Tonight I attended the much-anticipated debate between two well-respected NCNM physicians and professors: Dr. Steven Sandberg-Lewis and Dr. Paul Kalnins. They dueled out the following question: SIBO- cause or consequence? In the end, it seemed as if they shared more similarities than differences in regard to the way in which SIBO should be approached.
SIBO Debate Recap:
The following are some of my key takeaway notes from the debate. These notes are primarily my interpretation and thoughts on the information presented in the debate and are not portraying the exact messages of the speakers.
Lactulose breath testing
The lactulose breath test has a low sensitivity and specificity when compared to the gold standard: a jejunal aspirate. What does this mean? Sensitivity is the ability of a test to correctly diagnose people who have the disease as positive (as opposed to having false negatives). Specificity refers to the ability of the test to show up as negative in individuals without the disease (instead of having false positives).
Unfortunately, the sensitivity of the lactulose hydrogen breath test is 68% and the specificity is 44% . This means that, in theory, 32% of people who take the test will have a false negative result. And 56% of people who take it will have a false positive result. Basically, it means that the breath test is not very good at accurately detecting SIBO. But the gold standard test (jejenual aspirate) is unrealistic. It is invasive, expensive, and only tests the upper part of the small intestine and therefore may return more false negatives than the breath test.
We must also keep in mind that at this point, the lactulose breath test is all we’ve got in terms of our ability to place some sort of finger on what is going on inside the small intestine of people who are experiencing the miserable symptoms associated with SIBO. It is very validating for those who test positive to finally have something showing on paper that there is a phenomenon occurring in their body that is not normal. Rather than being treated as if their symptoms are all in their head.
But this information also means that we should approach the lactulose breath test with caution. Due to the low sensitivity and specificity of the test, it should not be used in everyone and certainly not as a first line approach. If the test is conducted, results should be interpreted with caution and based on the person’s symptomatic picture. In someone with diarrhea, the hydrogen values may appear highly elevated, when in fact, it could potentially be their large intestine with bacteria that is flourishing (this is a good thing!). If they did not really have SIBO, it would not only be unhelpful to give them antibiotics, but it could actually be harmful.
Long term solutions
In the majority of people, providing a course of antibiotics, herbal antimicrobials, or the elemental diet will not “cure” them of SIBO. Initially, they may feel great, but symptoms will likely recur over time- whether it be 2 days, 2 months, or 2 years.
A study looking at glucose breath testing and treatment with Rifaximin showed that after clearing SIBO, 12.6% of patients relapsed within 3 months, 27.5% relapsed within 6 months, and 43.7% relapsed within 9 months . Keep in mind that glucose is absorbed within the top portion of the small intestine, so the test could have missed many cases which would have made the recurrence rates even higher. These results beg the question of how do we keep SIBO in check more permanently?
This is where the importance of addressing the underlying cause of SIBO is crucial. Although that’s much easier said than done. Exploring immune, endocrine, and nervous system dysfunction as underlying causes are all possibilities. Adhesions, hypochlorhydria, poor vagus nerve tone, low pancreatic/gallbladder function, intestinal dysbiosis, and excessive sympathetic dominance are all worth exploring as well.
Don’t go full force ahead in a “kill the bugs” mindset
Naturopathic medicine has so much to offer individuals with chronic functional gastrointestinal disorders such as IBS and SIBO. While using antibiotics, herbal antimicrobials, and elemental diet are likely to result in symptomatic improvement in those afflicted with these conditions, they are also higher risk treatments than many alternative naturopathic remedies.
It is important to start with more gentle therapies before bringing out the big guns. Therapies that may be better first line approaches include implementing a nutritionally balanced diet, abdominal massage, acupuncture, deep breathing exercises, physical activity, meditation, stress management, mindful eating, probiotics, digestive enzymes, betaine HCL, castor oil packs, and more.
It is very enticing to fall into a mindset of wanting to “kill the bugs”. It is a concept that is fairly straightforward to comprehend and the solution is easy- take a pill. But for many people, antibiotic overuse may be a contributing factor to why they are experiencing SIBO symptoms in the first place. While antibiotics may be a necessary part of treatment for some people, I highly recommend exploring less risky methods first.
To conclude, SIBO is both a cause and a consequence. It is a cause for the mysterious IBS symptoms that afflict a large percentage of the population. And it is a consequence of impaired homeostatic mechanisms within the body.
A huge thank you to NCNM student Samantha Johnson from sibodietrecipes.com and everyone who helped her in organizing this event! And of course to the physicians for kindly sharing their approaches and putting themselves out there for the SIBO community.
 Simrén M, Stotzer PO. Use and abuse of hydrogen breath tests. Gut. 2006;55(3):297-303.
 Lauritano EC, Gabrielli M, Scarpellini E, et al. Small intestinal bacterial overgrowth recurrence after antibiotic therapy. Am J Gastroenterol. 2008;103(8):2031-5.
Hi Riley. You wrote “”We must also keep in mind that at this point, the lactulose breath test is all we’ve got in terms of our ability to place some sort of finger on what is going on inside the small intestine of people who are experiencing the miserable symptoms associated with SIBO””
Didn’t Pimentel come up with some kind of SIBO test? Have you heard whether it is effective or not and how accurate its record is?
Yes, Pimentel created IBSChek. This test analyzes antibodies to intestinal cells, indicating issues with the migrating motor complex. However, what it doesn’t tell us is what sort of gases are being produced. I am unsure of the accuracy. It can be effective for determining of there is an autoimmune component and perhaps help determine the length of time needed for prokinetics.
OK. Thanks for sharing that info about IBSCHEK.
I anybody looking at the possibility of parasites being a cause of SIBO? I’m convinced that is a factor for me.
Hi Cassandra, In Dr. Pimentel’s book “A New IBS Solution”, he has a short section on parasites and mentioned that certain types of parasites including giardia and amoeba can cause post-infectious IBS.