Preventing SIBO Relapse

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:

  1. Medications
  2. Food poisoning and resulting nerve damage
  3. Structural issues
  4. Dysbiosis in the large intestine
  5. 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.

Food poisoning

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. 

Structural blockages

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:

  • Reflux
  • Low enzyme production
  • Sluggish liver and gallbladder function
  • No gallbladder
  • Low stomach HCL production
  • Constipation
  • Diarrhea

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,

paris healing arts, doctor laura paris, dr. laura paris, dr laura paris

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  1. One possible cause of SIBO, which you don’t address, is low stomach acid. Not only does low stomach acid allow for bad bacteria to enter through the stomach but low acid levels result in incomplete digestion, particularly of carbohydrates. Thus, when the chyme enters the small intestine that portion representing more complex carbs are never properly prepared for absorption and present as a food source for bacteria and eventual overgrowth.

    1. Thanks for your comment Dennis!

      You bring up a great point.

      I do actually bring this issue up, under medications as the first cause of SIBO. Specifically “Acid-blocking medications such as PPIs and H2 blockers reduce stomach acid. Stomach acid keeps the stomach the right pH to kill bacteria that shouldn’t go further than the stomach into the small intestine. Acid-blocking medications are not meant to be used long-term because they can lead to small intestine bacterial overgrowth as well as 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 it worse.”

      The reduction on stomach acid can contribute to SIBO in more than one way, as you brought up. In the stomach, bacteria are not “killed” by stomach acid and food (especially protein) is poorly broken down. Additionally the “bolus” of food that enters the small intestine from the stomach is not the correct pH to trigger the release of pancreatic enzymes and bile for further digestion. Much research has been done to demonstrate that acid blocking medications, such as PPIs, can cause SIBO. One of the most recent papers is here.

      Acid blocking medications are one of the most common over the counter meds in the U.S., and people need to understand the consequences of long term use!

      Thanks for your input,


      1. Hi Laura: Thanks for the information. Possibly you can provide some input regarding an experience I’ve had that might be related to SIBO. About four months ago I was diagnosed with LPR (silent reflux). Symptoms included hoarseness, post nasal drip, asthma and frequent throat clearing. The ENT Doc gave me a PPI prescription that did nothing to relieve the symptoms and I stopped taking the PPI after a couple of weeks. I started researching LPR which led me to test myself for low stomach acid. It was low so I started taking supplemental HCL/w/pepsin and were taking five 648mg caps with most meals involving protein. Within a week, all my symptoms vanished. I am now down to taking only three or four caps as my stomach is starting to produce its own acid. The puzzling thing is that another seemingly unrelated problem has subsided as well. I have suffered with pelvic floor dysfunction for over 20 years and experience pain when sitting for too long or after any type of exercise. This problem has also mysteriously abated. It is my understanding from reading a few article that there could be a connection between SIBO and pelvic floor issues. Do you have any insight regarding this?


        1. Dennis, it sounds like you did fix your symptoms yourself, by increasing your HCl instead of decreasing it. Bravo! Ideally your stomach will “learn” to produce more HCl so you don’t have to take that supplement long-term.

          As far as the connection between SIBO and pelvic floor pain, I can think of at least a couple of mechanisms that would connect the two. One of them is that if there is SIBO, then bacterial toxins called LPS leak through the intestinal wall and create muscle pain, which could be anywhere in the body. This is often the cause of mysterious pain, like fibromyalgia. These bacterial toxins create inflammation as well. Another reason would be if there is SIBO, there can be bloating, which puts pressure on the lower abdominal organs and potentially the pelvic floor. Lastly, if there is an overgrowth of small intestine bacteria, there could be an irritating overgrowth of pelvic floor bacteria. Often this is E. coli.

          Thanks for stopping by!


          1. Just FYI, but GERD is not the same as LPR. Please do not use these terms interchangeably.

            LPR is also known as silent reflux and respiratory reflux amongst others. It’s unlikely that a PPI will help with LPR because the issue is pepsin and not acid. Pepsin is a stomach enzyme which is meant to break down proteins in the stomach…

            Anyone reading this and in pain from LPR…start drinking alkaline water to help denature the pepsin (vapours) in the pharynx, larynx, and mouth. Pepsin vapours can even get into the sinuses and ear canals.


          2. I am not sure what you are referring to – GERD and LPR are not mentioned in this article.

    2. I never had any digestive issues until October 2020. I was given an antibiotic for 5 days, then treated with align (probiotic) and fiber con. It took 4 months of treatment to get better, at which point I was taken off the fiber con and continued with one probiotic, instead of two, per day. I was fine for 4 months. Now I am experiencing sharp pain in the lower abdomen , which co e and go mostly in the morning hrs. This is different from the initial symptoms which was diarrhea mostly late afternoon and evening. Could my current symptoms be the return of SIBO OR SOMETHING ELSE. Being that the symptoms are so different.
      I also used a low food map diet . Something Zi did on my own.

      What do you recommend. I am going away in 1&1/2 weeks and want to be comfortable. Do you recommend seeing my GP if maybe my OBGYN, SINCE THE PAIN IS IN THE LOWER ABDOMEN.

  2. Hi Laura,
    I am trying to figure out my sudden onset of gastrointestinal distress that has been going on now for 2.5 months. At first I thought it was food poisoning or a bug. Symptoms were there for a week, then seemed to get better, only to return about 6 days later. Now they are on and off. Some days are better some are worse. Some blood work showed my bilirubin high and my stools were yellow so I got a CT scan of my gut to check my gallbladder. Everything looked ok with my digestive organs. I got a comprehensive stool test through my ND (Genova) and I had high levels of commensal bacteria and of(potential pathogens) Klebsiella Pnemonae, and a yeast. I thought that these were the cause, so I started taking herbal antimicrobials. Oregano oil, wormwood. Seemed to help a little. I went to a Nurse Practitioner and she suggested I start taking the antibiotics recommended by Genova since the herbals looked like they could be not as effective. I waited to talk to my ND. He put me on an H Pylori type of treatment with digestive enzymes, antimicrobials (Berberine), and a gut healing supplement. Did this for 3 weeks. Still had problems. Searched the internet and found out about SIBO and we are going to do the home test as soon as 2 weeks pass since I took my last antimicrobial. Another thought I had was possibly Giardia, but it did not show up on 2 stool tests, but heard that maybe doing more tests could find it.

    My main symptoms in the beginning were chills, sour stomach, sick stomach, stomach pain, malaise, burping, farting, some yellow diarrhea. Now I am constipated, burping, farting, sour stomach, nausea, stomach pain, intestinal pain gurgles. Sometimes it is barely there, and then other times is in full force.

    Not sure what started all of this. Not sure why it keeps going on. I have Gilbert’s. I was on Cholestyramine for 2 months for treating mold illness. Had been on other supplements including curcumin (which I read can cause gastrointestinal distress). It seemed to start after eating a caramel apple, also there was a trip to a hot spring two weeks earlier.

    I have never had anything go on like this with my guts ever….for short times yes…but not this long.
    I hope I find the answer soon. It is all so confusing with all the possibilities. Your articles hold a lot of information and I am grateful for them.

    1. Cara,
      I’m sorry for your suffering! It sounds very uncomfortable, frustrating, and mysterious. You seem to be in good integrative medical care, and I hope you find resolution soon. A history of mold illness can certainly complicate things. Many people do stool testing from 2 different labs, as no one lab “catches” everything. Something to think about. Thank you for sharing, I’m glad these posts are helpful, and keep us posted! Your self-education and determination are impressive.

  3. Hi Laura,
    Thank you for responding. Does it sound to you like I am on the right track? Does the overgrowth of commensal and a few bad bacteria and yeasts in the stool lean towards SIBO? Also my fecal fatty acids were really high. Does retesting for Giardia sound like a good idea? I have also set up an appointment with a Gastroenterologist just to see if they can come up with anything. My ND said he thought I would be disappointed, but I am going to try anyhow. Any testing that they can do that could be helpful? What they should look for?

    Also I keep reading about natural antimicrobials for SIBO but no one ever says what they are. Not even in the scientific study that showed this. I am guessing it depends on the type of gas producers the test finds. Not sure my ND is up to speed on the whole SIBO thing so I may have to find this information, if I have SIBO.

    And….. If I have SIBO then trying to figure out what caused it. I have some theories but nothing is provable. Cholestyramine possibly slowing my digestion down. Eating tons of refried beans every day, and not many veggies. Possible food poisoning. Recently eating a little more sugar and refined carbs. The curcumin? Maybe it was the perfect storm? A year ago my stool test from Genova was pretty much fine. Just a lack of diversity in my bacteria. This was all before the mold illness treatment began.

    How do you feel about antibiotics vs natural antimicrobials to kill off bacteria? Especially in SIBO. Especially with something like Klebsiella or an overgrown yeast. Genova said that Klebsiella is not super susceptible to the antimicrobials they tested.

    I have been using Dr. Siebecker’s SIBO diet to see if it helps with the symptoms and I do think it may a little. Not sure if it is much good though since I am not actively treating anything at the moment while waiting to take my SIBO test.

    This whole thing has been driving me nuts, and I am the type that won’t stop searching for answers until I feel better. I now really feel for anyone who has symptoms like these, I never understood how draining they can be.
    Thanks for listening and offering any insights.

    1. Cara,
      I understand how draining and frustrating your situation is! When our guts are off, everything is off. Unfortunately I can’t answer all your questions here – I can’t legally give medical advice here on the blog. One thing I can say is I do think if curcumin causes digestive symptoms, they would stop once the curcumin stops. I wish you the best, and keep us posted on your progress if you desire.

  4. My wife has been suffering from chronic nausea and fatigue for years. The medical professions has run numerous tests (brain mri, ect, heart lung, tyroid, blood work ups, 7 trips to ER) at a cost of $200M and have found no identifiable cause for her symptoms. Their recommendation is I go to the Mayo Clinic. So I went to the Mayo Clinic web site to research chronic nausea. I took what I learned and went to the GI doctor. He told me he had run every possible test and he want to know what I wanted him to do. My wife now became my patient.

    Since a resent endoscopy found nothing wrong I by passed a repeat of that test. I bought a glucose meter and ruled out low blood sugar as a cause. I next asked for a gastric emptying test be performed with the results showing her stomach emptying in 21 minutes signifiying GDS. Going on the assumption the stomach acids were not doing their job, the small intestine being asked to do some of the work of the stomach, I asked that a hydrogen breath test be performed. I was informed the GI practice could not find a local lab to do such a test so the practice didn’t do the test. So I went on line and found a lab that does the testing, got the kit, had her perform the test and withing 24 hours had the results back. The results, PRESENCE OF BACTERIAL OVERGROWTH IS SUPPORTED. I was then asked how I wanted to teat it and I prescribed Xafaxan 550mg x 3/day x 14 days at a cost of $1550, The nausea continued for the first week, but then she had five days with no nausea. It appeared that in two weeks at a cost of $175, I was able to make a diagnosis the medical profession couldn’t make in three years.

    The problem now is that since going off the Xafaxan the nausea has returned. I am awaiting the results of a new breath test to see if the bacteria that may have been eliminated has returned. She has also just started taking a probiotic hoping to build up any good bacteria that may have been destroyed by the Xafaxan. My question is that with her having “gastric dumping syndrome” can SIBO ever be eliminated going on the basis the stomach acid is not having sufficient time to aid the small intestine in the digestive process? With two thirds of SIBO patients relapsing, what can be done, short of Xafaxan at $35 a pill, to control the SIBO and the associated nausea?

    1. Hello Beth,

      It’s impressive how you have determinedly become your wife’s primary health practitioner! I hear your frustration about not getting the right diagnoses and treatment from the various practitioners and hospitals she has been to. Many doctors and gastroenterologists are not yet familiar with SIBO; however there are many who are! I’m not entirely sure your prescription for her did the job, for many reasons. One, Xifaxin alone is usually only effective with hydrogen producing bacteria. Methane producers often require a second antimicrobial. Also the treatment length may not have been sufficient. In addition, there are other factors that help such as prebiotics to draw out the bacteria, biofilm disruptors, and in some cases specific diets. I believe it’s also important to examine and treat any large intestine microbial factors simultaneously, as well as testing for H. pylori in the stomach. All that being said, I find the most useful approach for preventing relapse is to find the cause if possible – and it sounds like you may have done that with figuring out the gastric dumping. If the SIBO is a manifestation of the gastric dumping, it makes sense to target that is the primary cause. Unfortunately these complex gastrointestinal conditions take persistence to resolve. Don’t give up! I wish you the best of luck. -Laura

  5. Hello everyone.

    I had some problems in the recent months, I used to follow a high protein diet (I like body building) and i’m also celiac.

    It all started this may with a bit of reflux (solved with gaviscon) and some acne under my eyes (not really acne, i’m 30), but that were not a real problem.

    Then I got a food poisoning and there all has gone so bad. Vomiting all night and diarrhea, for 3 days I couldn’t touch food, started to have GERD with nausea and air in stomach, after 2 months the doctor gave me PPI and gaviscon, but I had no relief.

    In september I had a gastro, where they found Esophagitis and bile in the stomach, continued with PPI and changed a few other meds but got no improvements.

    So I changed doctor, who touching me found out that my liver was a bit too big, sending me to do an ecography (which resulted in nothing bad, just a bit of fat liver) and prescribing prokinetics.

    I’m now one month in to the new cure and still feeling bad after every meal, I dont smoke, I dont drink, my diet is good.

    Do you think I should do a SIBO breath test? Any advice?

    This thing is also ruining my social life cause I feel ill at ease everytime my friends ask me out for dinner.

    1. Andrew, I am sorry about your suffering! When the gut is off, it can affect all aspects of health and life – as you mention even your social life is affected. It sounds like you’re a good candidate for a SIBO test. However, it sounds like there’s other things going on, as you mention fatty liver. Sometimes it takes a while to get better, and I’m glad you’re in the care of a practitioner to help you. Hang in there!

  6. Hi Laura,

    I was curious if black coffee or matcha green tea would interrupt the MMC inbetween meals? I like to have coffee in the AM 2 hrs before breakfast and the matcha green tea inbetween lunch and dinner.
    Also, do supplements stop the MMC as well?
    One more question, is eating 2 hours before bed enough time or should more time be allowed for food to digest?
    Thanks for any advice!!


    1. Amber, good questions, and probably no one knows for certain…. but I would guess black coffee or green tea would not affect the MMC. Supplements – it depends what they are. I think a good target is 12 hours of not eating. Two hours before bed is certainly better than eating right before bed. Thanks for your questions!

  7. Hi Laura,

    I have had similar problems that I’d like to get your feedback. It has been four months of trauma for both my family and I. It all started with a light flank pain in the rear left from which I ended up in ER where they did a non-contrast CT scan. They did not find any abnormalities just some microscopic blood in urine which they believed to be gravel. I was under a lot of stress of course because the next few days, I was now having pain just below/under left rib. That pain began shooting in the left mid back and that led to more anxiety to thinking I could have Pancreatic Cancer. My GI pushed me for another CT scan but this time with double contrast. I did all kinds of blood tests, vitamin deficiencies, stool elastees for Pancrease, hormone testing since I had lot 15lbs in month and a half due to loose greenish stools. All came back normal. I began having a lot of bloating, even when drinking water. I was so bloated that my skin in the left side of the abdomen was hurting (those fat strings like muscle fibers). The GI then ordered Endoscopy where after 6 biopsies, they found h pylori. After a 10 day triple antibiotic treatment, I did a breath test which came back negative. I continues having bloating and pain by left rib which changed a bit in nature since I begin having some numbness at times in that area. Since this all started, my tongue has developed a white coating which a dental pathologist thinks it’s hairy tongue. All this time, it feels like I have a tennis ball inside there. Because of continued problems but a little better digestion, I was not loosing weight any longer but still not able to gain any. GI wanted me to do a SIBO breath test which came back positive for hydrogen bacteria overgrowth. Now they want me to start Xifaxan for 10 days. I have never taken antibiotics since I was a kid and I’m very hesitant to do so because I just don’t believe that the pain I have is associated with SIBO. Granted, nausea at times, alternating loose stool and constipation, less bloating are still signs of SIBO but not so much of that pain under left rib and back (at least based on my research). This is all done at Cedars Sinai where Dr. Climentel discovered SIBO!

    Sorry for the lengthy description but this has terrible effected my life in so many ways. Even though the pain is not constant and maybe only a 4 out of 10, it has effected me mentally. I have become very irritated, highly anxious, unfocused, unsocial, restless and depressed. I’ve lost hope that I will ever get out of this and I’m always worried that maybe the CT scan just did not pick up any issues with Pancreas (even though I’m a little early for that – I’m 33).

    Your feedback is much appreciated. I understand you are limited on what you can suggest but any thoughts would be highly appreciated.

    Thank you in advance!

    1. Wow it sounds like you’ve been through a lot! It sounds like you’re wanting feedback about whether or not to take Xifaxan for the hydrogen SIBO, and that you think there is something else going on. What I’m “hearing” in your message is your stress and worry. Understandable! While I cannot give medical diagnoses or advice on this format, stress does exacerbate many conditions, and that might be a great place to “work.” There could be many different causes of the kind of pain you describe, and I suggest getting more opinions if you think there’s more to uncover. Some folks prefer to treat SIBO with botanicals, however Xifaxan IS the gold standard antibiotic, and it IS a smart use of an antibiotic, because it’s a crystal form that is not systemically absorbed, it only affects the small intestine lumen, and doesn’t destroy the large intestine beneficial bacteria. It’s good to fill in the other pieces I write about when treating SIBO – finding the cause if possible, preventing relapse, building a good microbiome and gut lining. Each person is unique, as is your case. I hope you get the right help! There are always second and third opinions… Best, Laura

    2. Hi. I know this post is years old but I just came across it. I have many of the same symptoms. No one has been able to pinpoint why I have microscopic hematuria. I am curious after all these years what your diagnosis was. This all started for me four months ago.

      Thank you!

  8. HI Laura,
    Do you know if taking supplements/ medication during the MMC cycle interrupts it? Also, what about black coffee and tea… Does that stop it?
    Thanks, Amber

    1. Amber,
      These are great questions! I believe that drinking fluids can interrupt the MMC. This is because the sensation of stomach distention and fullness is what interrupts it. So I try to educate people to drink closer to meals. So coffee and tea, if black and zero calorie, slow the MMC, it would be because of this reason. I don’t know for a fact about supplements or medications, but it probably depends (on quantity, fillers, additives). I would guess that minimal amounts would not affect it. My best recommendation is if you are wanting to promote MMC activity, to do your best to minimize intake of anything for as many “slots” as you can. So daytime, 4 hours is great, and night time up to 12-14 hours. However, don’t obsess about it. Just getting one longer stretch of time on board within 24 hours can make a difference, in my opinion.

  9. Hi Laura,
    I’ve been diagnosed with SIBO and am treating with herbal antimicrobials so far with success. But it believe that I have possible nerve damage to my MMC. Have you seen something like that ever resolve or is it feasible to need a prokinetic very long term?

    Thanks for your articles!

    1. There can be nerve damage to your MMC, however this is not easily measured or tested! It can be feasible to need a prokinetic long-term. There’s confusion about the term prokinetic because it doesn’t have a clear definition. People think prokinetic means something that stimulates peristalsis. If there’s nerve damage, a prokinetic is meant to be a regulatory agent, not a stimulant, it’s for people with both diarrhea or constipation type SIBO. I’m not satisfied with the choices and the literature/research about prokinetics at this point. I also do not like to take the viewpoint that there is irreversible nerve damage in the MMC, unless it’s proven. If we are making that assumption, then one’s thinking can become down or negative about the possibility of getting better. But to answer your questions specifically, in theory it is possible to have nerve damage, and I don’t know if it completely resolves because I don’t have a way of testing the MMC, but I have certainly seen people get better! And yes, taking a prokinetic long-term is feasible.

      1. Thank you, Laura! I’m actually looking at making my own mix called Daikenchuto from Japanese medicine. It’s a mix of ginger, ginseng and szechuan pepper. It’s supposed to be stronger than many of the options I’ve looked at.

        I have also just discovered I probably have parasites, which could contribute to things not moving through me! It seems to get so complicated and can’t be something straightforward with our bodies.

        I guess whether it’s stimulating or actually being the agent that moves things, as long as it gets it done seems to be really important to help the body heal and move past SIBO or parasites or anything else. I appreciate you helping me understand that!

        1. That remedy sounds interesting. I am more often approaching large intestine (your parasite), stomach, liver/gallbladder, and general gut/microbiome health before “tackling” the SIBO – the SIBO grew there for a reason. Then if the SIBO still needs to be knocked down, bodies are better able to keep it down. So if it goes with constipation, important to have motility first – motility is different than prokinetic, which is regulating (at least in the SIBO lingo). Ginger and ginseng are both regulating, or can be.

  10. Hi, I was on 2 rounds of heavy antibiotics for h-pylori last summer. It was awful but I had tried other natural supplements before h- pylori and I knew I needed medication. I felt ok after my stool sample came clear. A couple months ago I started to feel awful again so I asked my gastrointestinal specialist if I could have h- pylori again. I did another stool sample and it came back negative. Question, why am I still having issues. Bloated after I eat anything, burning feeling in my stomach, dry cough, acid reflux, uncomfortable tight feeling in my stomach, sleep issues, diarrhea on an off. Explosive poop issues at times. Misery period. So I’m currently on day 11 of 14 of niacycin. It has not been as awful as my experience with the 3 does for h/ pylori but.. I’m still having issues stomach pain , some bloating, some acid reflux. I just requested a stool kit to test for worms parasites I’ll see how that turns out. My doctor wants me to do a breath test which I’m waiting to get scheduled. The h-pylori was diagnosed through an endoscopy. Everything else was clear. My doctor did say I could have SIBO and IBS. I never had stomach issues. I’m just not sure if this will ever go away. I’ve tried oils, many supplements with no relief.
    I sometimes feel like I’m doomed. Any ideas on natural homeopathy would be appreciated. I have researched and have spent money on stuff that sits unopened in my cabinets

    1. Sorry about your suffering! I would be happy to help you, and the steps are to first schedule a new patient appointment.

  11. Hi Laura,
    I was diagnosed with Sibo last year through a nature path. I have just finished four months of a natural antibiotic (tincture) and now I take a probiotic and lactulose to help with the constipation. Only issue is, couple of weeks ago (I exercise daily and with intense training so I am used to the rhythm) After my exercise class, I was extremely sore. I thought, maybe it is just the training and change of diet which has made me feel less energetic, but now after some weeks my muscles are aching, I wear the proper shoes and I have a good bed, (maybe a pillow could be the cause) but my back is becoming tense and sore more than usual and I have had some constipation again. My nature path has me on a natural tincture for sore muscles and magnesium but the pain is still there especially in the middle of my back. I am not sure what to do or what it could be, but it feels like it could be coming from my gut

  12. Hi! Thanks very much for the information you give in this web. Sorry if my English is bad, i am not an Anglosaxon person.
    I suffer digestive problems since several years and every year I felt worse. In 2015 i did the breath test twice and the results were positive. From these moment i take Rifaximin three months (sometimes during six months) and then i rest two months. My sympthons do not disappear and i feel my life is a horrible hell, I can not work, i can’t go out, I can’t eat almost nothing (I only eat meat, fish , eggs, rice and potatoes).
    I would like to do the SCD diet and besides I am looking for a naturopath doctor, do you know how to look for a doctor who understand sibo in Spain? Do you know someone? Some naturopaths doctors have said to me that they understand but when I talk with them I realised they have no idea about sibo because they only talk to me about stress and natural pills (but they do not know about oregano oil, antimicrobials, disruptor film, prokinetic…). They are too “spiritual” (iin my opinion). So I need a doctor who really knows about SIBO… In Spain conventional doctors asked to me: What is SIBO? And I only feel I want to cry when they ask me…
    When I read your writings and things from Pimentel, Siebrecker… etc… I think I have a problem with my MMC, but… what is the reason? Is possible that only stress can damage the SNC and therefore the MMC? Do you think the nerves are responsible of the problems of person who has IBS/SIBO?
    I know that it is unknown if is possible restore or not the MMC… And the million question… is really possible to cure SIBO, a really cure (forever) ? Do you know someone who has cured forever?
    Sorry if I ask many questions but I don’t know nobody who knows about this problem. I feel I died some years ago, when this problem appeared in my life.
    Thanks you very much.

    1. I’m sorry for your suffering, and can understand your frustration. I don’t know of anyone in Spain, although you could look up on the Institute for Functional Medicine’s site, they train people worldwide. Also the Kresser Institute. Many of us in the U.S. do work remotely. Yes, SIBO can be eradicated. In some people there’s a greater chance for recurrence so finding the underlying causes (SIBO is a symptom not a diagnosis) plus working on prevention/relapse is KEY.

  13. I’ve SIBO and I am on Rifaximin right now but unfortunately, I have gastritis right now as well. I think it’s not acute. we can say it’s intermediate and I am aware of life style changes and foods for gastrits. But I do not know what to do. I am afraid of taking H2 blockers or PPI’s because I know it contributes to SIBO. What should I do? I am thinking of taking h2 blockers 150mg i.e like Zantac at night and Maalox plus after meals at daylight? Or just take 300mg every day?

  14. Hi Laura,

    I tested positive for overgrowth of Klebsiella. Any recommendations on herbal antimicrobials that kill this bacteria and probiotics ? I also read they feed heavily on starch (which is in a lot of foods). Any diet recommendations for this type of bacteria?


    1. So I can’t give personal medical advice in this venue. That being said, I would not chase down a single bacteria in your GI tract with antimicrobials (which always have collateral damage) without evaluating the larger picture of your whole tract, and other aspects of your health. So pull back and look at the larger picture – if there is dysbiosis, what type and why? Ask the practitioner who tested you – balancing gut flora is a fine art and it’s best to have guidance. Hope these thoughts help.

  15. Hi Laura, I’ve been sick for 4 months , discomfort in my stomach, pain under my ribs, and lately some tension in my neck left side, I don’t know if it’s related to the stomach thing or just stress, I’ve had an ultrasound on my stomach, so fat on the liver, I’m not that big 190, 5-10, but not much else, had a colonoscopy and endoscopy and they said high white cell count in the lower intestines , so now waiting on a test mailed to me, for sibo, I haven’t been able to eat a lot without it getting worse, so I have found bananas, yogurt, white rice and sweet potato, and salmon, and chicken about it, if I eat to much or much else, I feel the dis comfort and a burning in my throat, the GI told me to take Gavagone, which works great and fast, but very tied of being sick, I’ve been sick so long I thought I had cancer, thank god wasn’t the case. I feel like I’ll never be normal again, my axiety is so bad I’m having a time working. I’m 49, and never been this sick, friends call me the phantom gourmet because I’m such a big foodie, I miss food, I was 210, when this started and now 190, I’m doing what I can , following doctors orders, taking the test they tell me to but I’m tied of this, even after this next test it seems people are sick for a long time even after meds, I want my life back, any advice?

    1. My advice is to work with a qualified practitioner and you will get your health back! Sorry to hear about your suffering.

  16. Hi Laura,
    I tested positive for Sibo – hydrogen via a 3-hour glucose test. My gastroenterologist then did a gastric emptying test and it said I had rapid transit, or dumping syndrome. My doc believes this is my root cause of the sibo. She is putting me on rifaximin for 14 days and then a low fodmap diet. But don’t you have to “fix the cause” of the sibo before treating it? The diet for dumping syndrom varies greatly from the low fodmap diet.
    My question is: everything I read by Pimentel and Siebecker say to definitely use a prokinetic after treatment to restore MMC . My doctor disagrees and says I don’t need it because I have rapid transit. Does this make sense to you or should I push for the “all Sibo people need a prokinetic” method?

    1. Kathy,
      I have not found that everyone needs a prokinetic, no. Prokinetics are in theory supposed to regulate the MMC while taking, not restore. But I personally do not use them with everyone, in spite of what those docs say. I like to take a broader picture that SIBO is more of a symptom not a disease in itself, and can be resolved. It sounds like that may be how your doctor is approaching it…. so ask how she/he thinks the underlying cause (“dumping syndrome”) is then resolved as the root cause of your SIBO?

      1. Thanks for your reply….it was helpful.
        The dumping syndrome diet and the sibo diet are quite different. One suggests 6-8 meals a day, and the other suggests spacing 3 meals and fasting. One likes fiber, one doesn’t. D.S. suggests only drinking between meals, while sibo says that might mess with the MMC.
        So which do I do??? I am in the middle of a 14-day Rifaximin course and will start some kind of a diet when finished with that.
        Thank you!

  17. Hi Laura,
    So even water interrupts the MMC? I had heard water, plain tea, and coffee were okay. Is this a new discovery? What would you recommend then to let the MMC do its cleansing waves?
    Also, if water affects it, I’m assuming things like thyroid meds, magnesium and prokinetics would disrupt it as well. I take these on an empty stomach before bed 4-5 hrs after eating and the thyroid med. early AM during my 12-16 hr overnight fast.
    Thanks for any comments and information!

  18. I have essentially cured or at least knocked out 90% of the Sibo Symptoms for good. I have been researching and going to some of the top Docs in the country, (Mayo, Albert Einstein, Cedars Sinai).I am happy to help others. I am not a Dr, just someone who has fought this for 5 years and finally found a rotation of antibiotics and motility drugs with a protocol that works. I am currently off all antibiotics, eat almost whatever I want and take two motility drugs (alternate). Just so you know PPI use has nothing to do with SIBO unless your stomach PH is high (hi PH, low acid). Stomach PH testing is critical, if your in the normal range with PPI stay on PPi it helps with symptoms of Gerd and protects the stomach. If you test low in acid then stop PPi or add HCL supplement. Only a Gastro doc can check stomach (PH)correctly. Again not a DR but happy to help with the protocol that works. Feel free to contact me.

    1. Kathryn one pad on the back of the left shoulder, and an ear clip on the right ear. It’s on my list to make video instructions for this. Meanwhile, feel free to email us for a PDF handout.

  19. Hi Laura,

    I have found this blog very interesting – thank you for all of the insight!

    I was diagnosed with SIBO 5 years ago, since then I have somewhat managed to control my symptoms using the FODMAP diet, however my bowel movements have never completely returned to normal and I suffer from (a usually mild) discomfort on a daily basis.

    A few weeks ago I had to have emergency surgery because scar tissue had blocked my small intestine in two places. After the surgery, I was not allowed to eat or drink for 48 hours and also had a tube that sucked matter out of my stomach. To my surprise, despite returning to a full diet, my SIBO symptoms appeared to have completely disappeared, my bowel movements returned to normal for the first time in 5 years, and for a few weeks I believed I was completely cured! Unfortunately I don’t think that was the case, as the symptoms appear to have now come back. Based on online reading, I now understand this relapses are common.

    In your article, you mention that a test exists to see whether your SIBO was caused by food poisoning. Based on my experience of having a sudden onset of severe symptoms with no previous history, I believe this is likely the case for me. Are you able to advise what the test is? I would like to go to a practitioner armed with as much information as possible.

    Thanks again!

  20. By chance do you have any advice on finding a good functional medicine practitioner with this knowledge of SIBO? I often feel that my GI is quick to prescribe things like PPI’s or antibiotics.

  21. I have been through the ringer the past two years with stress steaming from miscarriages, moving, new employment, family death, house hunting, and my biological clock. In January 2020 I experienced sharp pain in my lower right abdomen. PCP told me it was ibs. My 15 year old ibs diagnosis from food poisoning (resolved 10 years ago) told me this was not the same. It disapeared completely in 3 days.

    May 2020 a family member died and this caused me to spiral emotionally. I started seeing a therapist but my body instantly started breaking down – female infections, cracked teeth, TMJ symptoms, anxiety, etc. I see an Accupuncturist as well. Fertility wise IVF has put me on hold – I’m 39 next month and my husband is 45. We are devastated.

    In August I experienced the same lower right Abdominal stabbing pain…it never disappeared. My stool overnight went to fluff and yellowish brown. I tried the brat diet for one week and then two weeks. Went to GI #1 in August did stool tests for inflammation and blood and we’re negative. I pushed for SIBO testing and they told me they’d put me on xifaxan. They also told me to take whatever probiotics I wanted. GI #1 put me on famotidine 20mg twice daily in August. I took the probiotics and xifaxan and my pain relocated to below my right rib. They put me on ginger root capsule of my choice and lglutamine of my choice. Several visits to the ER and being told by GI #1 this is gastritis and refusal to do any upper GI or colonoscopy had me seeking GI #2.

    November 2020 I met with GI #2. My colonoscopy and upper GI came back negative for Hpylori or anything visible and no gastritis. He told me to remain on ginger root, lglutamine, and famotidine. He said I could stop all of these if it doesn’t cause issues but was a man of few words. Otherwise I don’t think he knew what to advise me on. I had a breath test December 2020 with positive results for hydrogen SIBO with some methane. GI #2 wants me to take xifaxan and neomycin. I start that this week once scripts are filled. He told me this is chronic and I will be treated based on symptoms. He killed me.

    GI #2 basically told me to eat whatever works. No diet guidance. He finally told me to get a dietitian…I did as well as a naturopathic. My naturopathic will not tell me prognosis nor will my GI. Naturopathic and dietitian meet with me the second week ill be on xifaxan and neomycin. I asked about the purpose of being on famotidine still…my naturopathic told me to stop it immediately in November and ginger root but use ginger if my body says so – nausea symptoms. I don’t have burning pain but do clear my throat of mucus often as of this year. I have a slight deviation of my nose so I don’t know if that comes from the grinding and clentching of my teeth related to my ear/nose/throat and post nasal drip.

    My anxiety is through the roof – I feel doomed. My PCP has been my backbone but is limited on SIBO knowledge. He doesn’t know what else to suggest. My PCP and I decided to put me back on lexapro for anxiety. I took it years ago and it was beneficial. IVF doesn’t want me on it… that’s why it took me so long to decide to treat me first.

    I want to get to the root cause…but I assume anxiety is the culprit. Did I damage my GI function? I feel doomed and scared that my GI will fail on me. What else can I do to mend or test and treat?

    1. My probiotic use has ended – after my colonoscopy prep my gut started fighting me on their use with severe cramping in other areas of my GI tract. Once I stopped them it resolved but my SIBO pain returned. Tried another probiotic and two weeks later the same thing happened. I also experienced what appeared to be an overgrowth of vaginal yeast (negative tests) and a positive uti despite all of the water I’m drinking.

  22. Hi Laura,

    Thank you so much for this article.

    I’m currently 2 weeks into treatment for my SIBO and I have a few Q’s I would like to ask about treatment and testing.

    So I’m currently taking probiotics and also oregano oil and Berberine as antimicrobials. Through research and asking other survivors/people suffering from sibo, I have been told that you should rotate your antibiotics/antimicrobials every 2 weeks as the bad bacteria becomes immune to them after that time period. Is this true? and if so what antibiotics/antimicrobials do you suggest to switch between during treatment.

    Also I am yet to take a sibo breath test although I have done a GI MAP test and that is how my naturopath discovered strong signs of sibo/leaky gut. Do you think it is worth having the breath test in terms of knowing what type of sibo I have? And should you treat each type of sibo differently to the other?

    I would much appreciate hearing back from you as soon as you get this!

    Thank you, Kind Regards


    1. Hi Bridie,
      I can’t give personal medical advice here, only in a patient consult appointment.

  23. Hello Laurie,
    Regarding MMC and drinking water between meals – I drink 16oz three times a day (48oz total) – half my body weight (100lbs) between meals. My SIBO has returned – 4 months after finally received a negative score on the hydrogen/methane breath test.

    I am suspecting 2 culprits:
    1) large intestine dysbiosis – was on garlic/oregano/berberine extracts for 6 months – left large intestine depleted of beneficial bacteria
    2) drinking 16 oz of water in two 8 oz servings between meals (although strictly following a 5-hour gap between eating solid food – eating only 2 meals a day).

    QUESTION: how to drink so much water so closely to meals, does it inhibit dijestion – Especially if those meals are relatively large, due to eating only twice a day? (I cannot eat 3 meals a day and follow the 5 hour apart recommendation – cannot eat at 6AM – exhausted and still in bed – I’m a senior) I also have to take supplements away from food (Intrinsa & SIBO-MMC)- Is it safe to do that with perhaps 3 oz of water?

    Thank you kindly for the informative posts
    Warm Regards,


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