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Small Intestinal Bacterial Overgrowth (SIBO)

Small intestinal bacterial overgrowth (SIBO) refers to an abnormal amount of bacteria in the small intestine, sometimes due to elevations in bacteria that are usually found only in the large intestine. The exact causes are unknown, and diagnosis can be challenging because SIBO shares symptoms with several other diseases. Breath tests are often used as an indirect way to detect it. SIBO can be treated with antibiotics, and certain probiotics may enhance their efficacy, but evidence supporting other supplements or dietary interventions is limited.

Our evidence-based analysis on small intestinal bacterial overgrowth (sibo) features 37 unique references to scientific papers.

Research analysis led by and reviewed by the Examine team.
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Research Breakdown on Small Intestinal Bacterial Overgrowth (SIBO)


1How is SIBO different from SIFO?

Small intestinal fungal overgrowth (SIFO) is characterized by a high quantity of fungi (such as yeast) in the small intestine, while SIBO is caused by elevated numbers of bacteria. Despite the conditions sounding similar, their risk factors, symptoms, and treatments differ.

Prescription antacids and altered gut motility may increase the risk of developing SIBO, but they aren’t associated with SIFO.[32] 

Studies have found that the rates of unexplained GI symptoms are similar in participants regardless of fungal colonization, which contrasts with the relationship between bacterial overgrowth and GI distress.

Also, while SIBO is conventionally treated with antibiotics, SIFO requires antifungal medications.[35] Probiotics may prevent or suppress intestinal overgrowth of Candida (a type of yeast), but they don’t prevent SIBO.[36][12]

However, in both cases, emerging research suggests that the composition of the fungi or bacteria — not simply a higher number of either — has a greater impact on whether the overgrowth might lead to symptoms.[3][37]

2How is hydrogen-positive SIBO different from methane-positive SIBO?

Hydrogen and methane are produced exclusively by gut microbes, so an abnormal rate or quantity of gas production can indicate the presence of SIBO. The ratio of these gasses determines whether a person is predominantly a hydrogen or methane producer. When it comes to SIBO, these gasses could also provide clues to which microbes are thriving (overgrowing) in the small intestine.[5]

While hydrogen is produced primarily by bacteria, most methane is produced by another group of microbes called Archaea, which belong to a domain of life separate from Bacteria or Eukarya (the cells that make up complex organisms, such as humans.) Archaea in the human gut consume hydrogen and carbon dioxide for energy, generating methane as a result, which is why they’re also known as methanogens.[5]

An estimated third of healthy adults produce more methane than hydrogen, so methane hasn’t been identified as a clear cause of GI symptoms. Recent theories suggest that methane plays a role in constipation by slowing the GI system, however, and suggest differentiating between intestinal methanogen overgrowth and SIBO.[5] 

A recent meta-analysis reported that the odds of having methane-positive SIBO (possibly indicating methanogen overgrowth) were approximately two to three times higher in constipation-predominant IBS compared with diarrhea-predominant or mixed IBS, according to data from five studies.[5]

Other research indicates that individuals with methane-positive breath tests are five times more likely to have constipation than people who primarily produce hydrogen.[9] However, because slowing down of the GI system may support the growth of methanogens, it’s unclear which comes first: the methanogens or the constipation.[5]

3What factors influence the accuracy of breath tests?

After fasting overnight, a breath test begins with the ingestion of a carbohydrate — most often glucose or lactulose when testing for SIBO — and the hydrogen and methane content of the person’s exhaled breath is measured at specific intervals over the next few hours. However, a number of factors can reduce the accuracy of breath tests and lead to a false positive or false negative.[9]

The person being tested could reduce the accuracy of the test in the following ways:

  • Using antibiotics within 4 weeks of testing

  • Using laxatives or gut-motility drugs within a week of testing

  • Not fasting long enough (8 to 12 hours) before the test

  • Eating fermentable foods, such as complex carbohydrates, the day before the test

  • Smoking before the test

The carbohydrate used during the test also affects the results. Glucose is more likely to lead to a false negative than lactulose, but glucose is regarded as a more accurate diagnostic tool. Lactulose is more likely to lead to a false positive by quickly reaching the large intestine, where hydrogen will be produced. Using too large a dose can speed up intestinal transit even more, leading to an early peak in gas production that could lead to a false positive.[10][9]

Clinicians and researchers may also set their own cutoffs for the level of gas production required to diagnose SIBO, which would obviously have an impact on results.[9]

References

  1. ^ a b Y A Kucheryavyy, D N Andreev, I V Maev. Prevalence of small bowel bacterial overgrowth in patients with functional dyspepsia: a meta-analysis. Ter Arkh. (2020)
  2. ^ a b c d Ayesha Shah, et al. Systematic review with meta-analysis: the prevalence of small intestinal bacterial overgrowth in inflammatory bowel disease. Aliment Pharmacol Ther. (2019)
  3. ^ a b c d George B Saffouri, et al. Small intestinal microbial dysbiosis underlies symptoms associated with functional gastrointestinal disorders. Nat Commun. (2019)
  4. ^ Uday C Ghoshal, et al. A proof-of-concept study showing antibiotics to be more effective in irritable bowel syndrome with than without small-intestinal bacterial overgrowth: a randomized, double-blind, placebo-controlled trial. Eur J Gastroenterol Hepatol. (2016)
  5. ^ a b c d e f g Arjun Gandhi, et al. Methane positive small intestinal bacterial overgrowth in inflammatory bowel disease and irritable bowel syndrome: A systematic review and meta-analysis. Gut Microbes. (Jan-Dec)
  6. ^ a b Karn Wijarnpreecha, et al. Small intestinal bacterial overgrowth and nonalcoholic fatty liver disease: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol. (2020)
  7. ^ a b Roman Maslennikov, Chavdar Pavlov, Vladimir Ivashkin. Small intestinal bacterial overgrowth in cirrhosis: systematic review and meta-analysis. Hepatol Int. (2018)
  8. ^ a b Ayesha Shah, et al. Systematic Review and Meta-Analysis: Prevalence of Small Intestinal Bacterial Overgrowth in Chronic Liver Disease. Semin Liver Dis. (2017)
  9. ^ a b c d e f g h i Ali Rezaie, et al. Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus. Am J Gastroenterol. (2017)
  10. ^ a b c d e Giuseppe Losurdo, et al. Breath Tests for the Non-invasive Diagnosis of Small Intestinal Bacterial Overgrowth: A Systematic Review With Meta-analysis. J Neurogastroenterol Motil. (2020)
  11. ^ a b L Gatta, C Scarpignato. Systematic review with meta-analysis: rifaximin is effective and safe for the treatment of small intestine bacterial overgrowth. Aliment Pharmacol Ther. (2017)
  12. ^ a b c d e Changqing Zhong, et al. Probiotics for Preventing and Treating Small Intestinal Bacterial Overgrowth: A Meta-Analysis and Systematic Review of Current Evidence. J Clin Gastroenterol. (2017)
  13. ^ Chloé Melchior, et al. Efficacy of antibiotherapy for treating flatus incontinence associated with small intestinal bacterial overgrowth: A pilot randomized trial. PLoS One. (2017)
  14. ^ Fenghua Xu, et al. Clinical efficacy of fecal microbiota transplantation for patients with small intestinal bacterial overgrowth: a randomized, placebo-controlled clinic study. BMC Gastroenterol. (2021)
  15. ^ Konstantinos Leventogiannis, et al. Effect of a Preparation of Four Probiotics on Symptoms of Patients with Irritable Bowel Syndrome: Association with Intestinal Bacterial Overgrowth. Probiotics Antimicrob Proteins. (2019)
  16. ^ a b c Grettel García-Collinot, et al. Effectiveness of Saccharomyces boulardii and Metronidazole for Small Intestinal Bacterial Overgrowth in Systemic Sclerosis. Dig Dis Sci. (2020)
  17. ^ Nathalia Ramori Farinha Wagner, et al. Effects of Probiotics Supplementation on Gastrointestinal Symptoms and SIBO after Roux-en-Y Gastric Bypass: a Prospective, Randomized, Double-Blind, Placebo-Controlled Trial. Obes Surg. (2021)
  18. ^ M Furnari, et al. Clinical trial: the combination of rifaximin with partially hydrolysed guar gum is more effective than rifaximin alone in eradicating small intestinal bacterial overgrowth. Aliment Pharmacol Ther. (2010)
  19. ^ Adrian L Lopresti, et al. Efficacy of a curcumin extract (Curcugen™) on gastrointestinal symptoms and intestinal microbiota in adults with self-reported digestive complaints: a randomised, double-blind, placebo-controlled study. BMC Complement Med Ther. (2021)
  20. ^ Bom-Taeck Kim, Kwang-Min Kim, Kyu-Nam Kim. The Effect of Ursodeoxycholic Acid on Small Intestinal Bacterial Overgrowth in Patients with Functional Dyspepsia: A Pilot Randomized Controlled Trial. Nutrients. (2020)
  21. ^ a b Mark Pimentel, et al. A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Dig Dis Sci. (2004)
  22. ^ a b J S Barrett, et al. Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon. Aliment Pharmacol Ther. (2010)
  23. ^ a b Emma Altobelli, et al. Low-FODMAP Diet Improves Irritable Bowel Syndrome Symptoms: A Meta-Analysis. Nutrients. (2017)
  24. ^ Clara Nilholm, et al. Assessment of a 4-Week Starch- and Sucrose-Reduced Diet and Its Effects on Gastrointestinal Symptoms and Inflammatory Parameters among Patients with Irritable Bowel Syndrome. Nutrients. (2021)
  25. ^ R A Hobday, et al. Dietary intervention in chronic fatigue syndrome. J Hum Nutr Diet. (2008)
  26. ^ David L Suskind, et al. The Specific Carbohydrate Diet and Diet Modification as Induction Therapy for Pediatric Crohn's Disease: A Randomized Diet Controlled Trial. Nutrients. (2020)
  27. ^ a b Xin Feng, Xiao-Qing Li, Zheng Jiang. Prevalence and predictors of small intestinal bacterial overgrowth in systemic sclerosis: a systematic review and meta-analysis. Clin Rheumatol. (2021)
  28. ^ Saravana Ruban Gurusamy, et al. Small Intestinal Bacterial Overgrowth in Functional Dyspepsia: A Systematic Review and Meta-Analysis. Am J Gastroenterol. (2021)
  29. ^ Binrui Chen, et al. Prevalence and predictors of small intestinal bacterial overgrowth in irritable bowel syndrome: a systematic review and meta-analysis. J Gastroenterol. (2018)
  30. ^ a b Jean-Marc Sabate, et al. Consequences of Small Intestinal Bacterial Overgrowth in Obese Patients Before and After Bariatric Surgery. Obes Surg. (2017)
  31. ^ Bara El Kurdi, et al. Factors That Affect Prevalence of Small Intestinal Bacterial Overgrowth in Chronic Pancreatitis: A Systematic Review, Meta-Analysis, and Meta-Regression. Clin Transl Gastroenterol. (2019)
  32. ^ a b C Jacobs, et al. Dysmotility and proton pump inhibitor use are independent risk factors for small intestinal bacterial and/or fungal overgrowth. Aliment Pharmacol Ther. (2013)
  33. ^ Tingting Su, et al. Meta-analysis: proton pump inhibitors moderately increase the risk of small intestinal bacterial overgrowth. J Gastroenterol. (2018)
  34. ^ Mohammad-Ayman A Safi, Asif A Jiman-Fatani, Omar I Saadah. Small intestinal bacterial overgrowth among patients with celiac disease unresponsive to a gluten free diet. Turk J Gastroenterol. (2020)
  35. ^ Wolfgang Knitsch, et al. A randomized, placebo-controlled trial of preemptive antifungal therapy for the prevention of invasive candidiasis following gastrointestinal surgery for intra-abdominal infections. Clin Infect Dis. (2015)
  36. ^ Hua-Jian Hu, et al. Probiotics Prevent Candida Colonization and Invasive Fungal Sepsis in Preterm Neonates: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pediatr Neonatol. (2017)
  37. ^ Gaichao Hong, et al. Gut fungal dysbiosis and altered bacterial-fungal interaction in patients with diarrhea-predominant irritable bowel syndrome: An explorative study. Neurogastroenterol Motil. (2020)