Could Your Acid Reflux Be Caused By SIBO?
Research Review: Intestinal dysbiosis in patients referred for antireflux surgery
A 2021 study has shown the high prevalence of intestinal dysbiosis in patients with GERD referred for antireflux surgery (1).
The study retrospectively looked at a group of patients (n=104) who were being reviewed for antireflux surgery because their symptoms of reflux were unresponsive to long-term PPI use. Over half of the group - around 60% had intestinal dysbiosis as diagnosed by hydrogen and methane breath testing (HMBT). These patients more frequently reported gas-related symptoms with excessive belching and bloating commonly associated with intestinal dysbiosis. The study showed 61 patients with SIBO were more likely than not to have reflux associated regurgitation.
Intestinal dysbiosis is an imbalance in the intestinal microbiota, which is associated with the medications used to treat GERD called proton pump inhibitors (PPIs). PPIs have been shown to moderately increase the risk of small intestinal bowel overgrowth (SIBO). SIBO is a type of dysbiosis due the excessive colonisation of hydrogen bacteria in the small bowel. SIBO is manifested by symptoms of diarrhoea and bloating and flatulence after eating, as a consequence of increase in gas production by bacterial fermentation in the small bowel.
Another type of dysbiosis known as intestinal methanogen overgrowth (IMO) describes the overgrowth of microorganisms that produce methane gas. Excessive methane production is due to an overgrowth of archaea, a microorganism different to bacteria.
Intestinal gas production by SIBO and IMO can lead to gas-related symptoms, such as bloating and belching, as shown in this study, indicate a link between intestinal dysbiosis and antireflux surgery candidates with GERD. The answer to the question, does SIBO cause GERD is a possibility. Another common factor in this study is that GERD patients have been on long-term PPI medication in which various studies have shown SIBO as a prevalence risk factor due to PPIs suppressing stomach acid production.
In my opinion, regardless of the cause, if a client is presenting with both reflux and intestinal dysbiosis symptoms and has a history long term medication (PPI, H2 blockers, antibiotics, opioids etc) use that can dysrupt the gut microbiome then further investigation such as the hydrogen and methane breath testing is warranted.
A general pracitioner (GP) doctor can’t test for SIBO. If your GP wants you to get a SIBO test, they have to refer you to a gastroenterologist who will carry out the test, usually at a hospital. An alternative option is to get a test ordered by other health professionals such as a nutritional therapist.
While SIBO can take time to treat, a recent guideline has identified dietary modification and antibiotics can be effective (2). Nutritional therapy plays an imperative role to provide a personalised dietary, functional testing and anti-microbial herb protocol to rebalance gut microbiome. I investigate with a full stool test and SIBO breath test then apply the 5R protocol which adopts a structured approach to resolve gut imbalances.
Want to learn more about testing for SIBO testing? Read the ‘What test is right for you?’ blog.
References:
Haworth, J.J., Boyle, N., Vales, A. et al. The prevalence of intestinal dysbiosis in patients referred for antireflux surgery. Surg Endosc 35, 7112–7119 (2021). https://doi.org/10.1007/s00464-020-08229-5
Pimentel, M., Saad, R. J., Long, M. D., & Rao, S. S. C. (2020). ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. The American journal of gastroenterology, 115(2), 165–178. https://doi.org/10.14309/ajg.0000000000000501