Small intestinal bacterial overgrowth, or SIBO, comes in a few different forms. Hydrogen dominant SIBO is more common but in my practice I tend to see patients with methane dominant SIBO. I suspect this is due to the stubborn and treatment resistant nature of some methane SIBO cases. Many people that come to the Byron Herbalist clinic are still looking for answers after having tried all the standard stuff including antibiotics, herbal antimicrobials and dietary changes. Today I wanted to share a success story from a patient with quite stubborn methane dominant SIBO.
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Let’s call this patient Chris – privacy is important and he has ok’d me sharing his results. Chris presented at the clinic with a number of tests including a SIBO breath test and an extensive stool test. He had been working with a functional medicine Dr and a mould specialist with moderate success on the symptom front. Below you can see a SIBO breath test showing moderate amounts of methane. Whether this is methane in the small bowel (a rise of 15ppm at the 90 minute mark) or it is simply too much methane being produced in the large bowel, large intestinal methane overgrowth, or LIMO, the symptoms were all there to encourage treatment. These symptoms, common enough with methane SIBO, included constipation, slow gut transit time (from mouth to toilet bowl) and bloating when he ate the wrong foods.
I have recently discussed methane LIMO and methane excess in general on the Wellness By Design Podcast with Andrew Whitfield-Cook. Have a listen for more of an overview.
If we wanted to get specific on whether Chris was methane SIBO positive I would order a fructose breath test – my favourite Australian SIBO lab here – as well as a glucose breath test to get full coverage. At the moment I have dropped the glucose breath test for most patients as it adds extra and often unnecessary expense to treatment.
Chris had been thoroughly worked up and treated well by his past practitioners but there were gaps in his treatment plans. Before jumping to conclusions and assuming that Chris was clear of SIBO – he still had persistent symptoms – I ordered another lactulose breath test. My thinking here was that the first lactulose breath test has picked up the excess methane so comparing apples to apples was the best approach.
Unsurprisingly Chris’s second SIBO breath test, performed before we had started any new treatments was slightly worse on the baseline methane front. We saw a jump of 18ppm in the methane being produced before he consumed the lactulose test sugar.
Why the increase in methane between tests?
Shouldn’t the methane have at least stayed the same if not decreased after an antimicrobial protocol from the past practitioner?
There are a few reasons why methane may have risen even though he had persisted with his past treatment plan from his previous practitioner including antimicrobial herbs and enzymes.
With most methane producers, slow gut transit time is a killer. Whether they are experiencing constipation, normal bowel movements or even loose and watery diarrhoea it is still crucial to track how long it is taking for food to pass from the mouth to the toilet bowl. It is cheap data and can be performed at home on a regular basis to track progress. The other major symptom that may be causing the stubborn methane SIBO/LIMO picture was the unresolved constipation.
Many of my patients come to me after months, or even years, working on their digestive health issues. In every intake we spend valuable time reviewing past treatments. Why?
The last point is important with methane positive SIBO.
Often I see previous treatment plans that haven’t focused on presenting symptoms like constipation. Treating the root cause is important, don’t get me wrong, but in most cases of methane SIBO proper bowel movements and completely emptying the bowels can be a major game changer for a person’s symptoms.
The other important thing here is that properly emptying the bowels can also reduce methane production. I’m still not 100% sure why and I haven’t seen any studies to support what I see clinically but I have my theories.
Stubborn Methane SIBO treatment protocol
With Chris we had a clear picture of excessive methane production, most likely in his large bowel. Working together I also had a clear picture of past treatments that had clearly come short.
Now just a caveat, this is holistic medicine. The following treatment plan is specific for Chris. I dislike the concept of protocols when dealing with chronic and difficult to treat conditions like SIBO, especially those that have failed past treatments.
For Chris, my recommendations were
- A low FODMAP prebiotic fibre to help feed butyrate producers in his large bowel. This is a long term approach and would not generally work on its own but it does help to slowly normalise.
- Higher dose magnesium before bed to ensure proper bowel movements the next day
- Bifidobacteria combo probiotic
- Herbal medicine tincture comprised of
- Rock rose (Cistus) – high dose
- Rock rose is a potent biofilm buster, commonly used in Lyme disease treatment. It also has antibacterial, antifungal and mycotoxin reducing properties.
- I really like rock rose and am using it more and more in my treatment resistant methane patients. It can be a harder medicine to work with and some more sensitive patients can react to this herbal medicine.
- Ginger (Zingiber officinale) – higher dose
- Ginger is a potent anti-inflammatory herbal medicine, it also helps support gut motility, is mildly antibacterial and can help to improve bloating and distention in some.
- Turkey rhubarb (Rheum palmatum) – moderate dose
- With a moderate amount of anthraquinone glycosides, turkey rhubarb is well known as a laxative. It also has prokinetic actions helping to speed gut motility and the tannins and glycosides are anti-methanogenic too!
- Not a herb to use forever, but in the initial phases of stubborn methane treatment this herb can be a gamechanger!
- Zhi shi aka Immature bitter orange (Citrus aurantium) – moderate dose
- Immature bitter orange comes from the Chinese materia medica. It is a potent gut motility herb.
- Clove (Syzygium aromaticum) – moderate dose
- As potent antibacterial, antifungal and antiparasitic herb clove gets a lot of use in my clinic. It can be hard to stomach but if it is tolerated higher doses can help to shift the gut terrain back to balance.
- Clove is also a beautiful spasmolytic. I find it can help with excess gas, bloating, and even visceral hypersensitivity.
- Guava (Psidium guajava) – moderate to low dose
- Guava is a new addition to my herb lab so I am just beginning to form a relationship with it and understand its nuances. So far I have appreciated its actions as an antimicrobial and for certain food reactions and sensitivities.
- Guava is full of certain essential oils, flavonoids, saponins and tannins. A perfect combo for gut microbiome restoration and rebalancing.
- Licorice root (Glycyrrhiza glabra) – low dose
- Licorice is a potent antiinflammatory herbal medicine. It is also very helpful for synergising herbs. Lately I have been dry frying our organic licorice root before I manufacture the herbal tincture. Energetically
- speaking this helps to warm up the otherwise cooling nature of licorice root. If I could find a way to honey fry it as my Chinese Medicine colleagues do before grinding it and turning it into a tincture I would.
- Rock rose (Cistus) – high dose
So there you have it, a pretty simple approach including a prebiotic, a probiotic and herbal medicine as the core treatment plan. This is the trifecta that I have seen work again and again to improve digestive symptoms and lab readings.
Prebiotics, probiotics and herbal medicine are the trifecta that get many of my patients feeling better.
As Chris was very motivated he opted to test one month after starting the treatment. I generally prefer to maintain tolerated therapies for 2-3 months at a minimum for methane SIBO cases but was happy to order the test and continue treatment after the test.
Results below show a significant reduction in methane production from baseline through to when lactulose hits the large bowel. There is still enough methane being produced in the small bowel (the jump from baseline of 4 to 15 at 60 minutes) plus there is the resulting elevation in hydrogen in the small bowel which can happen in certain cases when you clear methane.
Why The Hydrogen SIBO results above?
As always when there is excessive methane being produced there are always hydrogen producers hiding underneath the elevated methane breath test results.
Methane (CH4) needs hydrogen (H2) to be made.
Often herbal treatments can clear both the methane and hydrogen excess in the small bowel. Occasionally when you clear methane patients can become more bloated and distended. This is why follow up testing at certain junctions is so important, especially when symptoms haven’t completely resolved.
To myself and to Chris the results above are a major win. The methanogens leading to his constipation, bloating and slow gut transit time cleared in a significant manner, quickly.
Recommendations beyond this breath test result included a shift of herbal medicine towards the hydrogen SIBO side of things, even though he was close to symptom free and starting to enjoy foods that would have caused bloating in the past. With SIBO I feel it pays to treat just a tad longer than you feel necessary, there is nothing worse than symptom regression, especially when there has been good progress made.
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Are you struggling with digestive issues like bloating, abdominal pain, constipation or diarrhoea? Consider working with me here at Byron Herbalist. I offer one-on-one consultations via video conferencing to patients throughout Australia and New Zealand.
Now over to you. Are you struggling with stubborn digestive symptoms? What has helped? Leave a comment below to join the conversation!