How to prevent a relapse
I’ve written about small intestine bacterial overgrowth (SIBO) in my last four posts. To catch up, start at the beginning, or read the previous post. This fifth and final post is about how to prevent SIBO relapse once it’s been treated. This is perhaps the most important post of the five. It is the missing piece for many people.
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 when Functional Medicine clinicians fill the gap that conventional gastroenterologists may not provide: preventing SIBO relapse after treatment.
Immediately after you complete your antimicrobial treatment, go on a prevention plan tailored to you. Stay on your prevention plan for three to six months, and then taper off, with the risk that it may return. If it does return it can be retreated.
Figure out the root cause.
SIBO happens for a reason. Currently, the causes are believed to be:
- Food poisoning
- Structural issues
Acid-blocking medications, such as PPIs and H2 blockers reduce your stomach acid. Stomach acid keeps your stomach 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). A portion of this toxin can damage your small intestine nerve cells. This impairs your intestinal motility, which is dependent on these nerves. Impaired motility leads to bacterial overgrowth. If you have SIBO, think back to when it started and you may remember an incident of food poisoning. 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.
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.
Fix the cause
If the cause is medication, it’s important to reduce or wean off the medication with the help of a clinician.
If the cause is from food poisoning, a prevention plan may be enough to prevent relapse, if your nerve damage is not significant. In these cases the use of a motility agent to regulate your small intestine migrating motor complex (MMC) is important (more on this later).
If the cause is structural, a manual or physical therapist who specializes in releasing abdominal strictures can be very helpful. Acupuncture with the addition of microcurrent can also be effective.
Sometimes the cause is unknown. Whether or not the cause can be determined, once antimicrobial treatment is complete, it’s important to be on a prevention plan.
- Restore your migrating motor complex (MMC)
- Eat appropriately for you, with tolerated fermentable carbohydrates and prebiotics to feed good bacteria
- Probiotics may help
Restore your migrating motor complex (MMC)
This is essential for preventing SIBO relapse. Most people with SIBO have a dysfunctional MMC, which may be why the bacterial overgrowth occurs. 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.
With SIBO the MMC may be dysfunctional because of nerve damage. The MMC can be dysfunctional in both cases of constipation-type or diarrhea-type SIBO.
How to restore your MMC?
Take a prokinetic immediately after finishing antimicrobial treatment. A prokinetic is an agent that restores function of your MMC. Pharmaceuticals include low dose eurthemycen and low dose naltrexone. There are many herbal motility agents as well.
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. Often, I will recommend patients extend their night fast for 12 – 14 hours. This allows for a 10 – 12 hour “feeding time” during the day. Eat enough at meals so that you can go four hours before eating again. If you can’t wait that long, it’s either because your meal wasn’t sufficient, or you have blood sugar issues. If this applies to you, working on these issues will help your MMC improve as well.
Sugary drinks, or any calories between meals, will completely thwart your MMC. If you hear gurgling noises, that’s your MMC at work. Many people with SIBO never hear these noises. If your MMC is shut down, this wave process will not occur. You will feel your food stagnate, and not digest properly. Alternately, you may feel like you need to run to the bathroom with urgency and diarrhea. It tends to be one or the other, although some people have both or neither!
Determine your tolerance for fermentable plant foods and prebiotic fiber
Some people need to be on a special diet that reduces, but not eliminates, fermentable carbohydrates. The most nutrient dense carbohydrates are from vegetables and fruit, and they are important to include in your diet. Some of them are more fermentable as compared to others. Here is a great list.
In general, we clinicians do not want people to be on highly restricted diets long-term. However, there may be certain foods that trigger symptoms. These foods are often in the “avoid” column on this list. Foods to avoid are individual. Explore by trial and error, or get help from a clinician.
There are low fermentable diets such as the Specific Carbohydrate diet (SCD), the low FODMAP diet, and the Fast Track Digestion diet.
These diets are meant to be short term in my opinion, and only followed long-term if absolutely necessary, like in stubborn cases of frequent relapse. The goal is to handle fermentable plant fiber in order to feed the beneficial bacteria in your large intestine.
If you do follow a restricted fermentable food diet, you can still add prebiotic fiber supplements which can help normalize your gastrointestinal bacteria. This post describes fermentable foods. This post describes them more in depth, and describes the various prebiotic fiber supplements.
Choosing the right one is highly important. Many of the lactobacillus strains available in stores exacerbate SIBO! Strains that are designed to stay intact until reaching your large intestine are helpful. Soil-based organisms, which we used to get naturally from dirt and animals, make up a large part of the colonies in your large intestine. These are usually safe in the treatment of SIBO. They also have antimicrobial properties so they push out less-desirable strains.
Fermented foods such as 24 hour homemade yogurt, or fermented vegetables like sauerkraut, miso, and pickles, provide rich sources of lactobacillus strains. However, not everyone with SIBO can tolerate fermented foods. If you add a little bit per day, starting with one spoonful, you can usually grow your tolerance. These foods are far greater in probiotic content than capsules. They are also less expensive.
If you find you cannot tolerate fermented foods, it could be that you are sensitive to histamine, which is high in lactobacillus fermented foods. If that’s the case, use lactobacillus strains that decrease histamine rather than produce histamine. One of these is a strain of lactobacillus plantarum contained in Ideal Bowel Support.
If you are on a restricted diet that eliminates fermented foods or fermentable carbohydrates, it’s a good idea to include probiotics and/or prebiotic supplements. Again, this varies by individual and you will benefit from working with a clinician who can test your microbiota and gear things towards what’s optimal for you. This is not an exact science; however, we are learning more each day.
In summary, if you suspect you have SIBO:
- Get tested through a Functional Medicine clinician or gastroenterologist
- If positive, work with your clinician to develop an appropriate treatment plan (from two weeks up to four months)
- When treatment is finished, retest
- If clear, move to a prevention plan
- If not clear, troubleshoot and treat again
Thank you for sticking with me through these five posts on the same topic! Many of my patients, friends and family members have no idea that their symptoms are highly suggestive of SIBO. As I wrote in posts one and three, these are not only digestive symptoms, they include other inflammatory symptoms such as aches and pains, depression and anxiety, and high cholesterol. Many people have told me they were treated once for SIBO but they know they have it again, they can tell from their symptoms. This is why I wanted to include this fifth post on preventing SIBO relapse.
Join in the conversation with your comments!