Nirala Jacobi, BHSc, ND
“Mary,” a 65-year-old lady, was referred to me for additional therapy for small intestinal bacterial overgrowth (SIBO). She had been given the analysis of SIBO in 2015 following a lactulose breath check, and regardless of quite a few natural therapies and dietary interventions, she reported that “Nothing has ever improved with SIBO therapy.”
Mary’s principal complaints had been constipation, fatigue, melancholy, fibromyalgia, gasoline and bloating, ache across the umbilicus (which occurred randomly), and gastric reflux attributable to a hiatal hernia. Previous medical historical past was detrimental for recalling any case of meals poisoning and was optimistic for having had a cholecystectomy a few years prior.
Her bowel actions occurred 2-Three occasions weekly and had been a 1 or 2 on the Bristol Stool Chart. She was observing a low-FODMAP weight-reduction plan, however had stopped being very regimented together with her weight-reduction plan.
She had not been retested for SIBO in nearly 2 years, so I made a decision to get an excellent understanding of her digestive tract. I ordered a lactulose breath check and a complete stool evaluation together with microbiome DNA evaluation. I despatched Mary house with a bottle of natural bitters (gentian, Oregon grape, dandelion root, baical skullcap), with directions to take Three dropperfuls Three occasions per day earlier than meals. I additionally began her on Section 1 of the SIBO Bi-phasic weight-reduction plan.
I usually begin my therapy this manner whereas I await check outcomes. The SIBO Bi-phasic weight-reduction plan is a phased protocol that helps practitioners to arrange their therapy method. Section 1 is kind of restricted, eradicating all dairy and most FODMAPs, grains, and fruit. By the point the affected person with SIBO (confirmed by lactulose breath testing) returns, they usually report enchancment earlier than antimicrobials are even prescribed.
4-Week Comply with-up
Mary returned for her second appointment four weeks later. As a substitute of feeling higher, she felt “a lot worse.” Her fatigue, physique aches, temper, and constipation had all worsened and he or she felt like giving up.
Lactulose Breath Check
Her breath check (Determine 1) revealed a “flatlining” outcome for hydrogen, and a mildly optimistic outcome for SIBO within the mixed hydrogen/methane class. Throughout a Three-hour lactulose breath check, a big rise in hydrogen is predicted when the substrate (lactulose) arrives within the colon the place hydrogen-producing micro organism are plentiful. In circumstances the place methanogenic micro organism are plentiful within the small gut, hydrogen may be utilized by methanogens to supply methane – the explanation that each gases ought to be measured in a breath check. In Mary’s case, no such rise occurred, which raised my suspicion for the attainable presence of hydrogen sulfide-producing micro organism. Hydrogen sulfide can’t be revealed on a lactulose breath check.
Determine 1. Lactulose Breath Check
Intestine Microbiome Evaluation
The results of Mary’s stool check was much more revealing. Whereas all digestive and inflammatory markers had been inside vary, the next pertinent abnormalities had been discovered:
- Brief-chain fatty acid (SCFA) ranges (Determine 2) under detectable ranges! I had by no means seen such an excessive lack of short-chain fatty acids, and puzzled if this marker of microbiome well being could possibly be accountable for a few of Mary’s signs, particularly the fatigue and physique aches. SCFA have been proven to be concerned in power manufacturing, prevention of leaky intestine and absorption of endotoxin (aka lipopolysaccharide, or LPS), upregulation of mitochondrial operate, enhancement of colonic motility, and reducing systemic irritation.1,2
Determine 2. Brief-Chain Fatty Acids
- Elevated ranges of Bacteroides spp (Determine Three). This discovering has been related to diminished bacterial variety, an inflammatory phenotype, elevated beta-glucuronidase, manufacturing of secondary bile acids, and better adiposity.Three
Determine Three. Gastrointestinal Microbiome
- Elevated ranges of Escherichia coli and the hydrogen sulfide-producing micro organism, Desulfovibrio piger (Determine four). In addition to LPS manufacturing, larger E coli counts can result in poisonous indole manufacturing. Extreme hydrogen sulfide has been linked to colon most cancers, belly ache, and leaky intestine.four,5
Determine four. Gastrointestinal Microbiome (cont)
From the outcomes of Mary’s stool check, it was clear that we would have liked to vary her weight-reduction plan. Bacteroides spp, E coli, and significantly Desulfovibrio, thrive on bile acids and a weight-reduction plan excessive in animal fats and animal protein.6 Moreover, a weight-reduction plan excessive in saturated fats (together with coconut oil) has been proven to extend the absorption of LPS.9 To cut back dangerous micro organism and LPS, and to extend short-chain fatty acids, I really useful a low-fat vegan weight-reduction plan that was wealthy in high-fiber meals. I additionally prescribed the next prebiotics:
- Lactulose: This prebiotic has been proven to lower E coli and Bacteroides spp and to extend helpful micro organism.7 Lactulose can be the substrate used for SIBO breath testing, so I requested her to begin with 5 g each day and to slowly improve it to 10 g, provided that no extreme bloating was famous.
- Galacto-oligosaccharides: GOS been proven to attenuate development and manufacturing of hydrogen sulfide-producing micro organism, and to extend helpful Bifidobacteriumeight
As a result of inexperienced tea has antioxidant and prebiotic results, I additionally requested Mary to drink 5-6 cups of inexperienced tea each day to additional assist colonic well being. In addition to avoiding animal fats and protein, she was additionally to avoid-sulfite containing preservatives. Lastly, I prescribed zinc chelate, 30 mg 2 occasions each day, for mucosal/leaky intestine assist.
4 Weeks Later
Mary returned four weeks after beginning this easy weight-reduction plan and prebiotic prescription feeling way more energized and optimistic. Her constipation had modified over to 2 regular bowel motions each day, the reflux resolved “on day 1 of the weight-reduction plan,” and gasoline and bloating and the peri-umbilical ache had resolved. She was sleeping via the evening and had days with bursts of power. Although the aches and pains of fibromyalgia had not but improved, she was very happy with this final result, particularly since she had struggled for years with unresolved digestive points and systemic signs.
In SIBO, hydrogen sulfide manufacturing has been linked to “rotten egg”-smelling gasoline, diarrhea, and flatlining hydrogen breath assessments. These signs weren’t current on this case, indicating a extra complicated state of affairs. In addition to Desulfovibrio spp, Bilophilia wadsworthia can be a hydrogen sulfide-producing species, and there may be some query about different species. One other query on my thoughts is whether or not excessive sulfur-containing greens equivalent to brassicas would possibly contribute to hydrogen sulfide manufacturing? And what about sulfur-containing amino acids equivalent to N-acetylcysteine (NAC)?
Although questions stay about a perfect weight-reduction plan to scale back hydrogen sulfide-producing micro organism, this case demonstrates that microbiome-enhancing therapies don’t all the time have to incorporate probiotic supplementation or antimicrobials. Particularly within the case of suspected hydrogen sulfide manufacturing, therapy can embody a high-fiber, low-fat vegan weight-reduction plan and focused prebiotic supplementation.
- Canani RB, Costanzo MD, Leone L, et al. Potential helpful results of butyrate in intestinal and extraintestinal illnesses. World J Gastroenterol. 2011;17(12):1519-1528.
- Schwiertz A, Taras D, Schäfer Ok. Microbiota and SCFA in lean and obese wholesome topics. Weight problems (Silver Spring). 2010;18(1):190-195.
- Wexler HM. Bacteroides: the good, the unhealthy, and the nitty-gritty. Clin Microbiol Rev. 2007;20(four):593-621.
- Medani M, Collins D, Docherty NG, et al. Rising position of hydrogen sulfide in colonic physiology and pathophysiology. Inflamm Bowel Dis.2011;17(7):1620-1625.
- Singh SB, Lin HC. Hydrogen Sulfide in Physiology and Illnesses of the Digestive Tract. Microorganisms. 2015;Three(four):866-889.
- Wolf P, Cummings P, Shah N, et al. Sulfidogenic Micro organism Abundance in Colonic Mucosa is Positively Correlated with Milk and Animal Fats Consumption and Negatively Correlated with Mono and Polyunsaturated Fatty Acids. FASB J. 2015;29(1 Suppl 598):10.
- Salminen S, Salminen E. Lactulose, lactic acid micro organism, intestinal microecology and mucosal safety. Scand J Gastroenterol Suppl.1997;222:45-48.
- Vulevic J, Drakoularakou A, Yaqoob P, et al. Modulation of the fecal microflora profile and immune operate by a novel trans-galactooligosaccharide combination (B-GOS) in wholesome aged volunteers. Am J Clin Nutr.2008;88(5):1438-1446.
- Lyte JM, Gabler NK, Hollis JH. Postprandial serum endotoxin in wholesome people is modulated by dietary fats in a randomized, managed, cross-over research. Lipids Well being Dis.2016;15(1):186.
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Nirala Jacobi, BHSc, ND (USA), graduated from Bastyr College in 1998 with a doctorate in naturopathic drugs. She practiced as a main care doctor in Montana for 7 years earlier than transferring to Australia. Nirala is taken into account one in all Australia’s main consultants within the therapy of SIBO. She is the medical director for SIBOtest, a web based testing and academic service for practitioners, and can be the host of the favored podcast “The SIBO Physician” for practitioners. Nirala is the medical director and senior naturopathic doctor at The Biome Clinic, the Centre for Purposeful Digestive Problems, in Mullumbimby, New South Wales. Web site: www.thebiomeclinic.com