotics (including florastor and prescript-assist) with no luck, and that is when they told me I needed the antibiotic.

Elizabeth | November 13, 2015

Angela Pifer

Hi Marie,

Lactobacilli product lactic acid (this keeps the pH at a low acidic level - which is preferred), which is then converted to bacteriocins or hydrogen peroxide. It is processed quite quickly and does not build up in the system. There are two forms of lactic acid - D lactate and L lactate. When D lactate builds up in the system, this is very poorly converted/ processed and is associated with d lactic acidsosis. This is not SIBO. I wouldn't directly call this dysbiosis, I would say that this is more of an issue that results from too much d-lactate building up and that there is a small subset of the population that is going to be sensitive to this build up. It is more associated with short bowel syndrome, and I have seen some patients with IBD or fibromyalgia, be sensitive to this.

There is a study that points to lactobacillus as one of the microbes involved with SIBO, yet the study population had short bowel, surgery or a loop (where matter slows down through the loop and commensal microbes in the small intestine are able to grow in numbers, larger than they usually would. For people who have SIBO for other reasons, I would not say that lactobacillus is the issue. There are 180 species of lactobacillus and of these species (like lactobacillus acidophilus) there are many different strains of species. I would not hone in on lactobacillus acidophillus as the issue with SIBO.

Rifaximin affects the small intestine (with a modest effect on the colon - and the current TV commercial states one of the warnings, that if you have a liver issue, then consult with your doctor because this may lead to an increased level of rifaximin circulating in the system - so some must be absorbed in the body, out into circulation).

Angela

Angela Pifer | November 2, 2015

Are high d lacate levels from bacteria considered to be SIBO or just dysbiosis? My Organic Acid test showed a very high level of d-lactate which was attributed to acidolphilus. Not sure why it was was specified as that particular kind since it is not the only one that can produce d lactate, however all my other bacterial markers were low.

Would an overgrowth of l acidolphilus (or any other d lactate producing bacteria) produce hydrogen where it would even show up on a breath test? Would rifaximin kill acidolphilus since it is considered a good bacteria?

Thank you very much if anyone can help me piece this information together, there is not much that I could find regarding d lactate.

Marie | October 28, 2015

Angela Pifer

Hi Nicole,

I would really look at this from the top down - supporting stomach health, HCL betaine, digestive enzymes, perhaps bile acid support, addressing stress, assessing thyroid function (since this directly effects gut motility), addressing gut motility, try to figure out why your stomach acids may be low in the first place (autoimmune with pernicious anemia, do you have a zinc deficiency (this is part of the enzyme that drives acid production in the gut)... if you are unable to digest food well and you are chewing a long time, focus more on cooked vegetables, soups, stews, 'wet' foods, raw fruit is fine (cook all vegetables)...

Warmly
Angela

Angela Pifer | November 2, 2015

Hi there,
What great info! I have both candida and sibo coming off 15 years of nexium (I weaned myself off). I am struggling to digest food. I eat only meat and veggies. I'm on rifaximin ...round two and have taken antifungals daily for years. My digestion is so poor I'm unsure how to get out of this vicious cycle. What steps would you recommend first? I've tried diestive enzymes and betaine hcl to no real avail.

Nicole | October 26, 2015

Angela Pifer

Hi Paul,

Let me see if I might offer some direction here - I find that histamine intolerance (even though methylation issues can place you at higher risk for this) is really an end result of chronic gut stress/ dysbiosis/ inflammation (which is highlighted by your high S IgA levels) and that this will recover when you recover your gut health. Since you are having a hard time with die off symptoms, I would look to first addressing liver, detox pathways, adrenals... if anemia, then this must be overcome first to then address the gut. If in ketosis, it is near impossible to address candida/ fungal issues. I feel the same about SIBO.

With brain fog - this is brain inflammation and it is showing you a breakdown of the blood brain barrier (leaky gut/ leaky brain). There are protocols that you can use to start to address this, without tipping too far into the herbal/ antimicrobial protocols. Instead of grains, you could focus more on potatoes, turnips, parsnips, plantains and squash, but I would still include starches at each meal.

I don't feel that you are ready for biofilm supplements - this will 'dump' a lot of toxins into the system and your detox pathways are not where they need to be.

I really like NeuroFlam NT by Apex for brain fog.

I hope this helps Paul!

Angela

Angela Pifer | November 2, 2015

Hi Angela,
Appreciate your good work. I'm a bit lost and would appreciate your view. Not too confident in my naturopath so maybe I should consider working with you long distance (I'm in Ireland). An abbreviated summary:
- 36 year old male
- chronic antibiotic use & sugary diet until 23 years old (no abx since) and 8 amalgam fillings (removed 2010)
- multiple food intolerances (originally grains/dairy)
- did multiple rounds of "anti candida" cleanses with wholeapproach.com (2009-2012) and experienced improvement but could not get through die off of their broad spectrum herbal anti microbials
- GAPS diet from dec 2014 made me histamine intolerant and pushed me into anxiety/depression With diet now very difficult to manage (low carb/low protein??!)
- currently being treated for under methylation (high histamine) but having difficulties with protocol which is under review
- did Genova CDSA 2.0 with parasitology recently which showed no lactobacillus growth, bifido and ecoli ok, low gut ph and elevated beta glucuronidase. Candida/klebsiella/citrobacter/rhodotorula all "non pathogen" but just below "potential pathogen" marker.
- secretory iga over 1000 (max normal 471).
- have not done SIBO test.
- currently taking 20 billion lactobacillus GG and 250mg s boulardii per day.
- I experience brain fog and sinus inflammation from eating grains/starch.
- no abdominal discomfort whatsoever now or at any point in my history. Keep bowels moving with payllium/magnesium.
- I have been taking probiotics for years and years but still no lactobacillus growth and off the charts SIGA level.
- do I need to do a biofilm treatment to help my lactobacillus colonise the gut wall?
- have been working so hard on my gut health for years and feel I am falling down the rabbit hole now and it has taken over my life and I am feeling worse than ever.
Thanks for reading
Paul

Paul | October 24, 2015

Angela Pifer

Hi Katie,

I currently prefer spore forming probiotics - MegaSporeBiotic, BioSpora, Bacillus Coagulans - are all listed on my site under the 'shop' link. Prescript Assist is another - I don't carry this one. I have other non-spore forming probiotics listed there as well, including Sibiotica, another one of my favorites.

Angela

Angela Pifer | November 2, 2015

What probiotics do you recommend? What brand?

Katie | September 30, 2015

Angela Pifer

Hi Kryan,

Parasites are treated first, then bacteria then candida (fungus). I usually treat bacteria and candida at the same time (tailoring the treatment to address both). I would likely suggest probiotics with the bacteria/ candida treatment, but not the parasite treatment. Treat that first... you also shouldn't take a probiotic that is making you bloat to that degree. I often see a low grade reaction when a new probiotic is being introduced, but, this should only last a couple of days. It is likely that you are reacting to something in the probiotic, it is the wrong strain, or simply too high of dose.

The idea isn't to overpower the bad with good, it is to knock out the parasite, and knock down the SIBO organisms and candida to the degree that you can then start to rebalance the gut.

Angela

Angela Pifer | September 7, 2015

hi there ,
I have basically been through he** and back since January with digestive issues. I am beginning a 6 month parasite, fungus, bacteria treatment on Friday. My acupunturist is treating me for gu syndrome with thunder pearls. Would you recommend taking probiotics during or after? What kind is best? Currently I am taking florify because my husband seems to think the good can outnumber the bad bacteria if I stick with it, but this week has been awful. I look 6 months pregnant. Thank you!!!

kryan | August 5, 2015

Hi Angela,

How soon after rifaximin treatment should you retest to check you are clear for SIBO? Is it okay to retest immediately, or should you wait 1 or 2 weeks?

Thanks!

Mike | August 4, 2015

Angela Pifer

Some practitioners are using Prescript assist, others are using Lactoprime, I often use Sibiotica - it all depends on the person, what their digestive stool test shows (levels of good flora, unbeneficial... etc). and then we micro-dose this over time. I wouldn't take probiotics during antibiotic treatment for methanogens. 24 hour yogurt (which is lactose free) has some cultures, but not the level that would offer a therapeutic dose. You would likely tolerate the yogurt well (if you can have dairy).

Warmly,

Angela

Angela Pifer | July 31, 2015

Hi Angela,
I have read on other websites that bifido probiotics are not recommended during SIBO treatment because of their tendency to "take over". What do you think? Also, my recent breath test showed methane at 6 ppm and H2 at zero. Would you recommend probiotics during abx treatment for methanogens, and if so, should it be lactobacillus or bifido or both? If so, would eating 24 hour yogurt made with said probiotic be "too strong" in terms of too much probiotic bacteria if you say less is better?
Thank you for your fabulous website!

Katie | July 20, 2015

Angela Pifer

You'll need to be off the probiotics for the test - stop them a week before. When you do start probiotics, micro-dosing is the best approach. Best of luck with your breath test!!

Angela

Angela Pifer | July 31, 2015

Hi Angela. I have a question. Do I need to wait to start taking probiotics before retesting my SIBO numbers. I end of treatment next Wednesday and I can retest for 2 weeks.

Danielle | July 17, 2015

Angela Pifer

Hi Gordon,

I would retest the breath test to see what kind of recovery (the reduction in ppm, parts per million, resulted from taking the xifaxan). This is likely 12 ppm - 30 ppm from one round. There is much more to be done when treating SIBO than simply taking the antibiotic. You and your practitioner need to figure out what set this up in the first place and address it, address gut motility (diarrhea does not mean that you have good/ fast gut motility - it means that there is a trigger that is drawing water into the lumen and literally flushing your small intestine), address digestive insufficiencies, continue to treat SIBO until the breath test is normal, then SLOWLY start to reintroduce the fermentable food categories over time...

Angela

Angela Pifer | July 31, 2015

Kristie,

I was diagnosed with SIBO by a gastroenterologist. I was given a two week prescription of Xifaxan. I've completed my two weeks. In that time, I've had diarrhea twice. I feel as if I'm not sure if the Xifaxan has worked or not.

What else can I do to treat my case of SIBO?

Gordon | July 8, 2015

Angela Pifer

Thanks Marge!!

Angela Pifer | July 31, 2015

Awesome, thanks for the info! I just started Rifaximin and was wondering about probiotics, and this all makes perfect sense to me. Cheers!

Marge | July 6, 2015

Angela Pifer

Hi Melody,

Combining low FODMAP and low histamine is incredibly challenging! If you can't take l-glutamine, then I would try slippery elm, Hist-Dao, consider adding in a good amino acid complex (even though has 'histidine' in it - all animal proteins have this in it - take this with Hist-Dao). There is more of course, but these may help. Consider Quercetin and Nettles to reduce mast cell levels.

For the low FODMAP plan - I work with each patient to customize an eating plan, address the SIBO and then we start to work on reintroduction. The goal is zero bloat, so this takes time to work through, as we test out each fermentable food group and continue to work on gut healing. For histamine help I would look up Heidi Turner - she is a dietician in Seattle and works long distance. Find her through her private site and email her directly.

Angela

Angela Pifer | July 31, 2015

2 questions..

1. What modifications do you suggest to low-fodmap and how long does one need to do the diet if they have done a course of antimicrobials?

2. When I take L-glutamine I give a hives somewhere on my body and I am having trouble tolerating high histamine foods, this makes a low fodmap/scd (no diary or eggs) diet very restrictive. As a working mom with a 15 month old, I need healing but also need to function.

Melody | June 27, 2015

Angela Pifer

Hi Kristie,

That you are bloating when you haven't eaten is interesting - this symptom isn't likely due to SIBO. I would look at bile reflux issues, parasites... look for another cause for this. I would retest for SIBO to test your progress and consider a Digestive Stool Analysis x 3 day stool collection with parasitology to gain more insight as to how the gut is functioning. If you are still bloating, there is more that needs to be addressed before you move fully into gut healing and rebalancing.

Licorice sometimes sets SIBO symptoms off. There are a lot of options with adrenal support, so you can rotate through to find one that works for you. One insight here - you cannot heal the gut in the face of adrenal fatigue. It simply will not happen. If in adrenal fatigue, the goal is to minimize symptoms with diet and some supplement support, full force focus on adrenals and then once these are recovered then you can refocus on the gut.

Warmly,
Angela

Angela Pifer | June 25, 2015

I found a probiotic-Ultimate Flora RTS Senior Care Probiotic. It has only Bifidobacterium strains. I have been opening the capsule and sprinkling very little on my food because one pill has 30 billion live cultures. So, one pill has lasted me a while. Some of the first times that I took it I noticed I felt a little lightheaded and my hands were shaking. And I have had bloating at different times. But, I have had bloating for a lot of years though. (I was treated for a gut infection 4 or 5 years ago with triple antibiotic therapy.) I never have gotten rid of the bloating completely. I don't have bloating all day just at certain times. I tested positive for SIBO around a year ago. I didn't take the antibiotics because I have taken antibiotics at different times and my bloating and pain were never solved. I went through two bottles of Allimed, then I took colostrum and now I am taking the probiotic. Do you feel that I am missing a step that would be beneficial for healing?

I noticed that I often have bloating and pain when it has been 6 or more hours since I have eaten. Do you know of why this might be?

Also, I am considering taking Holy Basil or Licorice to support my adrenals and to help with digestion and/or histamine issues-are these generally helpful for SIBO?

Thank you so much for your answers! I really am grateful!

Kristie | June 16, 2015

Angela Pifer

Hi Tamara,

I don't usually recommend kefir to my SIBO patients until they are 2-3 months post treatment and gut healing phase. I do recommend 24 hour yogurt (plain full fat) during treatment if they can handle dairy. Again, this is to address SIBO. Kefir (plain, full fat) could be added in with pretty much every other treatment protocol (other than candida).

Warmly,
Angela

Angela Pifer | June 21, 2015

Have your patients had any success with kefir? I have read so many conflicting ideas its all a bit confusing. I already eat miso, kimchi and sauerkraut. I also take a probiotic at night and was going to have kefir every morning. If this has already been answered can you please then just post the link for this? Thank you so much.

Tamara T | June 13, 2015

Angela Pifer

Hi Lisa,

Most herbs are both antimicrobial and antifungal - this is usually the best approach at treating SIBO and SIFO. I absolutely recommend an antifungal along with Xifaxan, if there has been an identified fungal issue. That said, I don't recommend antifungal medications. These are too strong and will also knock down beneficial yeast, which help to keep gut flora in check. Whether treating with antibiotics or herbal antibiotics, gas production is recovered at 20-30ppm with each round. This may give you an idea of how many rounds it will take to get full recovery (negative breath test) and then the process begins with gut rebalancing.... etc. I don't recommend multiple rounds of antibiotics, that is why I prefer the herbals. Go to PubMed.gov and type in 'SIFO' - it is quite interesting how classic SIBO symptoms can present with SIFO as the issue. You might also type in 'SIBO Probiotic' to find the study that showed probiotics were as effective at helping SIBO symptoms recover as Rifaximin. I highly recommend probiotics, but you'll need to target the right kind to her case/ care/ recovery.

Best of luck to you...

Angela

Angela Pifer | June 9, 2015

My daughter is on xifaxan for SIBO. I have a GI doctor and naturopath working with her. The Naturopath ran an organic acids test on her sometime ago and found quit a bit of yeast, but no bacteria. The GI doctor has run breath tests on my daughter 2 different times about a year a part from each other. Both breath tests showed Sibo. We have been following an anti yeast protocol. She has made some improvements, but has seemed to back slide since November. So now we are treating SIBo, but the Naturopath is telling me to keep her on probiotics and anti yeast while on Xifaxan, the GI doctor says not to do probiotics or anti yeast until
Done with Xifaxan. What has been your experience with treating patients with probiotics and anti yeast during antibiotic treatment. One of my concerns is that we might have over treated for yeast and caused a SIBO flare up.

Lisa Heiser | June 4, 2015

Angela Pifer

Hi Kristie,
I usually rotate probiotics every few months - you can find single strain probiotics, but usually only at the pharmaceutical supplement level (the really good brands). One round of herbals will not take care of SIBO. You may find that your symptoms have recovered a bit, but the underlying issue wasn't addressed to the degree that it needed to be. Look up 'histamine probiotic' on pubmed.gov - I found some interesting articles on there that histamine production lowers inflammatory markers in the gut. This is not going to be true for the person that is histamine sensitive - but interesting all the same. The jury is still out on which probiotic strains increase histamine in the gut - there really isn't enough data to substantiate this. I say to listen to your body and go from there...

Angela

Angela Pifer | June 9, 2015

Angela Pifer

Thank you Kristie! You can find single strain probiotics, they are out there, though I find these more with lactobacillus strains than bifido strains. I find that if histamine foods are pulled, and we are working on gut healing, we do not have to worry as much about probiotics and histamine. I appreciate that you may be really sensitive to histamine, so this may be a concern of yours. I find that it is usually not an issue. I like Sibiotica by Apex, LactoPrime by Klaire Labs and various UltraFlora supplements by Metagenics. These are not single strain, but what I generally reach for.

Angela

Angela Pifer | May 26, 2015

I have learned so much from your website! Thank you!! I have 2 questions-
Are there certain brands of probiotics where you can try only one strain of bacteria at the time? And, do you recommend to switch to another strain after that bottle runs out? I was thinking of trying a probiotic with only bifido bacterium first but haven't been able to locate one. I have a long medical history, but I recently treated sibo with a herbal protocol (allimed). I still have some bloating and food sensitivities and would like to find a probiotic that is low histamine, helps with constipation, and will not cause any more bacterial imbalance. My testing showed that I didn't have the bifido bacterium. I would love to hear your opinion. Thank you!!

Kristie | May 16, 2015

Angela Pifer

Hi Hunter, I use a variety of probiotics - based on each patient's needs. I don't use just one product, so it is hard to suggest a single product when people ask me. There are hundreds of strains of lactobacillus. The trick is to find the ones that have been used in studies, assess goals, health, what you are trying to accomplish and go from there. I think it a great time to try one strain at one time (in small amounts).

Angela

Angela Pifer | April 24, 2015

Which powdered probiotic is best? There are so many and as you said you should slowly increase the amount. Should you start with one such as lactobacillus or the other one or both at the same time?
Thanks so much, you are great.

hunter | April 23, 2015

Angela Pifer

Hi Jamie,

You will get some absorption - it will simply be inhibited when you have SIBO and it may be even more inhibited during the initial treatment phase. When you start to fully address SIBO, the organisms are trying to survive and I find that nutrient deficiencies can increase, along with hypersensitivities during the initial treatment phase. I recommend a sublingual methylated B12. You could also opt for IV or B12 shots and bypass your gut.

Personally, I would treat this with herbal protocols over antibiotics and antifungals. I would also address SIBO first and then continue with Candida treatment. I use a LOW fermentable plan to treat this. The low fodmap doesn't go far enough to pull out all the fermentable foods. I did a video post on this that will go up in two weeks...

Angela

Angela Pifer | April 10, 2015

Thanks for your video Angela - vert informative. I have recently been diagnosed with Candida and SIBO along with a MTHR genetic issue. I have been on myriad supplements for years but was told that until the chronic infections are addressed, they will not be absorbed.
I just started a 2-week treatment of Nystatin and then an antibiotic in conjunction with a low FODMOPs diet has been recommended. I welcome your thoughts on this protocol.
Thanks in advance,

Jamie in LA

gr8ful4health | April 10, 2015

Angela Pifer

Hi Jackie,
You are bringing up a very good topic here - lactobacillus flora produce lactic acid. They are either D-lactate forming or L-lactate forming. D-lactate can build up in some people (with specific conditions/ sensitivities) and cause some trouble. It sounds like this is what you were experiencing. This doesn't mean that all lactobacillus is an issue. Simply try the forms that do not form D-Lactate. Find the forms that form L-Lactate and see if these work better for you. Lactobacillus is the dominant form of flora in the upper 2/3 of the small intestine. It is important to support and protect these colonies, especially if SIBO is also an issue.

Angela

Angela Pifer | April 10, 2015

Please note that those who have CFS may not be able to tolerate lacto based probiotics. I was taking them for awhile and began feeling very bad. When I saw this article: http://www.ncbi.nlm.nih.gov/pubmed/19567398, I stopped taking them and felt much better by the next day. I now take only bifido based probiotics, which definitely help me, and are hard to find. But Walgreens carries a branch called 4X: http://www.walgreens.com/store/c/walgreens-4x-probiotic-dietary-supplement-caplets/ID=prod6112392-product
Here is the abstract of the study mentioned above:

In Vivo. 2009 Jul-Aug;23(4):621-8.
Increased d-lactic Acid intestinal bacteria in patients with chronic fatigue syndrome.
Sheedy JR, Wettenhall RE, Scanlon D, Gooley PR, Lewis DP, McGregor N, Stapleton DI, Butt HL, DE Meirleir KL.
Author information

Abstract
Patients with chronic fatigue syndrome (CFS) are affected by symptoms of cognitive dysfunction and neurological impairment, the cause of which has yet to be elucidated. However, these symptoms are strikingly similar to those of patients presented with D-lactic acidosis. A significant increase of Gram positive facultative anaerobic faecal microorganisms in 108 CFS patients as compared to 177 control subjects (p<0.01) is presented in this report. The viable count of D-lactic acid producing Enterococcus and Streptococcus spp. in the faecal samples from the CFS group (3.5 x 10(7) cfu/L and 9.8 x 10(7) cfu/L respectively) were significantly higher than those for the control group (5.0 x 10(6) cfu/L and 8.9 x 10(4) cfu/L respectively). Analysis of exometabolic profiles of Enterococcus faecalis and Streptococcus sanguinis, representatives of Enterococcus and Streptococcus spp. respectively, by NMR and HPLC showed that these organisms produced significantly more lactic acid (p<0.01) from (13)C-labeled glucose, than the Gram negative Escherichia coli. Further, both E. faecalis and S. sanguinis secrete more D-lactic acid than E. coli. This study suggests a probable link between intestinal colonization of Gram positive facultative anaerobic D-lactic acid bacteria and symptom expressions in a subgroup of patients with CFS. Given the fact that this might explain not only neurocognitive dysfunction in CFS patients but also mitochondrial dysfunction, these findings may have important clinical implications.

Jackie | April 9, 2015

Angela

Hi Michelle,

I can't tell you how many times I hear - 'I was perfectly healthy one day, and then it seems like everything went sideways' - SIBO causes issues on a daily basis. Left unchecked it can really reek a lot of havoc. If your adrenals are taxed, I recommend first addressing your adrenals, detox pathways and nutritional status. THEN you can start to address SIBO to a deeper level. From your post I am reading adrenal fatigue and hashimotos (autoimmune thyroid) - so you'll need to first get your body into better balance before you go deeper with SIBO treatment. Otherwise, SIBO treatment will further tax your system. Healing the gut pulls a lot of energy from the system. I realize that this is a catch 22 - if no SIBO, then the rest of the body wouldn't be reacting this way, yet - there is really a hierarchy of treatment, when it comes to addressing SIBO.

http://siboguru.com/when-your-mucosal-defenses-are-down-secretory-iga-and-treating-sibo
Angela

Angela | March 23, 2015

sterrnp

Hi Chris,

High S IgA means that there is chronic inflammation going on in your gut, that hasn't been addressed. This could be leaky gut, SIBO, dysbiosis, parasite, celiac... could be a combination of these as well. To address this, the root cause will need to be determined. If SIBO (and not the rest), then you'll need to address SIBO (I prefer to do this with herbs and diet) and then you would start the process of gut healing (l-glutamine would be part of this) and addressing flora balance (lactobacillus, bifido and s. boulardii are all part of this - but we need to focus on the right strains). Large doses of l-glutamine won't heal leaky gut. This is part of the equation, but this can only be addressed when the root cause for why leaky gut is present is also addressed.

Angela

sterrnp | March 23, 2015

Hi Angela,
Thank you for replying to my questions. My doc thinks maybe all the anti-microbials and licorice root woke up a dormant virus. I am feeling a bit better, still really exhausted. Your suggestion of a low FODMAP diet is what I may be going to next. Currently, my diet is so limited, that to place me on a low FODMAP diet would give me few options. but I'm willing to try it! I am pre-diabetic (HbA1c 5.8/fasting BS high 90's-low 100's); Adrenal Exhaustion (low cortisol/DHEA); low T3 with normal thyroid levels and normal antibody levels. My weight is still up, which he believes is due to my insulin resistance. It's so weird because I've always worked out, lifted weights, taken very good care of myself. I went Paleo 4 1/2 years ago, and spent about 3 yrs intermittent fasting several times a week for 16-18 hours a day. I really think the IFing over stressed my body in ways I can't even imagine. I use to fast on bike rides that were 50 to 60 miles long, just drinking coconut water mixed with a scoop of whey protein powder. I thought I was doing myself so much good! What an idiot I am! What is the link to your article on Sig1A? Thanks so much for your input!
Michelle

Michelle | March 17, 2015

Sorry for the typing errors my phone is auto correcting to what it wants to put lol my siga levels were very high. And would l glutamine bring my siga levels down??

Chris | March 16, 2015

Thanks for the reply Angela my siga levels from my stool test were very My guess is inflammation from the bacterial overgrowth (leaky gut). Would taking high levels of l glutamine bring my diva levels down as it repairs the gut lining. And would bringing my lactobacillus levels back in range possibly reverse my sibo???

Chris | March 16, 2015

Angela

Hi Chris,

Stress and lack of Lactobacillus are both big contributors to SIBO. If you don't have healthy colonies of flora, then you won't be able to keep the balance/ gut homeostasis.

Did you have the breath test to identify SIBO?

On the stool test, was your Secretory IgA low or high? I just did a post on this regarding its implications with SIBO. With such low Lactobacillus, it wouldn't surprise me if these was low.

Angela

Angela | March 16, 2015

Angela

Hi Kenny,

I am sorry for what you are going through. While you actively have gastritis, I don't recommend HCL betaine/ pepsin or taking a digestive enzyme that has either of these in it. I don't dispense medical advice over email or through a blog post. What I would say to a patient who came to see me with gastritis, is to take 10-20 grams of l-glutamine (powder) in a liter of filtered water and sip this in between meals. This is one thing that I use to help heal gastritis - as well as being assessed for h. pylori, pull known irritant foods (coffee, caffeine, tomato, citrus). Love slippery elm and DGL licorice (Gastric Repair by Biogenesis is a good product)...

With regards to you having a strong reaction each time you try to 'treat' SIBO, whether probiotic or botanicals - you will definitely need a more targeted and gentle approach to treating this. The first goal when treating SIBO is to stabilize the body and then we would start to slowly and methodically treat SIBO. If you would like to learn more about how I work, programs and fees, please take a look at the new site that I just launched: www.SIBOGuru.com

Warmly,
Angela

Angela | March 16, 2015

Cd da stool assessment

Chris | March 16, 2015

So I finally got diagnosed with sibo I am in the military and this condition developed over seas during deployment high stress long working hours I have always had good digestion until 9 months ago I am working with an ND and my navel gastro my ND had me order a cuss stool assessment and sibo test revealing I had sibo but I also have a no growth of lactobacillus species could this no growth with the stress of military life be the root cause of my sibo and once I adress my lactobacillus count should I see remission along with a modified diet?

Chris | March 16, 2015

Hi Angela

I found your article while looking specifically into 'archea' species and Sibo, as It's what I suspect I'm mostly dealing with due to the fact I have more problems on the constipation side, that isn't to say I don't go enough, usually three to five times every morning with painful gas/cramps preceding and following, usually becoming steadily worse as the day continues. This has been the case for a year, having become steadily worse since it began in 2012. I was tested for Sibo last year, tested positive, numerous antibiotic treatments, none of which lasted if they helped at all. I turned to natural antimicrobials and only ended up feeling worse from those, so had to discontinue. Have tried probiotics, I recently tried a bifido specific mix, and just ended up making things worse, tried for two weeks and just couldn't handle it. Recently had an endoscopy and found gastritis, prescribed rifaxamin, have not taken due to worrying over further worsening things, as well prescribed nexium. I want to see a naturopath doctor but can't afford right now as the initial visit is really really expensive. I've tried other probiotics but they never seem to really help, including align and a lacto bifido mix, very frustrated and tired of living from day to day having to deal with these issues that consume every waking moment, I never have any ambition to do anything and some days don't even want to get out of bed. I'm just not sure what to do, I've been taking slippery elm to help stomach heal, I have dgl licorice, sugar and stevia free but am afraid to start, I've tried using betain and digestive enzymes but only aggravate stomach, suspect they caused the gastritis. I'm just seeking advice, or curious about your consolation prices, as I'm just out of ideas on what to do to treat myself, I barely eat and have lost so much weight, no matter how healthy or little or much I eat I still struggle with painful gas and cramping. Any help is appreciated.

Kenny | March 14, 2015

Angela

Hi Ruthann,

My goodness - I am sorry for where you are at right now! Are you working with a health care provider on the protocol that you listed out or using info off the web to try to figure this out on your own (with respect - I understand that you are trying to figure this out because you aren't finding the help that you need)?

I would say, if you walked into my office, the first thing that I would work with you on is getting you stable - stopping the weight loss, making sure that your adrenals and detox pathways are supported and then we would start a protocol to address SIBO. The protocols need to be done in a specific way - the right dosages and timing, etc... but at the same time, we can't 'attack' SIBO if you are losing weight and if you aren't feeling stable right now. Gut rebalancing takes a lot of energy from the body.

As for the antidepressant drug - I think that some doctors don't know what to do with the symptom set of SIBO. How this can change by the hour... this really isn't in the diagnose and medicate realm. What you really need is to work with someone to get stable and then start the systematic process of addressing SIBO. This will take months to address, but you would feel more stable from the start and this would feel doable to you. Is it the holistic doctor that isn't taking your calls? Is there anyone else in your area? I do work long distance - if you can't find someone, I am happy to work with you.

Angela

Angela | March 12, 2015

Angela

Hi Michelle,

That this was such a recent diagnosis and you are treating this with herbs and trying to rebalance the gut, really increases the likelihood of you being able to cure this for good. Regarding your weight - I wonder what set SIBO up in the first place? Stress, illness... etc, and if is just your body reacting to the increased immune reactions (added stress) going on in your system. From the foods you are listing you are still including a lot of fermentable sources of carbohydrates (that would feed these organisms). I would look more into low FODMAPs while treating this, but I go beyond this - none of the specialized diets were created to address SIBO. We really need to adapt them further...

I wouldn't expect the herbs or probiotics to trigger weight gain. I would talk with your doctor about your current symptoms - yes, these can be 'die off' and then can be something else. Check back with them since they know your case well. I don't find that everyone feels die off on the protocol - in fact, some people feel better taking it - BUT everyone is different. SIBO is a condition that warrants consistent support to really tease all the variables out.

Thanks for reading!

Angela

Angela | March 12, 2015

Hi Angela, I'm really enjoying your content. You seem more in line with my practitioner then other blogs I've read. I especially liked your take on SIBO that it does not have to be recurring and can be cured. That gave me a lot of hope. I was just diagnosed with SIBO in February. I'm on a strong anti-microbial (200mg oregeno oil 3xday) as well as a probiotic with 2 types lactobacillus and bifdobacterium breve. He started me on Sac B yesterday. My question for you: I have gained about 4 lbs that will not come off since starting this protocol. Is this normal? I am not a heavy person, but I was already at my top weight when I started the protocol. My diet is mostly grass fed beef, fish, organic chicken, lots of vegetables especially kale, broccoli, Brussels; sweet potatoes for carbs; berries and maybe an occasional Apple. No eggs, nuts, dairy, grains, nightshades, caffeine, alcohol, or sugar. I drink a ton of water, some green tea and a lot of herbal teas. My second question: I have felt awful for the last week. Am I experiencing "die off"? Or is it the large amounts of anti-microbials and probiotics I'm taking? I have no energy and no motivation. Is this normal at the beginning of a protocol in your experience? Thank you, Angela. I really appreciate your blog.

Michelle | March 11, 2015

Angela, I have been diagnosed with sibo. Trying to attract it from every end. Sadly I am getting nowhere. Taking digestive enzymes, Hcl, herbal antibiotics. Took xifaxan for two weeks,it did nothing. Taking a biofilm buster, interface plus. Changed probiotics,taking prescript assist.without probiotics I don't go to the bathroom. Following a scd diet. Eating basically protein and veg. I am five two ninth four lbs and going down. I am in constant pain. Trying to see if motility issues are the cause. Scheduled for atest called the smart pill. Found out the test has gluten in it. I am celiac. The dr. Has not returned my calls. Working with a holistic dr, and had hoped for some results. So far none. Was told an antidepressant drug may help. I am desperate. I have no life. This is consuming me twenty four seven. Help

ruthann | March 10, 2015

Angela

Hi Kristin,

I would look at a few things -to start, pick a probiotic that doesn't have any prebiotics (no 'FOS' 'MOS' etc). Then I would start with S. Boulardii. Open up the capsule and take 1/4 dose for a week and see how you do... move to 1/2 dose and so on. Once this dose is established, then I would add in a bifido (not lacto) probiotic first, following the same dosage suggestions. Choose a probiotic in the millions and not in the billions. Then, add in a lacto probiotic, but not one that forms d-lactate. You gut doesn't have the balance right now to handle this (all lacto probiotics produce lactic acid - two forms, l-lactate or d-lactate).

There is a lot to do beyond this, but hopefully this will get you started.

Angela

Angela | March 9, 2015

Hi Angela. I have SIBO and high levels of candida due to years of prescription antiobiotics and natural antibiotics. However, whenever I try any probiotics, either the capsules or in yogurt or kombucha, I get terrible brain fog and the worst depression from the fog. I can't think straight or concentrate, and whenever I cut the probiotics out the brain problems and depression go away. I also get extremely irritable and angry on probiotics, even very small amounts. Do you have any advise?
Thanks! Kristin

Kristin | March 8, 2015

Angela

Hi Rita,

Having to pull thiols definitely can make this a bit harder to address, but it is doable. Have you seen this site/ list? It is fairly robust:http://www.livingnetwork.co.za/chelationnetwork/food/high-sulfur-sulphur-food-list/ For SIBO, you wouldn't be emphasizing sulfur producing foods, so these two plans would mesh well. What I caution against, is that you are getting backed into a corner with very few foods choices. Overemphasizing only a few foods in your diet will create, over time, sensitivities to these foods. The underlying mechanisms still need to be addressed, healed and rebalanced.

Angela

Angela | March 9, 2015

Dear Angela,
I am desperately in need of help. Not only do I have SIBO I also am highly sulfur sensitive (sulfur producing thiols). I also have MCS with all sorts of accompanying food and chemical reactions. One doc told me I have candida, another did a blood test that came back neg. Right now I am living on chicken, turkey, Jasmine rice, millet, (both 1/4 c. raw) carrots, beets, bone broth, and some vegetable juices (cuke, carrot, beet, celery, ginger). I throw in a buffalo burger once in a while for variety. I had very high levels of mercury which I am told are now down to normal. I question that testing as it was not done by hair testing. Both docs I am seeing right now are discouraging me from taking supplements that would help with the detoxing such as selenium and molybdnum. That is a brief history. I really need ideas of what to eat. Am hoping you can give suggestions or other places to try. All of the diets I have looked at so far emphasize much in the way of sulfur (thiol producing foods) which leave me about where I am now. Thank you for any help you can offer

Rita | March 7, 2015

Hello Angela..Its Ankit from India.. In october 2013 I had an endoscopy n helicobacter pylori and antral gastritis were detected.. then I was on rabeprazole and levosulphiride for about 10 ..then I had diarrhoea.. I took a lot of antibiotics without prescription.. I felt vary good after each course but symptins reoccur.. in september 2014 when I was taking cipro I had diarrhoea continuously.. from that day I still have lots of discomfort.. also took xifaxan but not much improvement.. m suffrring with leaky gut.. undigested food particles in stool.. I think I have bacterial imbalance.. please help me.. kindly provide me your email id for personal treatment

Ankit | March 4, 2015

Angela

Hi Izzy,

I recommend starting with Saccharomyces Boulardii first and then shifting into other probiotics - no prebiotics now, non soil organism probiotics and stay away from lactobacilli strains that have the propensity to form D-lactate instead of L-lactate. I am offering suggestions here to chat with your health care provider about. I can't offer exact protocols over email or in this comment section - each SIBO patient that I work with is complex and my approach is different with each one. It is best to work with a health care provider to get targeted support. I usually run a digestive stool test to look at beneficial/ unbeneficial flora levels as well as assessing the mucosal immune response...etc. Assess past and current factors, conditions, symptoms... this is a complex issue that needs to have targeted therapy to successfully address.
Angela

Angela | February 27, 2015

Hi Anglela, thank you for your reply! I'm still a bit confused as to what I should be taking if I really want balance the levels of gut flora? Also what are herbs specifically?I've been taking Probio 7 which do contain FOS. Thanks, Izzy

Izzy | February 27, 2015

Angela

Hi Jen,

Wow - they really came at the skin condition with all they had. Sometimes antibiotics are necessary - I am definitely not anti- antibiotics. I simply want to keep them handy for the scary stuff and not for things like SIBO. Were you also on steroids? It is possible that the antibiotics shifted your gut flora to a large degree, but I would expect you to see changes in your health over time from this and not within one year. I wonder what else changed for you at the time? It may have been the stress of the situation, strong antibiotic use, plus? that triggered this.

SIBO tests are always good to try, but it everything else has been ruled out and you still have classic SIBO symptoms (even with a negative SIBO test - these are not affective on everybody) then I would work with your health care provider to treat this empirically. That said PLEASE do not look to address this with more antibiotics. Antibiotics do not cure SIBO. They never have. We have to look at this as an extreme imbalance that needs to be rebalanced and not an infection that is wiped out by an antibiotic.

I you don't find the support that you need to address this, I work long distance.
Best of luck to you!
Angela

Angela | February 26, 2015

Hello,

Thank you for your work. I was wondering if it is possible to gain a lot of weight (after an intense five day treatment for a skin infection with SIX antibiotics) I was always 110 and have gained 20 lbs in a year eating the same or less a times. I have tested negative for SIBO but my functional DR. thinks I do have it. I eat only meat and fat and some veggies. Any fiber seems to do me in pretty rapidly (W/in two hours). I am feeling fat and hopeless at this point.

Jen | February 25, 2015

Angela

Hi Izzy - do the probiotics that you are taking, have prebiotics in them? Do they have FOS, MOS or DOS or inulin or list an 'added fiber'? I would start with Saccharomyces Boulardii - one of my favorites is by Klaire Labs.

If probiotics make symptoms worse and/ or if added fiber makes symptoms worse, these are two telltale signs that SIBO has not been fully addressed. I would get evaluated to see if SIBO is still present and then put a plan in place to address the with herbs, rebalance the gut, address the factors that set this up in the first place and rebalance flora. Antibiotics never balance gut flora. Never. They will knock things down and often times, make things worse. To the degree that SIBO will be harder to address long term and that it will be harder to balance the flora after their use. That said, probiotics will not fix 95% of SIBO cases. The small intestine houses a delicate ecosystem that needs to be addressed on many levels.

Warmly,
Angela

Angela | February 26, 2015

Hi Angela, I'm an 18 year old student and in the last 5 months I've been experiencing symptoms including bloating and gas and have started taking probiotics to try and balance the gut flora. I found this video very helpful and interesting but I have a couple of follow up questions. I've been taking them for about 3 weeks now and my bloating seems to be getting worse. My first question was, is it possible that it is getting worse because the probiotics are working, and if so how long will it take to see positive effects? and my second question is, is it necessary to have antibiotics to balance the gut flora or can it be done solely using probiotics?

Izzy | February 25, 2015

Also have lost a lot of weight and can't seem to gain. All tests (Endoscopy, EUS, Tumor markers) all come back just fine.

Mary | February 20, 2015

Angela

Hi Mary, I am sorry to hear about your symptoms. Though many people with SIBO feel better while on antibiotics, antibiotics do not cure SIBO. They may knock down the overgrowth, but they don't do anything to address why SIBO was set up in the first place, they don't help to rebalance the gut and heal this system and what I find is that antibiotic use actually makes rebalancing the system harder in the long run (meaning that once you start antibiotics to treat SIBO it is likely that SIBO will reoccur more often over the lifetime). Cipro is not an effective antibiotic to knock SIBO down. Xifaxan is - yet, it is also really expensive (if not covered by insurance) so I have seen some doctors use Cipro instead - but this is going to make things worse in the long run. I greatly appreciate your doctor's stance - that the doctor doesn't want to overuse antibiotics.

SIBO is a dynamic condition that takes time to heal with a multiphase approach to addressing SIBO, addressing diet, supporting digestion, addressing deficiencies with digestion and nutrition, gut healing, addressing immune shifts that occur at the mucosal level and rebalancing gut flora. This approach has to be customized to each patient. At least half of my current patient load is working with me to address SIBO. I work with this extensively. If you would like further one on one support I am happy to team up with your doctor to support you.

Warmly,
Angela

Angela | February 20, 2015

Breath test for SIBO was positive. Was put on Flagyl and Cipro for 10 days. Felt better while I was on the antibiotics but now am having a lot of stomach discomfort. No appetite and nausea. Pill for nausea helps somewhat. Quality of life is greatly diminished. Take one probiotic capsule a day and also eat Activia. Dr. doesn't want to "overuse" antibiotics. Help!

Mary | February 20, 2015

Angela

Hi Elizabeth,
You are welcome - thank you for your post! I am currently working on a 16 video series (because it takes that many videos!!) on SIBO. Stay tuned!

Angela

Angela | February 20, 2015

I just found you today! Thank you for telling us something I, for one, did not know: that more [probiotics] is not automatically better. Countless thanks, Angela. - Elizabeth

Elizabeth | February 20, 2015

Angela

Wow. You have definitely tried to address this from many angles and even a fecal transplant - was this from your mother or a sibling (this is the only source of innate flora that would support your gut flora - you get your flora from your mom + environmental impact over a lifetime). I wouldn't expect Cipro to address SIBO. I would expect it to make addressing SIBO more difficult. Part of SIBO's ability to take hold is the gut already being in an imbalanced state. Cipro would add to this imbalanced state. FODMAP was not designed to treat SIBO (really none of the specialty diets were - they need to be further modified to pull fermentable compounds.

I would not try any more antibiotics or medications at this point (unless an acute diagnosis that needs immediate medical attention - simply stating that antibiotics and antifungals do not 'cure' SIBO and they may make it more difficult to knock out).

I respect what you have tried and the long process that this has been for you. I would try a more gentle approach of addressing symptoms and starting the healing process with the gut. Have you tried any of the prokinetics? What have you done to address gut motility?

Angela

Angela | February 8, 2015

Cipro x 2 round, xyfaxan x 4 rounds, metrinidazol x1 round, norofloxan X 1 round, 3 positive H2 breath tests, FodMap, elimination, low/no carb, every probiotic available to humankind, the entire healthfood store's herbals, accupuncture, yogo, Balinese healer, many doctors, fecal transplant... yeast treatments, fluconazole, nystatin, and the many varied herbal antifungals..

20 years now...

And you would suggest?

another desperate soul | February 7, 2015

Angela

Hi Amber,

That is young to get SIBO and it is absolutely possible. I agree with a slow approach AND this needs to be addressed. This will not go away on its own, anytime soon. I don't recommend antibiotics or herbal antimicrobials, or any prebiotics... instead, look at rebalancing the gut, pulling known food sensitivities (sounds like she starting to react when you reintroduced food, so this may be a sensitivity, it may be a lack of... innate digestive support and it may be both) and focusing on a low fermentable diet. I am not sure if you have already been looking at SIBO diets - FODMAPs wasn't designed to treat SIBO. It still has fibers in the plan, that will ferment. There are specific probiotics that work well that will start to rebalance the gut

I disagree with the GI doctor. Is the other doctor your primary care doctor? I am happy to work with you, but, with her age, I need to team up with another doctor that will be continuing primary care and support the protocol that we lay down. I'll reach out privately to connect with you via email.

Warmly,
Angela

Angela | February 5, 2015

Hi, my daughter Tatum is three and she has all the symptoms of SIBO. I have been to her pediatrician who diagnosed her with SIBO and then her GI that said this was something that every other person has and downplayed it. I am so frustrated!! I have one Dr telling me to change everything in her diet and give her supplements and the GI dr saying to not worry about diet and give her probiotics and prebiotics. The pediatrician says no prebiotics. Her tummy starts out flat and by the end of the day it looks like it's going to pop!! She has never had a normal bowel movement since I stoped breast feeding her at one. She lives in a loving stress free home, what do you think is causing this? I am so at a loss. Amber :(

Amber Williams | February 5, 2015

Angela

Hi Natalie,

I definitely hear your frustration. Thank you for sharing this with me. I am happy to set up a consultation to help you get to the bottom of this. I am looking forward to hearing more about your history and what you have tried - and when you did, what degree, if any, symptoms were addressed. I'll email you directly to schedule a consultation.

Warmly,
Angela

Angela | January 23, 2015

Hi Angela, I have spent two years battling SIBO after testing positive to a hydrogen breath test. I am 35, otherwise in perfect health, 120lbs and exercise regularly. I have spent hundreds of hours reading everything available online & in bookstores, been to 5 separate Gastroenterologists and tried almost every GI-prescribed antibiotic and probiotic (including Align & VSL3) with no reduction in symptoms, including Rifaximin & Metronidazole. I have a big plastic crate filled with herbal supplements & digestive emzymes that have done nothing. My GI even prescribed Tetracyclic antidepressants, which did nothing except give me a very dry mouth. The only drug I have not tried is Neomycin, as the often-permanent side-effects of hearing loss & kidney damage look scary. Fructose & wine seems to make symptoms worse so I avoid all fruit/ wine & follow a low FODMAP diet but foods I can tolerate one day causes massive bloating the next. I am 'lucky' in that extreme bloating is my only symptom (no pain, diarrhea or constipation). I wake with only minor to moderate bloating, but I can go up 2 jeans sizes in 20 mins after breakfast after eating a boiled egg with a glass of plain warm water. By diner-time every single day I have a pronounced '5 month's pregnant' pot belly which looks ridiculous on my slim frame. I am getting married soon and the only way I'll be able to fit onto a wedding dress is by going on a water fast for 3 days beforehand. I'd love to book a private email or phone consultation with you if you are available. Thank you so much for reading this.

Natalie | January 23, 2015

Angela

Hi Jason,

I'll follow up with you offline - thank you for your thanks!

Angela

Angela | January 16, 2015

Hi Angela,

I just wanted to say thanks for everything that you do. I actually have some questions about SIBO and I would like to ask you some questions offline.

Jason | January 16, 2015

Hi,
Where do I purchase the powdered probiotics -- lactobacilli or bifidobacteria?

Mary | January 9, 2015

Also, I do not take PPI's at all. I felt they hurt more than they help. I have not taken PPI's for over 1 1/2 - 2 1/2 weeks. I think I took them in a grand total including both the nexium and prolisec (not together but seperately taking 1 then just nexium when it was prescribed to take over the prollisec) of 8-10 days

Jeb | December 14, 2014

Angela

Hi Jeb,
Symptoms really vary - I look for restless leg syndrome, IBS symptoms (which run the gamut), dis-ease after garlic, onions, apples... high FODMAP foods, sometimes chronic fatigue - look at the history - any food poisoning/ travelers diarrhea, stress... burping, acid reflux, there are a collection of symptoms that can point towards SIBO and it is definitely something that you should get tested for. Make sure you find a doctor (whether MD, ND or GI specialist) that will run a 'lactulose breath test for SIBO - to test both hydrogen and methane.' I prefer Common Wealth's Lactulose breath test and not Genova's test (the latter runs a 2 hour test and I want to see a 3 hour test).

I second your choice to come off the PPI. No need to mask a symptom. Let's figure out what is causing this. Let me know how the test comes out...
Angela

Angela | December 14, 2014

What are the red flag signs of SIBO? Like what can I check off to confirm it? My parents haven't taken me to a g.i My most consistent symptoms If you will are 1.twitching in my legs and sometimes in my jaws (for the last month) 2. Very slight, feint but noticeable headaches 3. Just as I lay down to sleep or right as I wake up, lots of stomach rumbling and sometimes gas. 4. Lots of gas at those 2 points of the day. I was diagnosed with ibs and was put on prolisec the went to personal doctor and also said ibs and put me on nexium. I stopped using the nexium because I noticed I felt the absolute worse when I took it. I take a brand of Probiotics now, now called Nature Probiotics. My mother wants me to take it daily. It could be a placebo but I feel there is improvement since I started taking it. But I still have problems.

Jeb | December 14, 2014

Angela

Hi Shanon,

Thank you for reaching out - I can appreciate how much discomfort you are in. The diet (low FODMAP, SCD or a combo) need to be done in unison with the antibiotic treatment. The goal is to remove fermentable (food) particles that the organisms feed off of and we need to look at why this was set up in the first place - stress, low stomach acid, migrating motor complex inhibition... this all needs to be addressed to truly knock this out. I would look to see how much recovery you did get from the first round of antibiotics - this would be done with another test. Antibiotics and herbal treatments usually knock down the organisms by 30ppm/ per 14 day and one month treatment, respectively. If you did the breath test, did it look at both hydrogen and methane producing organisms? You may be treating for hydrogen producing organisms only and still have a methane issue - both antibiotics should have been done simultaneously. I do appreciate budgeting - I can work with you on a payment plan, but I don't work on a sliding scale. If interested - send me an email: angela@nutritionnorthwest.com

Angela | December 9, 2014

For approximately two years ive been experiencing massive bloating, gas, and "noisy" gut. I feel like im walking around in someone else's body. I have no control over my gut and how it feels. I can go days without eating and still be bloated as if i'm four months pregnant or ate an entire Thanksgiving turkey by myself. I had a hydrogen breath test which indicated I have sibo. I took riflaximin first which did nothing. I am currently taking doxycycline hyclate. My GI suggested a low FODMAP diet if this antibiotic doesn't work. I am halfway through the antibiotic and feel no different. I've been researching low FODMAP diet restrictions. But I feel as if no one can tell me why I have sibo and how to prevent it. Should I be on a probiotic after my antibiotic?! I want to see a nutritionist, but that is not covered under my ins of course. Money is extremely tight. Any advice on probiotics or FODMAP or SIBO would be so ver appreciated. I cannot live this way. It's so uncomfortable.
Thank you for your time.

Shanon Dean | December 8, 2014

Angela

Hi Innesa,

I am happy to set up a consultation with you. I can help you, very quickly, address SIBO and your symptoms and work to bring your gut back into balance. This is important during breastfeeding and for your baby. Some antibiotic is passed through the breast milk. Antibiotics are necessary sometimes - they save lives. They also wreak a lot of havoc. I will email you directly from my private practice email - right now.
Warmly,
Angela

Angela | December 1, 2014

I'm interested in a consultation with you. Dealing with horrible SIBO issues. Still breastfeeding. I think I know the root of my issue. Multiple Antiboitic rounds after recurring breast infections in one year. 8 to be exact!

Innesa | November 30, 2014

Angela

Hi Anne, Cipro and Flagyl are not commonly used to treat SIBO. You definitely do need to follow these with probiotics, but that won't 'fix' this. Getting at the root cause to address why SIBO was set up in the first place is the necessary step that may be missing. SIBO doesn't just happen. Something(s) caused it. Dietary changes are in order, as well as retesting (make sure that they SIBO was knocked out - methane should be under 3ppm and hydrogen under 20ppm). If the antibiotics did not take these numbers down enough (and I doubt that they did) then you will need another option to treat SIBO.

Bifidobacterium probiotics have been shown beneficial to prevention. Nothing with FOS, MOS, DOS in it - just Bifido and Lactobacillus blend. I wouldn't get this at the drug store. Go with a health care providers line to address this.

SIBO is incredibly difficult to treat and knock out for good. If you need further support, reach out. I can help.

Angela

Angela | November 20, 2014

Hello,
Can you give a recommendation for a good probiotic? I was diagnosed with SIBO and was put on Cipro and Flagyl and ws told to follow the treatment with a Probiotic but there are so many.

Thank you!

Ann | November 20, 2014

Angela

Hi Isaac,

The upper 2/3 of the intestine has gut flora present - it isn't sterile. The dominant flora present is lactobacillus. We need this present to keep the balance and we need this present in an area that sets up food sensitivities, allergies and can tip the balance with an autoimmune condition. Probiotics are part of the recovery phase of SIBO treatment.

Lack of balance of gut flora, is one reason SIBO was set up in the first place. Treating SIBO and then not replenishing this, isn't a good idea. You can find SCD compliant probiotics.

If you are guessing that peristalsis is one contributing factor, then you will also need to look at what is inhibiting the vagal nerve and inhibition on the migrating motor complex. Today's post speaks to issues with the Migrating Motor Complex. http://www.cleanandleanrevolution.com/when-your-stomach-growls-it-isnt-telling-you-it-is-hungry/#post-top

Warmly, Angela

Angela | November 6, 2014

Hello Angela,

I've heard conflicting things about SIBO and it's difficult to decide who to listen to when it comes to something like my health.

I was under the impression that even too much lactobacilli or bifidobacteria can overgrow in the SI? This is just what I've read from forums like Mark's Daily Apple and such, so i doubt it's that accurate...

I believe my SIBO originated from weak peristalsis, so I feel like no amount of antibiotics or probiotics will stop it from coming back.

Great video by the way.

Isaac | November 6, 2014

Angela

There are a lot of factors involved in creating a reoccurring condition. TO answer your question regarding which probiotics - seek out a SCD compliant probiotic. This will help, but this won't 'fix' things. There is more at play here. I do work long distance - if you find the you want help figuring this out, contact me: angela@nutritionnorthwest.com
Warmly,
Angela

Angela | November 6, 2014

I have been battling methane-type SIBO with numerous rounds of antibiotics and natural antibiotics for a year. After fearing taking probiotics for a long time, I now feel that probiotics are the missing link to my healing. You mentioned a probiotic powder would be a good option. Can you let me know more specifics about obtaining this type of probiotic please?

K | November 5, 2014

Angela

Hi Joyce,

I would want to know which type of SIBO you have - hydrogen producing or methane producing. Probiotics should be used as part of the regimen, but there are also antimicrobial herbs and supplements that will help address this (as well as figuring out what set this up in the first place and addressing that too - low stomach acid, for example). Insurance companies are more likely to cover this if prescribed twice daily for three weeks than three times daily for two weeks (then take it three times daily for two weeks). Again, this depends on your body, type of SIBO and additional symptoms. You are right that his comment was very vague. I would not recommend this, unless with very specific probiotics. You may cause a lot of unrest if you don't use the right ones. I am happy to work with you through my private practice: www.nutritionnorthwest.com

Angela

Angela | September 29, 2014

So glad I found this! Last week my doctor diagnosed me with SIBO. My insurance won't cover Riflaximin and it would be over $900 out of pocket, so I've been told to try the antibiotic Neomycin instead. My doctor said I should continue taking probiotics, but up my dose to 6 times what I normally take for 30 days, then go back down to my regular dose. She said this is the current theory of thought for SIBO treatment. But I'm confused by that because how do the doctors know what anyone's "regular" dose is? Does that sound rational to you that I should multiply my current dose by 6 (spread throughout the day)?

Joyce | September 28, 2014

Angela

Hi Jacqueline, thank you for reaching out and sharing all of this with me. YES, I can help!! Let's plan some time to get together to figure this out. This could be SIBO, a parasite/ traveler's bug or a big imbalance in your gut flora. I'll reach out to your privately to discuss this further.
Warmly,
Angela

Angela | September 23, 2014

Hello Angela,

I found you through Chriss Kresser's site. I am a devote of his and truly respect his research and advice.

I have had what I call "IBS" for my whole life. It has been a life altering problem. I have had to withdraw from many social opportunities and could never take any group classes because of this problem. The biggest symptom of my IBS is debilitating gas. I mean, clear the room, 4th of July fireworks noisy gas & constipation.

Of course, certain foods make it worse ie: whey protein and things like cabbage, broccoli etc... (insoluble fibre makes it worse) but it can last weeks and keep me house bound carrying air freshener with me and blaming the dog. I joke, but actually it's been a horrible experience. I can't go dancing, I often took enema's so I could go on a date, I would often not eat just so I wouldn't be noisy and smelly, I'd eat nothing but rice and chicken broth and egg whites some days ... I'd call in sick to work b/c I was just unable to walk or stand up without it bursting out of me.

Now that I have read a few articles on SIBO, I'm wondering if this is what I have been dealing with for over 30 years? I'd like to get to the bottom of this problem so I can have a full life and not live it wondering when my "IBS will flare up" again and if I can be apart of any group activities ever again.

IS this something you feel you could help me with and we could actually cure?

Jacqueline from Niagara-on-the-Lake, Ontario Canada

Jacqueline | September 23, 2014

Angela

Hi Alexander,
Thank you for watching! VSL#3 is a well studied commercially available probiotic. This is recommended by a lot of MDs because of this, but it is not a product that goes far enough in addressing digestive issues. The dose and duration AND type/ strain to take depends on the condition you are addressing, what you are trying to recover and what part of the digestive tract you are addressing. Small intestinal flora colonies are in the thousands to million (latter as it approaches the large intestine) and the large intestine carries flora colonies in the billions. You can and do evoke a change in the small intestine by taking moderate doses. Commercially, the average person usually chooses the probiotic bottle that has more listed on the label. This isn't a correct way to choose this supplement. More is not better.

Warmly,
Angela

Angela | September 1, 2014

This video was very interesting- I have been hearing for years now that probiotics should be avoided at all costs, but I always seemed to improve slowly but surely after using VSL #3. Quick question though: why not megadose with probiotics? And what do you consider a megadose? Thank you for your time.

Alexander | September 1, 2014


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