Panel of SIBO experts – Free Video

Join Dr Nirala Jacobi, Dr Alyssa Tait, Dr Allison Seibecker, Rebecca Coomes, Dr Jason Hawrelak, and Dr Iggy Soosay, for their Q&A Panel captured at the SIBO Summit 2016 in Melbourne.

SIBO Summit attendees were invited to engage with the experts, and to ask questions about their own cases.

Some of the topics discussed include:

  • Salicylate and histamine sensitivity treatment.
  • SIBO testing guidelines for children.
  • Treatment suggestions for Hydrogen Sulfide.
  • When is SIBO testing indicated, and when is stool testing indicated.
  • Opioids as risk factors for SIBO development, slowing the motility of the small intestine.
  • Pain management options that do not hinder the motility of the gut.
  • Fecal microbial transplants.

And much more..

Head on over to SIBO Summit for your free access to this panel, and listen in on the vast array of topics discussed that are relevant to SIBO practice.

Of course you’re always welcome to make use of our Practitioner Education Portal as well.

In health

SIBOtest Team

Advanced SIBO Treatment – How To

dr niralajacobi SIBOtest

Dr Nirala Jacobi, ND, leading expert in SIBO and IBS, international speaker, clinician, founder and medical director of SIBO Summit, spoke at the recent SIBO Summit.

In her talk, Dr Jacobi highlights

  • Advanced SIBO treatment.
  • The Bi-phasic Diet and how to use it.
  • Histamine and salicylate intolerances.
  • Herbal antimicrobials for small intestinal bacterial overgrowth (SIBO) and small intestinal fungal overgrowth (SIFO).
  • Malnutrition and deficiencies due to upper gut infection (SIBO).
  • How to attend to clients who are allergic to everything.
  • Therapeutic sequencing in SIBO treatment – eg when to use gut healers, enzymes, digestive aids, antimicrobials etc.
  • Specific formulas that Dr Jacobi recommends for treatment.
  • How to stimulate the migrating motor complex (MMC).
  • Customising treatment to the patient’s needs.
  • The recipe to Dr Jacobi’s famous herbal bitters formula

To walk through comprehensive advanced SIBO treatment with Dr Jacobi, head to SIBO Summit.

Of course you’re always welcome to make use of our Practitioner Education Portal as well.

In health

SIBOtest Team

The Prebiotic & Probiotic Controversy

Dr Hawrelak SIBO Summit 2016

Do we use prebiotics and probiotics in SIBO management?

Dr Jason Hawrelak, world renowned gastrointestinal health researcher, educator, clinician, and gut microbiota expert (founder and head of research at Probiotic Advisor), joined us at the SIBO Summit to discuss this controversial topic.


  • Are they effective
  • Are they ineffective?
  • Do they make SIBO worse?


In his talk, Dr Hawrelak highlights

  • The Prebiotic & Probiotic Controversy – do we or don’t we use this therapy in SIBO treatment?
  • Study analyses and exciting insights, such as there being a 700% increase in SIBO risk for people taking Proton Pump Inhibitors.
  • Strain specific probiotic use and the potential for amelioration of SIBO symptoms.
  • The range of probiotic actions, and how probiotics can help resolve SIBO.  For (a very brief) example, some stimulate the MMC, help heal leaky gut, have selective antimicrobial action, decrease intestinal inflammation, reduce visceral hypersensitivity, and enhance secretory IgA production.

To access your 1 hour and 27 minutes with Dr Hawrelak head to SIBO Summit.

Of course you’re always welcome to make use of our Practitioner Education Portal as well.

In health

SIBOtest Team

60% of IBS caused by SIBO

IBS is the most common gastrointestinal issue in the world, and studies have shown that 60% of IBS is caused by SIBO.

Do you want to know more about how to help your patients with this?

Dr Allison Siebecker, a world renowned SIBO specialist and pioneer of SIBO investigation, shares her insights with us.

Below is a little taste of Dr Siebecker’s talk.  To access your comprehensive 1.5 hour session with Dr Siebecker head to the SIBO Summit page.


  • SIBO is an overgrowth of normal bacteria in the small intestine, not pathogenic bacteria.  The issue is location, not bacterial type.
  • Digestion and absorption as a factor for the patient, due to bacteria competing with the host for food.
  • SIBO and the LPS relationship to mood disorders.

The Migrating Motor Complex

  • The migrating motor complex (MMC) is essential to normal healthy functioning of the small intestine. Dr Siebecker discusses how it is disrupted in SIBO.
  • The relationship of food poisoning, stress, drugs (such as commonly prescribed proton pump inhibitors), and antibiotics to MMC impairment.
  • Diseases that can cause impairment of the MMC, such as hypothyroidism and diabetes.
  • How important the quantity and integrity of the ICC cells is in the functioning of the MMC.
  • To view the MMC in action head here and click on #13

What causes SIBO?

Dr Siebecker further discusses underlying causes to SIBO, as well as risk factors, such as drugs, surgery, other diseases, lifestyle factors, injury, and genetics.  She also discusses various disorders and diseases associated with SIBO.

Further, Dr Siebecker discusses pathogenic bacteria and how their release of cytolethal distending toxin B (Cdt B) impairs the MMC through molecular mimicry with the vinculin protein in ICC cells.

The above is a brief summary of what Dr Siebecker discusses in the first half hour of her session. To access your full 1.5 hour session with Dr Siebecker, head to the SIBO Summit page.

For further SIBO research and reading, head to Dr Siebecker’s practitioner education website.

Of course we also have the Practitioner Education Portal available to you at any time as well.

In health

SIBOtest Team

Review of the Cedars-Sinai Global outreach symposium on IBS and SIBO conference with Dr. Mark Pimentel

Review by Dr. Nirala Jacobi, ND

This conference took place on Nov 5th in Los Angeles, CA and was also webcasted.

Prominent speakers included Dr Mark Pimentel and Dr Ali Rezae, Gastroenterologists from the Cedars-Sinai Motility clinic, and Dr Ruchi Mathur, an Endocrinologist at Cedars- Sinai.

I will highlight only those areas which I found interesting and useful to share.

To purchase the full webcast:

No natural treatments were discussed.  A section on probiotics was (in my opinion) fairly disappointing and a section on low FODMAP diets fairly basic and so will not be covered here.

My COMMENTARY is made where appropriate.  Apologies for the long post but I think it is useful.

General information:

  • It is estimated that the global prevalence of IBS is 11.3%. 60% of all cases of IBS are actually SIBO which means that there are roughly 508 MILLION SIBO sufferers worldwide. We heard from doctors in Korea, Mexico, and the UK and all report various levels of SIBO awareness in their countries ranging quite a bit.
  • Deep sequencing of bacteria in the small intestines of healthy subjects show that bacterial count should be low (less than 1000cfu/ml in the jejunum) but should be diverse. Less diverse microbiomes are linked to IBS
  • Methane is linked to weight gain as is helps hydrogen producers work more robustly and therefore extract calories from food
  • Methane and Hydrogen elevation at the same time (common in SIBO) was found in those IBS patients with the highest BMI
  • Food additives and emulsifiers: In animal studies polysorbate 80 and carboxymethylcellulose were shown to disrupt mucosal/microbial interactions and promote inflammation, obesity, liver dysfunction, and higher body weight
  • Patients treated with Rifaximin: 72% responded to one treatment round, and of those 36% had > 6 months benefit.


Testing- finally some consensus


As anyone who follows SIBO research knows, a major hurdle in this field is the administration and interpretation of breath tests which can differ from study to study.  Many will use lactulose results as a measure of transit time, whereas others will use lactulose as a test substrate.

A North American Consensus meeting, including 8 major medical schools from the US, Canada, and Mexico represented by prominent gastroenterologists finally agreed on a consensus statement on recommendations for breath testing in the diagnosis of SIBO.

These are their guidelines:


  • Fasting 8-12 hours before testing
  • Avoid antibiotics 4 weeks prior to testing
  • No physical activity before testing as this alters the CO2 levels
  • Using 10g of Lactulose and 50-75g of Glucose as substrate
  • PPI’s – no need to stop these prior to testing
  • Prokinetics and Laxatives: stop 1 week before testing
  • Breath testing is NOT a good way to assess oro-cecal transit time (studies implying this have not been reproduced)
  • A flat line throughout the entire breath test on both Hydrogen and Methane is indicative of Hydrogen sulfide gas
  • Methane of 10ppm anytime during the test is positive (see later section on IBS-C)
  • Hydrogen: a rise of 20ppm over baseline by 90 minutes is positive
  • High Hydrogen at baseline (usually considered to be a non-compliant patient who did not follow prep diet protocol).  There is now a thought that this may be a third type of SIBO—a different type of hydrogen producing bacteria.  Stay tuned.



Happy to report that SIBOtest has been following these testing guidelines since the beginning. To now have a consensus statement which validates the Lactulose breath test as a test, not a measure of oro-cecal transit time is a major breakthrough and should ease the minds of some skeptics out there.


  • Methanogenesis is suppressed in inflammatory bowel disease, such as Crohn’s disease and Ulcerative colitis. This is not surprising as hydrogen sulfide can be elevated IBD and this can suppress methane production. A study of 211 IBD patients had the following findings:
    • Excessive Hydrogen production was seen in
      • 6% Crohn’s patients
      • 4% UC patients
      • 9 IBS patients
    • Excessive Methane production
      • 3% Crohn’s disease
      • 1% UC
      • 6% IBS
    • Excessive Hydrogen sulfide (flatline on test)
      • 1% Crohn’s disease
      • 1% UC
      • 2% IBS


IBS-C:  SIBO or Microbial “Bloom”?

  • Methane is produced by the organism Methanobrevibacter smithii. It is now thought that people become constipated  only when methane levels reach a certain threshold. This is a departure from the thought that M.smithii must be eradicated for the treatment of constipation.  The goal now is to get methane levels below 10ppm on breath test. Best outcomes where seen at <3ppm.
  • Methane positive test results: 98% of the time methane on breath testing is elevated from baseline all the way through the testing period. A growing body of researchers and clinicians (myself included) consider this more of an indication of large intestinal M.smithii overgrowth.  Methane which rises on breath testing is indicative of SIBO
  • Prevalence of excessive methane production increases with age
  • As mentioned in the testing section, high methane throughout breath testing is likely to be large intestinal overgrowth (or Bloom) of Methanobrevibacter smithii. Methane will be produced wherever hydrogen producing bacteria are located. This is because methanogens require hydrogen to produce methane.  Hydrogen producing bacteria in the SI is SIBO, but hydrogen producers are common in the LI.


COMMENTARY:  So to recap:

Methane which is high all the way throughout the breath test is SIBO only if methane actually rises over baseline levels, indicating the hydrogen producer are active in the SI

Methane staying high throughout the test without significant rise is likely to be large intestinal overgrowth of M.smithii.

Both methane in SIBO and LI overgrowth causes IBS-constipation (IBS-C) but this is an important differentiation because we would not need as stringent a diet in LI overgrowth and could possibly use fiber therapeutically

We certainly see the methane phenomenon here at SIBOtest. I also had this conversation with Dr Lenny Weinstock at the SIBO symposium earlier this year who agreed that high methane throughout breath testing is possibly a different condition from SIBO and therefore needs different treatment. Stay tuned.

Post-infectious IBS – the most common cause of SIBO

PI-IBS is also known as “primary SIBO”. “Secondary SIBO” is when SIBO occurs from other underlying conditions, trapping bacteria in the SI.

COMMENTARY Dr Allison Siebecker did an excellent overview of secondary SIBO at the recent SIBO Summit.

The case for PI-IBS being the main cause of SIBO has been fairly well proven at this point. As presented in previous webinars and presentations, a case of gastroenteritis with any of the bacteria which release cytolethal distending toxin B (CdtB) can cause damage to the migrating motor complex (MMC) by the production of autoantibodies against vinculin, a major part of the MMC.  These bacteria are Shigella, E.coli, Campylobacter jejuni, C.diff, and Salmonella.

This then means those which have antibodies to vinculin and cytolethal distending toxin B (CdtB) have an actual disease which needs to be managed with periodic antimicrobials when relapse occurs and prokinetics possibly long term

The test which measures anti-vinculin and anti- CdtB antibodies is called IBS check and is not yet available in Australia. If you have a patient who presents with IBS symptoms ever since a case of food poisoning it is very likely that they have primary SIBO. Prokinetics are most important therapy for this type of SIBO.

The newly discovered anti-vinculin antibodies have also been found to be increased in scleroderma, fibromyalgia, pseudo-obstruction, and SLE

PI-IBS – this group is at a much higher risk for subsequent food poisoning, ie the risk of another case of food poisoning increases 3 fold

anti- CdtB antibodies are usually not elevated in Methane dominant cases and anti-vinculin antibodies are only slightly higher in these cases over normal controls. This further illustrates that methane dominant IBS is a different condition from primary SIBO

Motility Prescription Medications (Prokinetics)


This section is also well covered in Dr Siebecker’s recent talk at the SIBO Summit.

Motilin agonists

  • Erythromycin 50-62mg before bed (this constitutes of roughly 1/20th of a regular antibiotic dose) – starts MMC in stomach and propagates through SI
  • Azithromycin 200mg before bed

5-HT4 agonists

  • Prucalopride (Resotrans) – starts MMC from duodenum

Dopamine antagonist

  • Domperidone- black box warning due to QT elongation and arrhythmias


  • Pyridostigmine (older drug used for myasthenia gravis) – suppresses reuptake of acetylcholine which induces the MMC via the vagus nerve

COMMENTARY: as we learned at the SIBO Summit, 2/3 of SIBO patients are chronic relapsers, often due to damage to the MMC (1o SIBO). Though many of the abovementioned medications can have side effects, we need to keep an open mind to medications that may significantly improve patients lives until reliable natural alternatives are available

New Concepts for the treatment of SIBO

Plasmapheresis improved one patient’s symptoms with PI-IBS (SIBO) who tested very high for anti-vinculin antibodies.  The patient had severely impaired MMC. After plasmapheresis, patient reported improvement lasting 1 month. Plasmapheresis is a process in which the blood is filtered to remove ALL antibodies, however B cells are not filtered so will continue to produce antibodies, hence not curing the patient.

COMMENTARY: rather than a new treatment option for SIBO, I think this case more than anything proves the concept of autoimmunity being the cause of post-infectious IBS (SIBO).  Plasmaphereses is costly and has side effects so I don’t think this realistically offers solutions.

New Device for Measuring Hydrogen Sulfide (H2S)

Now being tested at Cedars Sinai.  Apparently this could be available soon.

COMMENTARY – currently Quintron’s BreathTracker machines do not measure hydrogen sulfide and all other testing is fairly inaccurate for H2S. so we are all eagerly anticipating more news about this technology.

Lovastatin Blocks Production of Methane

A time release Lovastatin drug called SYN-010 is in final stages of phase lll trials.  This follows a published study by Dr Pimentel showing Lovastatin to effectively reduce methane and normalise transit in constipated patients.  This time release version of lovastatin will also reach the colon.  The idea is that over time hydrogen producers will also reduce their output of hydrogen as it is not used by M.smithii to produce methane.

COMMENTARY as any SIBO treating practitioner knows, high methane cases tend to be the most difficult to treat.  SYN-010 may offer some symptomatic relief for those not responding to antimicrobial therapy. Could red yeast rice extract be an alternative?

Experts available on demand?

The SIBO Summit was a resounding success. We are so grateful to have hosted such incredible speakers, many of the world’s top specialists in the SIBO realm.

Are you keen to apply SIBO expertise in your practice?

We’ve captured the SIBO Summit 2016 on film, and we invite you to head over to the SIBO Summit page to access your copy.

And of course we always have the brilliant practitioner education portal available to you.  Here you will find  a plethora of resources to get you started on your path to confident SIBO diagnosis and treatment.

See you there!

The Healthy Gut interviews Dr Nirala Jacobi

Check out The Healthy Gut Podcast, episode 4, to catch Dr Nirala Jacobi’s recent interview with Rebecca Coomes of The Healthy Gut.

Dr Jacobi speaks about SIBO testing, the difference between hydrogen & methane dominant SIBO and her SIBO Bi-Phasic Diet protocol.

You’ll also gain insights into SIFO (small intestinal fungal overgrowth), what to do when food sensitivities present, and supporting the MMC (migrating motor complex) with various herbal medicines and supplements.

We have more exciting news – The SIBO Doctor Podcast is launching soon! Let us know what you’d like to learn about with the upcoming SIBO Doctor podcasts in the comments below.

Remember to head to the SIBO Summit page for instant access to hours of recent cutting edge SIBO information recorded at the SIBO Summit 2016.  These feature presentations by Dr Allison Siebecker, Dr Jason Hawrelak, Dr Nirala Jacobi, Alyssa Tait, Dr Iggy Soosay and Rebecca Coomes.

Dr Allison Siebecker – – Interview by Dr Nirala Jacobi ND

Dr Allison Siebecker ND, founder of the very popular website, talks about her upcoming visit to Australia and the SIBO Summit 2016.

The Summit will be live in Melbourne (8 October) and Sydney (10 Oct) PLUS thanks to our sponsor Quintron, will be made available via Video On Demand (1 week after the event).

We’re now able to offer a truly global SIBO Summit event, by now making the SIBO Summit recordings accessible to all SIBO-treating practitioners globally.

Be sure to join us for this event. Register now to snap up your ticket before early bird cut off (September 1st 2016)

See you there!

What is SIBO?

Do you want to increase your SIBO knowledge straight from an expert source?

Listen in on this podcast to learn the SIBO basics.

In this podcast Nirala Jacobi, ND, Australian SIBO expert is interviewed by Andrew Whitfield-Cook of FX Medicine Podcast.

This brilliant resource introduces you to key SIBO concepts, including:

  • Common causes of SIBO
  • Risk factors for developing SIBO
  • Pathophysiology of SIBO
  • The link between SIBO and IBS

and more…

Are you keen to continue ramping up your SIBO education?

We invite you to register as a practitioner to access a plethora of expert resources in our database, and the opportunity to be listed as a SIBO treating practitioner.

Remember to subscribe to our youtube channel and facebook page for regular SIBO updates.

In health

The basics of SIBO


Normally, bacteria are found in the trillions in the LARGE INTESTINE, where they perform various symbiotic functions for the human body.

SIBO is a condition where bacterial overgrowth occurs in the absorptive area of the body the SMALL INTESTINE.

Watch our short, informative video