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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