Understanding SIBO: What It Is, How It Differs from IBS, and What You Can Do About It

Jessie Wong 00:00:00 Welcome to the IBS Nutrition Podcast, your go to source for navigating the complex diagnosis of irritable bowel syndrome. Here, we dive deep into IBS and discover the power of diet and lifestyle to find freedom from your IBS symptoms. I’m your host, Jesse Wong, Fodmap dietitian and a gut expert. For years, I suffered from debilitating gut symptoms that kept me out of work, feeling constant discomfort in my body and anxious around food. Today, I’m in control of my IBS, able to eat the food I love again, travel whenever I want, and spend quality time with loved ones. It is my mission to help you do the same and transform the way you live with IBS. Let’s get started.

Brooke Keenan 00:00:41 Hi everyone! Welcome back to the IBS nutrition Podcast. I’m Brooke.

Jessie Wong 00:00:46 Hi and I’m Jessi. Today we are diving in a topic that many of you have asked about Sibo, small intestine, bacteria overgrowth and we have so much information for you today. If you have Sibo or suspect that you have Sibo, you need to listen to all of it.

Jessie Wong 00:01:06 So we’re going to cover what is Sibo? How is Sibo symptoms differ from IBS symptoms? What are some risk factors for developing Sibo and some of our body’s protection mechanism against Sibo? And what are some of the pathophysiological effects of Sibo in our body? How do we diagnose Sibo treatment options for Sibo and how diets can help Sibo as well? So a lot to cover. So you want to make sure to stay tuned and listen all the way until the end. So first up what is Sibo.

Brooke Keenan 00:01:42 Well it is a clinical syndrome of GI symptoms that are caused by an excessive number of bacteria within the small intestine. and it’s typically diagnosed based on an aspirate or culture. but important to note It’s not necessarily bad bacteria, it’s just an overgrowth of any bacteria, really. And it could be good bacteria.

Jessie Wong 00:02:05 Right. And there are two primary types of Sibo. The first type is hydrogen and hydrogen sulfide predominant Sibo. And the second type is methane predominant Sibo. But it was renamed to intestinal methanogens overgrowth IMO in 2022.

Jessie Wong 00:02:25 So let’s talk a little bit more about Sibo symptoms and how it differs from IBS symptoms. Yeah.

Brooke Keenan 00:02:32 So Sibo symptoms often include more upper GI bloating and possibly burping after eating. and these symptoms usually occur within a few hours after eating. And they can also cause bloating no matter what you’re eating. and it can be true that a low Fodmap diet is not as effective for Sibo as it might be for IBS.

Jessie Wong 00:02:56 Exactly So IBS typically involved a brain connection issue. And then of course with symptoms like abdominal pain, bloating, changes in bowel habits. Whereas Sibo is more about bacteria overgrowth. And this specific impact is usually in the upper GI tract. And one of the big symptoms we see too is, like you were saying, symptoms usually occur within a few hours after eating and then the symptoms can go away until you eat again. So with Sibo, the symptoms is a little bit different than IBS. And usually in our clinic by asking questions. Right. And we talked about documenting your bloats. And was it our first episode, our first episode how to document different symptoms.

Jessie Wong 00:03:40 This is where the little nuances of your symptoms will come in handy in identifying. Do you have Sibo or not? Because Sibo sometimes is an overlapping diagnosis with IBS. With Sibo two, we talked about having an aspirates with endoscopy can be a diagnosing tool. But then there are also other diagnosing tools as well, which we will talk more of later on in the episode. But let’s talk about what are some risk factor for developing Sibo. Yeah.

Brooke Keenan 00:04:11 So IBS can be a risk factor, especially when that’s kind of paired with motility issues, celiac disease or undiagnosed celiac disease. And non celiac gluten sensitivity can all be risk factors for Sibo.

Jessie Wong 00:04:28 Yeah. And then there are also other risk factors as well such as inflammatory bowel disease in particular when there is a stricture in the small intestine. And then also prolonged use of antibiotics or PPI which is a class of medication for acid reflux. And then another thing we see sometimes is, surgery to a person’s GI tract. So it could be bariatric surgery, it could be some other surgeries That’s, somewhere in your GI tract that may not be bariatric surgery.

Jessie Wong 00:05:00 And of course, another big one that we see all the time is inappropriate use of probiotics, which is more common than we think. But now that we are mentioning probiotics, we actually have a lot of clients come to us who are having a lot of diarrhea, who may be taking probiotics for whatever reason, that they think they need a probiotics and they have nonstop diarrhea. And usually our first recommendation is please stop all the supplements you are taking and see what is really going on. And a lot of the times, once they stop the probiotics, their diarrhea usually improves. And and in those cases, we know the probiotics is probably giving the person Sibo. And it’s not always necessary to get the person tested at that point. But stopping a probiotics is always good. First recommendation? Well, it’s always the first recommendation from our clinic because we want to see what the baseline is. And after removing probiotics, what happens because too much even of the group, too much of even the good bacteria sometimes can be problematic, especially for patients with irritable bowel syndrome.

Jessie Wong 00:06:13 And our body actually have multiple mechanisms to protect us against having Sibo. So you don’t have to worry as much even if you have IBS about having Sibo. And here are a few things that our body naturally do to prevent Sibo from happening. And of course with Sibo we are talking about microbes that potentially are good for us, that migrates from the colon to the small intestine, or we are eating food that are high in microbes, for example, like fermented foods. And then it goes through our small intestine. Go to a large intestine. Actually, the first thing that the food will go through is our esophagus. And it gets into our stomach. Our stomach secretes gastric acid that actually kills the majority of the microbes. So that’s one layer of protection from our body to protect us from having small intestine bacteria overgrowth. And then our pancreatic and biliary secretion also help further reduce the amount of microbes in the food that we are eating. And in our intestine. We also have mucosal immune system to suppress the bacteria from acting up in our small intestine.

Jessie Wong 00:07:25 And our small intestine also have what is called the migrating motor complex. And you can imagine that as a broom that kind of just rushes food out once in a while to keep our small intestine, keep the food moving in our small intestine. And that motion of moving things around will help you reduce the risk of having Sibo, too. And then there is sometimes even irritable bowel syndrome. There is dysregulation of the migrating motor complex, causing food to stay a little bit longer in the small intestine. And this is where we talk about improving a person’s gut motility is really important when resolving Sibo or when you are being treated for Sibo. Okay, last but not least, and that is our Ilio seco valve. And this is the valve that is between your small intestine and your large intestine. And ideally, it should only open when food is at that part of your small intestine. And then it opens. And if it goes through to your large intestine and then it closes. Sometimes there are some issues with the elliptical valve causing it not to function normally.

Jessie Wong 00:08:43 And or sometimes when a person is significantly constipated, it can’t cause the local valve to malfunction, and that malfunction, or keeping it open for longer than it should, might be the reason why the good microbes from your colon is migrating into your small intestine. So these are a body’s natural protection mechanism against having Sibo. Our body is really smart. But then sometimes some of these things malfunctions. Or sometimes if you’re taking PPI for a long time or antibiotics for a long time, that can cause some of the mechanism to not work as well when causing Sebo to happen. And these are things that you need to understand to really treat Sibo completely, because Sibo has a very high recurrence rate. Brock, you wanna share about maybe Laura’s story, one of our current clients, she takes a few of these boxes, right, causing her to have recurring Sibo and she was actually really worried about in her GI sent her to us.

Brooke Keenan 00:09:45 Yeah. So she was having 10 to 12 bowel movements a day, afraid to go out in public.

Brooke Keenan 00:09:54 losing weight, not just scared of eating. And so she went to her gi, and as she says, she got the, the gold level, of, of, diagnostics done because of the weight loss and multiple stools. And she tested positive for Sibo, and she started her antibiotic, and she is so much better. So much better. Doesn’t have to worry about where our bathroom is all the time. and she just feels so much better and relieved that, she no longer has Sibo.

Jessie Wong 00:10:29 Yes, yes. And she actually left us a note. Well, she and another group member were chatting in the our clients group chats and she was saying she’s so much better now. We worked our magic on her to stop her diarrhea, actually, because her diarrhea was so bad that her physician told her to come and work with us while they are eradicating or treating Sibo and she checked a few of the boxes of risk factors. So she’s had GI surgery in the past. She’s been on antibiotics for prolonged periods.

Jessie Wong 00:11:00 I can’t recall if she’s taken anti PPI before or reflux medications. I think she might have as well. She might.

Brooke Keenan 00:11:09 Have.

Jessie Wong 00:11:09 Yeah she might have. Yeah. But she checked multiple box o and she was taking a probiotics for a long time. There were multiple different factors. And I also suggested to her what you constipated before. And she responded and she said, you know, I didn’t think I was, but in hindsight now I think I was actually constipated. And that could have also contributed to her having Sibo as well. And a lot of the cases that we see are patients come to us. They might already be on multiple rounds of antibiotics and it’s not working. And usually that’s when their physician will say, why don’t you try the low-fodmap diets? And then they find us because they needed help with the diet. we’ll talk a little bit about diets later on in our podcast. It’s it’s a tool to help manage symptoms. It does not eradicate Sibo, but but it can be really helpful when identifying what may be causing your Sibo, because once you know what may be causing your Sibo, we can really resolve it.

Jessie Wong 00:12:05 And in her case, what we are suggesting is please don’t just take any probiotics for any periods of time because of the other risk factors that she also has, and she’s doing so much better. At first we suspected a food intolerance, but she actually, past those food challenges with flying colors. I don’t think she actually has any food intolerance. I think it was the combination of the risk factors that she has that gave her the Sibo, and now she is actually challenging for maps again. And she said she has never been so excited for a slither of avocado because that’s one of the challenge, for, for one group of the FODMAPs is actually testing avocados over three days. And and for those of you listening, if you’ve been cutting out food, you would know what I’m talking about. Sometimes, you know, challenging these foods is just so exciting. And of course, she’s feeling so good and I think she will pass most of the challenges if, if not all, you know, that might just be a few things that she doesn’t tolerate.

Jessie Wong 00:13:02 At higher doses, she can probably still eat all of them in smaller dosage. and she’s also a health care provider herself, so she knows all her risk factors really well, but she just needed a little bit of help on the other side to get from us to get her over to this side. But I was, you know, when I was reading what she wrote, she was, like, broken. Jesse worked magic on me. I was reading, I was like, oh, okay. Yes. Okay. So that now what are some pathophysiological effect of Sibo that sometimes we see. Yeah.

Brooke Keenan 00:13:38 So inflammatory responses. There can be competition for luminal nutrients which can cause malabsorption of nutrients like B12, folate and ferritin. And sometimes, like in our client’s case, weight loss.

Jessie Wong 00:13:52 Right? She actually lost about £20 before coming to work with us, which, of course is significant. If you have IBS, you should not be losing weight. If you are losing weight, this is an indication that something might be more severe.

Jessie Wong 00:14:06 It could be Sibo or it could be something else. You really want to work with a provider who will dive deeper with you to help you. And of course, the nutrient malabsorption. These are often things that we ask our clients to go back to their physicians, or we ask their physicians to get these labs because with IBS, right, people usually don’t have B12, folate, ferritin deficiencies, or even vitamin D, but with Sibo or maybe other overlapping diagnosis with IBS, that’s when we see nutrient deficiency. So most likely we will ask our clients for their labs if they’ve not been done before. And in second episode of the IBS nutrition podcast, we talked about what tests we usually ask patients to get and what tests to to be done before getting an IBS diagnosis. So if you’re interested to learn more about that, you can go back and listen to our second episode. Okay. Now let’s talk about diagnosing Sibo.

Brooke Keenan 00:15:06 Yeah. So like I mentioned, getting the aspirate is kind of the gold standard.

Brooke Keenan 00:15:12 the other one that we use more frequently is a breath test. So unfortunately though, the accuracy of breath tests can vary. A lot of times, though, we’re just looking at what symptoms people have the upper GI, bloating, belching after food, persistent bloating even after you know you fully evacuated your bowels. That’s, kind of what can clue us in sometimes to request a breath test. but a lot of times we don’t get a breath test, so we just use those symptoms and our symptom tracker really to see what’s going on.

Jessie Wong 00:15:49 And I want to add to that to a lot of the times if our clients really have Sibo, they know the symptom differences. Once they go back to baseline, once their Sibo is resolved they know, oh symptoms are gone. I don’t have Sibo anymore and they know. But of course a lot of our clients are also healthcare providers themselves so that they might be more aware. and you were saying to I want to add to this a little bit, is the gold standard of diagnosing Sibo is taking an aspirate.

Jessie Wong 00:16:18 And what that means is doing an endoscopy. So you do the scope that goes down your throat, go to your stomach, and it will bypass the stomach to go into the small intestine. And that’s where they will take a sample of the fluid in your small intestine. And they’re going to test that sample. If it’s above a certain level of bacteria then you will get a diagnosis of Sibo. Now as much as it sounds, this is a very invasive procedure, which is why it’s not always done unless you are already getting an endoscopy for maybe ruling out celiac disease, or just checking your stomach to see if everything is okay. So it’s not routinely done. some physicians will order breath tests. We can order breath tests for our clients too, but it’s kind of fallen out of favor for the most part because of the accuracy and the high, false positive or false negative rates. Usually what we do is we don’t recommend it. Like what Brooke said, we assess the symptoms and determine whether a person is at high risk of having Sibo or does their symptoms.

Jessie Wong 00:17:21 And like Sybil, could it be something else? If nothing works, then sometimes we may recommend it and we prefer their physicians to order it than us ordering it. Actually, nowadays patients can order Sibo simple breath tests themselves from the the lab that we usually recommend, which is Treo smart. So if you suspect having seen Bill, you can order Triple smart yourself and then bring the results to your physician. But remember, you have to do the breath test prep very carefully. and one thing I like about Treo smarts is they do have, I think, better collection methods. And they do have a very good video teaching you how to do the prep properly, because if you’re not doing the prep properly, this is where there can be significant higher, false positive or false negative test results. And I think one of the research suggested up to 47% of the results might be not accurate, which is also why most of the providers are steering away from ordering breath test. Because if half of it is not coming back accurate, what is the point of ordering right? So think about that.

Jessie Wong 00:18:31 Talk to your healthcare team before you do a breath test, because you may not need it. For experienced providers like ourselves, we can kind of assess it with just symptoms, because it is a different set of symptoms compared to IBS. All right. Treatment of Siebel.

Brooke Keenan 00:18:50 So the gold standard for treating Sibo is with antibiotics. But it’s also important that we work on the gut motility and identify what is shifting someone’s motility so that their, you know, could be more likely to get Sibo. So we need to treat with antibiotics but also work on the underlying causes. you know, obviously outside of having previous gut surgery. But even then we could always work on improving gut motility so that they can avoid it in the future.

Jessie Wong 00:19:25 Right, exactly. and then, of course, one of the biggest that we see is people taking random probiotics, thinking that it’s better for their health. And that ends up being what gives them persistency. But actually, one of my very early cases when I started my practice here was these lovely eight year old couple, and they came in because the husband had recurring Siebel and he was having a lot of diarrhea and losing weight.

Jessie Wong 00:19:55 So he was on multiple rounds of antibiotics, and his primary care physician actually diagnosed him with Sibo because his symptoms match. He did not do a breath test. His symptom matched and it was Sibo. And after one round of antibiotics, his diarrhea came. So he had the diarrhea type. His diarrhea came back after a round of antibiotics. So his doctor said, why don’t you try the low Fodmap diet too while you’re doing the second round of antibiotics? And that’s what they came to me for. And of course, most of the time people really wants to do their diets. But after talking to him and really understanding what is going on, I said, I think something you’re eating is actually giving you Sibo. So what happened is he had diarrhea every day. So he took the first round of antibiotics, and when he was on the antibiotics, his diarrhea stopped. But as soon as he stopped the antibiotics, his diarrhea came back. So that gave me a clue that, okay, something he’s doing is giving him Sibo.

Jessie Wong 00:20:56 And guess what? When I did a thorough intake of his medications and supplements, he was taking 15 to 20 supplements. And out of those 15 to 20 supplements, there was a probiotics. And I said to him, I think this is what is giving you the non-stop diarrhea. I don’t think they believed me at first because he and his wife, they’re both 80 year old. They were both taking the probiotics. She was completely fine, but he was running to the bathroom and losing weight. So. So I said, you know, if you know, let’s go ahead and remove your probiotics. and then also finish your round of second round of antibiotics while we’re doing that. And then let’s follow up in a few weeks and see how you’re doing. If you’re still not doing great, then we can talk about the low Fodmap diet. But given his age, I really don’t want to put him on the low Fodmap diet. And he’s already losing weight. So like we said before, right? Diet is not always benign.

Jessie Wong 00:21:55 It can be very difficult. And I think we followed up in about two weeks. And he said his diarrhea did not come back. And I said see you are at higher risk of developing see both. So I would not ever recommend a probiotics again for your case. And they were really confused because she was taking it and she was fine. But when he takes it he’s not fine. But regardless, you know, that resolved his people basically completely. And also, you know, we’re sharing it as a cautionary tale. You don’t need supplements to fix your gut. And in reality, supplements often cause more damage than, giving you more benefits. All right. So let’s talk about diet for Sibo. There are multiple diets that are studied for Sibo. A few that I can think of. Of course low Fodmap diets is one that we are all trained for. There is the low fermentation diet and then there is also the Sibo diet. So the diet does not have any evidence to support that it works for anything is made up.

Jessie Wong 00:23:00 and then the low Fodmap diet is what a lot of dietitians would recommend, including us. Now, the low Fodmap diet helps you reduce your symptoms when you have Sibo or when you’re being treated for people. It does not cure Sibo. The low Fodmap diet does not cure Sibo, but it does remove fermentable carbohydrates from your gut because that’s what the bacteria will ferment. And when they’re in your small intestine, causing a lot of bloating and belching and discomfort. So when you go low Fodmap, when you have Sibo, you’re going to feel better but it doesn’t cure your Sibo. And then, of course, the low fermentation diet is another diet. But that diet can be quite restrictive because it is a long term diet without reintroduction, whereas the low Fodmap diets there is reintroduction to identify your food triggers and then so that you can expand your diet after testing for your tolerance level. So we eliminate and challenge and help you expand your diet. And the low fermentation diet doesn’t have that. Basically, you’re put on a low Fodmap diet for life, and that’s how you’re supposed to eat.

Jessie Wong 00:24:10 And supposedly it will suppress Sibo from coming back, which I think most of us can agree is not very helpful in the long run because it is very, very restrictive and it’s very confusing to okay, so besides diet, what are some other helpful measures that can help a patient better manage their symptoms?

Brooke Keenan 00:24:32 Fiber. Fiber is very important for our gut motility.

Jessie Wong 00:24:36 Yes. And that’s something we recommend sometimes, of course. Again, case by case basis and fiber. When we are recommending a fiber, there are a few things we want to think about in terms of the fibers characteristics. One is the solubility. That’s the fiber dissolve in water. Right. And if it dissolve, the second thing we want to think about is does it form gel. So it’s viscosity. Is it gel forming. Because if it’s gel forming it’s helps with gut motility a little bit better. But the last thing we want to think about which can cause more symptoms in people is a fibers ferment ability. That’s it. Ferment. Because if you have Sibo and you’re taking a fermentable fiber, it’s the Sibo.

Jessie Wong 00:25:23 The bacteria in your small intestine will start fermenting the fiber, and it can cause you to have significant gas and bloating and very much a lot of discomfort. If it’s happening in your small intestine. So these are the fiber characteristics that we really want to look out for right. Something that is soluble. Something that is viscous gel forming and is not fermentable. And the two fibers that we recommend mostly to our client is psyllium husk and also FG, which is partially hydrolyzed guar gum. We find that because these two fibers are non fermentable, while FG is fermentable to some degree that they but they are pretty well tolerated and FDG is actually a prebiotic fiber to that can help restore your gut microbiome. Per very small research. The evidence is not that strong, but we know that it helps most. it doesn’t cause a lot of symptoms and we helps a lot of people. So that’s something you can consider trying. But again, when you’re trying any form of supplements, even fiber, you always want to talk to your healthcare provider to make sure that it is the right fit for you, and also ask about how long to stay on the fiber for even it’s just fiber.

Jessie Wong 00:26:40 How long to stay on the supplements for and what symptoms you are looking for to improve with this. So with, fiber and Sibo, what we are really looking for is improved gut motility, better bowel movements every day, and also reduced Sibo symptoms. So reduced belching, upper GI bloating, etc.. Okay, that is a lot of information. And we know Sibo is a trickier diagnosis than IBS, but of course maybe half of the population we work with also have Sibo. if you do have Sibo, we really recommend for you to work with someone who is experienced because Sibo is tricky, recurrence rate is high, and sometimes it can cause a lot of fear in people because of the recurrence rates being so high. All right. Thank you everybody for joining us today. If you find this episode helpful, please subscribe and leave us a five star review. I thank you for tuning into the IBS Nutrition podcast. We hope today’s episode has brought you closer to understanding and managing IBS. Remember, you are not alone on this journey and finding freedom is possible.

Jessie Wong 00:27:52 For more on IBS, make sure to follow us on your favorite podcast platforms and please leave us a five star review! We would really appreciate that you can access links mentioned in this episode in the show notes. To learn more about your type of IBS and how to identify your own food or lifestyle triggers, Register for our free IBS Masterclass. Three steps to IBS relief for our proven, holistic, three steps approach to managing IBS once and for all, head to IBS dietician.com/masterclass to register and till next time, take good care of your gut and here’s to your health and happiness.