My treatment approach & Common Questions

Which treatment path is the best?

That is such a common question (and understandably so), but when it comes down to it there really is no "right" way. In my experience, people respond to the same treatments differently. You're unique! We know you have heard it before but it is true. When it comes to treating your body and your distinct history, it will likely require a combination of approaches, including digestive support, antimicrobials, microbiome restoration, and lifestyle changes to create positive change. It's simple - different health solutions work for different people.

See below for some answers to the most common questions I get about SIBO and treatment.

I have diarrhea, So why do I need a prokinetic?

In the treatment and prevention of SIBO, prokinetics are often used to stimulate the migrating motor complex (AKA janitorial cleansing wave) through the small intestine to prevent bacteria and food particles from accumulating. This is not the only use of pro-kinetics - these medications can also be used to help with gastric emptying, nausea, and constipation, among other things. Pro-kinetic medications are often dosed in the evening for SIBO prevention, and do not (necessarily) impact large intestine motility, which is why they are often still recommended for folks with diarrhea-type SIBO.

What's the deal with Probiotics?

Confused? So are many... There is research and opinions across the board about the usefulness and efficacy of probiotics in SIBO. Bottom line - there is no one-size-fits-all approach to this topic. Probiotics may be one of the best tools in your toolkit, or trigger significant symptoms - you can't know until you try. But be sure to work with a competent provider to steer you in the direction of quality products that may be most appropriate for your situation. One of my favorite resources for the latest and greatest research on probiotics is The Probiotic Advisor - just search for your symptoms or diagnosis to get links to research on specific strains or blends that may be beneficial.

Do kids get SIBO?

While SIBO can and does occur in kids (see pediatric resources page and podcasts), in my practice, I see many more cases of chronic constipation leading to frequent stomachaches and sometimes bloating. These kids often will have positive breath testing, indicating the presence of SIBO, and my even benefit from antibiotic or antimicrobial treatment, but symptoms often return if the underlying cause of their symptoms (constipation!) is not addressed.

Are prokinetics safe for kids and teens?

Prokinetics are used to prevent the recurrence of SIBO, but are not always used in all cases. Pharmaceutical prokinetics can have unsafe side effects, and are often avoided in pediatric patients without notable motility disorders. Instead, herbal remedies that support digestive motility are sometimes used, including ginger, triphala, or other herbal combinations. Check with your provider about whether these remedies would be right for your child.

How do I know if my breath testing is positive for SIBO?

Well, this one is an easy one! Just ask your physician to refer to the North American Breath Testing Consensus Guidelines published in 2017 to interpret your results. Do not rely on the labs' interpretation guide, which is often wrong or outdated. While some physicians may interpret testing differently depending on their level of experience (test interpretation can be complex!), these consensus guidelines are a solid starting place.

Methane elevations? Is it SIBO?

The jury is still out on this one. While methane production is often seen on breath testing results, we still do not have conclusive evidence to point to whether this production is happening in the small or large intestine, or both. We do know that methane gas is produced from the conversion of hydrogen gas, and can therefore, if present, cause falsely lowered hydrogen levels. Methane is produced typically by methanobrevibacter smithii, which is not a bacteria at all, but rather an archae! It is found normally in the guts of many, but appears to contribute to constipation in some. 

What is Low dose Naltrexone and should I consider It?

Naltrexone is a medication used to treat opiate abuse or alcohol addiction, but at very low doses (approximately 1/10th to 1/50th of the typical dose) it has been shown to have an immune modulating and anti-inflammatory action. Though not effective for everyone, this medication has been shown to be safe in inflammatory bowel disease, fibromyalgia and chronic fatigue, chronic pain, mood disorders, and a number of other conditions. Some practitioners believe that it also has a mild prokinetic action and can be useful in preventing SIBO relapse. For more information about this medication, check out this site.

Erythromycin is an antibiotic, but also used as a prokinetic!?!

You are right to be confused! Yes, erythromycin is an antibiotic, but at low doses of 50mg has been shown to trigger the migrating motor complex (MMC) of the stomach and small intestine. It has been employed for decades for this use to treat a condition of slowed stomach emptying, called gastroparesis. This study compared erythromycin in low doses to a prokinetic on the market at the time in the prevention of SIBO relapse, with notable benefit. Erythromycin is not safe for every patient, and careful consideration should be made to cardiovascular side effects and drug interactions prior to prescribing this as a prokinetic. Erythromycin is not typically used as an antibiotic to treat SIBO.

Are herbal antibiotics as effective as prescription antibiotics?

As it turns out, yes! According to one study published in 2014, two separate combinations of herbal antimicrobials were as effective as the prescription antibiotic, Rifaximin, in normalizing hydrogen levels on a breath test. Talk to your provider about whether herbal treatments may be a safe and appropriate option for you.

Methane and constipation. Chicken or the egg?

We know that methane production in the intestinal tract can cause slowed (or reversed) motility, which can contribute to constipation. If your gut has a high amount of methane producing microbes AKA methanogens, then you will likely have higher levels of methane production, which slows intestinal transit, leading to constipation, and can allow for more methanogens to reproduce, produce more methane, further slow intestinal transit, and...you get the picture. So, a main treatment for addressing high methane levels on per breath testing is to simply TREAT THE CONSTIPATION and clear those methanogens out of the colon. Doing so in a safe manner, under the guidance of a trusted practitioner, will get you closer to feeling better and keeping your methane excess (and constipation!) at bay.

Have more questions? Consider scheduling a educational consultation or check out my mentor’s site, which is full of useful information, links to research, and other fascinating tidbits.