SIBO (Small Intestinal Bacterial Overgrowth) and GERD (Gastroesophageal Reflux Disease): what a puzzle

This article is a “case study” based on a testimony posted on our support group:

“I underwent a fiberoscopy which revealed incompetent cardia associated with gastritis. This exam was prescribed because nocturnal GERD, in particular, caused me to wake up many times. I also suffer from swelling which has affected my heart rate. I’m better now, but the swelling is still there. The gastroenterologist suspects SIBO and intestinal porosity. I was on a not FODMAP diet which helped me at the time as well as food supplements, but right now it’s getting worse again”.

Below a commented analysis of this testimony that provides a possible, rational and scientifically based explanation of the situation described:

SIBO is a form of complex intestinal dysbiosis because it is intertwined with

-> an alteration of the balance of the microbiota in favor of a bacterial overgrowth (to the detriment of the other strains of microorganisms that make it up)

-> an increase in this dysbiotic microbiota that invades the small intestine (= ectopic site) and therefore causes digestion, absorption and transit problems (swelling and localized pain/discomfort in the upper abdomen, in particular)

SIBO causes metabolic alterations inside the intestinal lumen, causing constant irritation and aggression of the enterocyte wall (intestinal mucosa) that progressively leads to chronic inflammation of the latter.

The inflammation of the intestines causes:

-> worsening of digestive disorders = increased pain and discomfort

-> modification of the digestive functionality and, in particular, alteration of the absorption and filtering capacities that the intestinal barrier usually provides

Functional alterations cause malabsorption (risk of deficiencies, weight loss or gain, metabolic syndrome, etc.) and an intestinal hyperpermeability syndrome that, in turn, aggravates the problem.

Indeed, the “leakage” of toxic substances from the intestine (digestion and metabolism products of the dysbiotic microbiota) causes an accumulation of proinflammatory materials in the digestive mucosa that, in the long term, end up in the circulation to be then distributed throughout the organism.

These mechanisms cause:

-> a subsequent intestinal inflammatory stimulus (mediated by allergic processes)

-> multiple extradigestive manifestations that vary according to the subject (from dermatological reactions to neurological, muscular, ligamentous or tendinous, pulmonary or respiratory, etc.)

In this context, the immune system is obviously very reduced, which leaves the field open to opportunistic infectious pathologies that, with their therapies (often antibiotics), are added to the symptomatological picture.

In the particular case above, dyspepsia, GERD and cardia incompetence are, in fact, a collateral effect of SIBO and its symptoms, since swelling, by causing mechanical compression of the diaphragm, prevents physiological gastric emptying and “mechanically pushes” the bolus of food from the stomach into the esophagus.

When these disorders occur, the most widespread allopathic response is to act through treatment with PPIs (proton pump inhibitors) or gastric antacids which, unfortunately, will relieve the symptoms but, by altering the gastric pH, are responsible for a worsening of the SIBO. This creates a “vicious circle” effect: SIBO -> bloating -> reflux worsening -> antacid treatment -> SIBO worsening, etc.


What to do?

In such a situation, it is essential to implement a coherent and adequate management plan to:

1) temporarily palliate side effects of SIBO/inflammation/hyperpermeability to control symptoms and prevent overcomplication of the initial problem

2) prioritize the resolution of the risk factors that are at the origin of the symptoms to control them and make them go back until a return to physiological balance is achieved, from which a spontaneous resolution of the consecutive symptoms will be derived

Therefore, we can imagine an approach that would be articulated, in phase 1, as follows:

-> management and control of gastritis (the gastroenterologist will probably suggest treatment with PPIs or antacids which, although totally contraindicated in SIBO, should be followed for a short period to protect the gastric wall from ulceration)

-> GERD management with a natural approach (Gastrivox is recommended here)

-> reduction of swelling and regularization of transit with:

– a diet low in FODMAPs, which is still “the best” nutritional approach

– splitting meals

– oral supplementation with Ausilium Tisana

-> fight against bacterial overgrowth with a combination of natural antibiotics such as Batteril or Alimed to return the microbiota to its physiological anatomical home

-> a first approach against inflammatory and allergic processes mediated by histamine to reduce edema, spasm and irritation of the wall (Nonidea + Pealen)

These indications can be considered for a period of 2 to 4 weeks and then developed based on individual symptom changes before moving to phase 2.

NB. In the case of SIBO, the use of probiotics in phase 1 is still a matter of debate; however, with the intention of using natural antibiotics to reduce bacterial proliferation, the introduction of active ingredients in the initial phase of management should be avoided.

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