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SIBO Part 1: Real Condition or Myth?

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Today we have another educational installment from Karl Seddon, founder of the British biotech manufacturing firm that produces Elixa Probiotic.

Years back, I recall hearing almost daily about Adrenal Fatigue and it struck me as one of those things with a list of symptoms so numerous, vague, and broadly defined that it was as though it could be argued that both every condition is Adrenal Fatigue and no condition is Adrenal Fatigue, all at the same time.

Does SIBO constitute a similar vein of catch-all-and-none? Well, let’s see.


The road to self-diagnosis is paved with wishful thinking

If you’re currently on a quest to correct some aspect of your health, then likely you’ll be able to associate with that feeling of excitement when you come across a theory that you’d not heard of before and everything… suddenly… just…. clicks!

‘Yes, this makes perfect sense! All my symptoms fit, and the logic on paper is infallible!’

A part of this euphoria and ones willingness to progress to a state of excitation comes from desperation. Nothing wrong, or surprising, about that. I’ve felt this same thing many times. Just like the inventor who has been mulling over a sticking point in her design and has a spark of what the solution may be…or a physicist who suddenly has some potential breakthrough in his theory while laying in bed, staring at the ceiling.

Unfortunately, quite often what follows is the actual test of the theory as per the guidelines of whichever resource you are reading. This is where people get sorely let down and waste a lot of time and money. Different people have different thresholds of when and under what circumstances they can look at the matter objectively and realise it just ain’t working.

By all means, test everything that has logic to it. Just don’t waste time by not being objective with your analysis of the results or baselessly believing that weeks or months must pass before progress is visible. There may be some reason why results can be delayed by weeks and then suddenly arise. But at least have some mechanism explaining that delay.

Playing devil’s advocate against yourself is an invaluable trait.

In this article, I shall share my thoughts on one of the most commonly self-diagnosed conditions: SIBO. I shall list the two most common observations that people make to arrive at their self-diagnosis. We’ll have a look at the typical conclusion that most people make.

Then I’ll present an alternative conclusion for both observations; changing the implications entirely.

SIBO – Small Intestinal Bacterial Overgrowth

My product, Elixa, is an ultra high strength probiotic, and so I mainly get questions related to gut health. And one of the most common conditions that people ask me about is SIBO. This stands for Small Intestinal Bacterial Overgrowth. In essence, it’s an excess of bacteria throughout all or part of the duodenum, jejunum, and ileum, the three sections comprising the small intestine.

Digestive System

Credit: Blausen.com staff

SIBO is not the mere presence of bacteria in the small intestine because the small intestine in a healthy state is far from sterile. In fact, it’s only relatively sterile when compared with the large intestine—its downstream neighbour.

Bacterial excess in the small intestine can be defined directly—by a certain number of bacterial cells per millilitre of intestinal fluid—or indirectly—as some empirically arrived-at score on a diagnostic test, such as a hydrogen or methane breath test.

Let’s briefly recap the layout of the digestive tract between the stomach and the large intestine.

The Stomach

Stomach

Credit: Cancer Research UK

Imagine you take an uninflated balloon and insert a funnel into its opening. You pour a cup of water into the balloon and add some chewed up food. Then, put a little air into it and tie up the end. Imagine using both hands to slowly massage the food and fluid back and forth. This is essentially what the stomach does when you eat food. The food plops down into the hydrochloric acid and digestive enzymes. The stomach massages it back and forth, occasionally opening the pyloric sphincter—leading into the small intestine—to squirt a bit of this mush onwards when it’s deemed ready.

The main difference between how this works and how some may imagine it to work is (1) the massaging action, and (2) the extremely developed control of different food substances being retained or being moved on by the stomach via the pyloric sphincter. Rather than the fixed, bucket-like stomach seen in diagrams—with its always-open entrance and an always-open exit—the stomach is more like an accordion being extended and contracted slowly and with an exit valve that can release partially-digested food matter based on chemical and physical signals.

Stomach peristalsis

Credit: Cancer Research UK

The Small Intestine

The small intestine begins directly after the stomach. It’s divided into three sections along its 23-ft length (the length of 4 average height men). The first section is the duodenum, then the jejunum and last is the ileum.

Small Intestine

Credit: Blausen.com staff

The last two sections—jejunum and ileum—comprise the majority of the length of the small intestine, because their main function is the absorption of nutrients. Absorption requires a large surface area, which is in part facilitated by its length and principally by the whole villi and microvilli array. In fact, the first section—the duodenum—is less than one ft long. However, a lot happens there.

The Duodenum

Several unique actions occur in the duodenum, but if you want to remember just one, then view it as a buffer zone between the pH of the stomach and that of the small intestine. The gastrointestinal tract flows from stomach to small intestine continuously, so there must be a mechanism by which to convert the acidic contents of the stomach into an alkaline slurry downstream because the small intestine is the primary site of carbohydrate enzyme activity, which requires an alkaline pH.

This is done in the duodenum by the release of bicarbonate from the pancreas into the duodenum and from the lining of the duodenum itself.

Pancreas and Duodenum

Credit: Cancer Research UK

If you’re struggling to envisage this, then imagine having an acidic river, where at some position you constantly unload dumper trucks of baking soda (sodium bicarbonate—an alkali) into it: mixing and churning together, such that the flow downstream of this dumping point is now alkaline.

After the partially broken-down, fully broken-down, and enzyme-resistant food passes through the duodenum, it enters the jejunum and ileum. This is where nutrient absorption occurs. Both micronutrients (vitamins & minerals) and the enzymatically fragmented sub-units of macronutrients (carbs/fats/proteins) are absorbed along this section.

Directly after the Ileum is the Cecum, which is the beginning of the large intestine. So, we’ll stop at this point along the gastrointestinal tract and re-focus on the small intestine.

As could be expected, the bacterial concentrations slowly increase as we move from the duodenum (neighbouring the harsh, acidic environment of the stomach) along to the Ileum (which harbors the bacterial fleet—the large intestine).

SIBO (Small Intestinal Bacterial Overgrowth) is the condition of overgrowth somewhere in the region between the exit of the stomach and the entrance to the large intestine.

People contact me asking whether Elixa can resolve their SIBO. Very few stop to ask whether I think they have the condition in the first place. Some even get back to me a few weeks later saying that Elixa did dramatically reduce their bloating, pain, etc., and conclude that their SIBO hunch must have been correct after all—ignoring the fact that bloat does not automatically equal SIBO and that a probiotic is far more likely to have eradicated bloating via its action in the large intestine than in the small intestine.

Why you think you have SIBO

Here are the two most common reasons many people believe they have an overgrowth of bacteria in their small intestine, as opposed to a dysbiosis of their large intestine. The conclusion to the first observation, in particular, appears to be logical. Nevertheless, I have provided alternative conclusions for both points.

1. Time until bloat

Observation:

  • You eat a meal and within about 1 hour your belly is distended, and you feel uncomfortably tight and bloated.
  • This may even occur immediately after consuming the meal.
  • Bloating is not the only effect that may occur. There may also be pain, diarrhoea, and a feeling of mental fog.

Conclusion: The food can’t possibly have reached the large intestine in that time, and so it must be related to the small intestine.

2. Symptoms’ lists

Observation:

  • abdominal pain
  • bloating
  • flatulence
  • constipation
  • diarrhoea
  • etc.

Conclusion: You suffer from many of these symptoms, so it seems like a perfect fit.

Alternative conclusion to Observation #1

Rapid onset of bloating and other symptoms after eating is a compelling reason to believe it is SIBO, but there is an alternative explanation. When we consume food, it triggers a domino effect along the gastrointestinal tract.

Domino effect
This is known as the gastrocolic reflex.

This Mexican wave effect begins when food enters the stomach and can reach measurable (myoelectrical) levels within just 15 minutes and possibly earlier, depending on your gastroenterological state, including your visceral sensitivity and neurotransmitter levels related to gastric motility. The gastrocolic reflex is the upregulation in peristaltic action, thus shifting all the matter in your intestinal tract further along. Its magnitude varies along the tract but, generally speaking, all the food is pushed forward along the entire GI tract.

It ought to be apparent from everyday observation: the urge to take a bathroom break after eating a large meal. It’s obviously not the food you’ve just eaten that needs to be evacuated, but the meal was certainly the trigger. ‘Making room’ for the incoming food is the common-sense explanation for why we have evolved this response.

…As an aside, let’s play around with the implications of this for a minute. If we eat less frequently, we could assume that food is moved through our digestive tracts more slowly (or at least more slowly through certain sections). That may at first seem odd because surely there is some required amount of time that food must be in contact with the small intestinal wall to allow complete absorption of nutrients. And, this would imply that eating more frequently would ‘cut short’ the time that the previous meal[s] get to spend in the caress of the small intestinal microvilli.

Well, this ‘cutting short’ might be completely sensical. Because, when the body has the option of making room for a fresh, undigested bolus of food versus continuing to dredge out the last morsels from the previous meal, it would obviously opt for the incoming meal. When a hunter-gatherer had food in abundance and was eating and not storing it, why would the body put up resistance to taking in that next meal only so as to not ‘waste’ some of what was previously ate?

The longer the food remains in the small intestine, the less time-efficient the nutrient extraction would be. Better to keep the energy-packed food coming while the coming is good. The alternative would be that the hunter-gatherer is repelled by further intake of food or vomits the meal back up until complete small intestinal digestion of the previous meal is complete. There’s no other option: either make room for it or don’t consume it. Clearly, making room is the best way to take advantage of what’s on offer.

Back on point

So, if the consumption of a meal can trigger a gastrocolic reflex, it means that it can (a) cause fermentable components of the diet (FODMAPs et al.) to move along the GI tract. It can also (b) shift lumenal fermentation byproducts (SCFAs, ethanol, acetaldehyde, unconjugated compounds, pockets of gas, etc.) from one place in the large intestine along to another place in the large intestine. To put simply: It can (a) move bacterial food along, and (b) move the byproducts of bacterial feeding along.

Looking at (a), moving bacterial food along, we zoom in on the Ileum. The Ileum is the final part of the small intestine, directly before the Cecum.

Cecum

Credit: Blausen.com staff

I view the Cecum as a bacterial fermentation melting pot. I believe this area is the most critical portion of the large intestinal microbiota if you had to pick an area.

  1. It’s where the fermentable components first arrive.
  2. It’s shaped in a pouch-like manner, which implies to me that this is an intended point of temporary accumulation and mixing of substrates and bacteria. If you watch a colonoscope filming food passing from the ileum into the cecum, then you’ll get my point.
  3. It is upstream of the remainder of the large intestine—thus being a huge determinant of what byproducts, substrates, and microorganisms are carried downstream to the later sections: the ascending, transverse, descending, and sigmoid portions of the large intestine.
  4. The appendix connects directly to the cecum. The appendix is designed to restore a gut microbiota that has been dramatically ravaged by an acute gastrointestinal infection. Think: Hunter-gatherer ate a chunk of diseased meat and had explosive diarrhoea for three days straight. So it would make evolutionary sense that the appendix would be positioned at the most critical point required for reinoculation of the large intestine.

The (a) point is the movement of the fermentable substrate, the residue of your meal which has not been absorbed in the small intestine and that can be broken down by microbes.

If there was some fermentable substrate hanging around the Ileum and then the gastrocolic reflex kicks in and shunts it through the ileocecal valve into the bacterial cauldron aka cecum, then this would cause it to begin immediately breaking down into the various byproducts. If these byproducts were gaseous, they would lead to bloating. If they were something like ethanol or acetaldehyde, then they could result in mental effects. If they were some pain-inducing metabolite, then they may lead to that sharp stabbing pain, right there in the bottom right of your abdomen—that dreaded IBS pain.

Nota bene: do not assume that gas produced in the large intestine only leads to flatulence and that gas in the small intestine is what leads to bloating. Gas can be trapped in the large intestine for a long period before making its way over to the exit 1.5 slow-moving metres away. And until it exits, is absorbed, or degraded, it will be experienced in the form of abdominal bloat.

Pause for a moment to recall the overarching point we’re making: the alternative conclusion to Observation # 1, above, ‘Time until bloat,’ so we don’t lose the thread of what we are exploring here.

The (b) point is the movement of the gas and other metabolites. If the gastrocolic reflex shunts them along from one point to another in the large intestine, there’s an opportunity for different concentrations of these metabolites to be exposed to different portions of the large intestinal wall, thus making their effects more or less pronounced based on the visceral sensitivity of that area of the GI tract.

Let’s make it clearer by considering an example: If you had a pocket of gas that was building up along the transverse section of the large intestine, the gastrocolic effect might kick it along to the flexure between the transverse portion and the descending portion. Maybe there’s already a pocket of gas accumulated there (these are common areas of accumulation), and so now, this flexure is feeling increased stretch from the gas pressure and a more pronounced bloating sensation.

Before movementAfter movementConsidering other metabolites, we can hypothesise that some of them building within a bolus of matter in the lumen of the intestine may now be rearranged by the peristaltic Mexican wave and release volumes of the metabolite closer to the intestinal wall, thus allowing them to have their effect via diffusion into the bloodstream or otherwise (e.g. localised pain).

Both these mechanisms can explain why your symptoms follow rapidly after consuming a meal, yet neither are related to fermentation in the small intestine.

The alternative conclusion to Observation #2 is far briefer: There are almost NO symptoms on the SIBO symptoms’ lists (at least the ones I have seen circulated online) which are not identical to that of a large intestinal dysbiosis. The few symptoms that would be exclusively indicative of an issue within the small intestine would be those stemming from malnutrition or small intestinal hyperpermeability because these conditions can relate to abnormalities of the brush border of the small intestine.

So if you’re basing your SIBO self-diagnosis on bloating, flatulence, brain fog, diarrhoea, abdominal distension, and abdominal pain, then consider that none of these exclusively indicate the site of action within the small intestine.

Unless there was a confirmed motor problem or anatomical defect in the small intestine, I believe it is far more likely for problems to stem from the large intestine. And there is also potential for problems localised in the small intestine to be instigated by large intestinal problems anyway. Just in the same way that another membrane (the skin) is hugely affected by the flora of our large intestine.

Two questions remain:

  1. What if I really do have SIBO – What caused it and how can I resolve it?
  2. What are these malnutrition and intestinal hyper-permeability consequences of genuine SIBO?

I’ll share my thoughts on those in Part 2.


No matter how you slice it, in my experience of a long time now with Elixa, with so many readers trying it, sending Karl and I hundreds of testimonials, repeat product orders, and lots of comments on the blog, it seems to improve the lives of most that have frequent or chronic digestive problems—whether they believe it’s SIBO or not.

I must say I find that most ‘hypesters’ of SIBO tend to be generally or fervently promoters of various forms of low-carbohydrate, anti-carbohydrate, anti-fiber-carbohydrate, nothing-but-big-meat-and-big-fat kinda folk. And FODMAP is a pejorative term.

To put it plainly: one must seriously consider that their proposed “cure” for all of these self-diagnosed and assumed “SIBO problems” is in fact—Occam’s Razor syle—the very cause of their problems by means of a starving large intestine.


Elixa Probiotic is a British biotech manufacturer in Oxford, UK. U.S. Demand is now so high they’ve established distribution centers in Illinois, Nevada, and New Jersey.
Still, sell-outs happen regularly, so order now to avoid a waiting list.

Richard Nikoley

I'm Richard Nikoley. Free The Animal began in 2003 and as of 2021, contains 5,000 posts. I blog what I wish...from health, diet, and food to travel and lifestyle; to politics, social antagonism, expat-living location and time independent—while you sleep—income. I celebrate the audacity and hubris to live by your own exclusive authority and take your own chances. Read More

40 Comments

  1. Tim Steele on July 1, 2016 at 18:52

    Nice explanation, Karl – And let’s not forget that there can be many ‘mechanical’ defects that cause SIBO-like symptoms. The ileocecal valve can malfunction, peristalsis can be off, pyloric and cardiac sphincters can contract improperly.

    Generally, people with SIBO-like symptoms can be quickly “cured” with proton pump inhibitors, yet these do nothing to treat bacterial overgrowths, and missing a single dose causes a relapse.

    Great topic. looking forward to part 2.
    Tim

    • Richard Nikoley on July 1, 2016 at 19:54

      Nailed it, Tim.

      I was mulling over an email to Karl about following this series with one on another 4-letter “word,” GERD.

      In editing this, I was surprised he didn’t mention GERD, as SIBO is supposedly the new case. Remember way back when, all the alternatives were saying GERD is too little, not too much acid, the idea being that stuff persists too long before emptying. This had everyone taking Betaine HCL and digestive enzymes.

      I knew it was bullshit because when I get heartburn and stir 1 tsp baking soda in water, down it, do the twist, and so burp explosively for three minutes and the heartburn is killed, that can only be substantial acid (that is backing up into the esophogas).

      But further to the dysfunction of the whole peristalsis chain, anyone who has suffered severe heartburn ought to have experienced a time where if they happen to have the urge and take a big dump, then bang, heartburn gone in minutes. SIBO can’t possibly be related to that without a whole lot of “explanation.”



    • Tim Steele on July 1, 2016 at 21:19

      Yep. When I was having symptoms of gallstones, the GERD King and Gut Goddess said “GERD” and “SIBO” respectively. Both would have happily took my money to order tests and set-up specific protocols.

      I believe there is such a thing as GERD and SIBO, but these two diagnoses are made too quickly. I think the “couple spoonfuls of baking soda” test is enough to rule SIBO out. “Gastro-esophogeal reflux disease” is more descriptive, but can have a wide range of causes. But if PPIs take care of GERD, bacteria are not the immediate problem.

      And, as I have been preaching, once dysbiosis sets in, good luck in fixing it. Better to prevent through good diet, exercise, fiber, etc…

      I’m curious to see where Karl goes with his probiotic Elixa. I’ve been hearing lots of good things.



    • John Brisson on July 2, 2016 at 09:49

      I agree with most of what Karl wrote about, but we need to look at the microbiome and the anatomy in a greater picture. There are six different parts of the digestive system where dysbiosis can occur, the mouth, the esophagus, the stomach, the small intestine, the biliary / enzyme organs, and the large intestine. Does large intestine dysbiosis occur? Yes, it can, and Karl outlined it well in the post above. But SIBO and upper gut overgrowth can occur as well.

      When Richard was talking about GERD be relieved by belching, that would be indicative of an upper gut overgrowth, H. pylori, Proteus mirabilis, Citrobacter, and low amounts of Lactobacillus. Now when he talks about GERD be relieved by a bowel movement that would indicate either colonic overfermentation combine with stool causing increased gastrointestinal pressure which can occur from SIBO or LIBO. GERD can occur from stomach distension both ways, it being pulled up or down depending where the overfermentation is occurring, forces contents up and weakens the LES. To say SIBO doesn’t exist and only large intestine dysbiosis occurs is a fallacy.

      Now does everyone have SIBO that has gut issues? No, and it is being made out to be the new Candida. You can have digestive issues and dysbiosis in different parts of the digestive tract, some all at once. The tests we have currently are mediocre at best. Most of the time we have to go off reaction to certain supplements and diet and symptoms to determine a person’s issues. It is a crude art, not a science.

      For example as much as I love Elixa someone with an upper gut overgrowth of H. pylori might have issues with consuming it from the histamine producing strains of Lacto in the probiotic and TH1 dominant immune reactions from ingesting probiotics. There are other factors in play like histamine genes like DAO, but the gut has a lot to do with it. Elixa is a great probiotic, and I do recommend it in some cases, but probiotics are like medicine and do not help everyone that take them.



    • Richard Nikoley on July 2, 2016 at 10:45

      “When Richard was talking about GERD be relieved by belching”

      You conveniently left out the part of a tsp of baking soda being swallowed in water. Try it, particularly an hour after a meal where you have significan’t acid. The baking soda reacts and releases huge amounts of carbon dioxide. This is well established and not controversial.

      Didn’t you see the Myth Busters episode where they made a mock stomach explode by introducing enough baking soda to enough acid?

      Fact is, I never burp otherwise, and I ONLY get heartburn when eating in conjunction with drinking alcohol. It ain’t fucking H. pylori, any other bacteria, or fucking SIBO Myth.



    • Bobby Dean on July 28, 2016 at 20:31

      Mr. Nickoley, I think John Brisson knows you were describing belching from ingesting bicarbinate with water. I would like to see you both discuss this matter. Are you familiar with the fast tract diet by Norm Robillard? I am not saying his diet is the best or anything, however for a lot of people it seems to work. His theory as well as others is that a lot of the time heartburn is caused by fermentation in the small intestine. The gases travel upwards rather than down (mmc problem) and it results in putting pressure on the stomach and LES as well as causing belching from gases produced by fermentation of carbohydrates. I am interested in your theories about this. Personally I have had gerd for a couple years now trying to figure it out ( which i no longer get heartburn but something still seems wrong) but when I would get Gerd in the past I belch a lot an hour or two after having a meal with carbs and when the gases die down my heartburn is gone. Now I have taken many experimental measures to improve digestion and absorbption and I wisely eat highly palatable carbs like jasmine rice,pineapple etc..and as long as I dont overdo it, no belching, no goofy throat pressure or burning of the LES. I am simply sharing my own oberservations. I am very open minded and I will try anything that makes a lot of sense just like this article says haha. Please share your thoughts. Am I experiencing small intestinal fermentation causing gases to rise making my stomach acid splash onto my esophagus? Or is something else going on? Or did you already answer that for me? Is it possible that the “gases” and back pressure are from the large intestine instead but the fact that its all linked makes it seem like its from the small intestine? I hope I am not screwed in this manner because I had an appendectomy at age 17 and I am now 26. Thank you so much for your time. Sorry if I misinterpreted anything you have said.



    • Richard Nikoley on July 29, 2016 at 10:09

      Bobby:

      We’ve entered the realm where it’s somewhat diminishing returns for me to explain very much more.

      My three brothers and I grew up with a rail thin dad in his 30s who ate Rollaids like candy. SIBO? Perhaps, but all four of us had heartburn from very young ages. My first time I can recall was like at 10. We were at my great grandmother’s house and she knew just what to do. Baking soda. My mom does not typically get heartburn.

      It seems more likely to me that we have some genetic thing that makes us hyper producers of acid under certain circumstances. Over decades, I’ve pretty much learned what is most likely to bring it on.

      1. alcohol
      2. huge meal
      3. heavy fatty meal
      4. combinations of the above

      And it’s easy to avoid. Modest whole food meals, regardless of whether heavy protein or heavy carb, proportionally, combined with little or no alcohol, no problem. Introduce lots of alcohol and/or lots of added fat, big problem.

      And, since baking soda kills it in its tracks, with enormous belching, it’s certain it’s a lot of acid, and not the too little acid, or SIBO explanations.



    • Bobby Dean on July 29, 2016 at 18:25

      Thanks for responding Mr. Nickoley. We’re all entitled to our opinions. You know its funny I had super bad heartburn for a while as a child where id just keep spitting up gobs of sailva. It went away by itself. I dont remember experiencing belching though. There are definitely lots of causes. Hiatal hernias for example. This time its different for me I believe. I have experimented with acv, bentain etc..It did not change anything for me. I highly doubted low acid was the culprit. The baking soda test is pretty decent for ruling that out. If someone didnt experience lots of belching from bicarb id say theres an issue. Perhaps the people with low acid have a thyroid issue or something else metabolic and this is certainly the exception to the “rule”. I remember reading the 180degreehealth blog a long time ago and Matt Stone believed he experienced heartburn simply because he wasnt eating enough. He of course experimented a lot and inadvertently compromised his digestion. He exclaims that as soon as he had no dietary inhibitions his heartburn quickly subsided. Funny thing is, a couple months ago I contracted the flu and it hit my really hard. I needed an excuse for work otherwise i wouldve avoided a physician. She insisted I take an antibiotic for risk of secondary lung infection. At the time I said fuck it ill do it just because I felt so damn horrible and 103 fevers off and on were a little intense for me. I dont remember if I was thinking “oh itll help me eradicate whatever is bothering me in my small bowel” but after a couple of days I began feeling slightly better (although very weird probably from shitty antibiotics that id rather avoid forever) and I finally started to have an appetite and at this point I was just trying to put back some meat on my bones from not eating much at all for a few days. I said screw it and was indulging in many things id previously been avoiding. I didnt realize at first but eventually noticed my digestion seemed much better. No belching, no heartburn after meals. This was however short lived. I believe a few days after my antibiotic course was over I slowly began to have the same symptoms and switched back to eating carbohydrates strategically for good absorption. SHIT. I felt normal again for a moment..I think shitty guts runs in my family anyway..haha. But see this sort of phenomenon has happened to many other people ( unless theyre lying?) In comments and blogs, websites Ive visited etc…including pharmacueticals and herbal anti microbials etc…Whats goin on here bud? Obviously a lot of the time relapse is most likely from people eating shitty and perhaps not doing what they should do I.E. eat better make sure mmc is good reinoculate with good gut bugs stess blah blah blah. Who knows whats happening..but its real and it blows. I encourage everyone to have an open mind about it. In my particular case im definitely “feeling” back pressure only when consuming too many carbs or carbs that are difficult to digest. ( im a big dude i need them =*( ) Where and what is happening im not qualified to answer. I wish i could just “carpet bomb” my gut with good bugs but it seems much more complicated than that..Maybe one day Ill give up and go back to eating more loosely and itll just go away like when I was a child..One can only dream… In my first comment i meant to put a ? In front of mmc. Im not arrogant like that. Thank you so much for your time. This was a good post nonethless cool visuals too. Thanks Richard and Karl.



    • Richard Nikoley on July 30, 2016 at 08:25

      Something must have been lost in the back and forth but belching isn’t part of heartburn for me and never was. The belching comes with the ingestion of sodium bicarbonate, which creates a massive load of C02 when it reacts with stomach acid.



    • Bobby Dean on July 30, 2016 at 14:38

      Sorry for the confusion. I understand your belching you spoke of was from the baking soda and stomach acid interaction. I was trying to explain that my more recent heartburn involves belching whereas my childhood heartburn seemed different and I did not belch. I remember it also being much more intense hence the rapid saliva formation. Very interested to read part 2. Good day Sir.



    • JAMES H on July 3, 2016 at 03:10

      Baking soda and water, my favorite “heartburn” remedy. The only time the malady strikes me is after a meal that includes a sugary dessert. A teaspoon or two of baking soda in water results in immediate relief and the always amusing release of a large amount of CO2. (The Wife Unit doesn’t find this as funny as I do.)

      I usually snicker at the commercials hawking expensive heartburn remedies. The cheapest remedy is to stop eating the food(s) causing the discomfort. The second cheapest is to use sodium bicarbonate in a glass of water. (Assuming of course a genuine problem doesn’t exist.)



    • Karl S on July 3, 2016 at 07:06

      Hi Tim!
      Thanks for reading and commenting 🙂
      I appreciate your input!

      Yes I agree entirely.
      I wanted to try and transcribe that point towards the end – ‘Unless there was a confirmed motor problem or anatomical defect in the small intestine, I believe it is far more likely for problems to stem from the large intestine.’
      And, also, to emphasise that SIBO is definitely a real thing. It’s just the *prevalence* that we should call in to question. But, even on the issue of prevalance/incidence, I should keep my mind open since this medical field is so undeveloped as of now, as is my understanding of it.

      Hi Richard,
      Yep, I’ve noticed a similar trend in people suffering from various symptoms of gut problems. Whereby a bowel movement can extinguish the symptom temporarily. E.g. someone is having a severe headache which resolves after taking a BM. Almost as if the substrate/bacterial source of the offending metabolic byproduct had gotten excreted out during the BM and thus was no longer diffusing into the bloodstream…

      Hi John,
      Thank you for reading and commenting!
      ‘Most of the time we have to go off reaction to certain supplements and diet and symptoms to determine a person’s issues.’
      I agree 100%. Right now that approach is the best and fastest way to diagnose/treat most gut conditions. It’s similar to how they screen drugs and similar to how MDs narrow down a differential diagnosis.
      Hopefully you don’t infer from this article that I think SIBO doesn’t exist. Only the diagnostic criteria is being questioned. (and only questioned, not debunked)
      In fact, I do not have any informed opinion on the prevalence myself. The take away point is how postprandial symptoms can originate in the large intestine via the domino effect of the gastrocolic reflex. Self-diagnosis takes a lot of black box thinking: look at inputs and observe outputs, with frustratingly low information on what’s happening inside the box.
      So shedding a bit of light inside the box can allow people to re-evaluate some of their SIBO assumptions and then continue on down the road of self-diagnosis in perhaps a more accurate direction.

      Kind Regards,
      Karl (Elixa)



  2. hap on July 2, 2016 at 00:40

    It should be mentioned that h2 receptor inhibitors have pleotropic effects, some whib may be in play with Gerd and nsaid gsstropathy and could be as far fetched as implicated in cognitive impairments. Ppi’s also
    demonstrate antibiotic activity.

    These drugs have delayed action in Gerd and to say not a bacterial problem is a bit overstated.

  3. gabkad on July 3, 2016 at 14:06

    Pardon me, but doesn’t the digestive tract start at the lips? Chicken and the egg, but if someone has rotten teeth and gum disease (poor diet), all those bacteria go down the hatch along with the food. Wouldn’t these bacteria also contribute to problems in the rest of the GI tract?

    • Richard Nikoley on July 3, 2016 at 15:05

      What are you, a dentist or something? 😉

      (Got adorable Scout pics for your collection)



    • Richard Nikoley on July 3, 2016 at 15:09

      Gab luv. A serious Q.

      I brush rarely, but I wooden pick between teeth all the time. I think people fool themselves brushing. They have smooth surfaces but truckloads of rotting shit between.

      Picking, in my view, is way upstream in importance than is brushing.



  4. gabkad on July 3, 2016 at 15:40

    Yeah, I think as we get older and, well, most of us weren’t all that conscientious about our lifestyles throughout our lifetimes, a bit of gum recession and maybe not quite as tight contacts between teeth and whatnot, fibrey foods get stuck. Sesame seeds lodge themselves between my lower front teeth! Super annoying so I avoid seedy stuff most of the time.

    I’ve done a few experiments with myself to find out how much plaque and therefore gingivitis do I get if I don’t brush for 5 days. Very very little plaque and zero gingivitis. I don’t eat sugar and only occasionally eat fruit. Probably once a month at most I’ll eat some garbage like a piece of cake or a cookie.

    I brush my teeth mostly so I don’t get stains. Stains are not from plaque but from the pellicle layer that is always present on tooth surfaces. The hygienist had a look at my teeth a couple of months ago. A bit of stain, minimal amounts of calculus and the last time I had my teeth cleaned was 9 years ago.

    Mind you, it also depends on the type of saliva we produce. Some people produce a more buffered saliva than others. Some people produce thinner or thicker saliva. And then men always produce more saliva than women.

    As you found out, good levels of vitamin K2, D3, and B12 help with dental health as well.

    People need to stop eating sweet carby crap that turns into a slurry cesspool in their mouths.

    • Richard Nikoley on July 3, 2016 at 16:31

      Gabs.

      Here’s exactly how weird I am. Back in the 80’s, trips to Thailand, I hooked up with some Brits and over month-long trips over a few years, went from hitting bars to renting a home with lots of young girls who liked the house we rented.

      …Anyway, I basically ate off food carts, didn’t have a toothbrush. But, I knew there was uncmfortable shit between my teeth, also that my fingernails weren’t enough, but I knew toothpics. So, I found bamboo and made pics.

      It’s quite remarkable, because you know the difference between new food and putrid shit that’s been degrading for days.

      This is shit I was realizing in the 80s.



  5. Amy Hollenkamp on July 3, 2016 at 17:11

    I think you are right on the money about people with large intestine issues misdiagnosing themselves with SIBO! I actually went to a practitioner who told me that any amount of bloating means that it is SIBO. After conducting my own research, I determined this was a pretty ridiculous notion. The sad thing is that so many practitioners preach the same message…which is scary. So even when a person has SIBO, they are often over treated with rounds and rounds of antibiotics, because they are still feeling bloated and symptomatic, when in reality the SIBO is wiped out, but the dysbiosis in the colon still remains.

    Then the FODMAP diets further raise the pH in the colon creating even more dysbiosis and digestive dysfunction! In my opinion, our treatment focus really needs to move away from the “kill” mentality to a more “rebalance” mentality.

    Actually, I recently blogged about why I don’t believe in SIBO diets you can check it out here: https://sibodiaries.com/2016/06/24/why-i-dont-believe-in-sibo-diets/

    Glad to read some divergent thinking in regards to SIBO! Looking forward to part 2!

    • Richard Nikoley on July 4, 2016 at 08:01

      Nice post, Amy.

      Yep, way back when Tim and I were digging into all of this stuff it became clear to me that the first approach would best be to feed way more, way more fibers of various sorts and let the bugs all sort it out amongst themselves. Probiotics can and do help in various ways but the principal fundamental thing is lots of food the good guys like to eat. Let them fight the war for you.

      If it didn’t work this way then everyone would have dysbiosis and nobody would be able to fix it.

      My only quibble would be the no gluten, no grain stance. I do quite well on true whole, unrefined, non-fortified grains of all sorts (including bran and germ, where most of the nutrients are). I have a new porridge I do where one batch is about a half cup of oat groats, 1/4 cup wheat berries, 1/4 whole teff grains. Bring to boil in 3 cups of water, cover and simmer for 35 minutes, then stir in 2 TBS of oat bran and 2 TBS wheat germ.

      Then I stir in a pat of butter and top with either raw honey or maple syrup. Half that batch lasts all day, even doing a 10-mile trail hike with multiple ascent and descent, no provisions except water. My wife eats the other half, same result. It’s now our go-to breakfast any time we’re going to be very active, like hikes, working in the yard, big house cleaning, etc.



    • Karl S on July 5, 2016 at 06:10

      Great post, Amy!
      I agree with all your points raised; in particular with your points 1, 3 (not only micronutrient deficiency via exgoenous/dietary deficiency but also the indirect drop of endogenous/intestinal vitamin synthesis due to drop in gut bacteria diversity and number), and 5.
      Having trialled VERY low FODMAP diets for extended periods of time I have witnessed fingernail abnormalities. About 3 different types, at one time or another, ha! (vertical ridges, horizontal ridges, and flattening). It was very odd. Never had these before and they started within a couple months of beginning v.low FODMAP.
      I also had an occasional pure white hair among my dark brown hair. It wasn’t grey or anything like that. It was stronger, thicker, pure white strand. I can’t be sure, but it seems very likely these were related to deficiency in exogenous or endogenous (intestinally produced) vitamins. It may have been something akin to thiamine deficiency due to the high consumption of white rice with no significant sources of B1 in my diet. I’ve noticed these pure white hairs very commonly in Chinese people. I always had a bro-science hunch it was related to rice intake. Maybe it was thiamine deficiency…. I got them as soon as the mountains of white rice started being consumed. Maybe it’s totally unrelated. I’ve not researched it at all!

      The low FODMAP diet is not sustainable LONG TERM for those reasons alone. It is also likely to make you more sensitive to the offending FODMAPs (and create newly offending FODMAPs) when you reintroduce them. Although transiently, in some cases.
      Simplest example is when people acquire lactose intolerance when they discontinue milk consumption. Some may say the genetic expression for the lactase enzyme is being switched off (and back on again if you regain tolerance), but I think it is far more likely to be a microbiotic shift. Ugandans are well aware that when they start drinking litres per day of the Rwandans fresh milk that they will have diarrhoea for a couple days and then BAM, it disappears and they can drink litres with no problem whatsoever (milk in US will be different.. lactulose, etc.). This will need to be repeated any time they take more than about 2 weeks off from dairy. Another hunch; but it seems more plausible that this is fluctuation in lactose degrading bacteria, not gene expression. An uninformed guess – little more.

      Low-FODMAP has its uses for short-term rapid action to treat urgent problems, such as pain, bloating, constipation, etc.
      I’m speaking with regards to large intestinal dysbiosis, btw.
      As for SIBO…. well I’d always assumed I did not have SIBO, so I was not experimenting with low-FODMAP with that in mind (I excluded SIBO after taking a crap tonne of Rifaximin only to feel worse gut-wise).

      Thanks for reading and commenting, Amy!
      Kind Regards,
      Karl (Elixa)



    • Amy Hollenkamp on February 10, 2017 at 15:43

      I just saw you guys commented back! Sorry for the 6 month lag lol!! Richard, that is very interesting about grains. Do you feel that there is ever a period of time in which grain elimination is necessary to heal a leaky gut? Or do you think a leaky gut can heal without grain elimination? Thanks again for your feedback!



    • Richard Nikoley on February 10, 2017 at 16:48

      Hi. Amy.

      Well, I’m sure they’re problematic for some, but I don’t think for many. And I also think regular consumption of some helps keep you tolerant.

      There is also a new line of inquiry The Duck Dodgers is looking into that suggests that acute “leaky gut” gluten causes is actually beneficial for the absorption of polyphenols into the bloodstream.

      That said, grain consumption ought to be predominantly whole and non-fortified or enriched.



  6. gabkad on July 3, 2016 at 17:40

    Best to use Stimudents. That’s another thing that’s been moved to China. American basswood is shipped over there, some Americans lost their jobs, the picks are made in China and shipped back. Unfortunate. I think they used to be a J&J product but the factory was sold off, lock, stock, and barrel.

    American basswood is a very soft wood and won’t wear away your teeth like bamboo or pine. Or whatever else toothpicks are made of.

  7. Drini on July 11, 2016 at 00:39

    Great post. Long time reader, but I comment very rarely. After reading the post today, I was wondering what’s your take on appendectomy? I notice that I have many more gut related issues (bloating, brain fog, flatulence, etc.) than people close to me, despite arguably having a healthier diet (more fiber, less refined and junk food), and the only striking difference is that I had my appendix removed in my late teens. I was doing a bit of reading and it turns out the appendix appears to play an important role in our gut’s health and generally in our immune system. Does this mean that for people who had appendectomy curing dysbiosis will take greater effort and time? Keen to hear everybody’s thoughts!

    • Karl S on July 13, 2016 at 03:48

      Hi Drini,
      In my opinion, it may reduce your ability to *recover* from antibiotics and/or GI infections. However, my hunch is that an appendectomy would not initiate a dysbiosis in the first place. In fact, even the prophylactic antibiotics administered during the operation may be a far more significant factor than the removal of the appendix, per se.
      While my understanding of the appendix needs much work – I would guess that the following factors would be more likely to set you up for these gut problems despite your healthy diet (‘healthy’ being contextual; based on the incumbent flora):
      — C-section birth,
      — Courses of antibiotics at any time in your life,
      — ‘Dysbiotic’ breast milk (due to the mother’s intestinal dysbiosis),
      — Lack of breast feeding,
      — And, finally, inoculation with dysbiotic flora from the mother during birth (due to antibiotics given during pregnancy or otherwise)

      In terms of whether it will affect the time/effort required to correct the dysbiosis. Once again I am not sure on that, however I have another hunch that the historical length of the dysbiosis you are trying to cure plays one of the largest roles in determining how easy it is to recover.
      I have known of many people who have taken antibiotics without an appendix and gotten AAD or other gut problems and they have bounced back very easily simply just waiting it out or taking just a single pack of Elixa.
      (Most recently, someone took doxycycline for acne and ended up with some severe gut problems after the course. He took just one pack of Elixa and was fine from then onwards. In fact, his indifference and lack of surprise to the dramatic resolution was comical to me. Like he just expected it… Little does he know that some have been stuck with these conditions for years, not days!)

      So those with stubborn lifelong IBS-D (for example) may have much milder D, but have a much harder time shifting it.
      It may be related to a decreased immune response if a pathogen is present for long enough without either (A) being removed or, (B) causing severe problems or death. (I.e. something chronic + ‘benign’)
      I’ve forgotten the medical term for that…
      Kind Regards,
      Karl (Elixa)



  8. Sarah on July 16, 2016 at 16:48

    I’ve got a lot of the SIBO symptoms listed in this article, extreme bloating and sensation of fullness one hour after eating and constipation being the worst ones.

    I did two courses of Elixa, each time it made my symptoms worse!

    The effect is not unique to Elixa, all probiotics seem to make my constipation worse but with it being so potent the effects were magnified, any suggestions as to what is going on?

    • Karl S on July 18, 2016 at 12:43

      Hi Sarah!
      Thank you for reading 🙂

      Maybe you DO have Sibo.

      Quick Q: was it only the constipation that probiotics exacerbate? Or is it also the bloating and gas?

      Kind Regards,
      Karl (Elixa)



    • Sarah on July 19, 2016 at 00:51

      Hi Karl,

      Thanks for replying!

      General exacerbation in all symptoms. But not suddenly, it gradually deteriorated in the weeks after the course.



    • Karl S on July 27, 2016 at 11:42

      Sorry for the slow follow-up on this! I missed it!

      Ok, so the gradual deterioration of the problem implies that this is NOT anything to do with the instantaneous effect of consuming probiotics – such as any gastrocolic reflex or reaction by the lower GIT muscular action to the initial presence of the probiotic (comparable to a nausea reaction initiated by the upper GIT from taking non-encapsulated bacteria).
      It would imply it was a reaction to the bacterial populations themselves as they slowly accumulate from continual usage. Or to the accumulation of population feeding on any excipient in the formula (PS, FOS, etc.).
      Have all the probiotics that resulted in this effect been Lactic Acid bacteria?
      Or to put it another way: Have they been species from the Lactobacillus genus? (and Bifidobacterium genus?)

      Thanks,
      Karl



  9. […] SIBO Part 1: Real Condition or Myth? (22 Comments) […]

  10. Pauline on July 26, 2016 at 01:41

    https://www.newscientist.com/article/2095769-gut-bacteria-spotted-eating-brain-chemicals-for-the-first-time/

    just a side note – for some time now your webpage freetheanimal.com does not open in Safari, only google chrome.

    • Richard Nikoley on July 26, 2016 at 06:58

      It’s complicated, Pauline, but issue is most likely caching on your end, insisting on a secure socket layer connection which we don’t use anymore for a number of reasons. Google how to clear your Safari cache and it should work fine.



    • Richard Nikoley on July 26, 2016 at 07:03

      Also, if you’re using a bookmark or old links, make sure it’s pointed to http://… and not https://



    • Pauline on July 26, 2016 at 10:22

      I cleared the history in Safari and that seems to have done the trick. Thank you .



  11. Pauine on July 26, 2016 at 07:37

    Well it worked today, so maybe it was the old version or link I had been using – but google chrome is fast and Safari is much slower generally, so I use both 🙂 for different things

  12. Ana on February 9, 2017 at 03:28

    Hi Richard and Karl,

    Thanks for the great article.
    Has part 2 been published yet? A search on this site didn’t pull anything up.
    Thanks!

  13. Peter Hyme on August 10, 2018 at 16:48

    Interesting. What do you think about studies and reports indicating that SIBO can be caused by malfunctions in gut motility? Is that just dysbiosis then? I would think that if the motility in the gut is affected then the entire gut is affected and there would be dysbiosis through the gut and not just the small bowel.

    Do you think SIBO is turning out to be a term like “chronic candida” that people use to encapsulate every problem known to man and blaming it?

    What about tests that show IBS patient having no result on a breath test but SIBO patients showing very high values? I am curious because I have had thought about SIBO for myself and wanted to get tested. I was worried that after a long period of Keto and low fodmap that if I start eating dietary fiber or taking probiotics I would make my hypothesised SIBO much much worse.

    Complicated subject this.

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