SIBO and Probiotics?

A common question I get in my practice is, “Should I be taking a probiotic if I have SIBO?”  My reply is always, “NO, do not take probiotics if you have SIBO.”  One of the most important things to remember about SIBO is that it isn’t bad bacteria, it’s bacteria that is in the wrong location.   SIBO will not be cured by taking a probiotic, in fact recent studies indicate probiotics make SIBO symptoms worse.  (Rao S. et al 2018).  Let's take a look at why? 

How bacteria arrived in the small intestine, which is meant to be relatively bacteria free, could be from many causes. The underlying causes thought to contribute to SIBO are; H. Pylori or other parasitic infections, hypochlorhydria, food poisoning, autoimmune diseases that impair digestive transit time, plus some medications such as antibiotics, proton pump inhibitors, SSRI’s, opiods and NSAID’s in addition to poor diet.  Unless the underlying cause of SIBO is addressed, the overgrowth is likely to return.  (Pimental M. 2011) Therefore, some of the best studies that shed light on SIBO have come from studying underlying/related conditions.  For example, H. Pylori infections can cause hypochlorhydria where the lack of stomach acid secretions leads to bacterial overgrowth and can long term lead to gastric cancer.  (Sheh A., Fox J. 2013) Studies indicate that patients with Rhumatoid Arthritis, (Henriksson A. et al 1993), Hashimoto’s Thyroiditis (Patil A. 2014) and both Type 1 and 2 Diabetes (Brunello S. et al 2013) (Bhadada S. et al 2011) all are at increased risk of developing SIBO.  These studies all indicate a decrease in orocecal transit time.  In other cases, medications slow the digestive transit by reducing stomach acid secretions. 
 
The common thread in most underlying causes of SIBO is that food is moving too slowly through the digestive tract and has extra time to ferment and for bacteria to overgrow while in the small intestine. Oral probiotics add fuel to the bacterial overgrowth and can exacerbate SIBO symptoms.  A recent study confirmed the link between taking probiotics for SIBO and an increase of bloating, gas and brain fog symptoms.  (Rao S. et al 2018) What I recommend to my patients instead is after successful treatment of SIBO, deliver probiotics to the large intestine via an enema therefore bypassing the small intestine and eliminating the opportunity for overgrowth to occur.  This places the probiotic where it can be most effective without risking a relapse of SIBO.


References  
 
Bhansali A, Bhadada S, Rana S, Sharma S, Kaur J, Singh K. (2011) Orocecal transit time and small intestinal bacterial overgrowth in type 2 diabetes patients from North India.  Diabestes Technology and Therapeutics. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/21770765
 
Blomquist L, Henriksson A, Nord C, Midtvedt T, Uribe A, (1993), Small intestinal bacterial overgrowth in patients with rheumatoid arthritis, Annals of the Rheumatic Diseases.. Retrieved from:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1005088/
Fox J, Sheh A (2013) The role of the gastrointestinal microbiome in Helicobacter pylori pathogenesis.  Gut Microbes.  Retrieved from:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928162/
 
Lauritano EC, Bilotta AL, Gabrielli M, Scarpellini E, Lupascu A, Laginestra A, et al.
Association between hypothyroidism and small intestinal bacterial overgrowth. J Clin Endocrinol Metab. 2007;92:4180–4. [PubMed]
 
Pimental, M. (June, 2012), Methanogens in Human Health and Disease, from The Journal of
Gastroenterology.  Retrieved from: http://www.nature.com/ajgsup/journal/v1/n1/full/ajgsup20126a.html
 
Pimental, M. (2011), A New IBS Solution, Bacteria the Missing Link in Treating Irritable Bowel Syndrome. Health Point Press, California

Rao C., Rehman A, Yu S., Martinez de Andino N., Brain fogginess, gas and bloating: a link between SIBO, probiotics and metabolic acidosis., Clincal and Translational Gastroenterology, volume 9, Article number 162 (2018).  Retrieved from: 
https://www.nature.com/articles/s41424-018-0030-7?_ke=eyJrbF9lbWFpbCI6ICJia2hvb3BlckBhb2wuY29tIiwgImtsX2NvbXBhbnlfaWQiOiAibXk3NXk2In0%3D
 
Zekry OA, Abd E., 2013 Dec. The association between Helicobacter pylori infection, type 1
diabetes mellitus, and autoimmune thyroiditis.  J Egypt Public Health Associates, Retrieved From: https://www.ncbi.nlm.nih.gov/pubmed/24374947