by Amy Burkhart MD, RD, Integrative Medicine, guest author
Dr. Burkhart is a board certified Emergency Medicine Physician and a Registered Dietitian. She is also trained in integrative medicine. She now has an integrative medicine practice and specializes in treating digestive ailments such as ibs, celiac disease and gluten sensitivity. She uses traditional therapies in combination with nutrition, exercise, stress reduction and mind-body techniques to most optimally treat her patients.
She received her MD degree at University of California, Irvine College of Medicine. She completed an Emergency medicine Residency at the Highland Hospital/UCSF program, followed by a two year fellowship in integrative medicine with Dr. Andrew Weil at the University of Arizona. Prior to her medical training she completed her undergraduate degree in nutrition and clinical dietetics at University of California, Berkeley. She also completed her dietetic internship through UC Berkeley and earned her certification as a registered dietitian.
Dr. Burkhart is a board member for the Celiac Community Foundation of Northern California and has educated physicians, dietitians and the general public about celiac disease and gluten sensitivity since 2008. She is also a volunteer physician at Camp Celiac in Livermore, CA.
When a patient came into my office recently she was complaining of ongoing symptoms while strictly adhering to her gluten–free diet. She had bloating, cramping and diarrhea and joint pain that her primary care physician assumed was due to “cheating” on her prescribed diet for celiac disease. She swore she was vigilant on her diet and knew it must be something else. She had no desire to “cheat” only a desire to get well.
I see people like this all day in my office. No one wants to be ill and when pieces of the puzzle don’t fit, we need to look elsewhere. I care for many patients with celiac disease and non-celiac gluten sensitivity. Every single one of them is different, but all have one thing in common, they aren’t choosing to be sick-they all want to be well.
When someone has symptoms after starting a gluten-free diet, it is a bit of detective work to figure out the cause. After assuring ongoing gluten exposure is not the issue, one thing I see commonly is called small intestinal bacterial overgrowth-also known as SIBO. This entity can be symptomatically mild for some and completely debilitating for others. The good news is that treatment can be life changing.
SIBO stands for small intestinal bacterial overgrowth. Normally, the small intestine has few bacteria. Most intestinal bacteria are contained in the large intestine. When there are too many, or they are the wrong type of bacteria in the small intestine, it is called SIBO.
We do. Bacteria are important for our immune system, digestion, vitamin production and more. But, when SIBO is present, there are too many bacteria and they are in the wrong place. This can cause malabsorption, inflammation, and some or many of the symptoms below.
Nutrient deficiencies and their associated symptoms: Vitamin B12, A, D, E, iron, other B vitamins, fat, protein and carbohydrate malabsorption
Carbohydrate intolerance-symptoms such as bloating/pain/gas fatigue after eating
To keep bacteria counts at a healthy low level in the small intestine, your body must have normal levels of stomach acid; properly functioning pancreas and gall bladder; normal intestinal motility (ability to move food through the digestive tract); normal mucosa (lining of the digestive tract); and structurally normal valves.
These medical conditions and treatments that affect one of the factors above can predispose someone to SIBO:
Liver or pancreas disease
Celiac Disease/Non-celiac GS
Inflammatory Bowel Disease
Chronic Antibiotic Use
Immune suppressed states i.e. AIDS, Cancer, chronic steroid use
Other chronic diseases
Chronic use of acid blocking medication
In addition to the diseases that predispose someone to SIBO, it is also seen more commonly in people with rosacea, restless leg syndrome, interstitial cystitis and cirrhosis.
SIBO is typically diagnosed using a breath test in which the patient drinks a sugar-containing drink and exhaled gases are measured. If there are too many bacteria, excess gases (hydrogen, methane or both) will be produced. Due to the fact that some cases will be missed with breath testing, some practioners will treat based on symptoms.
People with celiac disease have a higher incidence of SIBO. A 2003 paper found there was a high incidence of SIBO in celiac patients on a gluten-free diet with ongoing symptoms. Anecdotally, there is a higher incidence of SIBO in non-celiac gluten sensitivity (NCGS) patients, but due to the lack of data surrounding NCGS, the science is that arena is still to come.
Irritable bowel syndrome (IBS) is a common condition. A person with IBS typically has symptoms such as bloating, cramping, abdominal pain, diarrhea and/ or constipation. There is no definitive test or diagnostic marker at this time (although one is under development), so diagnosis is based on symptoms and history. Until we have a better understanding of IBS, there will be debate on its cause and treatment. Some studies say that up to 50-60% of people with IBS may have SIBO and that by treating the SIBO you will get resolution of the IBS symptoms.
So, are some cases of IBS actually SIBO? A recent review paper addressed the use of Rifaxamin, an antibiotic used to treat SIBO, as a treatment for IBS patients. Many of the studies showed improvement or resolution of IBS symptoms if the IBS patients were diagnosed with SIBO. Another recent study in children found that 66% of children diagnosed with IBS had SIBO. Treating the SIBO resolved the IBS symptoms.
The underlying cause of the SIBO must be addressed first or treatment will not be effective. For example, if SIBO is due to celiac disease it will never get better without first adhering to a strict gluten-free diet. After treating the underlying cause, the subsequent therapy will depend on a traditional or integrative approach.
Traditional SIBO treatment:
Antibiotics are the mainstay of therapy and are often used in conjunction with motility agents to prevent “build up” of bacteria by moving things through the intestinal tract. Some physicians will also prescribe a low sugar diet. In severe cases, elemental diets are used. These are liquid diets in which all of the nutrients are broken down and don’t require digestion. The nutrients are absorbed so quickly that the bacteria don’t have time to act on them and produce symptoms. This is done for a short duration to effectively “starve” the bacteria.
Integrative SIBO treatment:
As mentioned above, the underlying cause must first be treated. From there, the following integrative therapies may be used:
Probiotics +/- ( These can improve or worsen symptoms)
Addressing sleep disorders
Many diets are used to treat SIBO. Which diet is used depends on the clinical scenario and the practitioner. Most of the diets have the same goal of reducing sugars that the bacteria would consume. Commonly used diets are Paleo, SCD, GAPS, Candida, FODMAPS, or a general low sugar diet.
Long term outcome varies, but recurrence is common.
You may be able to prevent or minimize the risk of recurrence by eating a “clean diet” of primarily plant-based whole foods; minimizing processed foods and sugar; reducing stress; exercising;and adopting good sleep habits. Probiotics may or may not be helpful. Some people will use a less restricted form of one of the above-mentioned diets on a long term basis; each person is different.
Discuss this with your physician, gastroenterologist or other health care practioner. Treatment varies from person to person and is based on symptoms and breath test results. Best long term results will be obtained by working with a practioner familiar with SIBO.
Amy Burkhart MD, RD
Thank you Dr. Burkhart!
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phone: (707) 927.5622