Information for patients with an abnormal lactulose breath test indicating SIBO
Small intestinal bacterial overgrowth, or SIBO, is not the same in all people. Everyone has a different mix of bacterial species, and the sources of the bacteria, the normal bacterial population of the colon or large intestine and/or the oral bacterial flora, are also different in each person. SIBO can cause no symptoms, symptoms such as bloating, diarrhea, or constipation, or more severe symptoms such as diarrhea with malabsorption and weight loss. There is not a single treatment that is best for all patients, and there is currently no single treatment for SIBO that will “cure” everyone. There are multiple diseases and types of surgical history that can increase the risk for SIBO and medications that reduce stomach acid, for example, can also increase the risk.
If you have an abnormal lactulose breath test with an abnormal level of either hydrogen or methane or both, you and your physician will need to decide about treatment. While physicians with MD or DO degrees typically offer antibiotic treatment for SIBO with rifaximin (Xifaxan), and also neomycin or metronidazole for patients who have an elevated methane level on lactulose breath testing, this is not the only form of treatment available. Naturopaths, health care practitioners with ND degrees, more often use a combination of dietary guidance and use of some antimicrobial herbal preparations. Some MD and DO physicians are offering this treatment to some patients as well. Another possible treatment is a 2 week elemental diet, which is using shakes with simple nutrients that do not require digestion as the sole source of calories. There have been some small studies that have shown improvement in breath test results after 4-6 weeks of certain probiotics, but there are also studies showing no improvement in breath testing for SIBO after probiotics.
Rifaximin (Xifaxan) is a special antibiotic that must be dissolved in bile to have its antibacterial effect, and very little of this antibiotic is absorbed into the blood stream. This results in much less of an effect on the normal colonic bacteria than from most other antibiotics. But neomycin and metronidazole do affect the colonic bacteria, and there have been rare cases in which Clostridium difficile colitis has occurred during treatment with rifaximin. Clostridium difficile or C diff grows in the colon when the normal bacterial flora has been reduced by antibiotic therapy, and can produce very severe diarrhea which can be fatal. Patients who have had C diff try to avoid being treated with antibiotics, and may be especially interested in treatment for SIBO that does not include oral antibiotics.
After treatment with antibiotics, herbal preparations, or 2 weeks of elemental diet, patients are advised to follow a diet that is lower in processed or refined carbohydrates, such as foods made from white flour, white rice, pastries, sodas, high-carb snacks, pasta, cakes and cookies, candy, and processed breakfast cereals. But it is not clear that there is a single diet that is best for all SIBO patients. Registered dieticians are very familiar with helping people with IBS and SIBO to analyze their usual diets and recommend the most important changes to make. Physicians can refer patients to dieticians, and any fees involved in seeing a dietician are usually very reasonable.
In the section below are some articles and links explaining treatment for SIBO, pages with herbal preparations that have been used to treat SIBO along with links to purchase the products on Amazon.com, examples of suggested diets for people with SIBO, a link to a low FODMAP diet website, and a diet from the book The Microbiome Solution by Robynne Chutkan, MD. Dr. Chutkan has made diet part of treatment for all her patients with gastrointestinal conditions and tries to help patients avoid unnecessary antibiotic treatment and avoid unnecessary exposure to hormones, antibiotics and other chemicals in food. Her books are all very good.
I hope that this introduction and the resources below are helpful to patients and their health care providers as they treat the symptoms of SIBO.
Information for gastroenterologists and other health care providers treating SIBO
The documents and website links included here are ones that I have found helpful in deciding how to treat patients with abnormal lactulose hydrogen-methane breath results. My thanks to the authors of these resources at Cedars Sinai Medical Center in Los Angeles, The Johns Hopkins Hospital in Baltimore, the University Pittsburgh Medical Center, the University of Michigan Medical Center in Ann Arbor, and Allison Siebecker, ND, one of the creators of the NUNM SIBO Center. After the UpToDate article by Mark Pimentel is the article about elemental diet to treat SIBO, and below that is the link for an easy to obtain, palatable elemental diet product. Next is the Johns Hopkins-U Pittsburgh article about herbal treatment for hydrogen- or methane-positive SIBO, and below that that is a document with links to purchase the herbal supplements. Note that in that study, the same herbal treatment combinations were used for patients with abnormal lactulose breath tests whether they had only elevated hydrogen or had elevated methane. Next are the SIBO diet handout from Cedars-Sinai, and a very good resource about low FODMAP diet from U Michigan GI. Below this is the link to the website of the NUNM SIBO Center and the SIBO Specific Diet food guide by Dr. Siebecker. Following that is a short summary of one set of recommendations for use of herbal treatment for patients who test positive either only for hydrogen or for methane.
At the end is a short version of the diet used in treatment of patients with SIBO and other forms of gut microbiome dysbiosis by Robynne Chutkan, MD, author of The Microbiome Solution and other books about the use of diet in treatment of GI diseases and symptoms.