There are any number of belly-based ills that can make life very uncomfortable. Ailments like gas, bloating, constipation, diarrhea, IBS or all of the above can, in addition to making you feel lousy, interfere with your body’s ability to get nutrients to where they’re needed, negatively impact your mental and emotional well-being and set you up for serious health problems down the road. One possible underlying cause of all this unhappiness? SIBO, or small intestinal bacterial overgrowth. Trouble is, medical professionals often overlook it or misdiagnose it. How to know if SIBO is the culprit? Here’s a primer on this bad actor and what to do about it:

Digestion in a nutshell.

To understand SIBO, you need to understand the way the digestive system is supposed to work, so for starters: digestion kicks off in the mouth, with your teeth and saliva starting to break down your food, then moving it down to the stomach to continue the process. From there, it’s on to your small intestine, where digestive enzymes break down most of the food we eat, carbs, fats, and protein, into their basic building blocks which are absorbed into the bloodstream and sent throughout the body to nourish it. But slower-digesting dietary fiber passes down to the large intestine or colon – think of it as your own personal bio-reactor – where it’s broken down via fermentation by the trillions of bacteria that live there, gut bacteria that are also key players in the body’s immune system. Then, as digestion heads further south, waste products make their way to the exit door and are eliminated.

Small intestine, big job.

Your small intestine is home to just a fraction of the beneficial bacteria that the large intestine houses, but those bacteria have an important role to play as well. They support the immune system, helping to defend your system against pathogens, and they support the muscular movements that help physically move food through the digestive tract. All good…except when the bacteria population in the small intestine expands beyond healthy limits or becomes too diverse, attracting species that perform useful functions in the colon but gum up the works in the small intestine. And that is SIBO.

A little overgrowth is never good.

As the name suggests, bacterial overgrowth inside the body is never a good thing. The bad bacteria in the small intestine can interfere with nutrient absorption and reduce pathogen defenses. It can also create the kind of cell damage that leads to leaky gut (or increased gut permeability) , along with the ensuing inflammation, autoimmune problems and allergies.

SIBO is a sneaky problem, with many possible causes.

Most of the time, our bodies are pretty good at keeping SIBO at bay, naturally. Fighting the good fight to keep overgrowth in check are your body’s gastric acids; the muscle movements or ‘waves’ that nudge the digestive process along (and down the hatch as it were); a valve that acts as a physical barrier to keep the food you’re digesting heading in the right direction; and even immunoglobulins, which act as protective antibodies. For some people, however, it’s not enough. Some SIBO risk factors are some common conditions and diseases; random, luck-of-the-draw structural defects; and behavioral habits that make it easier for SIBO to get a toe-hold.

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Among the most common culprits:

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• Alcohol use, even in relatively small amounts, i.e., one drink per day, is a usual suspect. It can increase risk by contributing to the cellular damage that can trigger leaky gut.
• The standard American Diet (SAD) which is full of sugar, starchy foods, processed foods and glyphosate sprayed crops
• Frequent use of antibiotics
• Low stomach acid, often caused by the frequent use or overuse of gastric acid suppressing medications, like Nexium, Prevacid, Zantac and Pepsid
• Long term use of oral contraceptives, probably in part due to their tendency to exacerbate IBS symptoms,  and leaky gut issues.
• Smoking, which has also been shown to increase SIBO risk , in addition to all of that nasty habit’s other dangers.

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Other fairly common culprits include conditions like celiac disease; Crohn’s disease, malnutrition, IBS; diabetes or the slow passage of food through the small intestine. SIBO also can be caused by bowel and gastric bypass surgeries, as well as by surgeries used to treat ulcers and stomach cancers, intestinal organ damage caused by cirrhosis, pancreatitis and diverticulosis.

SIBO is tricky to diagnose.

What can also be frustrating about SIBO is simply that it’s tough to diagnose. Many doctors don’t even have SIBO on their radar to begin with, so chances are good they’ll miss it in most patients. Assuming your practitioner is familiar with SIBO, they’ll likely offer a standard breath test, which measures the amount of certain gases emitted by bacteria fermenting in your small intestine. You can also try a DIY home testing kit but, either way, both tests are less than ideal in that their frequent false negative results can add to the problem of misdiagnosis.

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In my practice, SIBO is probably one of the commonest problems I see, so familiarly with its many faces helps a lot with diagnosis. Sometimes helpful is our use of a more specialized test called the ‘Gut Zoomer,’ which gives us more in-depth information about the state of the guts we’re working with – and helps guide our choices of healing protocols, be it for SIBO or a different gut issue altogether.

SIBO symptoms can feel like any number of gut ills.

Another challenge with SIBO is that the usual SIBO symptoms can easily be mistaken for other gastrointestinal problems. Common symptoms include: gas, abdominal pain, nausea, bloating (usually soon after eating), abdominal distention, diarrhea (or constipation), unintended weight loss and uncomfortable feelings of fullness after eating.

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These symptoms are not ‘normal,’ so don’t just grin and bear and hope they’ll pass! It’s essential that you discuss these issues with your doctor and bring up the possibility of SIBO (if they neglect to do so), particularly if symptoms are on-going and especially if you’ve had abdominal surgery in the past.

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So how to know if SIBO is the cause of your troubles? Granted, it’s an imprecise science but if you have one or more symptoms and/or risk factors mentioned above, it’s worth investigating. Though the prevalence of SIBO is thought to be relatively low in the general population, is more prevalent in women, and even more so in middle-aged women. So, if for example, you’re female and suffer with IBS, your likelihood of having SIBO increases dramatically, anywhere from 50% to 80% higher.

Don’t let SIBO win – treat it wisely.

Should your GP or internist decide to treat your SIBO with the standard antibiotic Rifaximin, just say no thanks. Though it does work for a while, SIBO almost always returns shortly after, and you’ll wind up right back on the antibiotic merry-go-round, not to mention the path to antibiotic resistance. Instead of defaulting to antibiotics, I highly recommend you enlist the help of an integrative medicine doctor or integrative nutritionist to create a healthier, non-pharmaceutical treatment plan.

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In my practice, instead of antibiotics, I often prescribe gut-friendly anti-microbial herbs over the course of one to three months, depending on individual’s needs. In my experience, anti-microbial herbs are more effective on SIBO and gentler on the rest of the body than antibiotics. Integrative protocols will often include a combination of health-supportive protocols, such as:

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• Herbal anti-microbial support, like GI MicrobX by Designs for Health with Intestinol by Ortho Molecular, or Candibactin BR with Candibactin AR both by Metagenics
• A low carb diet or a low FODMAP diet, which can be helpful to treat symptoms (but not the root cause of the bacterial overgrowth).
• Stopping alcohol for a few months
• Initially I do not use traditional probiotics, as it tends to worsen the symptoms. Although in some cases, I do use spore-based probiotics.

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How else to best tend your gut and keep ills like SIBO at bay? Check out 10 Essential Ways to Protect Your Gut Microbiome .