ahs13 allison siebecker — small intestine bacterial overgrowth
DESCRIPTION
Many people who try an Ancestral Diet don’t get adequate relief for their digestive complaints. A key reason why may be the presence of SIBO. This presentation will discuss symptoms, causes, pathophysiology, diagnosis and treatment of SIBO. A simple breath test can diagnose SIBO and treatments include diet, antibiotics, herbal antibiotics, elemental diet, and probiotics. Central in all treatment of SIBO is a low- carbohydrate, grain-free diet (Specific Carbohydrate Diet, Gut and Psychology Diet, modified Low Fodmaps Diet). Discussion will include why an ancestral diet can benefit digestion and how the SIBO diets differ from standard Paleo/Primal diets.TRANSCRIPT
Small Intestine Bacterial Overgrowth
Dr Allison SiebeckerAHS, August 2013
www.siboinfo.com
copyright Dr Allison Siebecker 2013
copyright Dr Allison Siebecker 2013
SIBO Symptoms: GI & Systemic
• Bloating/ abdominal Gas– Belching, flatulence
• Abdominal Pain, Cramps
• Constipation, Diarrhea, both
• Heartburn/ GERD
• Nausea• Leaky Gut/SI Sx- any Systemic sx: food
sensitivities, h/a, joint P, respiratory, skin, brain
• Malabsorption Sx- steatorrhea, anemia
IBS
SIBO= Underlying Cause of IBS
• Drs Pimentel/Lin/ Chow: 2000
• Tx’ed thousands of IBS pt’s successfully with SIBO protocol
• 84% IBS test+ SIBO• 75% of those whose
breath tests normalized after tx, had improvement in sx’s (Am J Gastroenterology 2003)
copyright Dr Allison Siebecker
Prevalence:SIBO is extremely common
• IBS alone effects up to 20% of US= 62,782,808– Up to 84% of people w/ IBS have SIBO= 52,737,558
– Not all studies show rates that high= 60% avg
= 37,669,684
• Then we have to factor in all the other dz that occur with SIBO (35+ so far), either as 1. a cause, 2. a comorbidity, or 3. a result. – It’s possible that 35%-50% of US has SIBO
=109,869,914- 156,957,020 people
copyright Dr Allison Siebecker
SIBO Associated Conditions & Risk Factors
Study links on www.siboinfo.com: About SIBO; Assoc Dz AcneAcne RosaceaAcromegalyAlcohol Consumption (moderate intake)AnemiaAutismCeliac Disease/ Tropical SprueChronic Fatigue SyndromeCLL (Chronic Lymphocytic Leukemia)Cystic FibrosisDiabetesDiverticulitisDyspepsiaElderly AgeErosive EsophagitisGallstonesGastroparesisFibromyalgiaGERD Hepatic Encephalopathy (Minimal)H pylori InfectionHypochlorhydria
Hypothyroid/ Hashimoto's Thyroiditis
IBD (Crohn's, Ulcerative Colitis)IBS Interstitial CystitisLeaky GutLiver CirrhosisLymeMedications: Proton Pump Inhibitors,
OpiatesMuscular Dystrophy (myotonic Type 1)NASH /NAFLD (non-alcoholic:
steatohepatitis/fatty liver disease)ObesityPancreatitisParkinson's Prostatitis (chronic)Restless Leg SyndromeRheumatoid ArthritisSclerodermaSurgery: Post-Gastrectomy
copyright Dr Allison Siebecker
Dr Allison Siebecker
Small Intestine Review
What is SIBO?
• Bacterial Colonization of the SI– SI should have low Bacterial counts (101-2/top)– LI is the place for Bacterial colonization (1010-11)
• SIBO= Damage SI structure & function– SI compartment not designed for colonization– SI bact coloniz intereferes w/ digest & absorb
• Protective measures keep bact low in SI– St acid, Bile, Enz, Galt, Migrating Motor Complex
• SIBO= normal GIT bacteria, not pathogenic
copyright Dr Allison Siebecker
Etiology (Cause)Anything that allows bacteria to back
up in the Small Intestine
1. Slowed motility in the SI ( MMC)•Dz: Gastroenteritis, Diabetes, Hypothyroid, Musc Dystrophy, Sclerosis, SLE, Br/Spinal Injury, IG• Drugs: Opiates Test subjects given morphine (which
inhibits MMC) develop SIBO
• Surgery: nerve damage, scarring, adhesions• Stress: Increased CRF inhibits MMC & HCl
copyright Dr Allison Siebecker
2. Obstruction of the SI•Dz: Cancer: tumors, IBD-strictures, Cystic Fibrosis- xs mucus •Surgery: strictures, adhesions•Congenital: malrotation, atresia
3. Non draining pockets/sections of SI•Dz: SI Diverticulitis•Surgery: Blind loops
copyright Dr Allison Siebecker 2013
Etiology (Cause)Anything that allows bacteria to back up in SI
Gastroenteritis (GE)Post-infectious IBS/SIBO Pimentel
• 7-31% (50%) gastroenteritis > PI-IBS/SIBO
• bact secrete a toxin>disrupt musc & nerve connections, inactivating MMC> colonization
• Cdt b looks like something on our SI nerves, IS attacks SI nerves while attacking cdt b= damaging our nerves> MMC> SIBO
• MOA: Cx rx/molecular mimicry= AI mediated
• #, severity, tx, weakness, can go unnoticedcopyright Dr Allison Siebecker
2013
Etiology (Cause)
• SIBO is a disease that recurs often b/c underlying cause either can’t be corrected or unknown how
– Scarring=scleroderma: progressive, incurable– MMC dt nerve dmg from acute GE (perm?)• How Most Get SIBO= Combo of factors, ea
adding up until breaking point.
– hx GE + hypothyroid + period of stress (2wks)
– hx GE + hx occ mild IBS + opioids
• Thought= evolving ruminant digestion?copyright Dr Allison Siebecker
2013
Pathophysiology
copyright Dr Allison Siebecker 2013
copyright Dr Allison Siebecker
SIBO Pathophysiology #1Bacteria compete for & steal our Food
SI Bacterial OvergrowthSI Bacterial Overgrowth
Bacteria Eat Our FoodBacteria Eat Our Food
Gas Gas GI Sx bloating, pain GI Sx bloating, pain constipation/diarrhea constipation/diarrhea
Premature Bacterial Exposure to Host’s Food
Fermentation
Food = Growth
Dr Allison Siebecker
Bacterial GasHydrogen, Methane, Hydrogen Sulfide
• Hydrogen, Methane not made by humans– Certain bacteria convert H M or HS
• Gas Causes Abdominal Sx of IBS– Bloating/distention= physical swelling– Pain= GIT sensitive to pressure, musc
contract against gas, Visc Hypersens in IBS– Eructation, flatulence= gas exiting– GERD/Nausea= gas back pressure – Altered BM’s = H>diarrhea/ M>constipation
Fiber/ Prebiotcs (Prebx)
• Indigestible to us= no enz break bonds • Digestible to bact= have enz
– Fiber exclusively feeds bact= Prebx (food for bact)
• Soluble Fiber: Inulin, psyllium, flax, chia, hemp, gums (guar, xanthan, locust bean, acacia/arabic,
mastic), beta glucan (oat bran/mushroom), alginate, glucomanan (konjac mannan), carrageenan, agar agar, arabinogalactan, pectin
• Oligosaccharides: FOS, GOS, MOS
copyright Dr Allison Siebecker
Key Point
• In the case of SIBO, non-prebiotic carbs, carbs that we should be able to digest & absorb= become Prebx (feeding them, not us)
– feed bact in the SI- just b/c bact are there
• Starch from Grains & Tubers
• Lactose (only digestible to some- genes) – Worse lactose intolerance in SIBO
• Sucrose & sometimes Fructose & Glucose
copyright Dr Allison Siebecker 2013
Dr Allison Siebecker
SIBO Pathophysiology #2Damage= GI & Systemic Sx
SI Bacterial OvergrowthSI Bacterial Overgrowth
DisaccharidasesDisaccharidases(-) Carb Transporters(-) Carb TransportersBlunted Villi Blunted Villi GI Sx’sGI Sx’sElongated Crypt DepthElongated Crypt DepthIntestinal Permeability Intestinal Permeability Systemic Sx’sSystemic Sx’s
Hydrogen, Methane GasHydrogen, Methane GasGI Sx’s: GI Sx’s: Bloating Bloating Constipation/ DiarrheaConstipation/ Diarrhea Pain Pain
Inflammatory cytokinesInflammatory cytokinesDigest Brush BorderDigest Brush BorderBile Deconjugation Bile Deconjugation steatorrheasteatorrhea fat sol vit deficiencyfat sol vit deficiency A, D, E, KA, D, E, K
Bacterial Actions
Fermentation ofUnabsorbed Carbohydrate Damage the Brush Border
Bacterial Growth
Diagnosis/Testing
copyright Dr Allison Siebecker 2013
copyright Dr Allison Siebecker 2013
When to consider SIBO?
• If the symptoms (sx) of IBS are present– Bloating, constipation/diarrhea, abdom pain
• If one of the associated diseases along with digestive symptoms is present
• If a key indicator is present– See your notes
Key Indicators
• Antibiotics (Abx) improve GI sx • Prebiotics (Prebx) worsen GI sx (in Pbx)
• Fiber worsens constipation (& other GI sx’s)
• Carbs worsen GI sx (grains/veg/beans)
• GI sx start after opiate use (dt surgery)
• Chronic low ferritin with no other cause
• Gluten-free diet fails to improve Celiac pt
• Pancreas obscured by gas bubble on CT copyright Dr Allison Siebecker
2013
Dr Allison Siebecker
• Challenge test: lactulose=prebx meant to feed bact>gas. Sx/dz may increase/aggr
• Measures gas that only bacteria produce, (H,M) which indirectly shows their presence – collections every 15-20 min x 2 or 3 hrs= it’s the
timing that reflects the SI= avg 2 hrs – 1/5 H/M in SI diffuses across Brush Border>
blood> lungs= expired
• Performed at home with mail-in kits or in a facility with a machine (lab/hospital/office)
Testing- Lactulose Breath Test (LBT)
Dr Allison Siebecker
SIBO Breath Testing- LBT
• Stool tests reflect the LI, not the SI– Stool dx LIBO, not SIBO (dx:fat malabsorption)
• Other Breath tests: Urea-H pylori, CHO intol (lactose, fructose, sucrose, mannitol)
• Glucose can be used dx duodenal SIBO
• SIBO Testing is controversial- much debate – Gluc vs Lact, (+) criteria, timing, sen/spec stats– Indirect, imperfect, future options limited– I find it reliable. Simple/detailed/non-invas/inexpensive
Treatment
copyright Dr Allison Siebecker 2013
SIBO Treatment Protocol Variation of the Cedars-Sinai Protocol (Pimentel 2006)
Drs Siebecker & Sandberg-Lewis (2010)
SIBO Suspected
Hx GI/Extra GI, Meds, Dz
Antibiotic Elemental Diet
x 2-3 wks
Diet SCD, GAPS x 1.5+ years
1. Rifaximin: Diarrhea/Mixed 550mg tid x 10-14 days 2. Rifaximin + Neomycin: Constipation 550mg tid + 500mg bid x 10-14 days or Rif + Metronidazole 250mg tid x 10-14 d Optional: Probiotic, Antifungal
SIBO Lactulose Breath Test Or: GBT, Organic Acid Test
SIBO Breath Re-Test
Feel Better- 90%
Partial Improvement/ Not Better Re-Assess within 2 weeks
Prevention
1. Diet (SCD/Gaps, C-SD, Fodmap) 2. Prokinetic x 3 mo+ :Prucalopride 1-4mg hs :Erythromycin 50mg hs :LDN 2.5-5mg hs Optional: Probiotic, HCl/bitters, BB healing supplements Re-Treat
SIBO (+) SIBO (-)
Consider other Dx
Treat SIBO 4 options
Hx
Herbal Antibiotics
1. Berberine Herbs 2. Garlic/Allicin (methane) 3. Oregano 4. Cinnamon 1-3 caps 2-3 x day x 4 weeks Optional: Probiotic, Antifungal
Relapse
Treatment
• Algorithm + Key Tx Points – Tx takes time to master & SIBO takes time to tx
• Bacteria are sensitive to diff killing agents– No sensitivity testing for SI bact– May not get result you hoped for= try st else
• Adults often need more than Diet for Tx– Diet= insufficient sx relief -Diet=underweight– Diet= severly limited to get any sx relief– My opinion:Diet is not enough to dislodge SIBO
copyright Dr Allison Siebecker 2013
copyright Dr Allison Siebecker
Key SIBO Tx Points for Success
• Test (3 hour Lactulose Breath Test)– dx, severity, gas type, methodical approach
• Successive Tx Rounds (Abx/HAbx) needed– If gas is above 35-45 ppm – Because avg gas dec from Abx/HAbx=25-35 ppm
• Methane &/or constipation cases are harder to treat
• Double Abx Tx or Allicin needed for methane/constipation cases
• Vary tx method as needed (Abx, HAbx, ED)
Key SIBO Tx Points for Success
• Re-Test to assess results
• Both Prokinetic & Diet for prevention
• Diet must be customized to the individual through their own trial & error – There’s no one “diet” that is perfect for anyone – There’s no test to find one’s perfect diet
copyright Dr Allison Siebecker
Diet
copyright Dr Allison Siebecker 2013
copyright Dr Allison Siebecker
Dietary Treatments for SIBO
1. Specific Carbohydrate Diet (SCD)
2. Gut And Psychology Syndrome Diet (GAPS)
3. Modified Low Fodmap diet (Modfod)
– no grains, tubers, sgr & combined w/ SCD/Gaps
For prevention only, after SIBO gone– Diet may expand as tolerated= grains/tubers/sgr– Cedars-Sinai Diet, Low Fodmap Diet, Less Strict
Paleo/Primal Diets• Don’t remove polysacch’s/go far enough for tx
copyright Dr Allison Siebecker 2013
Key Points of SIBO Diets
• Decrease CHO: poly/oligo/di-saccharides – Avoids Grains, Starch, Starchy Veggies, some Beans,
Sugar & most sweeteners, Lactose, Fiber/Prebx foods
• Allow monosac= glucose/fructose as honey
• Intro Diet to decrease bact, aid tiss healing• Progressive- easier to digest foods at 1st
– no raw fruit or veg, nuts or beans at 1st – fruit & veg= peel, de-seed, cook & puree at 1st
• Like Paleo focused on digestioncopyright Dr Allison Siebecker
2013
SIBO Diets: AllowStricter Paleo: Not allowedNot allowed
• Dairy- as lactose free, esp HM ygt
• Legumes- later in diet & only certain types
• Winter squash, beets, rutabagas
• Fruit juice- Scd: not from conc, Gaps: HM
• Honey- esp clover (sm= stevia)
• Alcohol/wine: later, sm amts, certain types
• Coffee: later, weak
• SCD (not Gaps):Vegetable oil, Saccharinecopyright Dr Allison Siebecker
2013
Lactose Free Dairy Points
• SCD= nutrition/calories/Pbx (HM ygt)
• Many w/ SIBO tolerate it & do better with it– Increased energy, stabilize weight loss, helps
digestion (ygt), increases food pleasure– Surprising! Dairy= bad? Not for many w/SIBO
• Key prob for Dairy Paleo= Store bought yogurt is not lactose free– Most fermented for 4 hours = 30% reduction
in lactose, LcF versions= pectincopyright Dr Allison Siebecker
2013
SCDLactose Free Dairy Foods
• Homemade 24 hr yogurt/sour cream
• Aged cheese, Dry Curd Cottage Cheese
• Ghee/butter
• Lactase enzyme treated cream in small amts
• Commercial lactose-free dairy (LcF milk discouraged on SCD, pectin often in LcF ygt)
copyright Dr Allison Siebecker 2013
SIBO Diets: Don’t AllowPaleo: AllowedAllowed (per version)
• Raw vegetables (salads)- at start
• Vegetable seed/skins- at start
• Raw fruit- at start (except v ripe banana)
• Fiber food/supps: chia/hemp/psyllium
• Tubers (pot/sw pot/yam)
• White Rice
• Cocoa/chocolate/cacao (even w/out sgr)
• Sugars other than honey/sacch/steviacopyright Dr Allison Siebecker
2013
• Dairy* Yes:Lc Free No or Yes• Grains No No or Yes• Legumes No:1st/Yes:later No (or Yes)• Veg: tubers No No or Yes• Veg: raw, skins No:1st/Yes:later Yes• Fruit: raw/juice* Mb:later/Yes Yes/No• Fiber foods No Yes• Sweeteners* Yes:Hny/stv/sacc No or Yes• Alcohol Mb:later No or Yes• Chocolate No No or Yes• Coffee* Yes:weak No or Yes*individually based
copyright Dr Allison Siebecker 2013
SIBO diets vs Paleo dietsFood SIBO Paleo
Summary
• SIBO is common
• Sx are the same as IBS
• Bacteria ferment carbs into gas> GI sx
• Dx= Lactulose Breath Test
• Tx= 4 options, 3=quick killing & Diet
• Prevention= Diet + Prokinetics
• Diet= Scd/Gaps/Modfod very similar Paleo
• Paleo w/SIBO= reduce listed carbscopyright Dr Allison Siebecker
2013
Diet Summary for Paleo folks with SIBO
• Consider: Lactose free dairy, esp HM ygt
• Avoid: starchy tubers, beans, raw vegetables & fruit, fiber/Prebx foods, sweeteners other than honey, grains
• May need to avoid certain veggies (see Fodmaps), high amt’s of veggies (dose matters), fruit, nuts/seeds
copyright Dr Allison Siebecker 2013
Announcement:Upcoming SIBO Symposium!
• Drs Pimentel, Weinstock, Siebecker and Sandberg-Lewis= speakers
• In Portland, Or
• Live webinar for distance viewers
• Recorded webinar may be purchased after
• Jan 17,18 2014
• Visit www.ncnm.edu/sibo-conference
copyright Dr Allison Siebecker 2013
Resources
See www.siboinfo.com under:•‘Resources’ for:
– Labs -Books– Websites -Cookbooks– MMC videos -you tubes/classes
•‘Treatment’: ‘Diet’, for more diet info•For (+) test criteria, see ‘About’: ‘Testing’ or my Townsend article (‘Contact’: ‘Bio’)
copyright Dr Allison Siebecker 2013