how to treat SIBO with Chinese medicine

ABSTRACT
Small Intestine Bacterial Overgrowth or (SIBO) is a relatively newly diagnosed disorder that falls as a subset of Irritable Bowel Syndrome (IBS).  SIBO is very controversial amongst Western medical practitioners as there are not many RCT to support diagnosis and treatment of the disorder.  Plus, the current treatments are more short term in nature as SIBO has a high rate of reoccurrence.  Naturopaths are doing a lot of research on SIBO and working to understand and treat the root causes of it. Chinese Medicine can offer balanced treatments to patients by using a combination of herbs, acupuncture, qi gong and dietary therapy designed to clear the dampness and heat of the bacterial overgrowth while supporting the SP/ST and restoring balance to whole system for long lasting results. 
Keywords:. SIBO, IBS, Diarrhea, Constipation
 
BACKGROUND
SIBO occurs when commensal bacteria from the large intestine migrates to the small intestine.  While the large intestine is colonated with many bacteria, the small intestine is meant to be relatively bacteria free.  When bacteria finds its way into the small intestine, where there is an endless source of food, it can rapidly overgrow causing many unpleasant symptoms.  For many people that overgrowth produces hydrogen gasses, disrupts digestion, impairs nutrient absorption and causes abdominal pain, diarrhea and exhaustion.  For others, the overgrowth produces both hydrogen and methane gases.  This also disrupts digestion, impairs nutrient absorption and causes abdominal pain, but it also causes severe constipation, acid reflux and burping.  In both cases SIBO will cause gastritis, damaging the lining of the small intestine.  This damaged lining or leaky gut allows larger molecules of food to enter the bloodstream and can trigger food sensitivities and possibly even trigger autoimmune diseases.  (Pimental M. 2011) (Pimental M. 2012)
 
WESTERN MEDICINE
The term SIBO was coined by Dr. Mark Pimental of Cedars Sinai Hospital in Los Angeles in 2004.  Dr. Pimental is a gastroenterologist who noticed in many of his IBS patients that their symptoms improved after taking antibiotics for other conditions.  He confirmed the presence of too much bacteria in the small intestine via small intestine biopsy.  Diagnosis now is typically made by a non-invasive lactulose breath test.  The test measures the amount of hydrogen and methane in a person’s breath over a period of several hours after drinking a mixture of lactulose. As humans do not produce hydrogen and methane gases on their own if there are measureable amounts in their breath it is indicative of SIBO.  (Pimental M. 2012)
 
Western medicine treats SIBO with antibiotics that primarily work in the gut and don’t circulate much outside of that system.  Diarrhea type SIBO is typically treated with a 10-14 day course of Rifaximin (Xifaxin).  This medication treats traveler’s diarrhea, but was approved by the FDA to treat diarrhea predominant IBS in May, 2015.  (Fischer, A. 2015)  Constipation type SIBO is typically treated with both Rifiximin in addition to a second antibiotic, either Metronidazole (Flagyl) or Neomycin for 10-14 days.  If the patient fails the SIBO breath test after taking the above medications, they are repeated.  SIBO has a high rate of reoccurrence after 9-12 months where the patient will be given the antibiotics again each time the SIBO returns.  Dietary recommendations and lifestyle changes are not typically part of the Western medical treatment for SIBO.  The high reoccurrence rate of SIBO is because SIBO is not an end diagnosis, it is the symptom of an underlying condition.  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 such as Hashimotos Thyroiditis or Diabetes Mellitus, plus antibiotic, proton pump inhibitor and NSAID overuse.  Unless the underlying cause of SIBO is addressed, the overgrowth is likely to return.  (Pimental M. 2011)
 
CHINESE MEDICINE
In Chinese medicine we can look at SIBO as damp heat stagnation in the Lower Jiao.  However, that diagnosis does not include the reasons for the underlying cause of SIBO.  The differential diagnosis for the underlying conditions can be broken down into the excess patters of LV Qi Stagnation, LV overacting on SP/ST and deficiency patterns of SP Qi, SP Yang and Wei Qi deficiency. 
 
The first step in treating SIBO with Chinese medicine is to clear the SIBO from the small intestine before beginning tonification.  For diarrhea type SIBO, this can be done by having the patient take Huang Lian Su (Berberine) for 2-3 weeks.  During this treatment time it is also important to have the patient adhere to a lower carbohydrate, anti-inflammatory diet, such as the Specific Carbohydrate Diet (SDC).  (Gottschall E. 1994) Of primary importance is the elimination of common food triggers like gluten/other grains, dairy, soy, eggs and starchy vegetables.  The idea is to eliminate foods that get digested in the ileum portion of the small intestine where the highest concentration of SIBO exists.  This helps to eliminate their endless supply of food and allows the damaged area of the intestines to heal.  Other dietary considerations should include having the patient spread out their meals by 3-4 hours with no snacking so the stomach completely empties allowing for smooth flow of digestion, plus having them drink fresh Sheng Jiang, (ginger) tea, a natural pro-kinetic also encourages that flow.  Ginger also helps breakdown the biofilm that builds up around bacteria that prevents antibiotics from destroying it.
 
The less common constipation type SIBO can be treated with medical grade Allicin from Da Suan, (garlic) for 2-3 weeks before taking the Huang Lian Su.  According to the Huang Di Nei Jing (Yellow Emperor’s Inner Classic), garlic is "warming in nature and has an affinity toward the Stomach and Spleen, Heart and Small Intestine, and the Lungs and Large Intestine."  (Unschuld P, 2011).  The Chinese Materia Medica categorizes Da Suan (garlic) as an anti-parasitic.  In cases of constipation type SIBO garlic will help eliminate the archea or methane producing organisms in the gut.  Once the archea are eliminated, the patient can move on to Huang Lian Su to treat the hydrogen producing bacteria and heal the lining of the small intestine.  (Pimental, M. 2012)
 
Having SIBO can be very stressful and developing a mindfulness meditation practices, either through qi gong or a gentle yoga class can help a patient manage that stress.  Acupuncture is also supportive and helpful to clearing SIBO and calming the patient’s nervous system.  Points to consider, adjusting for presentation include: Hegu LI-4, Wai Guan SJ5, Qu Quan LV8, Yin Ling Quan SP9, Da Ling PC-6, Tong Li HT5, Lei Que LU7, Zu San Li ST-36, Yang Ling Quan GB34, Daju ST27 and Dadu SP3 along with Ear Shen Men and Sympathetic. 
 
After the 4-6 weeks of treatment listed above to clear the SIBO, if the patient is feeling significantly better and their digestive symptoms have resolved, turn your attention towards bringing the patient’s health back into balance.  Some herbal formulas to consider include:
LV Qi Stagnation – Chai Hu Shu Gan Wan, Bupleurum Powder to Spread the Liver
LV overacting on SP/ST – Shu Gan Wan, Dredge the Liver Decoction
ST Qi Stagnation – Xiang Xia Yang Wei Wan, Nourish the Stomach Decoction with Aucklandia and Amomum
 
SP Qi Deficiency – Xiang Sha Liu Jun Zi Tang Six Gentlemen Decoction with Aucklandia and Amomum OR Zi Sheng Wan Nourish Life Pill
 
SP Yang Deficiency – Fu Zi Li Zhong Tan, Prepared Aconite Pill to Regulate the Middle
Wei Qi Deficiceny – Yu Ping Feng San, Jade Windscreen Powder
 
Many of these formulas help increase natural HCL production and all of them are good at healing the small intestine lining. 
 
Patients should continue to monitor their diets, reduce stress and aim towards a healthy lifestyle that includes a mindfulness meditation practice for the best long term recovery from SIBO and its underlying causes. 
 
BIOGRAPHY
Beth Hooper, DACM has been in private practice in New York City since 2003 where she specializes in gastrointestinal disorders and women’s health.  www.bethhooperhealth.com.

REFERENCES
Fischer A., (May 27, 2015), FDA approves two therapies to treat IBS-D, US Food and Drug Administration, Retrieved from: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm448328.htm

Gottschall E., (1994), Breaking the Vicious Cycle, Intestinal Health Through Diet, The Kirkton Press
 
O’Brien P., Garlic in Traditional Chinese Medicine, Spezzitino.com, Retrieved from: http://www.meridian-acupuncture-clinic.com/support-files/garlic-in-tcm.pdf
 
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

Unschuld P, Tessenow H, (2011), Huang Di Nei Jing Su Wen: An Annotated Translation of Yellow Emperor’s Inner Classic – Basic Questions, University of California Press