What is Irritable Bowel Syndrome?

Irritable bowel syndrome (IBS) is a common chronic disorder that affects the digestive system. It is characterized by abdominal pain, cramps, bloating, gas, and diarrhea or constipation, or both. It can be further classified by diarrheal-type (IBS-D), constipation-type(IBS-C), or mixed type (IBS-M)

The Rome IV criteria for IBS are as follows:

• Recurrent abdominal pain, on average, at least one day per week in the last three months, associated with ≥ 2 of the following criteria:

  • Related to defecation

  • Associated with a change in frequency of stool

  • Associated with a change in form (appearance) of stool

IBS is also diagnosed by ruling out other medical conditions that can cause similar symptoms, such as celiac disease, inflammatory bowel disease (IBD), and colon cancer.

Recently, two tests IBS-Smart and IBSChek have been developed to detect two anti-bodies (anti-CdtB and anti-vinculin), which are elevated in the majority of patients with IBS-D & IBS-M after having an episode of gastroenteritis. However, these markers are not diagnostic.

What is SIBO/SIFO?
Small intestinal bacterial overgrowth (SIBO) is a condition in which an excessive number of bacteria are present in the small intestine. The small intestine is the part of the digestive system that is responsible for absorbing nutrients from food. When there is an overgrowth of bacteria in the small intestine, they can compete with the body for nutrients and cause the production of Hydrogen (diarrhea-causing) and Methane (constipation then diarrhea causing). The symptoms vary between the gas produced but they include:

• Abdominal pain

• Bloating

• Gas

• Diarrhea

• Constipation

• Malnutrition

• Weight loss

Small intestinal fungal overgrowth (SIFO) is a condition in which an excessive number of fungi are present in the small intestine. Fungi are normally present in the small intestine in small numbers, but an overgrowth can lead to a variety of symptoms, including:

• Abdominal pain

• Bloating

• Gas

• Diarrhea

• Constipation

• Nausea and vomiting

• Fatigue

• Brain fog

• Mood swings

Possible causes of IBS, SIBO, and SIFO:

The exact cause of SIBO and SIFO may not be, but there are a number of factors that can contribute to these conditions, including:

• Anatomical changes in the small intestine, such as strictures or adhesions

• Reduced stomach acid production

• Impaired motility of the small intestine

• Medications that suppress stomach acid or impair motility

• Certain medical conditions, such as diabetes, hypothyroidism, and HIV/AIDS

• Use of antibiotics

Timeline for SIBO Treatment and Recovery

Treating SIBO involves several stages, each with specific goals and timelines. Here’s a general timeline of what patients might expect during their treatment journey:

1. Initial Diagnosis and Evaluation (Week 1)

• Symptom Assessment: Patients typically visit a healthcare provider after experiencing symptoms such as bloating, abdominal pain, diarrhea, or constipation.

• Diagnostic Testing: Breath tests (hydrogen and methane) are the most common diagnostic tools used to confirm SIBO. These tests measure the gases produced by bacteria in the small intestine.

• Initial Consultation: Based on symptoms and test results, the healthcare provider will recommend an appropriate treatment plan, which may include antibiotics, dietary changes, or further testing to identify underlying conditions.

2. Antibiotic or Herbal Treatment Phase (Weeks 2-4)

• Antibiotic Therapy: If prescribed, a typical course of antibiotics like Rifaximin lasts about 10-14 days. For methane-dominant SIBO, a combination of Rifaximin and Neomycin may be used.

• Herbal Treatment: Herbal antibiotics may be used instead of or in addition to pharmaceutical antibiotics. Herbal protocols often last longer, typically 4-6 weeks.

• Symptom Monitoring: During this phase, patients may start to see symptom improvement. However, it’s common for symptoms to fluctuate as bacteria are being killed off.

3. Dietary Adjustments (Weeks 2-6)

• Low FODMAP or SCD Diet: These diets are usually started alongside antibiotic or herbal treatments to reduce symptoms and starve the bacteria. Diet changes are typically maintained for the duration of the treatment and sometimes beyond, depending on the patient's response.

• Elemental Diet: If used as a primary treatment, the elemental diet is usually followed for 2-3 weeks. It may be used as a follow-up to antibiotics or herbal treatments if symptoms persist.

4. Prokinetics and Lifestyle Modifications (Weeks 4-8 and Ongoing)

• Introduction of Prokinetics: Once the active bacterial overgrowth has been reduced, prokinetics may be introduced to help maintain gut motility and prevent SIBO recurrence. These medications are often continued for several months or longer.

• Lifestyle Changes: Patients are encouraged to implement long-term changes such as meal spacing, stress management, and regular exercise. These practices help support digestive health and prevent SIBO recurrence.

5. Post-Treatment Evaluation and Maintenance (Months 2-6)

• Follow-Up Testing: Depending on the severity of SIBO and the patient's response to treatment, follow-up breath tests may be conducted 4-6 weeks after completing antibiotics or herbal treatments to assess whether SIBO has been resolved.

• Symptom Reassessment: The healthcare provider will reassess symptoms and may adjust the treatment plan based on the patient's progress. If symptoms persist or recur, additional rounds of treatment may be necessary.

• Long-Term Dietary Management: Some patients may need to continue a modified diet long-term to maintain symptom relief. This might involve a less restrictive version of the Low FODMAP or SCD diet, gradually reintroducing foods while monitoring symptoms.

6. Long-Term Monitoring and Prevention (Ongoing)

• Ongoing Care: SIBO has a high recurrence rate, so long-term monitoring and management are crucial. Patients may need periodic check-ins with their healthcare provider to monitor symptoms and adjust treatments as needed.

• Prevention Strategies: Continued use of prokinetics, attention to diet, and addressing any underlying conditions (such as hypothyroidism, diabetes, or structural issues) are key to preventing recurrence.

• Re-treatment: If SIBO recurs, the treatment process may need to be repeated. The timeline for re-treatment is typically similar to the initial treatment phase.

The SIBO Journey

SIBO treatment typically spans several weeks to months, starting with diagnosis and progressing through active treatment, dietary adjustments, and long-term management to prevent recurrence. The journey is individualized, with some patients requiring additional rounds of treatment or ongoing interventions to maintain symptom relief. Working closely with a healthcare provider throughout this timeline ensures that the treatment is tailored to the patient's specific needs and responses.