I’ve written about small intestine bacterial overgrowth (SIBO) in my last three posts. To catch up, start at the beginning, or read the previous post. This final post is about how to prevent SIBO relapse once it’s been treated. This is hugely important, and often THE missing piece to successfully resolving SIBO once and for all.
Unfortunately, many people relapse easily after SIBO treatment. Approximately two-thirds of people treated for SIBO relapse either right away or over the course of the next year! This is where Functional Medicine clinicians fill the gap that conventional gastroenterologists may not provide: preventing relapse after treatment, which requires a broader view of this condition.
Figure out the root cause
SIBO is a symptom of other things that happened first. So, finding out the root cause of your SIBO is instrumental in turning it around. Currently, the primary causes are believed to be:
- Food poisoning and resulting nerve damage
- Structural issues
- Dysbiosis in the large intestine
- Vagus nerve dysfunction
Acid-blocking medications, such as PPIs and H2 blockers reduce your stomach acid. Stomach acid keeps your stomach at the right pH to kill bacteria that shouldn’t go beyond your stomach. Acid-blocking medications are not meant to be used long-term. They can lead to small intestine bacterial overgrowth, and nutrient deficiencies.
Weaning off acid-blocking medications is possible with the help of a clinician. Acid reflux is often caused by small intestine bacterial overgrowth. So SIBO can exist before acid reflux starts, and then acid-blocking medication makes the SIBO worse.
Opiate medications that are used on a long-term basis completely shut down your small intestine motility. This can lead to bacterial overgrowth, which ferments and causes bloating. Opiate medications also slow down peristalsis in your large intestine, which can cause reflux of large intestine bacteria up into your small intestine. Ideally, these medications should be used only on a short-term basis.
Many people become dependent on opiates without awareness. When people are in a lot of pain they are unlikely to be cognizant of the long-term side effects, and potential dependency, of the medications they are prescribed by trusted physicians. Fortunately, there are programs to wean off opiate medications. Acupuncture is a wonderful solo or adjunct therapy for opiate withdrawal symptoms.
Bacteria from food poisoning secrete a toxin called CDT (cytolethal distending toxin), which can damage your small intestine nerve cells. This means that the migrating motor complex (MMC) of your small intestine doesn’t work right.
Your MMC is a wave of movement through your stomach and small intestine, that occurs when you are fasting. It occurs every 90 minutes, only when your stomach is empty. The sweeping action moves bacteria and food through your small intestine. Your MMC can be dysfunctional in both cases of constipation-type or diarrhea-type SIBO.
There is a new test that exists that can tell you if your SIBO is caused by food poisoning. This condition is also called post-infectious IBS. The main reason to identify if your SIBO was caused by food poisoning in your past (even years ago) is so that you can angle your prevention plan towards restoring your MMC.
Restore your Migrating Motor Complex (MMC)
Take a prokinetic immediately after finishing antimicrobial treatment. Prokinetic technically means “promote movement” but in terms of functional GI disorders like SIBO, we use the term prokinetic to include agents that regulate the nerves of your small intestine. Thus, prokinetic really means “neuroregulator.”
There are many pharmaceutical prokinetics including low-dose erythromycin or naltrexone. There are many natural prokinetics as well, such as ginger, 5HTP, and many herbs. Read more about prokinetics from sibo survivor.
The most important aspect of restoring MMC function is to allow it to happen! If you are a constant snacker, you never allow time for your migrating motor complex to work. You need to wait four or more hours after eating to give it a chance. Any calories between meals, and unfortunately even water, will thwart your MMC.
Alternatively, you can extend your night fast for 12 – 16 hours. This allows for an 8 – 12 hour “feeding time” during the day. Your MMC does slow down at night, so the longer you can comfortably extend your fast, the better.
After abdominal surgery, scar tissue forms. This can cause strictures, or narrowing, of your intestines. This is especially true in the case of ruptured appendix surgeries. Any abdominal surgery can result in strictures, including C-sections, laparoscopies, bariatric surgery, and hernia surgeries. Endometriosis can cause strictures.
You may have structural issues not related to surgery, such as a blind loop in your intestines. When there are strictures, blockages, or narrowing of the intestines, it can cause bacteria to stagnate and move up into your small intestine.
To work with structural issues, you can see a physical therapist, acupuncturist, or body worker who specializes in scar tissue release. Pelvic physical therapists specialize in this, as do bodyworkers certified in Mayan Arvigo abdominal massage. An osteopathic physician who practices hands-on manipulation can also release scar tissue and surrounding fascia.
Large intestine dysbiosis
Read this blog about dysbiosis, and this about the GI Map to test for it. Hands down, you’ll be less likely to relapse if you fix colonic dysbiosis, especially if you have inflammatory bacterial overgrowth in your colon. This inflammation actually weakens the gate between your small intestine and large intestine, which is your ileocecal valve. A weak valve flops open, thus allowing colonic bacteria to backwash, or translocate, into your small intestine. Anti-inflammatory agents specific for the gut are useful in this case.
In addition, small intestine bacterial overgrowth often goes with an overgrowth of undesirable yeast in your large intestine OR small intestine. The GI Map should pick up fungal overgrowth in your large intestine. In addition, a candida questionnaire is a good tool.
Vagus nerve dysfunction
Your vagus nerve is the primary way your brain communicates with your gut. Two things can cause the vagal nerve to lose tone and therefore lose effectiveness: inflammation and stress. Classic signs of low vagal tone include reflux, SIBO, and constipation.
To restore vagal nerve tone, see my friend’s blog here. In addition, you can use a tens unit at home to stimulate your vagus nerve, and acupuncture does this as well.
Fix your digestion
Folks with SIBO often have digestive dysfunction that exists with their SIBO, either as part of the cause or as a side effect. This can include:
- Low enzyme production
- Sluggish liver and gallbladder function
- No gallbladder
- Low stomach HCL production
You may not get that far with SIBO treatment if you don’t optimize the function of your entire digestive tract, based on your symptoms and on what shows up in a functional digestive analysis stool test such as the GI Map. For example, if you still have constipation after SIBO treatment, it’s likely to come back. Fix the constipation! And constipation in this context means not having at least one complete bowel movement every single day.
A SIBO diet
In this series, I didn’t talk about the SIBO diets, which include physicians’ elemental diets (for treatment, not long term), the Specific Carbohydrate Diet (SCD), and the low FODMAP diet. That’s because I rarely use these diets for the treatment OR prevention of SIBO.
These diets all starve your body of fibers that feed your good colonic bacteria. They can be useful in the short term for symptom relief, however, my goal is for folks to be able to eat most or all of these foods, as otherwise, you may end up with low colonies of beneficial bacteria, which leads to overgrowth of inflammatory bacteria, which leads to SIBO…..
So, these diets can be used therapeutically on a short-term basis, and if so, it is important to include tolerated probiotics and prebiotics in your plan. My favorite SIBO-friendly prebiotic is arabinogalactan.
Hopefully, this series helped you understand what SIBO is and how to treat and prevent it.
Please join in the conversation with your comments and questions,