# SIBO Small intestinal bacterial overgrowth (SIBO) is a common comorbidity in ME/CFS and may cause symptoms indistinguishable from irritable bowel syndrome (IBS). To test for SIBO, patients are often referred to a gastroenterologist for testing. However, in my experience, patients often have difficulty getting testing done through GI departments. The wait can be long, the fee expensive, and GI providers often treat empirically anyway. Dysbiosis is an umbrella term for "messed up gut microbiome." Someone who does not have SIBO may still have underlying dysbiosis that needs correcting. # Laboratory Findings Associated with SIBO - B12 deficiency - Consumption of B12 by anaerobes - Malabsorption due to competitive binding with bacterially generated metabolites of cobalamin - (in more severe overgrowth) mucosal injury - Thiamine deficiency - Nicotinamide deficiency - Fat and fat-soluble vitamins >> steatorrhea - Deconjugation of bile acids >> depletion of the bile acid pool - Elevated total bilirubin # Testing for SIBO It is not uncommon to skip testing and treat SIBO empirically based on symptoms. One reason this route is chosen is because the breath test has a decently high false negative rate and treatment for SIBO is pretty low risk. If you do want to test for SIBO, I recommend paying $200 cash for the hydrogen and methane breath test provided by [Metabolic Solutions](https://www.metsol.com/hydrogen-breath-test/small-intestinal-bacterial-overgrowth/). Testing for both hydrogen and methane increases test sensitivity. # Treatment for SIBO ## Oregano Oil One over the counter option for SIBO treatment is oregano oil. The [A.D.P by Biotics Research](https://amzn.to/4bX6l8Q) brand uses emulsified oregano oil which is the best quality. I generally choose this route instead of prescription antibiotics because it is just as effective and also has antifungal properties which is helpful if SIFO (small intestinal fungal overgrowth) is present. ### Recommended Dose ADP 5 tablets three times a day for a week and then 3 tablets three times a day for the following four weeks. This is a total of 357 tablets which, at $36 for 60 tablets, adds up to $216 for a full treatment. This is not feasible for many patients. ### Alternative Regimens Include ADP 2 capsules three times daily for 4 weeks ($108) ADP 2 capsules twice daily for 4 weeks ($72) [400 mg oil of oregano](https://amzn.to/4iKLN64) twice daily for 4 weeks ($10). This brand has worked for other patients of mine and is much cheaper than ADP but may be less reliable. ## Fasting and Elemental Diets Though I have not used this method personally it is worth noting, if no other reason than to mention the dangers that can accompany it. This method should not be used in patients with fasting intolerance until that intolerance is addressed. For patients who are underweight and struggling to eat this may not be the best option either. Elemental diets may give a similar effect but can cause some people to crash severely, possibly due to die-off reactions. ## Low Fermentation Diet The low fermentation diet consists of two parts: 1. Avoiding foods that feed gut bacteria 2. Allow 4-5 hours between meals to allow for peristalsis (the gut’s cleaning waves) The diet is designed to be less restrictive than a low FODMAP diet and just as effective. Peristalsis only occurs when fasting so eating too often can contribute to sluggish digestion and SIBO. This means that you should not snack between meals at all, but allow a full 4-5 hours to elapse before you eat again. Foods to Avoid: - Non-absorbable sugars (sucralose, sorbitol, lactitol, xylitol, mannitol, stevia) - High fiber foods - Foods high in inulin - Lentils and legumes (peas, soy beans, etc.) - Dairy products (milk, yogurt, cheese) You can find a complete list of approved foods and foods to avoid at [Goodlife.com]( https://goodlfe.com/pages/lfe-sibo-food-list) [Low Fermentation Diet Eating Guide](https://goodlfe.com/pages/low-fermentation-eating?srsltid=AfmBOorAx2G_dfIbWFY7hFpAaJqoyoMoXfDEB_c7Itkey7V2egowWgTE) [Guide to reintroducing food after elemental diet SIBO treatment](https://cdn.shopify.com/s/files/1/0611/0078/5860/files/Good_LFE_x_mBIOTA_Elemental_Diet_Transition_Guide.pdf?v=1740605951&utm_source=Transition%20Guide&utm_medium=email&utm_campaign=Transition%20Guide%20%28UTPK4w%29&_kx=7jpgpXN6Ej096vICUGdvRlQo8F63yFRebwn6tQTb4Gw.XDfwuB) # Aftercare Treat [[Publish/Patient Resources/Dysmotility|Dysmotility]] if indicated - during or immediately after SIBO treatment, I recommend starting Low Dose Naltrexone or Motilipro by Pure Encapsulations (other options are Iberogast and Motility Activator by Integrative Therapeutics). These prokinetic agents will increase gastrointestinal motility, reducing the likelihood that SIBO will reoccur. Despite this precaution, SIBO regrowth is common and more than half of patients will require a second treatment. Prokinetic therapy may be more important in those who have mycotoxicity, history of gastroenteritis or [[Hypermobility|hEDS]] because these conditions are associated with a sluggish major motor complex. It may be less important when SIBO is a result of [[Celiac Disease]] or other malabsorption disorder. If malabsorption or poor digestion is the more likely root cause of SIBO, digestive enzymes are indicated. Some may benefit from HCl (stomach acid) supplementation with meals.