Could Low Stomach Acid Be the Cause of Your SIBO?

It's taken me a long time to arrive at low stomach acid as a potential problem for me, because I've never had the classic complaints — heartburn or acid reflux. However, there are other symptoms that are not as readily discussed and these include bloating, slow digestive transit time, occasional belching, light-colored stools, and undigested food in stool.

I'm happy to pounce on this latest aspect of the digestive process that can go wrong, yet it irks me to learn that this may be the cause all along of my SIBO, but no doctor has ever even discussed it as a possible cause, even though it is so very common and so easily (and inexpensively) remedied.

When a person isn't producing sufficient stomach acids, a cascade of bad events is set off:

1. Food lies longer in the stomach, while the body waits to achieve proper pH level, which it never does. Without proper breakdown of food, nutrients cannot be extracted. The resulting malnutrition causes a host of symptoms that mimic serious health conditions. For example, lack of vitamin b12 alone can cause severe joint pain, numbness and burning in your hands and feet. Severe B12 deficiency can lead to depression, anxiety, paranoia, delusions, memory loss, loss of taste and smell, and more.

2. At the same time, low stomach acid creates the perfect environment for the overgrowth of bad microorganisms, which feed off the undigested carbohydrates that are fermenting. As part of their own digestive process, these bad bugs give off gas (this is what's being measured and detected in the SIBO breath test) plus they spew endotoxins into your bloodstream, eventually causing inflammation that can lead to various types of disease. Very commonly, the liver working overtime to remove the toxins becomes damaged over time leading to a condition known as nonalcoholic fatty liver disease, which destroys the metabolism and the balance of insulin and other hormones and throws your body into fat-storage mode.

Pressure builds (there's that all-too familiar bloating) and two important valves of the digestive system malfunction.

3. The lower esophageal sphincter (LES) at the top of the stomach has only one option and that is to open the wrong way, releasing up into the esophagus and causing symptoms of heartburn and acid reflux. The tissues lining the esophagus can't handle this burn of stomach acid. Frequent opening of the LES in this way will eventually weaken the valve. So, while removing known food allergens is a good idea, the underlying valve dysfunction must be reversed or it will lead to additional food sensitivities and allergies.

4. Meanwhile, another valve at the bottom of the stomach called the pyloric sphincter is waiting, waiting, waiting for the proper PH to build up. Due to low stomach acid, it never does. After a while, pressure forces the stomach to move partially digested food (chyme) through the pyloric sphincter into the small intestine, but because it's not at the proper pH, the chyme doesn't trigger the release of sodium bicarbonate or pancreatic enzymes. The small intestine is unable to break down the chyme and large, undigested particles irritate the lining of the small intestine, eventually causing it to become permeable, allowing undigested food particles to enter the bloodstream. The body’s immune response system sees large proteins, such as casein and gluten, as foreign invaders and triggers an immune response. Thus begins the vicious circle of food sensitivities, inflammation, and autoimmune response known as leaky gut syndrome.

How Do You Know If You Have Low Stomach Acid

According to SCD Lifestyle, there is an easy test you can try at home by taking an inexpensive supplement called Betaine HCL with Pepsin. I tried one by Thorne, because it's free of food additives that I'm sensitive to, but any will work.

Three Simple Steps:

1. Eat a meal that includes at least 15-20 grams of protein (about 4-6 ounces of meat) 

2. Take 1 capsule partway through the meal, then continue eating until you're satisfied

3. Pay close attention to your body's response. Either you won’t notice anything, in which case you probably DO have low stomach acid. Or you'll start to feel symptoms like burning, heat, or heaviness, which are signs that you DON'T have low stomach acid.

If you do have low stomach acid, continue to take 1 capsule at every protein meal the next day or two. If you don’t notice any burning, heat, or other GI distress by the 3rd day, increase your intake to 2 capsules. Stay there for another day, then try 3 pills. Keep increasing the dose until you notice some GI discomfort. When you finally detect some distress, go back down a pill and you'll be at your ideal Betaine HCL dosage.

I started the Betaine HCL with Pepsin test a few weeks ago and I'm up to 5 capsules with every protein meal. (You can go as high as 10, according to SCD Lifestyle.) The first thing I've noticed is that I'm sleeping better at night and I'm taking this as a sign that my gut is starting to produce the proper serotonin precursors (I hope!). My bowel movements also improved a bit, so that I've been able to reduce the amount of daily magnesium I take by half, and stools are softer and darker. Best of all, there are no negative side effects so far.

Resources

Tests for Low Stomach Acid
How to Supplement with Betaine HCL for Low Stomach Acid
Low Stomach Acid: The Epidemic and Lifelong Implications
How Low Stomach Acid Can Jeopardize Your Health
Low Stomach Acid and Weight Gain
Vitamin B12 Deficiency Can Be Sneaky and Harmful to Your Health

Causes of SIBO-C (Methane)

Small Intestinal Bacterial Overgrowth (SIBO) is a gut dysbiosis. This means there's an imbalance of good-to-bad bacteria. When gut flora is unbalanced, there's always a reason, and the most common is years of eating a standard American diet that's heavy on chemical additives and processed grains and sugars and low in whole-food nutrients. Food toxins damage the intestine and make it "leaky" to gut bacteria and bacterial proteins. Malnutrition impairs the immune response and slows the healing of intestinal injuries. Add some type of "insult" to the gut, like food poisoning or a slew of antibiotic treatments that wipe out all the "good" bacteria, and you've got a perfect storm rising for SIBO to develop.

In SIBO, bacteria that are naturally occurring in the body but generally in the large intestine have migrated up to the small intestine, where they have less competition from "good bacteria" and are able to quickly over-colonize. Now that they're in the small intestine, they encounter our nutrients earlier in the digestive process and they're able to snap up essential nutrients like fats, iron and vitamin B-12. That's why people who have SIBO are almost always vitamin deficient.

The nutrient deficiencies caused by SIBO lead to leaky gut, so now the absorption of large protein molecules is possible, and this can cause an array of problems with the immune system and contribute to allergies, asthma and all types of autoimmune disorders, plus a general overall decline in health.

If you suspect you have SIBO, you'll be referred to a gastroenterologist. The gastro will want to run tests that usually include a colonoscopy, endoscopy and SIBO breath test. The colonoscopy and endoscopy, sometimes called an upper- and lower-GI, are to look for blockages and to take biopsies to rule out cancer and other infections. The breath test will measure the type and amount of gases your gut is producing. If you're a hydrogen producer, you have SIBO-D, the type of SIBO that causes diarrhea. If methane gas is found, you have SIBO-C, the constipation version.

Getting a SIBO diagnosis is one thing; tracking down the actual cause of your SIBO is even more complex.

Besides food toxins, other causes of leaky gut and SIBO can include use of prescription painkillers or other opiate drugs, birth control hormones or alcohol abuse.

Further causes that I seldom see discussed are:

• Parasympathetic nervous system disruption, which can be induced by stress
• Vagus nerve dysfunction, possibly from an injury to the head or spine
• A disruption in the Migrating Motor Complex, which cleans the gut during sleep, possibly from insomnia or other sleep dysfunction
• Nerve damage to the interstitial cells of Cajal (ICC)

If you're interested in learning the actual CAUSE of your SIBO, you'll need to find a functional medicine doctor, a type of doc who looks at disease systemically. The Institute for Functional Medicine has a doctor lookup by city.

My condition was likely the result of years of eating a low-carb diet, which leads to severe mucin-2 deficiency in the gut lining and finally to gastrointestinal disease. I also experienced several instances of food poisoning in the past ten years and that might have been a contributing factor.

In the book The Perfect Health Diet, author Paul Jaminet describes how low-carb diets lead to mucus deficiency and how that causes gastrointestinal diseases.

References:

SIBO: Methane or Hydrogen Dominant, What Is The Difference?

Physiology, injury and recovery of interstitial cells of Cajal: basic and clinical science

How Gut Disease Begins

33 Hidden Scientific Causes of IBS That Your Doctor Doesn’t Know About

SIBO-C Can Make You Gain Weight

One of the first symptoms of SIBO that sent me to my doctor two summers ago was weight gain, despite being on a restricted diet. I could tell he didn't believe me. I felt like Ingrid Bergman in the film noir classic Gaslight. (Hah, gas = methane = SIBO — hiyo!). Having SIBO-C and watching your weight can be similarly maddening.

In the film, Ingrid's husband Gregory is trying to make her seem crazy, so he can institutionalize her and claim her inheritance. One of Gregory's evil tactics is to flicker all the lights in the house which, thanks to eerie mood music, comes off a lot creepier in the movie than it sounds. Ingrid keeps telling her psychiatrist that her nerves are shattered living in that house because the lights flicker on and off all the time. But there's Gregory standing in the background, shaking his head no. And who does the psychiatrist believe? Yeah, it's like that.

Because my weight gain was occurring along with symptoms like muscle cramps, joint pain, hair loss, dry skin, and feeling cold all the time, I suspected hypothyroid. My doctor at the time ran the standard blood and urine screens and my TSH level was within what's considered normal range. I had read at Stop the Thyroid Madness that the TSH test is not a good indicator, and I asked him if he could test my free T3, free T4 and reverse T3 levels and also look for thyroid antibodies. He handed me a lab sheet and said check off the tests you want and mail it back, but I'm telling you right now, I'm not prescribing thyroid medication to a patient whose TSH is in range.

Whoa! — who said anything about thyroid meds? I'd just asked to learn what my hormone levels are.

As a parting shot as he was walking me out, he said try a low-carb diet. But I was already on a low-carb diet. I'd eating low carb for most of the eight years I'd been his patient.  In fact, as I would soon come to find out, a low-carb diet for so many years may have been a causal factor in my gut dysbiosis.

Recovering from a shoulder injury that grounded me from my usual summer activities like biking and kayaking, I was concerned about weight gain, so I had been eating even fewer carbs than usual. I'd been watching my diet extra carefully and keeping an online food diary. What I was seeing was very strange. For most of my life when I was active I could eat 1800 calories a day and maintain my weight. When I needed to lose weight, reducing consumption to 1600 calories a day would result in about a two pound weight loss per week. But now here I was down to 1200 calories a day and steadily gaining weight.

I could tell he didn't believe me, so I exported my food diary into a PDF and sent it to him, but was met with stony silence. He wasn't the only one not listening. Even some of my closest friends were saying unhelpful things, like "a calorie is a calorie" and "there were no fat people in Auschwitz." And I couldn't blame them, as I'd spent a lifetime subscribing to the same "eat less, move more" philosophy.

If you have SIBO-C and think you're gaining weight even on a restricted diet, it's not all in your head. This paper by SIBO pioneer Dr. Mark Pimentel explains how methane gas production in SIBO-C leads to constipation, irritable bowel syndrome (IBS), and obesity.

In this Chris Kresser podcast, Dr. Pimentel further explains:

"... Methanogens, it turns out, based on the microbiome work that’s being done on that particular organism, are super important to help liberate calories from nondigestibles. So let’s say you have a high-fiber diet. Humans generally can’t eat fiber. Cows and ruminating animals have a lot of methanogens because the methanogens help facilitate digestion of fiber. So what does that mean? That means that you can get more calories from a meal if you’re a methane producer because you’re liberating calories from things that people who don’t have methane can’t get.

So where am I going with this? What I’m saying is if you take a population from Africa and immigrate them into the United States, and those folks, for genetic reasons or environmental reasons, have methanogens flourishing in their gut, which is an evolutionary advantage for getting and harvesting nutrients, it’s not an advantage when food is abundant and food is so processed and easily digested that you get more calories."

Hearing this from the world expert on SIBO didn't help cure my condition, but it did explain what was happening in my body. The bacteria colonizing my small intestine are extracting MORE calories from fiber foods that I eat.

I'm all for efficiency, but just once in my life I'd like to have the ailment that makes a person LOSE weight!

Optimizing Nutrients: Vitamins I'm Taking to Help Cure SIBO

I'd been a lifelong sceptic about supplements, until I was diagnosed with SIBO. When you have SIBO, bacteria that are normally located in the large intestine have migrated up to the small intestine, where they encounter your nutrients earlier in the digestive process and get to them before you do. SIBO patients are deficient in many vitamins, especially fat-soluble ones, and these vitamin deficiencies can actually mimic other very serious health issues. For example, a B12 deficiency can look amazingly alot like MS, ALS, Parkinson's or other incurable disease.

The PHD diet advises getting our nutrients from food wherever possible, but those of us with SIBO have malabsorption issues and are very likely deficient in Vitamin B12 and D3, among others. To heal the gut it's essential to optimize your nutrients as quickly as possible. This means asking your doctor for an extensive vitamin and mineral panel and researching the type of vitamin you need to take for best absorption. (Example: Methylcobalamin B12 is more bioavailable than the less expensive cyanocobalamin.)

Multivitamins aren't a good option. They'll never have the right proportion of each vitamin that you need. Why? Because some vitamins like C and magnesium are so big that to put all that into a single multivitamin would not be swallowable. In addition, you don't need to take all vitamins daily — just those you're deficient in or ones critical to correcting a health condition. To bring my nutrition up to speed I take this panel recommended by the Perfect Health Diet:

Daily
* D3 — to go weekly, after serum 25OHD of 40 ng/ml is achieved
* B12 500 mcg — to go weekly after deficiency is addressed
* B-5 500 mg
* C 1 g
* K2 100 mcg
* Magnesium 200 mg (when not taking Natural Calm)
* Iodine 225 mcg

Weekly
* B vitamins:
    * 50 to 100 mg each of B1, B2, and B6
    * 5 mg biotin
* Boron 3 mg
* Zinc 50 to 100 mg

And when not eating 1/4 lb of liver per week:
* Copper 50 mg
* Vitamin A from cod liver oil, 50,000 IU/week

And when not eating brazil nuts::
* Selenium 200 mcg

Additionally
I start my morning with a tsp of virgin cod liver oil — that's right, our grandmas knew a thing or two that we've forgotten. The omega-3s in cod liver oil balance out the omega-6s I get in olive oil. The only other oils I cook with are grassfed butter and coconut oil.

Next, I mix a 1/2 tsp of glycine powder in a glass and drink it down with 1 NAC capsule. Both are healing to the gut lining, and NAC helps get neurotransmitters back on track, which can help with the sleep disruption that throws the migrating motor complex off, slowing up digestion.

I fast until noon, when I eat my first meal — usually eggs in some type of veggie frittata. While I'm eating I gulp down two Atrantil capsules. Atrantil is a botanical antimicrobial that tamp down my "bad" gut bacteria population. About a half hour later, I pop a soil-based probiotic (usually Prescript Assist).

I mix a 1/4 tsp of vitamin c powder in a 1-liter travel bottle and take it with me to work. When I've finished it, I fill it up again. I try to drink two of these during the day before it's time to commute home.

After dinner I take all of the above supplements, and I'm done for the day, unless constipation symptoms have raised their ugly head. When that happens, I take mix two teaspoons of Natural Calm magnesium drink into a mug of warm water and drink it down before bed.

Could Vagus Nerve Dysfunction Be the Cause of SIBO?

The vagus nerve is the longest of the 12 cranial nerves, running from brainstem to gut and touching multiple organs along the way, including the brain, heart, esophagus, and lungs. It forms part of the parasympathetic nervous system that supports unconscious body processes, such as breathing, heart rate, body temperature and — yes, digestion — by managing communication between organs and the brain via neurotransmitters. While we're accustomed to hearing the media talk about serotonin as a "feel-good chemical in the brain," there are far more serotonin receptors in the gut than anywhere else in the body. That's why so many people with gut issues also deal with symptoms of depression, anxiety and even agoraphobia.

Interacting with the brain, the vagus helps manage anxiety and depression. Interacting with the gut, it controls neurotransmitters and enzymes responsible for the production of stomach acid, digestion, and motility, so having poor vagal tone increases risk of SIBO-C. By releasing intrinsic factor, the vagus nerve also helps with B12 absorption — and that's important because most SIBO-C sufferers are B12 deficient.

People with gut problems are very likely to have vagus nerve dysfunction. The vagus nerve can be damaged by any gut insult, such as food poisoning, antibiotics, chronic infection or illness. Luckily, there are many ways to stimulate the vagus nerve and most are easy and inexpensive. Here are the ones I've worked into my protocol so far:

• Yoga — I'm a beginner and practice a very gentle himalayan yoga with a lot of focus on the breath and relaxation
• 4/8 breathing at random times during the day — a four-counts inhale, eight-count exhale almost immediately calms all systems of the body
• Gargling two days a week — I gargle with warm salt water because it has the added benefit of breaking up biofilms in the mouth and sinuses
• Singing/humming while I drive to work
• Laughter — I've begun actively following comedian podcasts and watching comedy shows and movies

Other things I've learned that may help are coffee enemas and herbal medications that stimulate the postganglionic portion of the vagus nerve, like Parasym Plus.  I haven't been brave enough to try the former,and I'm not ready to add more medicines to my already aggressive daily regimen of supplements right now, but I've made a mental note of these.

Simple Lifestyle Changes That Can Help Cure SIBO

The PHD diet is more than just a diet. There are a number of recommendations in the book to improve health, nutrition status and sleep — and they will also help eradicate SIBO:

Circadian Rhythm Entrainment

Curing sleep problems is key to curing SIBO. The migrating motor complex (MMC) that cleans our gut while we sleep tends to be disrupted in those with interrupted sleep. It can actually be THE cause of SIBO-C in some, because when the small intestine is not getting cleaned out at night, it creates a perfect environment for bacterial overgrowth.

To get myself back on the path to good sleep, I walk outside every morning to get early sun, I exercise daily, wear blue-light blocking glasses after 8pm while reading on my ipad, watching TV or using the computer, and take 5 mg of melatonin 20 minutes before bedtime.

Daily Exercise
Daily exercise not only helps with circadian rhythm entrainment, it helps with motility. So I'm walking for one hour every day, followed by 30 minutes of stretching and muscle work.

Intermittent fasting

Most people stop eating around 8pm and don't eat again until breakfast. That is, they "break the fast" around 7am the next day. That's an overnight fast of about 10 hours. Intermittent fasting expands the fast to 16 hours by delaying the first meal until around noon.

By having the first meal at noon and last meal at 8pm, you create an eight-hour feeding window. Why is this important? Jaminet goes into this at length in his book The Perfect Health Diet.

Prolonging the overnight fast improves gut motility. The migrating motor complex (MMC) that cleans our gut while we sleep is disrupted in people like me who wake periodically through the night. Interrupted sleep and MMC dysfunction can actually be a cause of SIBO. When the small intestine is not getting cleaned out at night and constipation is keeping toxins from being eliminated, it creates a perfect environment for bacterial overgrowth.

By waiting until noon to have my first meal, I'm allowing additional opportunity for the MMC to kick in and do it's thing. And I don't find it difficult. After a few months following the PHP diet, I no longer experience food cravings. And like many SIBO-C sufferers, I actually feel best (less fatigue, brain fog and bloating) when I'm not eating.

I generally have two meals a day — the first at noon and the last before 8pm. As an added bonus, 8/16 fasting, as it's called, boosts the immune system by encouraging autophagy — a body cleansing mechanism that cleans out toxins and recycles damaged cell components. This is important when your small intestine is teeming with bacteria that are eating all your nutrients before you can get to them and spewing methane gas and other detritus that erode the gut barrier and lead to leaky gut that in turn causes autoimmune flares.

Eating only twice a day also simplifies the challenge many of us face of when to take various supplements, as some require meals and others require an empty stomach, per instructions on the label.

Even more importantly, it helps with circadian rhythm entrainment.

Alcohol

Though the PHD diet allows moderate alcohol intake, I'm limiting it for now, while my liver is being taxed with cleaning up endotoxins that the SIBO is spewing into my body. Once I've healed the leaky gut and stopped the joint flares and neuropathy, I do look forward to having a glass of wine again. 

Other Lifestyle Changes

I was skeptical about Squatty Potty, which you may have seen on Shark Tank, but it's so inexpensive that gave it a try and I'm glad I did. All the promo info about the right position to encourage bowel movements and letting gravity take it's course must be true because it works. In fact, it may be the most effective $20 I've spent since being diagnosed with SIBO. 

In addition to all of this, I'm taking actions to stimulate the vagus nerve — but that's a pretty complex topic that deserves it's own post so stay tuned.

References:

The Perfect Health Diet: Circadian Rhythm
The Perfect Health Diet: Intermittent Fasting
Self-Hacked: 33 Hidden Scientific Causes of IBS That Your Doctor Doesn’t Know About

My SIBO Diet (Hint: It's Not About the FODMAPs)

If you google "diet for SIBO," you're sure to come across the GAPs Diet, Specific Carbohydrate Diet, Paleo AIP Diet and Low-FODMAPs diet. These diets have calmed symptoms for millions of IBS sufferers and they deserve all the praise they get, but they don't cure the source of the problem, especially when it comes to SIBO methane — the constipation variety of SIBO that I have. Practitioners like Chris Kresser make the case that diet alone is not enough and, further, that a diet that starves the gut of carbs could have a deleterious effect on the large intestine biome. I certainly don't want to fix SIBO in the small intestine only to create a different problem in my large intestine. Additionally, persuaded by Paul Jaminet's argument that very low carb diets can actually cause gastrointestinal disease by depleting the gut of Mucin-2, I chose to follow the diet prescribed by his book The Perfect Health Diet — and in fact I had already started three months before I got the actual SIBO-C diagnosis, when I was merely hoping to improve my symptoms.

Diet

PHD is a whole-foods, moderate-carb diet that, similar to other ancestral diets like Paleo recommends eating a plethora of wholesome vegetables and fruits, as well as grass-fed, pastured and wild protein sources, while eliminating refined sugar, grains, legumes, and chemical additives. Jaminet is a scientist, and his site is extremely well-researched with exhaustive footnotes. The philosophy of the Perfect Health Diet (the title is aspirational) goes like this: Poor health is the result of nutrient deficiencies, food toxins, and infection. So the primary goal of any diet should be to provide optimal intake of all necessary nutrients (optimal meaning "enough to derive the biological benefits, but not enough to become toxic"); to avoid food toxins; and to address any underlying infection in the body.

To quote Jaminet: "Given two equally nourishing alternatives, say wheat or white rice, if there is evidence that one is significantly more toxic than the other (in this case, wheat more toxic than rice), we should avoid that one and get the nutrition from the safer source."

On the diet I eat grass-fed, pastured and wild protein, dairy and eggs; the rainbow of fruits and vegetables; all starchy root vegetables; white rice; and homemade gelatin-rich bone broth.

I don't eat sugar, seed oils, soy, peanuts, legumes, chemical additives, or any grains at all except white rice.

I'm not finding the diet difficult. It probably helps that I'd given up sugar many years ago. I'd also eliminated gluten six years ago, when I started getting an itchy rash on my elbows, knees and tailbone that a friend told me looked like a food reaction. Though I tested negative for celiac and for gluten antibodies, the rash does return any time I've been inadvertently "glutened." It was slightly harder to give up other grains like corn and GF oats, which so many gluten-free folks depend upon, but I've been able to adjust, experimenting with coconut flour and cassava flour. In a future post I'll share some of my favorite recipes, including a cassava pizza crust.

The toughest thing for me to give up on PHP has been legumes, including peanut butter (peanuts are actually a bean — boo!). I used to love having steamed lentils for lunch or making a big vat of chili, and I have yet to find a decent substitute for hummus, which I practically lived on in my previous life.

I'm also avoiding alcohol for now, while my liver is being taxed with cleaning up endotoxins that the SIBO is spewing into my body. I used to love visiting wineries of the Northfork in the summer. Once I've healed the leaky gut and stopped the joint flares and neuropathy, I do look forward to having a glass of wine again, which the PHP diet supports.

In addition to diet, there are a number of lifestyle changes that the PHD book encourages, such as intermittent fasting and circadian rhythm entrainment and I'm doing those as well. (See: Health Hacks.) I'm also optimizing nutrients by getting my vitamin levels up. (See: Optimizing Nutrients with Vitamins.)

Testing for IBS-C: Colonoscopy, Endoscopy and SIBO Breath Test

I chose to see the same gastroenterologist who had performed my "screening colonoscopy" just six months previous. I reasoned that any new doc would want to have their own look-see and it really wasn't an experience that I was eager to repeat. I also knew that six months ago everything had looked normal and I was hoping she'd give me a full pass so I could move my primary doc onto some other line of inquiry. But that's not what happened.

While the gastro didn't make me repeat the colonoscopy, she did order an endoscopy and a SIBO breath test. The endoscopy, like the former colonoscopy, did require anesthesia but it didn't require the icky prep — no drinking a vast amount of solution designed to clean me out before the procedure. I had to follow a light diet 12 hours beforehand. If I recall, I was allowed broth and some chicken breast the day before and nothing after 8pm. The endoscopy scope is inserted down your throat while you're "out." I had a slight sore throat afterward, but otherwise didn't feel a thing.

The SIBO breath test was absolutely painless. I just had to drink a lactulose solution, wait about 20 minutes for it to digest, then breath into a tube every 10 minutes over the course of a few hours while they measured levels of gasses my stomach was producing.

The endoscopy came back clear, which was a relief, however, the SIBO breath test came back positive for methane, which was a total surprise. Methane gas indicates an over colonization by an organism called archaea that naturally occur in the body but usually in the large intestine. This type of organism cause the constipation variety of SIBO. If hydrogen gas had been present, that would indicate an overgrowth of a type of bacteria that causes the diarrhea version of SIBO.

So, I had SIBO. It felt good to have a diagnosis, but what did it really mean? How could SIBO be causing my kind of symptoms?

Well, like most people who have SIBO, I have leaky gut. The erosion of the mucus lining that's the barrier that normally keeps food we eat from getting into our bloodstream has become permeable, allowing food particles into my blood. When my immune system detects these, it treats them like an invader and a cascade of events is triggered. One of these is histamine production. The same histamine involved in allergy attacks, for which many people take over the counter antihistamine tablets. Things like skin rashes and other autoimmune reactions like joint pain may very well be attributed to this.

Other symptoms like numbness and tingling and leg cramps are likely due to vitamin deficiencies caused by SIBO. Because bacteria have colonized the small intestine, where they don't belong, they are able to get to our nutrients earlier in the digestive process, depleting us of vitamins. And some vitamin deficiencies can mimic the symptoms of very serious health ailments.

So, what now? A combo of antibiotics xifaxin and erythromycin had been the forward thinking treatment for the past few years, formulated by SIBO pioneers Dr. Mark Pimentel and Dr. Allison Siebecker. But I was dismayed to read about the dismal failure rate of antibiotic treatment for my type of SIBO, SIBO-C (40-50% recurrence rate, according to many studies). Even those who are initially "cured" by the antibiotic duo are likely to relapse and require rounds and rounds of more antibiotics, which can eventually lead to antibiotic resistance and even bigger problems such as C-dif. Studies showed herbal antimicrobials are sometimes more effective than antibiotics. I was further encouraged by the accounts of bloggers at Hollywood Homestead and Animal Pharm/The Gut Institute, who eradicated SIBO using botanical medicines. I did my research on the various botanicals and was just about to purchase a slew of herbal antibiotics, prebiotics and probiotics when I came across this Chris Kresser podcast and learned about a new herbal drug called Atrantil that targeted the archaea that cause SIBO-C. 

I changed track and started formulating a treatment protocol, and prepared to discuss it intelligently with my gastro.

My Symptoms Didn't Seem SIBO-Related

Getting the diagnosis that I had Small Intestinal Bacterial Overgrowth (SIBO) — an imbalance of certain bacteria in my intestines — didn't happen overnight. In fact, everything I learned about my condition has been like peeling the proverbial onion, one layer after another. The troubling symptoms that first sent me to the doctor didn't seem like a gut issue:

• Nightly leg cramps
• Tingling in my hands
• Numbness in my feet
• Hair loss
• Always feeling cold
• Weight gain (despite being on a restricted diet)
• Constipation
• Various skin rashes
• Vitamin deficiencies (despite taking supplements)

All of these were symptoms that my previous doctor of eight years had dismissed. He implied they were just part and parcel of menopause. But I hadn't actually begun menopause yet.

My new doctor did not dismiss the symptoms, especially the vitamin deficiencies. She jumped in right away with a slew of tests to systematically rule out one condition after another — from hypothyroid to diabetes to anemia to pernicious anemia — then, honing in on the constipation symptom, she referred me to a gastro specialist to see if perhaps IBS was causing malabsorption.

To my doc's credit, I would never have gone down the IBS path had she not suggested it. Before I became the voracious reader of digestive health info that I've now become, I had a general sense of IBS as being about stomach pain, gas, nausea, GERD, acid stomach and diarrhea, none of which I was experiencing. I'd never heard of IBS-C, the constipation version of IBS, and my constipation was more an occasional annoyance than a real problem, I thought. I recall reading many articles in women's magazines through the years advising that constipation is different for every person and some people go every day or even twice a day and others go every three days and all of these are normal.

Knowing what I now know of course, I take a completely different view. I now know that everyone should be having a bowel movement every day. If we're not being swept clean daily, there's opportunity for overgrowth of the bacterias that commonly reside in the gut and we're not ridding our body of the endotoxins created by those bacteria.

But I'm getting ahead of myself. My next step was testing.

My SIBO-C (Methane) Treatment Protocol

When I was finally diagnosed with the methane type of Small Intestinal Bacterial Overgrowth (SIBO) after a breath test, my primary care doc suggested that I be treated with Rifaximin and neomycin. This had been the most forward thinking treatment in recent years, formulated by SIBO pioneers Dr. Mark Pimentel and Dr. Allison Siebecker, and my doc advised me to make a case for it to my Gastroenterologist.

While I appreciate her forward thinking — it's a sad fact that many doctors across the country are not aware of the pioneering SIBO work — I decided not to follow her advice, no offense intended. I'm grateful to her for putting me on the path of a gut disorder as the cause of vitamin deficiencies that were giving me scary neuropathy and autoimmune joint flares — after eliminating conditions like diabetes, hypothyroid, and celiac — but she's running a busy family medical practice and doesn't have time to stay up to the minute on the very latest developments in this one not-so-common disorder. New information is arriving every day that wasn't known even six months before. That's why when you get diagnosed with SIBO, you have to become your own medical sleuth.

One of the unfortunate SIBO symptoms affecting me right now is insomnia. I say unfortunate, because research shows that disrupted sleep interrupts the cleansing mechanism of the gut, called the Migrating Motor Complex (MCM), and can in and of itself be the cause of SIBO.

I'd been a lifelong "good sleeper" and not getting good rest is almost the worst of my symptoms — coming in rough second only to the ugly autoimmune attacks on my finger joints. The one benefit of insomnia, if there can be said to be one, is that it gives me lots of additional time for quiet reading. As a result, I spend about three hours a night reading up on SIBO and other related gut issues, and this information has helped me tremendously as I direct the path to what will hopefully be my recovery.

It was only through reading and research that I learned the dismal failure rate of antibiotic treatment for SIBO-C (40-50% recurrence rate, according to many studies) and shared these studies with my primary care doc. Once I saw the failure rate for the Rifaximin and neomycin protocol to treat SIBO-C, I knew that wasn't the course for me. Even patients who are initially "cured" by the antibiotic duo usually relapse and most require rounds and rounds of more antibiotics, which for some can eventually lead to antibiotic resistance and even bigger problems such as C-dif. No thanks.

Almost immediately I was on a path to find a botanical antibiotic protocol instead. In many studies herbal antimicrobials are more effective than antibiotics.

In fact, I was just about to hit the "buy" button on Amazon Prime for a slew of herbal antibiotics, prebiotics and probiotics that bloggers at Animal Pharm/The Gut Institute and Hollywood Homestead had used to cure their SIBO when I learned that the bacterias that cause SIBO-D (diarrhea) and SIBO-C (constipation) are quite different and that there was a brand new botanical treatment available to treat SIBO-C called Atrantil that actually targeted the archaea bacteria that cause SIBO-C. I corrected my course accordingly.

MY PROTOCOL

Your SIBO treatment will likely not be exactly the same as mine. Every body is different and responds differently to treatment, based on existing conditions or infections, genetic expression, metabolic makeup and diet. But I'm writing this blog in the hopes that what I'm experiencing might help others like me.

Medicines

My herbal protocol is simple:

• Atrantil, to create an unfriendly environment for the archaebacteria that's colonizing my small intestine, weaken their cell walls to eliminate them, and sop up the methane production that causes severe bloating
• Iberogast, a prokinetic proven to increase gut motility
• Natural Calm, a powder form of magnesium citrate, to bring water into my small intestine and encourage bowel movements (tastes better than the liquid magnesium citrate you can buy at any pharmacy for a few dollars, but works exactly the same way)
• Apple cider vinegar-spiked water drunk with every meal, to increase stomach acid and bile

Diet

If you've looked into diets for SIBO, you've likely come across the GAPs Diet, Specific Carbohydrate Diet, Paleo AIP Diet and FODMAPs diet. These diets have calmed symptoms for millions with gut problems, but when it comes to SIBO-C, they don't cure the source of the problem and may even over time make things worse. Practitioners like Chris Kresser have made the case that diet alone is not enough and that starving the gut of carbs and FODMAPs could have a deleterious effect on the large intestine biome. Additionally persuaded by evidence that very low carb diets can actually cause gastrointestinal disease by depleting the gut of Mucin-2, I decided to follow The Perfect Health Diet, and in fact I had already started the diet three months before I even got the actual SIBO-C diagnosis.

You can read more about my diet and nutritional supplements here. In addition, I'm implementing other lifestyle changes that might help, like yoga and other forms of vagus nerve stimulation.

Resources

Sites I owe a debt of gratitude to:

• The Perfect Health Diet: For setting me on the path to good nutrition and improved gut health and arming me with a vast amount of well-documented research to show my doctors.
• Chris Kresser: For breaking down very complex digestive issues into laymen's terms and for introducing readers to experts in the field, like SIBO pioneers Pimentel and Seibecker in addition to Dr. Kenneth Brown, the gastro who developed the botanical treatment Atrantil that I'm taking.
• Fix Your Gut: For clearly illustrating the difference between SIBO-C and SIBO-D.
• The Gut Institute: For sharing an herbal antibiotic protocol that has cured many SIBO patients — it is the protocol I would have tried if I hadn't come across the newly released Atrantil.
• Hollywood Homestead: For the lead on motility dysfunction and vagus nerve damage as possible causes of SIBO.
• Digestive Health Blog: For the lead on botanical medicine Atrantil to treat the archaea bacteria that cause the constipation version of SIBO that I have.