Below is a podcast of Chris Kresser, a functional medicine practitioner discussing several aspects of dealing with and treating SIBO which is widespread and fairly difficult to get a handle on. You can find this on his webpage at:
There is a link on that page to listen to the podcast and the transcript of the show as posted below.
I think the best way to dive into this is just to say that Iíve started to doubt many of the standard assumptions or beliefs around SIBO that many of you are probably already aware of. I just want to go through five or six of these assumptions and tell you what my current thinking about them is, and this might be a little bit of a frustrating podcast to listen to because Iím not necessarily going to give you answers. Iím just going to tell you what the questions are, where my doubts are, and what further research or exploration or investigation I think we need to do.
Question #1: Is lactulose breath testing an accurate way to diagnose SIBO?
Letís start with assumption number one, which is that lactulose breath testing is an accurate way of diagnosing SIBO. As many of you know, the standard way of diagnosing SIBO in an outpatient setting is using lactulose breath testing. There is another way, which is an endoscopy, where they put a tube down your throat and take a sample of bacteria from your small intestine, but thatís never used in outpatient settings because itís invasive and expensive. Itís just not done. There are actually a lot of problems with that method as well, which leads us to probably the biggest issue of all from a 30,000-foot-view perspective with SIBO, is that in order for a test to be accurate, it needs to be validated against something thatís a gold standard, and we have no gold standard way of diagnosing SIBO. The endoscopy, which I just mentioned, has been used as the gold standard test against which breath testing is validated. But what if the gold standard test itself is not accurate? That obviously creates some pretty big problems in terms of developing another test like breath testing and then validating it against a test that itself is not very valid. Thatís the biggest issue.
The problems with SIBO diagnosis and treatment
Iím not going to go into all the nitty-gritty details on why breath testing isnít necessarily as accurate as some people may believe. But in this context, Iíll just say thatóand this is a guess, I havenít done any rigorous studyóbut I would estimate that over 90 percent of the patients we test for SIBO test positive. Now this is using the former criteria and Iíll come back to this in a second, but if you just use the machine-generated criteria that are printed on any of the SIBO breath testing labs, I would say over 90 percent of our patients test positive. Now, that alone should be a red flag. When more than 90 percent of your patients test positive for a condition, that should raise some eyebrows.
Certainly SIBO is common, but do we really expect that 90 percent of patients, even people who are sick and dealing with chronic health issues have SIBO? Iíve never seen any research suggesting that over 90 percent of people with any particular conditions also have SIBO. The exception might be Acne rosacea. I think I saw one study of 42 patients where 100 percent of patients with Acne rosacea had SIBO [Correction: study I was referring to found that SIBO was 17 times more prevalent in patients with rosacea than in controls.] This doesnít mean for sure that the test is inaccurate, but it definitely raises my eyebrows. It makes me wonder whether weíre over-diagnosing SIBO.
Changes in criteria
Now I mentioned the criteria, so up until pretty recently the idea was that if you see an increase in 20 parts per million or more of hydrogen in the first 120 minutes of the test, that would indicate a positive result, and the criteria were an increase in 12 parts per million for methane, but those criteria recently changed; there was a consensus statement issued in the spring. A bunch of SIBO experts got together and talked about how to update the breath-testing criteria to make it more accurate and ensure that the criteria were modified to, on the one hand with hydrogen, the changes would lead to fewer diagnoses, less overdiagnosis of hydrogen-predominant SIBO. But in the case of methane, theyíre going to lead to a greater number of diagnoses because those criteria, instead of becoming more strict, became more liberal. The new hydrogen criteria are increasing 20 parts per million within the first 90 minutes, and then with methane, itís any value over 10 parts per million at any point during the test, including during the third hour. Thatís a pretty big difference, and thatís going to lead to a lot more positive results for methane.
Itís also worth pointing out that there are a lot of different studies that are critical of lactulose breath testing that suggest that there is a very high potential for false positives, especially using lactulose instead of glucose. With glucose breath testing, the opposite problem is true. Thereís a high potential for false negatives. If there is a positive, it should be positive. But if thereís a negative, you canít rule out that SIBO might be present. Again, Iím not going to go into great detail here, but letís just say that there is a lot of uncertainty about breath testing as a way of diagnosing SIBO.
Question #2: Is SIBO always pathological?
The second assumption is that SIBO is always pathological. The idea is that if SIBO is present, itís always causing the patientís problems, whatever they are, but thatís not sound thinking, of course, because we know that correlation is not causation. Itís possible that SIBO could be present, but itís not actually driving whatever the patientís symptoms are. We know that early studies suggested that up to 20 to 30 percent of healthy controls have SIBO but donít have symptoms. Of course, I have to offer a side note here, which is, I donít know where these studies are finding these so-called ďvery healthy controls with no symptoms.Ē I havenít met that many of those people, but letís assume that thatís true. That could mean that 20 to 30 percent of the population has SIBO, but itís not causing any problems for them.
In many cases, we treat SIBO, and the numbers improve, so the patient goes from being breath-test positive to breath-test negative, but their symptoms donít necessarily improve. That would suggest that maybe SIBO was present, but it wasnít causing their symptoms. Itís possible that the testing is accurate as far as what itís measuring, but what we call SIBO as a condition is not always pathological. Itís also possible that SIBO might be present in a patient and might be causing some issues, maybe a mild nutrient deficiency or something like that, but itís not causing the main complaints.
The reason I bring this up is that I see some patients just getting hyperfocused, almost obsessed about SIBO, at the expense of everything else. And cliniciansóthere is that saying, ďIf youíve got a hammer, everything looks like a nailĒóI see both clinicians and patients becoming over-focused, I think, on SIBO, and the risk there is that you actually miss other pathologies or underlying mechanisms that are really actually driving the condition in those cases if weíre just myopically focused on SIBO.
Question #3: Are our treatments effective?
The third assumption is that our current treatments are effective and optimal. The typical treatments for SIBO are antimicrobials. Initially, there were prescription medications. Rifaximin is the most commonly used, especially for hydrogen-predominant SIBO, and neomycin is also added at times when methane is present. Metronidazole is another medication, or Flagyl is used in some cases for treating SIBO, as well as other Antibiotics , but rifaximin certainly has become the drug of choice. But then there have been some studies recently that have found that botanicals, herbs, are as effective as rifaximin treatment or even more effective and cause fewer side effects. In general, the approach is if SIBO is there, then you use antimicrobials to reduce the growth of bacteria in the small intestine.
The problem with this approach is that the efficacy is often quite low. Iíve seen some studies that we use rifaximin individually that show as low as 40 percent efficacy. Of course, there are other studies that show higher efficacy, and then if you combine other agents in the treatment, you can make it more effective. There was one treatment where the researchers speculated that using partially hydrolyzed guar gum would improve the efficacy of rifaximin, and in fact it did. It increased it significantly. In our clinic we use a combination protocol that uses a bunch of different things together, all of which are designed to maximize the efficacy. It also depends whether itís just hydrogen alone thatís high, or methane alone thatís high, or both hydrogen and methane, and each of those scenarios requires a different approach.
But the problem remains that efficacy is much lower than I certainly would like to see it. Not only that, in some cases, not only do patients not get better, they actually get worse after treatment. They might get worse right away or they might improve initially, but then the symptoms return and when they come back, they come back even worse. Iíve seen this actually happen in multiple cycles, meaning with each treatment and each return of symptoms, the symptoms get worse after each cycle, which is obviously problematic.
Then thereís the very high rates of recurrence for SIBO, which is related to what I just said. One study, I think, found a recurrence rate of 45 percent in patients who had been treated by rifaximin. In our practice, despite using all of the evidence-based methods and combining several different methods, we still see recurrence rates a lot higher than optimal, than I think is acceptable. Thatís one of the main things that has led me to question many of these beliefs and assumptions because when the treatments are not that effective and the recurrence rates are very high, then I think that something is definitely wrong.
Question #4: Is SIBO always the underlying cause?
The fourth assumption is that SIBO was always the underlying cause of a particular condition. This is somewhat related to what I mentioned earlier, but a little bit different. In functional medicine, weíre always trying to get to the root of the problem, but sometimes thatís easier said than done, and it can be like peeling layers of an onion back to keep going deeper to find the deepest underlying issue. If a patient has SIBO, for example, and we treat their SIBO and it doesnít go away, or maybe it does go away and it comes back, and we do that two or three times, then of course I start wondering, ďAll right. Well, is there some other deeper condition that is causing the SIBO?Ē
In this case SIBO is not necessarily a cause itself, but almost a symptom of a deeper underlying problem. In my experience, those problems can be things like:
mold or chronic inflammatory response syndrome
chronic infections like tick-borne illnesses
other gut infections that have escaped detection
heavy metal toxicity
other types of toxicity
And a range of other problems. But the point being that in those cases, those problems are the real thing thatís driving SIBO and then whatever symptoms the SIBO is causing. Itís like layers, and so you have to keep going deeper in order to identify and address those conditions, otherwise that patient is never going to get over SIBO. Weíll just keep treating it, it might improve a little bit or not, and then it just keeps coming back. Even though rifaximin and the botanicals are relatively safe compared to other antimicrobials, theyíre still antimicrobials, and we still want to minimize our use of them.
Question #5: Should probiotics and prebiotics be avoided during treatment?
Assumption number five is that probiotics and prebiotics should always be avoided when a patient has SIBO and shouldnít be included in treatment. I think Iíve discussed this before and Iím not totally sure where this belief or assumption came from. Itís pretty prevalent within the mainstream SIBO community, if you want to call it that. But all of the studies that Iíve seen, I think, without exception, have found that when you use probiotics, either along with Antibiotics or as separate distinct treatment for SIBO, they are effective. Theyíre either effective as solo treatment, or they increase the efficacy of SIBO [treatment protocols]. Even the studies that have used probiotics have shown positive results, which might be a little counterintuitive because you would expect probiotics to feed the bacteria that are present in the small intestine. I think there are still quite a few questions here. Certainly, I have seen probiotics, and prebiotics make patients with SIBO worse, but in other cases, Iíve seen them make patients with SIBO significantly better. We do include very specific types of probiotics and even prebiotics in our SIBO treatment protocol. Weíve done that for many years because of the research Iíve seen on this, and I do think it is effective in most cases.
This sort of points to another question or concept, which historically a lot of SIBO authorities have claimed that SIBO is just really kind of a small intestine, itís not really related to the health of the large intestine or the overall gut microbiome. That doesnít make sense to me. There is a sphincter that separates the small and large intestine, but one of the prevailing theories about how SIBO got started in the first place is itís an inappropriate transfer of bacteria from the large intestine to the small intestine. Itís entirely possible, and even likely, in my opinion, that one of the predisposing factors that can lead to that translocation of bacteria from the large intestine to the small intestine is an unhealthy large intestine. It may be that thatís one of the reasons that prebiotics and probiotics work in terms of treating and even preventing recurrence of SIBO is that they help to improve the gut microbiome. That, in turn, has a sort of upstream effect on the small intestine. Really, still a lot of unanswered questions here related to probiotics and prebiotics, but Iíve seen enough now to convince me that the dominant idea that they should always be avoided is not true.
Question #6: Does a long-term low-FODMAP diet help prevent recurrence?
Then finally, the last assumption, number six, is that a long-term low-FODMAP diet is always a good idea in order to prevent recurrence. I have discussed this and written about this before, so Iím just going to mention it briefly. But studies have shown that a long-term low-FODMAP diet can reduce the diversity and quality of beneficial bacteria in the large intestine, and for the reasons that I just mentioned, I think that that can be problematic. Even though the low-FODMAP diet can reduce symptoms, it may be setting patients up for recurrence if itís leading to undesirable changes in the beneficial bacteria in the colon. Also, there was a recent study that just came out that found that patients with IBS are often able to reintroduce certain FODMAPs without any adverse effects. This study didnít consider SIBO, but as you probably know, many patients with IBS do have SIBO. My guess is that they would have found a similar effect if they had done the study in patients that only had SIBO. It seems that even in patients who do have SIBO or IBS that reintroducing some FODMAPs not only could be potentially beneficial, but doesnít actually lead to a return of symptoms. Thatís what Iíve always encouraged my patients to do is reintroduce as many FODMAPs as they can without significant discomfort. I think thatís a wise approach because we want to keep our diet as diverse as possible, and especially when it comes to fermentable fiber, it can support our beneficial gut bacteria.