SIBO Treatment Options According to German Guidelines
Content
1. What is SIBO?
1.1 SIBO Diagnosis
2. SIBO Treatment
2.1 SIBO Diets
2.1.1 Different SIBO Diets
2.2 SIBO Treatment Without Antibiotics: Herbal Alternatives
2.3 Lifestyle Changes
3. Guidelines for SIBO Treamtment
4. Strategies to Maintain Well-Being After SIBO Treatment
1. What is SIBO?
SIBO stands for “Small Intestinal Bacterial Overgrowth.” SIBO can cause symptoms such as abdominal pain, bloating, diarrhea, constipation, belching, fullness, and heartburn. It is caused by an unnatural overgrowth of bacteria in the small intestine. A healthy small intestine is sparsely populated with bacteria compared to the large intestine, which harbors countless microorganisms. The bacterial overgrowth can overwhelm the small intestine, leading to the symptoms mentioned.
1.1 SIBO Diagnosis
The diagnosis of SIBO typically involves a breath test that takes advantage of the fact that human cells do not produce hydrogen or methane. However, methane and hydrogen are produced by bacteria. During the test, certain substances like lactulose, lactose, glucose, or fructose are administered to the patient. If methane or hydrogen are detected in the breath after a certain period, it indicates the presence of bacteria in the small intestine.
2. SIBO Treatment
There are various treatment methods for small intestinal bacterial overgrowth. Specialized diets, the use of herbal or conventional antibiotics, and probiotics are among them. The treatment approach is chosen individually based on the type of bacteria present and the primary symptoms.
2.1 SIBO Diets
Diet is a key factor in SIBO treatment, as it can significantly contribute to symptom relief. An adjusted diet can help reduce the bacterial overgrowth in the small intestine and restore the balance of the gut flora. Additionally, correcting any nutrient deficiencies is an important part of a successful SIBO treatment. There are different diet models that can help reduce SIBO symptoms. The purpose of each of these diets is to deprive bacteria of food and thereby reduce symptoms. Therefore, these diets can support SIBO therapy, but they often need additional therapeutic support.
2.1.1 Different SIBO Diets
There are various nutritional therapies that can be used as part of SIBO treatment. These include the low-FODMAP diet, the specific carbohydrate diet (SCD), the SIBO-specific dietary guidelines (SSFG), the bi-phasic diet (BPD) and the low-fermentation diet. By and large, all of these diets aim to reduce the food components that can be metabolized by the intestinal bacteria. This slows down the growth of the intestinal bacteria and thus gives the intestine some rest.
FODMAPs are a well-known food source for intestinal bacteria. You can find out more about FODMAPs and the low-FODMAP diet here.
The various dietary models can be traced back to different people. The specific carbohydrate diet was developed by the American physician Dr. Haas and focuses on the reduction of certain grains and carbohydrate sources. Dr. Allison Siebecker developed the SIBO-specific dietary guidelines as a combination of the low-FODMAP diet and the specific carbohydrate diet.
The Bi-phasic diet goes back to Dr. Nirala Jacobi and also focuses on avoiding fermentable food hydrates. The low-fermentation diet was developed by Dr. Pimentel and takes into account not only the type of food consumed but also the timing of food intake. Dr. Siebecker, Dr. Nirala Jacobi and Dr. Pimentel have worked intensively on the research, diagnosis and treatment of SIBO throughout their careers and are considered experts in the field. You can find more information on the individual diets here.
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2.2 SIBO Treatment Without Antibiotics: Herbal Alternatives
A main component of SIBO therapy includes herbal or conventional antibiotics. The goal of therapy is always to reduce problematic bacteria using antibiotics, thus addressing the cause rather than just the symptoms.
A well-known conventional antibiotic is Rifaximin. This antibiotic is especially suitable for treating gut overgrowths, as it specifically works in the gastrointestinal tract. It is not absorbed by the human body and thus does not enter the bloodstream but works locally in the gut. However, in Germany, Rifaximin is currently (as of September 2024) only approved for the treatment of traveler’s diarrhea. This means that the use of Rifaximin for SIBO treatment is considered off-label and is usually not covered by the health insurance. You can get more information about Rifaximin in SIBO treatment here.
Natural remedies can be a valuable addition to SIBO therapy and help alleviate symptoms. Many individuals benefit from herbal supplements like oregano oil or garlic, which have antibacterial properties and can inhibit the growth of harmful bacteria in the small intestine. Additionally, consuming special herbal teas like peppermint or ginger can support digestion and have a calming effect on the gut.
2.3 Lifestyle Changes
Lifestyle changes can have a significant positive impact as part of SIBO therapy. Regular exercise promotes gut motility and contributes to overall health. Stress management, such as through techniques like meditation or yoga, can also positively influence the success of therapy. Furthermore, it is advisable to ensure adequate hydration, as this can support digestion.
3. Guidelines for SIBO Treamtment
Currently, there is no official German guideline from the AWMF (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V.) for treating SIBO. However, small intestinal bacterial overgrowth is discussed in other German guidelines (2), particularly in the guidelines for Irritable Bowel Syndrome (IBS) and for intestinal motility disorders (3).
The American College of Gastroenterology (ACG) publishes guidelines for the American region. There is also a guideline on Irritable Bowel Syndrome (4), but SIBO has had its own guideline since 2020 (5).
The ACG guideline recommends treating symptomatic patients with antibiotics to eradicate the bacterial overgrowth. A diet containing few fermentable components can be helpful in SIBO therapy, as can the use of probiotics. Generally, the number of therapy recommendations is still limited. SIBO is an area that still requires substantial research as of September 2024. However, many doctors and naturopaths have had good practical experience with certain treatment approaches and base their therapy on their own experience, in addition to the guidelines.
4. Strategies to Maintain Well-Being After SIBO Treatment
In order to achieve long-term success with SIBO treatment, maintain long-term well-being and prevent a relapse, it is crucial to develop individual strategies. As with SIBO treatment, this includes diet, among other things. It may seem counterintuitive, but a diet that helps maintain gut health is one that is rich in fiber, probiotic foods and prebiotic ingredients. SIBO therapy is about symptom reduction and the eradication of harmful gut bacteria, which is why fiber and FODMAPs should be avoided. Once the intestinal environment has been restored, however, it is important to maintain it. Fiber and FODMAPs are needed for this, as they serve as a nutritional basis for intestinal bacteria that are considered positive. It is also advisable to avoid highly processed foods, sugar and alcohol, as these can promote the growth of harmful bacteria.
Regular exercise, stress management through techniques such as meditation or yoga, and adequate sleep also play an important role in maintaining a healthy gut. In addition, if symptoms persist or recur, regular medical check-ups should be considered for early intervention.
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