Small Intestinal Bacterial Overgrowth (SIBO) 2019-10-24T10:10:04+00:00

Small Intestinal Bacterial Overgrowth (SIBO)

The entire gastrointestinal tract – a continuous muscular tube through which digesting food is transported on its way to the colon – including the small intestine, normally contains bacteria. The number of bacteria is greatest in the colon (at least 1,000,000,000 bacteria per millilitre (ml) of fluid) and much lower in the small intestine (less than 10,000 bacteria per ml of fluid). You have SIBO if the numbers of bacteria in your small intestine are significantly higher than normal levels.

The muscles of the stomach and small intestine propel food from the stomach, through the small intestine and into the colon. Even when there is no food in the small intestine, this muscular activity continues, which is important for the digestion of food, and also for sweeping bacteria out of the small intestine. The upper gut is supposed to have a low concentration of bacteria, and this Migrating Motor Complex (MMC) is the body’s way of maintaining a low bacterial population in the small intestine. Anything that interferes with the progression of normal muscular activity through the small intestine can lead to Small Intestinal Bacterial Overgrowth.

Small-Intestinal

Causes of SIBO

We now know that in many cases SIBO is a result of acute gastroenteritis or food poisoning but it can also be

  • an effect of surgery (blind loop or ileocecal valve removal)

  • a side-effect of using of Proton-pump Inhibitors (PPIs) such as Omeprazole or Lanzoprazole (prescribed to reduce the secretion of stomach acid)

  • found alongside Coeliac disease or Inflammatory Bowel Diseases.

Simply stated, any condition that interferes with muscular activity in the small intestine allows the bacteria to stay longer and multiply in the small intestine. The lack of muscular activity also may allow bacteria to spread backwards from the colon and into the small intestine.

Symptoms

The main symptoms of this are typically those of:

Latest research suggests that, in many cases, SIBO might underlie Irritable Bowel Syndrome. One study in the American Journal of Gastroenterology found SIBO to be present in 84% of IBS patients tested, although other studies have suggested that this figure may be lower and closer to 50%.

In my clinical experience around 60 – 65% of IBS patients have Small Intestinal Bacterial Overgrowth

Associated disorders

It is also possible that SIBO could be associated with other disorders either as a cause or effect. These may include:

  • Heartburn
  • Nausea
  • Leaky Gut Syndrome
  • Food intolerance
  • Joint pain
  • Fatigue
  • Eczema
  • Asthma
  • Depression
  • Steatorrhea
  • Anaemia (Iron or B12)
  • Acne Rosacea
  • Coeliac Disease
  • Chronic Prostatitis
  • CLL (Chronic Lymphocytic Leukemia)
  • H pylori Infection
  • Heartburn
  • Hypochlorhydria
  • Hypothyroidism / Hashimoto’s Thyroiditis
  • Restless Legs Syndrome
  • Crohn’s Disease
  • Ulcerative Colitis
  • Interstitial Cystitis

As a general rule, if the symptoms of IBS and one of the above conditions are present, then SIBO should be considered.

SIBO Treatment Approaches

There are 4 main treatment approaches for SIBO:

Antibiotics

Prescribed by a GP. The typical course is 2 weeks, the antibiotic used in much of the US research is not approved for use in the UK but may be obtained by private prescription and is somewhat costly. SIBO can and often does rebound so antibiotics by themselves can be ineffective in resolving SIBO permanently. It is imperative to combine antibiotics with a low carb style diet to be effective and to achieve a permanent resolution.

Herbal antibiotics

Which may include Enteric coated peppermint, Golden seal, Oregano or Grapefruit Seed Extract. A combination of these is recommended and is very effective. These herbal antibiotics should be taken for a longer period than the antibiotics and can be safely continued for longer periods of time. Many of my patients follow a course of GP prescribed antibiotics with my herbal protocol and this works well.

Specific Carbohydrate Diet (SCD)

This starves the bacteria and takes longer than antibiotics. The length of time needed on the SCD diet varies enormously and can be a number of weeks to several months depending on symptom severity.

Elemental Diet

This involves the use of a liquid diet containing predigested food which is rapidly absorbed in the upper part of the small intestine and in so doing feeds the host and not the bacteria. The diet needs to be taken for 14 days and is considered to be very effective. Unfortunately the shakes are not very pleasant tasting and the cost is very prohibitive for many people.

Each of the SIBO treatment options can be used individually but two or more approaches used simultaneously get the best results.

Small Intestinal Bacterial Overgrowth– frequently asked questions

How does Small Intestinal Bacterial Overgrowth affect us? 2018-02-20T14:34:21+00:00
  1.  The bacteria interfere with normal digestion and nutrient absorption and can damage the intestinal lining causing “Leaky Gut Syndrome”.
  2.  The bacteria consume our food which, over time, leads to deficiencies in nutrients such as iron and B12, causing anaemia and leading to more bacterial overgrowth (a vicious cycle).
  3.  Large volumes of gas are produced in the small intestine or upper gut. This causes abdominal bloating, pain, constipation, diarrhoea or both (the symptoms of IBS), belching and flatulence.
  4. The bacteria also interfere with fat absorption by de-conjugating bile acids, this in turn leads to deficiencies of vitamins A & D and gives the sufferer fatty stools.
  5. As the gut lining is damaged, larger food particles (not able to be fully digested) enter the body, and the immune system reacts to them. This causes food allergies/ sensitivities.
  6. Bacteria themselves can also enter the body/bloodstream. The subsequent immune reaction to bacteria and their cell walls can cause chronic fatigue and body pain and burden the liver.
  7. The bacteria excrete acids which, at high levels, can cause neurological and cognitive symptoms such as brain fog, where you find thoughts hard to process, and which is caused by low-grade inflammation in the brain.
SIBO – is it auto-immune? 2018-05-23T13:31:00+00:00

Small Intestinal Bacterial Overgrowth SIBOAwareness of SIBO has grown enormously in the past 4 years and research in the field has been led by Dr Mark Pimentel of Cedars Sinai Hospital in California and Dr Allison Siebecker of www.siboinfo.org.

Dr Mark Pimentel explained the rationale for considering SIBO to be auto-immune in origin at the 2014 SIBO symposium.

It is common for IBS symptoms to be experienced following acute episodes of infectious gastroenteritis or food poisoning. This is considered to be IBS-PI or post infectious IBS. Many patients link their IBS symptoms with being ill on holiday or following a gastro bug or make the link when prompted.

When infected with a gastro bug, the bug creates toxins, and in some instances a person’s immune system makes antibodies to attack and neutralise them. Once the infection has cleared, the antibodies remain in circulation in the body in case they are needed at a later time.

However, the toxin antibodies can mistake a special protein in the wall of the small intestine called – vinculin – needed for normal gut function – for the bug toxins. The immune system then sees the special vinculin proteins as the enemy and attacks them. The antibody attack on the vinculin affects normal gut function and can cause IBS symptoms.

Further research is underway to create a blood test for the vinculin antibody, as this will be a huge help in identifying Post Infectious IBS/SIBO.

Is IBS really SIBO? 2018-02-20T14:30:49+00:00

This question has been posed a lot recently and as a nutritional therapist who specialises in IBS my experience is that SIBO – or some degree of bacterial overgrowth – is present in the majority of IBS patients I see.

For some people, a bacterial overgrowth is the predominant factor in their IBS, whilst other people have what I have termed a Small Intestine Microbial Overgrowth (SIMO).

It’s worth remembering that if you have a motility issue with your small intestine then all forms of microbes, not just bacteria, can overgrow – yeasts and parasites too. In any event, it pays to undergo some clinical tests to identify the type and severity of your own form of SIBO and, once known, this information can guide as to the type of diet and supplements which are most appropriate.

References – IBS Clinics

  

Click here to see References

Dukowicz AC, Lacy BE, Levine GM: Small Intestinal Bacterial Overgrowth. A Comprehensive Review. Gastroenterol Hepatol (NY). 2007 Feb; 3(2): 112–122.

Gibson GR, Cummings JH, Macfarlane GT, et al: Alternative pathways for hydrogen disposal during fermentation in the human colon. Gut. 1990;31:679–683.

Kerlin P, Wong L: Breath hydrogen testing in bacterial overgrowth of the small intestine. Gastroenterology. 1988 Oct; 95(4):982-8.

Mattson J, Minaya MT, Monegro M, et al: Outcome of breath tests in adult patients with suspected small intestinal bacterial overgrowth. Gastroenterol Hepatol Bed Bench. 2017 Summer; 10(3): 168–172.

Romagnuolo J, Schiller, D, Bailey, RJ: Using breath tests wisely in a gastroenterology practice: an evidence-based review of indications and pitfalls in interpretation. Am J Gastroenterol. 2002;97:1113–1126.

Rezaie A, Pimentel M, Rao SS: How to Test and Treat Small Intestinal Bacterial Overgrowth: an Evidence-Based Approach. Curr Gastroenterol Rep. 2016 Feb;18(2):8.

Saad RJ, Chey WD: Breath testing for small intestinal bacterial overgrowth: maximizing test accuracy. Clin Gastroenterol Hepatol. 2014 Dec;12(12):1964-72; quiz e119-20.

Suri J, Kataria R, Malik Z, Parkman HP, Schey R: Elevated methane levels in small intestinal bacterial overgrowth suggests delayed small bowel and colonic transit. Medicine (Baltimore). 2018 May; 97(21):e10554.

Zhang M, Hong-Ming Z, He F, et al: Association between acute pancreatitis and small intestinal bacterial overgrowth assessed by hydrogen breath test. World J Gastroenterol. 2017 Dec 28; 23(48): 8591–8596.

Small-Intestinal Bacterial Overgrowth (SIBO)

gut-conditions/small-intestinal-bacterial-overgrowth-sibo-new/

Definition

Deloose E, Janssen P, Depoortere I, Tack J: The migrating motor complex: control mechanisms and its role in health and disease. Nat Rev Gastroenterol Hepatol. 2012 Mar 27;9(5):271-85.

Deloose E, Tack J: Redefining the functional roles of the gastrointestinal migrating motor complex and motilin in small bacterial overgrowth and hunger signalling. Am J Physiol Gastrointest Liver Physiol. 2016 Feb 15;310(4):G228-33.

Roland BC, Ciarleglio MM, Clarke JO et al: Small Intestinal Transit Time is Delayed in Small Intestinal Bacterial Overgrowth. J Clin Gastroenterol. 2015 Aug;49(7):571-6.

Causes

Borghini R, Donato G, Alvaro D, Picarelli A: New insights in IBS-like disorders: Pandora’s box has been opened; a review. Gastroenterol Hepatol Bed Bench. 2017 Spring; 10(2): 79–89.

Chander Roland B, Mullin GE, Passi M et al: A Prospective Evaluation of Ileocecal Valve Dysfunction and Intestinal Motility Derangements in Small Intestinal Bacterial Overgrowth. Dig Dis Sci. 2017 Dec; 62(12):3525-3535.

complex in Suncus murinus: a change in gastrointestinal pH is the key regulator. Physiol Rep. 2017 Jan; 5(1): e13105.

Ghoshal UC, Gwee KA: Post-infectious IBS, tropical sprue and small intestinal bacterial overgrowth: the missing link. Nat Rev Gastroenterol Hepatol. 2017 Jul;14(7):435-441.

Ghoshal UC, Shukla R, Ghoshal U: Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge between Functional Organic Dichotomy. Gut Liver. 2017 Mar 15;11(2):196-208.

Kim DB, Paik CN, Kim YJ et al: Positive Glucose Breath Tests in Patients with Hysterectomy, Gastrectomy, and Cholecystectomy. Gut Liver. 2017 Mar 15; 11(2):237-242.

Lo WK, Chan WW. Proton pump inhibitor use and the risk of small intestinal bacterial overgrowth: a meta-analysis. Clin Gastroenterol Hepatol. 2013 May; 11(5):483-90.

Losurdo G, Marra A, Shahini E et al: Small intestinal bacterial overgrowth and celiac disease: A systematic review with pooled-data analysis. Neurogastroenterol Motil. 2017 Jun;29(6).

Mondal A, Koyama K, Mikami T et al: Underlying mechanism of the cyclic migrating motor

Revaiah PC, Kochhar R, Rana SV et al: Risk of small intestinal bacterial overgrowth in patients receiving proton pump inhibitors versus proton pump inhibitors plus prokinetics. JGH Open. 2018 Apr 2;2(2):47-53.

Roland BC, Ciarleglio MM, Clarke JO et al: Low ileocecal valve pressure is significantly associated with small intestinal bacterial overgrowth (SIBO). Dig Dis Sci. 2014 Jun; 59(6):1269-77.

Sabete JM, Coupaye M, Ledoux S et al: Consequences of Small Intestinal Bacterial Overgrowth in Obese Patients Before and After Bariatric Surgery. Obes Surg. 2017 Mar;27(3):599-605.

Rao SSC, Tan G, Abdulla H: Does colectomy predispose to small intestinal bacterial (SIBO) and fungal overgrowth (SIFO)?Clin Transl Gastroenterol. 2018 Apr; 9(4):146.

Su T, Lai S, Lee A et al: Meta-analysis: proton pump inhibitors moderately increase the risk of small intestinal bacterial overgrowth. J Gastroenterol. 2018 Jan;53(1):27-36.

Thompson JR: Is irritable bowel syndrome an infectious disease? World J Gastroenterol. 2016 Jan 28; 22(4):1331-4.

Lombardo L, Foti M, Ruggia O, Chiecchio A: Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy. Clin Gastroenterol Hepatol. 2010 Jun; 8(6):504-8.

Symptoms

Pimentel M, Chow EJ, Lin HC: Normalization of lactulose breath testing correlates with symptom improvement in irritable bowel syndrome. a double-blind, randomized, placebo-controlled study. Am J Gastroenterol. 2003 Feb;98(2):412-9.

Associated Conditions

Heartburn appears twice on the list. I have found references that mention an association of SIBO with systemic sclerosis, diabetes, NAFLD, DVT, chronic pancreatitis, obesity fibromyalgia, cystic fibrosis, type 1 myotonic dystrophy and gastroparesis, which are currently not on the list. However, I haven’t been able to find any research about SIBO and joint pain, CLL and asthma.

Addolorato G, Mirijello A, D’Angelo C et al: State and trait anxiety and depression in patients affected by gastrointestinal diseases: psychometric evaluation of 1641 patients referred to an internal medicine outpatient setting. Int J Clin Pract. 2008;62:1063–1069.

Barrett JS, Gibson PR: Fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and nonallergic food intolerance: FODMAPs or food chemicals? Therap Adv Gastroenterol. 2012 Jul; 5(4): 261–268.

Brechmann T, Sperlbaum A, Schmiegel W: Levothyroxine therapy and impaired clearance are the strongest contributors to small intestinal bacterial overgrowth: Results of a retrospective cohort study. World J Gastroenterol. 2017 Feb 7; 23(5): 842–852.

Bures J, Cyrany J, Kohoutova D et al: Small intestinal bacterial overgrowth syndrome. World journal of gastroenterology. 2010 Jun 28; 16(24): 2978–2990.

Conlon MA, Bird AR: The Impact of Diet and Lifestyle on Gut Microbiota and Human Health. Nutrients. 2015 Jan; 7(1):17–44.

Craig JM: Atopic dermatitis and the intestinal microbiota in humans and dogs. Vet Med Sci. 2016 May; 2(2): 95–105.

Fialho A, Fialho A, Schenone A et al: Association between small intestinal bacterial overgrowth and deep vein thrombosis. Gastroenterol Rep (Oxf). 2016 Nov; 4(4): 299–303. (The association of SIBO with DVT is not yet mentioned on the website.)

Fialho A, Fialho A, Thota P et al: Small Intestinal Bacterial Overgrowth Is Associated with Non-Alcoholic Fatty Liver Disease. 2016 Jun;25(2):159-65. (The association of SIBO with NAFLD is not yet mentioned on the website.)

Ghosh G, Jesudian AB: Small Intestinal Bacterial Overgrowth in Patients with Cirrhosis. J Clin Exp Hepatol. 2019 Mar-Apr;9(2):257-267.

Ghoshal UC, Shukla R, Ghoshal U: Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge between Functional Organic Dichotomy. Gut Liver. 2017 Mar 15;11(2):196-208.

Greco A, Caviglia GP, Brignolo P et al: Glucose breath test and Crohn’s disease: Diagnosis of small intestinal bacterial overgrowth and evaluation of therapeutic response. Scand J Gastroenterol. 2015;50(11):1376-81.

Bested AC, Logan AC, Selhub EM: Intestinal microbiota, probiotics and mental health: from Metchnikoff to modern advances: Part II – contemporary contextual research. Gut Pathog. 2013;5:3.

Kim KM, Kim BT, Lee DJ et al: Erosive esophagitis may be related to small intestinal bacterial overgrowth. Scand J Gastroenterol. 2012;47:493–498.

Konrad P, Chojnacki J, Gasiorowska A: Therapeutic efficacy of amoxicillin and rifaximin in patients with small intestinal bacterial overgrowth and Helicobacter pylori infection. Prz Gastroenterol. 2018;13(3):213-217.

Lauritano EC, Valenza V, Sparano L et al: Small intestinal bacterial overgrowth and intestinal permeability. Scand J Gastroenterol. 2010;45:1131–1132.

Lee AA, Baker JR, Wamsteker EJ et al: Small Intestinal Bacterial Overgrowth Is Common in Chronic Pancreatitis and Associates with Diabetes, Chronic Pancreatitis Severity, Low Zinc Levels, and Opiate Use. Am J Gastroenterol. 2019 Jul;114(7):1163-1171. (The association of SIBO with pancreatitis (only steatorrhea), diabetes and opiate use is not yet mentioned on the website.)

Madrid AM, Poniachik J, Quera R, Defilippi C: Small intestinal clustered contractions and bacterial overgrowth: a frequent finding in obese patients. Dig Dis Sci. 2011;56:155–160.

Miazga A, Osiński M, Cichy W, Żaba R: Current views on the etiopathogenesis, clinical manifestation, diagnostics, treatment and correlation with other nosological entities of SIBO. Adv Med Sci. 2015 Mar; 60(1):118-24. (This study lists some more associated conditions: chronic abdominal pain/IBS, erosive oesophagitis (as a result of GORD/heartburn), lactose intolerance (included in ‘food intolerances’), cystic fibrosis, myotonic dystrophy type 1, gastroparesis.)

Park JH, Park DI, Kim HJ: The Relationship between Small-Intestinal Bacterial Overgrowth and Intestinal Permeability in Patients with Irritable Bowel Syndrome. Gut Liver. 2009 Sep; 3(3): 174–179.

Parodi A, Paolino S, Greco et al: Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication. Clin Gastroenterol Hepatol. 2008 Jul;6(7):759-64.

Patil AD: Link between hypothyroidism and small intestinal bacterial overgrowth. Indian J Endocrinol Metab. 2014 May;18(3):307-9.

Pimentel M, Hallegua D, Chow EJ et al: Eradication of small intestinal bacterial overgrowth decreases symptoms in chronic fatigue syndrome: a double blind, randomized study. Gastroenterology. 2000;118:A414.

Pimentel M, Wallace D, Hallegua D et al: A link between irritable bowel syndrome and fibromyalgia may be related to findings on lactulose breath testing. Ann Rheum Dis. 2004;63:450–452.

Polkowska-Pruszynska B, Gerkowicz A, Szczepanik-Kulak P, Krasowska D: Small intestinal bacterial overgrowth in systemic sclerosis: a review of the literature. Arch Dermatol Res. 2019; 311(1): 1–8.

Pyleris E, Giamarellos-Bourboulis EJ, Tzivras D et al: The prevalence of overgrowth by aerobic bacteria in the small intestine by small bowel culture: relationship with irritable bowel syndrome. Dig Dis Sci. 2012 May; 57(5):1321-9.

Rao AV, Bested AC, Beaulne TM et al: A randomized, double-blind, placebo-controlled pilot study of a probiotic in emotional symptoms of chronic fatigue syndrome. Gut pathogens. 2009;1:6.

Rao SSC, Rehman A, Yu S: Brain fogginess, gas and bloating: a link between SIBO, probiotics and metabolic acidosis. Clin Transl Gastroenterol. 2018 Jun; 9(6): 162.

Saffouri GB, Shields-Cutler R, Chen J: Small intestinal microbial dysbiosis underlies symptoms associated with functional gastrointestinal disorders. Nat Commun. 2019; 10: 2012.

Shah A, Morrison M, Burger D et al: Systematic review with meta-analysis: the prevalence of small intestinal bacterial overgrowth in inflammatory bowel disease. Aliment Pharmacol Ther. 2019 Mar;49(6):624-635.

Shimura S, Ishimura N, Mikami H: Small Intestinal Bacterial Overgrowth in Patients with Refractory Functional Gastrointestinal Disorders. J Neurogastroenterol Motil. 2016 Jan; 22(1): 60–68.

Suri J, Kataria R, Malik Z: Elevated methane levels in small intestinal bacterial overgrowth suggests delayed small bowel and colonic transit. Medicine (Baltimore). 2018 May;97(21):e10554.

Theisen J, Nehra D, Citron D et al: Suppression of gastric acid secretion in patients with gastroesophageal reflux disease results in gastric bacterial overgrowth and deconjugation of bile acids. Journal of Gastrointestinal Surgery 4, 50–54.

Weinstock LB, Geng B, Brandes SB: Chronic prostatitis and small intestinal bacterial overgrowth: effect of rifaximin. Can J Urol. 2011 Aug;18(4):5826-30.

Weinstock LB, Klutke CG, Lin HC: Small intestinal bacterial overgrowth in patients with interstitial cystitis and gastrointestinal symptoms. Dig Dis Sci. 2008 May;53(5):1246-51.

Weinstock LB, Steinhoff M. Rosacea and small intestinal bacterial overgrowth: Prevalence and response to rifaximin. May 2013;68(1):5:875-876.

Weinstock LB, Walters AS: Restless legs syndrome is associated with irritable bowel syndrome and small intestinal bacterial overgrowth. Sleep Med. 2011 Jun; 12(6):610-3.

Williams C: Occurrence and significance of gastric colonization during acid‐inhibitory therapy. Best Practice & Research Clinical Gastroenterology 2001 Jun;15(3):511-21.

SIBO Treatment Approaches

Antibiotics

Di Stefano M, Strocchi A, Malservisi S, Veneto G, Ferrieri A, Corazza GR: Non-absorbable antibiotics for managing intestinal gas production and gas-related symptoms. Aliment Pharmacol Ther. 2000 Aug; 14(8):1001-8.

Frissora CL, Cash BD: Review article: the role of antibiotics vs. conventional pharmacotherapy in treating symptoms of irritable bowel syndrome. Aliment Pharmacol Ther. 2007 Jun 1; 25(11):1271-81.

Koo HL, DuPont HL: Rifaximin: a unique gastrointestinal-selective antibiotic for enteric diseases. Curr Opin Gastroenterol. 2010 Jan; 26(1):17-25.

Miazga A, Osiński M, Cichy W, Żaba R: Current views on the etiopathogenesis, clinical manifestation, diagnostics, treatment and correlation with other nosological entities of SIBO. Adv Med Sci. 2015 Mar; 60(1):118-24.

Pimentel M, Morales W, Chua K, et al: Effects of rifaximin treatment and retreatment in non-constipated IBS subjects. Dig Dis Sci. 2011 Jul; 56(7):2067-72.

Rabenstein T, Fromm MF, Zolk O: [Rifaximin–a non-resorbable antibiotic with many indications in gastroenterology]. Z Gastroenterol. 2011 Feb; 49(2):211-24.

Sachdev AH, Pimentel M: Gastrointestinal bacterial overgrowth: pathogenesis and clinical significance. Ther Adv Chronic Dis. 2013 Sep; 4(5): 223–231.

Singh VV, Toskes PP: Small Bowel Bacterial Overgrowth: Presentation, Diagnosis, and Treatment. Curr Treat Options Gastroenterol. 2004 Feb; 7(1):19-28.

Vanderhoof JA, Young RJ, Murray N, Kaufman SS. Treatment strategies for small bowel bacterial overgrowth in short bowel syndrome. J Pediatr Gastroenterol Nutr. 1998 Aug; 27(2):155-60.

Yang J, Lee HR, Low K, Chatterjee S, Pimentel M: Rifaximin versus other antibiotics in the primary treatment and retreatment of bacterial overgrowth in IBS. Dig Dis Sci. 2008 Jan; 53(1):169-74.

Herbal Antibiotics

Chedid V, Dhalla S, Clarke JO, et al. Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth. Glob Adv Health Med. 2014;3:16–24. 44.

Curr Med Chem. 2004 Jun; 11(11):1451-60.

Lai PK, Roy J: Antimicrobial and chemopreventive properties of herbs and spices.

Logan AC, Beaulne TM. The treatment of small intestinal bacterial overgrowth with enteric-coated peppermint oil: a case report. Altern Med Rev. 2002;7:410–7.

Rezaie A, Pimentel M, Rao SS: How to Test and Treat Small Intestinal Bacterial Overgrowth: an Evidence-Based Approach. Curr Gastroenterol Rep. 2016 Feb;18(2):8.

Specific Carbohydrate Diet

Cohen SA, Gold BD, Oliva S, et al: Clinical and mucosal improvement with specific carbohydrate diet in pediatric Crohn disease. J Pediatr Gastroenterol Nutr. 2014;59:516‐521. (for the mechanism of action)

Saffouri GB, Shields-Cutler R, Chen J: Small intestinal microbial dysbiosis underlies symptoms associated with functional gastrointestinal disorders. Nat Commun. 2019; 10: 2012. (This study does not mention the SCD diet but compared a low-fibre/high simple sugar diet to a high-fibre diet.)

Tuck CJ, Vanner SJ: Dietary therapies for functional bowel symptoms: Recent advances, challenges, and future directions. Neurogastroenterology & Motility, 2017 30(1).

Vincenzi M, Del Ciondolo I, Pasquini E, et al: Effects of a low FODMAP diet and specific carbohydrate diet on symptoms and nutritional adequacy of patients with irritable bowel syndrome: preliminary results of a single-blinded randomized trial. J Transl Int Med. 2017;5:120‐126.

Elemental Diet

Rezaie A, Pimentel M, Rao SS: How to Test and Treat Small Intestinal Bacterial Overgrowth: an Evidence-Based Approach. Curr Gastroenterol Rep. 2016 Feb;18(2):8.

Pimentel M, Constantino T, Kong Y, et al. A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Dig Dis Sci. 2004;49:73–7. 43.

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