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Dysbiosis Has a New Name by Steven Sandberg-Lewis, ND, DHANP and Allison Siebecker, ND, MSOM

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Dysbiosis Has a New Name by Steven Sandberg-Lewis, ND, DHANP and Allison Siebecker, ND, MSOM SIBO: Dysbiosis Has A New Name by Steven Sandberg-Lewis, ND, DHANP and Allison Siebecker, ND, MSOM Many patients with bloating, to excessive numbers, IBS is likely. chances that a patient's IBS is caused by abdominal pain, constipation, or Hydrogen/methane breath testing is the SIBO: diarrhea are diagnosed with irritable most widely used diagnostic method • when a patient develops IBS following bowel syndrome and never get for this condition. Stool analysis has no a bout of acute gastroenteritis adequate responses to treatment. Others value in diagnosing SIBO. (postinfectious IBS); are given no diagnosis at all for their Symptoms of SIBO include: • when a patient reports dramatic suffering, which leads to even less transient improvement in IBS • bloating/abdominal gas chance of recovery. Our experience is symptoms after antibiotic treatment; • flatulence, belching that many of these perplexing patients • when a patient reports worsening of • abdominal pain, discomfort, or cramps have commensal microbial overgrowth. IBS symptoms from ingesting probiotic • constipation, diarrhea, or a mixture of This article details the complex issue supplements that also contain the two of small intestine bacterial overgrowth prebiotics; • heartburn (SIBO) • when a patient reports that eating • nausea SIBO is a condition in which more fiber increases constipation and • malabsorption: steatorrhea; iron, other IBS symptoms; abnormally large numbers of vitamin D, vitamin K, or B12 • when a celiac patient reports commensal bacteria (or other deficiency with or without anemia; insufficient improvement in digestive microorganisms) are present in the small and osteoporosis5 symptoms even when carefully intestine. SIBO is a common cause of • systemic symptoms: headache, following a gluten-free diet; IBS - in fact it is involved in over half fatigue, joint/muscle pain, and certain • when a patient develops constipation the cases of IBS and as high as 84% in dermatology conditions type IBS (IBS-C) after taking opiates; one study using breath testing as the Other diseases associated with • when a patient has a chronic low diagnostic marker.2 It accounts for 37% SIBO include hypothyroidism, lactose ferritin level with no other apparent of cases when endoscopic cultures of intolerance, gallstones, Crohn's disease, cause; aerobic bacteria are used for diagnosis.3 systemic sclerosis, celiac disease, • when abdominal imaging reveals a Eradication of this overgrowth leads chronic pancreatitis, diverticulitis, large gas accumulation obscuring the to a 75% reduction in IBS symptoms.4 diabetes with autonomic neuropathy, pancreas Either bacterial overgrowth or the • when small bowel follow- fibromyalgia and chronic regional pain overgrowth of methanogenic archaea through imaging reveals areas of syndrome, hepatic encephalopathy, leads to impairment of digestion "flocculation."22 non-alcoholic steatohepatitis, interstitial and absorption and produces excess cystitis, restless leg syndrome, acne quantities of hydrogen, hydrogen Mechanisms by Which Overgrowth Is rosacea, and erosive esophagitis.6~21 sulfide, or methane gas. Hydrogen and Prevented Based on clinical experience, we methane are not produced by human An important protective mechanism suspect that biliary dyskinesia and cells but are the metabolic products against SIBO is proper small intestine lymphocytic colitis may also be of fermentation of carbohydrates by motility via the migrating motor associated with SIBO. intestinal organisms. When commensals complex because stasis promotes In our practices we have found that (oral, small intestine, or large intestine bacterial growth.23 Also key in the following indicators increase the flora) multiply in the small intestine prevention are gastric, pancreatic, > TOWNSEND LETTER - FEBRUARY/MARCH 2015 BEST OF NATUROPATHIC MEDICINE 67 SIBO pneumonia 24%, and Proteus mirabilis pacemakers for the migrating motor 6.5%.36 Colonic hydrogen production complex (MMC). A key underlying > is believed to be anti-inflammatory and cause of SIBO is thought to be antineoplastic, whereas excessive small deficiency of the MMC, which moves and gall bladder secretions, since intestine hydrogen causes the symptoms debris and bacteria down into the hydrochloric acid, enzymes, and bile and signs of diarrhea-type irritable large intestine during fasting at night are bactericidal/static.24 Conditions that bowel syndrome (IBS-D).37 In addition and between meals.47 The number of disrupt the glycocalyx and microvillus to bacteria, the source of methane ICC is reduced in post-Campylobacter portions of the brush border may fuel generation in SIBO is the archaeon jejuni gastroenteritis infected rats that overgrowth. The pathophysiology Methanobrevibacter smithii. This eventually develop SIBO.48 Three involved is the loss of disaccharidases organism has been linked to obesity in months after C. jejuni gastroenteritis, in these areas and the resulting humans.36 In addition, sulfate-reducing 27% of rats had SIBO. These rats had carbohydrate malabsorption which bacteria, such as Desulfovibrio species, a lower number of ICC than controls in provides excess substrate for microbial are anaerobes that reduce sulfate to the jejunum and ileum (0.12 ICC/villus growth. The role of proper ileocecal hydrogen sulfide (H2S). In addition to was the threshold for developing SIBO). valve function in preventing cecoileal its role in SIBO, H2S is being studied as CDT toxin may destroy the interstitial reflux of colonic bacteria into the small a possible etiologic factor in ulcerative cell of Cajal by stimulating the intestine may also be important.25-26 colitis and colonic carcinogenesis.39 In production of autoantibodies against a Surprisingly, a recent study suggests normal low levels H2S has Gl protective cytoskeletal protein known as vinculin. that surgical removal of the gall bladder activity.40 The antigen-antibody complexes reduces the risk as well.27 Mucosal between antivinculin antibodies and biofilms may be preventive or may be Pathophysiology of SIBO: cytolytic distending toxin lead to a risk.28-29 Heavy drinking, as well as Autoimmunity autoimmune destruction of ICC.49'50 moderate use of alcohol, is significantly Postinfectious IBS (PI-IBS) has been associated with increased SIBO risk.30 shown to have an autoimmune etiology How SIBO Causes the Symptoms of The use of proton pump inhibitors in both murine and human studies IBS encourages overgrowth, especially of (see figure 1). Infectious gastroenteritis There are two main the hydrogen-producing type.31-32 is the most significant environmental pathophysiological issues involved risk factor for IBS.41 Organisms that in SIBO. First, bacteria can ferment Definition trigger PI-IBS include Campylobacter, carbohydrates and consume other Traditionally, >105 colony-forming Salmonella, Shigella, E. coli, viruses, nutrients ingested by the host simply by units (CFU) per m!_ of proximal jejunal and Giardia.42-45 their inappropriate location in the small aspiration has been the definition of Cytolethal distending toxin (CDT) intestine. This allows them premature SIBO in culturing studies. >103 CFU is produced by enteric pathogens that exposure to host nutrition before is now the suggested definition from cause PI-IBS. Campylobacter jejuni there is time for absorption. Bacterial more recent studies revealing that < 103 is the prototypical bacterium that fermentation produces hydrogen and/ CFU is the normal level in healthy produces CDT.46 Other bacteria that or hydrogen sulfide gas. In addition M. controls.33-34 The bacteria which are produce CDT include Haemophilus smithii produces methane.51 M. smithii most commonly overgrown are both ducreyi (chancroid), Aggregatibacter may be present in the intestinal tracts of commensal anaerobes - Bacteroides actinomycetemcomitans (periodontitis), up to 95.7% of humans.52 Microbial gas 39%, Lactobacillus 25%, Clostridium Escherichia coli (traveler's diarrhea), leads to the IBS symptoms of bloating, 20% - and commensal aerobes - Shigella dysenteriae (dysentery), pain, altered bowel movements, Streptococcus 60%, Escherichia coli Salmonella enterica (typhoid fever), eructation, and flatulence (Figure 2). 36%, Staphylococcus 13%, Klebsiella and Campylobacter upsaliensis The quantity of gas may be extensive, 11%.35 A more recent study found the (enterocolitis). causing severe bloating and distention.53 aerobes to be Escherichia coli 37%, The interstitial cells of Cajal (ICC) It is estimated that with normal levels of Enterococcus spp 32%, Klebsiella are fibroblast-like cells that act as enteric flora, the quantity of lactose in an ounce of milk fuels the production of 50 Figure 1 cc of gas. With microbial overgrowth, gas levels produced from 1 ounce of milk may approach 5000 cc.54 Excess gas can then exit the body as flatulence or eructation. A portion is also absorbed into the blood and eventually filters through the pulmonary alveolus to exit on exhalation. The intestines are sensitive to pressure, and therefore the pressure of distention can lead to abdominal pain. In addition, visceral hypersensitivity, a feature of IBS, may 68 BEST OF NATUROPATHIC MEDICINE TOWNSEND LETTER - FEBRUARY/MARCH 2015 create a lower threshold for pain/ and systemic symptoms induced by SIBO discomfort and a hyperresponsiveness these changes are listed in Figure of muscular contraction in response to 3. Key factors include bacterial the gas, leading to cramps.55'56 The gases deconjugation of bile, which induces and immediately analyzed at a lab,
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