5. Prevalence of GI Involvement
& SIBO in Scleroderma
• After the skin, the Gastrointestinal Tract is the
2nd most common target of symptoms (Marie ‘07)
• Esophagus = most common 70-95%
• Then the Anus/Rectum 70-95%
• Then the Small Intestine
• Though 100% have decreased SI motility w/in 5 yrs
• Then the Stomach 32%
• SIBO prevalence= 50% average
• 43% (Marie 2009), 46% (Savarino), 63% (Parodi)
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7. What is SIBO?
• Bacterial Colonization of the SI
• SI should have low Bacterial counts (101-2/duodenum)
• LI is the place for Bacterial colonization (1010-11)
• Protective measures keep bact low in SI
• Stomach Acid (HCl), Bile, Digestive Enzymes, GI
Immune System (Galt), Migrating Motor Complex
• Deficient MMC= a 1° cause of SIBO
• SIBO= normal GIT bacteria, not pathogenic
• Problem= wrong place in wrong amounts
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8. Etiology (Cause)
• Anything that allows bacteria to back up in the
Small Intestine
1. Slowed motility in the SI (decreased MMC)
• Ex: Dz- Acute Gastroenteritis, Diabetes, Scleroderma;
Opiate drugs; Surgical nerve damage/scarring
2. Obstruction of the SI
• Ex: tumors, strictures, adhesions, excess mucus
3. Non draining pockets/sections of SI
• Ex: Small Intestine Diverticulitis, surgical Blind loops
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11. copyrightDrAllison
Siebecker2014
SIBO Pathophysiology #1
Bacteria compete for & steal our Food
SI Bacterial Overgrowth
Bacteria Eat Our Food
Bacterial Gas GI Sx bloating, pain
(Hydrogen/Methane) constipation/diarrhea
GERD, nausea
Premature
Bacterial
Exposure to
Host’s Food
Fermentation
Food = Growth
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Bacterial Gas Causes
Abdominal Symptoms of IBS
• Bloating/distention= physical swelling
• Pain= GIT sensitive to pressure, musc
contract against gas, Visc Hypersens in IBS
• Eructation, flatulence= gas exiting
• GERD/Nausea= gas back pressure
• Altered BM’s
• Hydrogen= associated with diarrhea
• Methane = causes constipation
13. Problem: Carbohydrates
• Bacteria’s main food source is
carbohydrate (CHO)
• Problem #1: CHO feed bacteria worsening
overgrowth
• Problem #2: Bacteria ferment CHO > gas >
symptoms
• Bacteria can ferment (eat) any and all CHO
• All plant food can feed bacteria &
potentially worsen SIBO
copyrightJan2014DrAllison
Siebecker
14. copyrightDrAllison
Siebecker2014
SIBO Pathophysiology #2
Damage= GI & Systemic Sx
SI Bacterial Overgrowth
Disaccharidases
(-) Carb Transporters
Blunted Villi GI Sx’s
Elongated Crypt Depth
Intestinal Permeability Systemic Sx’s
Hydrogen, Methane Gas
GI Sx’s:
Bloating
Constipation/ Diarrhea
Pain , GERD, Nausea
Inflammatory cytokines
Digest Brush Border
Bile Deconjugation steatorrhea
fat sol vit deficiency
A, D, E, K
Bacterial Actions
Fermentation of
Unabsorbed Carbohydrate Damage the Brush Border
Bacterial Growth
16. copyrightDrAllison
Siebecker2014
When to consider SIBO?
• If the symptoms of IBS are present
• Bloating, constipation/diarrhea,
abdominal pain
• If malabsorption is present
• Low weight, low ferritin/anemia, fatty
stools (steatorrhea)
• It’s reasonable to screen all scleroderma
patients for SIBO
17. Lactulose Breath Test
• Measures Gas produced only by Bacteria
• Challenge test- sx may occur during/after
• Positive Interpretations Vary by Dr/Lab
• H 20 ppm w/in 120min (w/in 100min best)
• M 3 ppm at any point in the test (Dr P)
• 3 hour test=best, 2 hr= sufficient
• Must test for both hydrogen & methane
• Locally: NCNM Clinic, OHSU, Emanuel
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2014
19. copyrightDrAllisonSiebecker
2014
SIBO Treatment Protocol
Variation of the Cedars-Sinai Protocol (Pimentel 2006)
Drs Siebecker & Sandberg-Lewis (2010)
SIBO Suspected
1. PE: ICV, Acid/Pancreas Reflex
2. Blood Test: CBC, ESR, thyroid, CV, KD
3. Stool Test (fat malabsorption)
4. String/Gastro-Test or Heidelberg
5. Celiac, Intestinal permeability,
Food allergy/sensitivity
6. Endo/Colonoscopy
Hx
GI/Extra GI Sx, Meds, Dz
Antibio
tic
Elemental Diet
x 2-3 wks
Diet
SCD,
SCD + Fodmap
1. Rifaximin: Diarrhea/Alternating
550mg tid x 14 days
2a. Rifaximin + Neomycin: Constipation
550mg tid + 500mg bid x 14 days
or
2b. Rif + Metronidazole 250mg tid x 14 days
Optional: Probiotic, Antifungal
SIBO Lactulose Breath Test
Or: GBT, Organic Acid Test
SIBO Breath Re-Test
Feel Better- 90%
Partial Improvement/ Not Better
Re-Assess within 2 weeks
Prevention
1. Diet (SCD/Gaps, C-SD, Fodmap)
2. Prokinetic x 3 mo+
:Prucalopride .5-2mg hs
:Erythromycin 50mg hs
:LDN 2.5-5mg hs
Optional: Probiotic, HCl/bitters
Brush Border healing supplements
Re-Treat
SIBO (+)SIBO (-)
Consider other Dx
Non-Dx/ other Tests
Treat SIBO
4 options
Hx
AntibioticAntibioticHerbal Antibiotics
1. Berberine Herbs
2. Allicin (methane)
3. Oregano
4. Neem
1-3 caps 2-3 x day x 4 weeks
Optional: Probiotic, Antifungal
Relapse
20. copyrightDrAllison
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Key SIBO Tx Points for Success
• Test (LBT)
• Successive Tx Rounds (Abx/HAbx) needed
• If gas is above 35-45 ppm (avg gas dec
from Abx/HAbx=25-35 ppm)
• Methane &/or constipation cases are
harder to treat
• Double Abx Tx or Allicin needed for
methane/constipation cases
• Vary tx method as needed (Abx, HAbx, ED)
21. Key SIBO Tx Points for Success
• Re-Test to assess results (if not 90% better)
• Both Prokinetic & Diet for prevention
• Diet must be customized to the individual
through their own trial & error over time
• There’s no one “diet” that is perfect for
anyone
• There’s no test to find one’s perfect diet
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22. Prokinetics
• Commonly used in Scleroderma for
improving esophagus/GI motility
• Most= cardiac /neurological side effects
• Prucalopride (Canada/Europe)= safe
• Recommended for Scleroderma (Ebert)
• Used for SIBO
• Mosapride (Asian)= ano-rectal ICC’s
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2014
23. Incurable SIBO
• With advanced/progressed Scleroderma or
continuous PPI’s or Opiates
• Continuous Antimicrobials may be needed
• Rifaximin 550mg every other day
• Monitor liver enzymes
• Rotating Herbal Antibiotics (Sandberg-Lewis)
• Berberine- 100mg 1-4x day
• Allicin- 450mg 2-3x day
• Neem 500mg 3x day
• Oregano- 50mg 3-4x day
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2014
24. Proton Pump Inhibitors (PPI’s)
• Commonly prescribed in scleroderma for
esophagus protection or sx of GERD
• Problems
• Risk Factor for SIBO (Lo)
• Acid kills bacteria
• Risk Factor for Bone Fracture (Geller, Gray)
• Acid helps Calcium/mineral absorption
• Many will need it but try removing it
• Rebound reflux is common x 8-26 wks after
long term PPI use (Fossmark , Waldum)
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2014
25. Other Digestive Support
• Pancreatic Insufficiency in Scleroderma (Ebert)
• Enzymes: Prescription=Creon, OTC= Thorne
Dipan
• Malabsorption may be due to:
• SIBO: bact stealing or damaged wall
• Thickened Wall, Poor Circulation
• SIBO Leaky gut healers: L-Glutamine, Zinc
Carnosine, Colostrum, Vit D/A/Cod Liver Oil,
Turmeric, Resveratrol, Glutathione
• Circulation improving remedies
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2014
29. What the Diets were
Formulated to Treat
• Formulated for active SIBO, as a treatment
• SCD, GAPS, SCD+ Fodmaps
• SCD= IBD/diarrheal dz
• GAPS= GI + brain/mood symptoms (autism)
• SCD+LFD= more severe SIBO
• Formulated for IBS, not SIBO specifically
• Low FODMAP Diet
• Formulated for SIBO Prevention
• Cedars-Sinai Low Fermentability Diet
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2014
30. Continuum of Diet Tolerance in
SIBO
SCD+LFD SCD/GAPS Low Fodmap Diet
No Starch, Low Fiber Fermentable Gluten Free Grains(Starch, Fiber)
No Beans at 1st Fruit/Veg Beans, Sugar
Low Fermentable Fruits/Veg C-S Low Fermentation Diet
Refined Grains (Starch, Gluten) Sugar
No Beans
copyrightJan2014DrAllison
Siebecker
Less Tolerance/More Severe Case More Tolerance/Less Sever Case
31. Key Points of
SIBO Treatment Diets
• Decrease Fermentable Food (Carbs) for bacteria
• Avoid Grains, Starch, Starchy Veggies, some Beans,
Sugar/most sweeteners, Lactose, Fiber/Prebiotics
• Allow monosaccharides= glucose/fructose as honey
• Intro Diet (SCD/GAPS) to decrease bacteria/sx
• SCD+LFD = Intro is optional since Abx/HAbx/ED will
decrease bacteria
• Progressive- easier to digest foods at 1st
• no raw fruit or veg, nuts or beans at 1st
• fruit & veg= peel, de-seed, cook & puree at 1st
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32. SIBO Diets Match Scleroderma
Diets for Esophagus/GI (Recasens)
• Liquid/pureed/soft food
• Soup/broth. Bone broth healing to tissue
but wait till SIBO is gone (mucopolysacc)
• Yogurt
• Low Fiber/Fermentable Carbs
• Except meal timing
• Scleroderma= small freq meals for esoph
• SIBO= 4-5 hrs between meals to allow MMC
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2014
33. Cons of SIBO Diets
• Weight Loss (5-15#)- not good for underweight
• Difficult
• removal of common/favorite foods
• more home cooking required
• lack of portable snacks
• difficulty participating in food events (weddings,
holidays, dinner parties, ‘other people’s food’)
• traveling
• eating out
• Psychologically Difficult: feeling different, out of synch
with society, like an outsider, not normal
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34. How to gain weight?
• Reduce bacteria with tx: Abx, HAbx
• Caution: Elemental Diet can cause wgt loss
• Eat more food, more often: set a timer (it’s a job)
• Eat more allowed CHO: honey, squash, fruit, nuts, beans
• Eat Lactose free dairy
• Shakes: HM 24 hr ½ & ½ ygt/lactose-free whole milk/coconut
milk; nut butter; egg yolks, fruit; fruit juice; honey; cinnamon
(ingredients as tolerated)
• Eat refined CHO (white- rice/potato/bread/pasta)
or Whole CHO if tolerated (whole grains/tubers/beans)
• Heal brush border (abs), take Enzymes (dig)
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35. Diet Pro’s: Benefits Beyond GI Sx
(SCD+LFD,SCD,GAPS)
• Weight Loss (inches off waist)
• Stabilization of blood sugar; high & low, stops sugar cravings
• Decrease in chronic infection and inflammation: arthritis,
chronic gingivitis
• Improved immunity: decreased seasonal colds/flu/allergies
• Improved skin, mood, sleep, energy and overall well-being
• IBD: off all medicines, normal colonoscopy
• Removes ‘obstacles to cure’, repairs the gut, tx’s other pt
complaints
• “I’ll never go back to the way I was eating before”, “I got my
life back”
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36. Diet Points
• Gluten (wheat,barley,rye) correlated with AI Dz
• Best avoided by anyone with AI Dz
• Or Test= Cyrex Array III (Wheat/Gluten)
• Lactose Free Dairy= many w/ SIBO tolerate it &
do better with it
• Increased energy, stabilize weight loss, helps
digestion (ygt-Pbx), increases food pleasure
• But casein can cross-react with Gluten, test via
IgG/A blood & correlate w/ TTG (+)
• Cyrex Array IV= cross reactive
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37. Lactose Free Dairy Foods
• Homemade 24 hr yogurt/sour cream
• Aged cheese, Dry Curd Cottage Cheese
• Ghee/butter
• Lactase enzyme treated cream in sm amts
• Commercial lactose-free dairy
• Lactaid Milk- SCD Illegal but if tolerated=OK
• Pectin is in “lactose-free” (Green Valley)
yogurt, but if tolerated= OK
• True Greek yogurt (no pectin)= low lactose
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38. Scleroderma SIBO Case 1
• CC: osteoporosis/malabsorption
• Current Meds: Nexium
• Sx: diarrhea tendency x 1 yr (previously
constipated), bloated feeling, esophagus
irritation, low weight
• Test: LBT (+) Hydrogen 78ppm
Methane 4ppm
• After 2 courses Abx given by other Dr’s
• Rifaximin for SIBO & ? For Gastroenteritis/ER
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2014
39. Scleroderma SIBO Case 1
• Treatment
• Consider removal of Nexium (referral)
• Berberine Complex (Integrative Therapeutics)
• 5 grams/11 pills per day x 4 weeks
• Specific Carbohydrate Diet
• Result: neg test H 4ppm/M 0ppm
• Test- H dec 74ppm, M dec 4ppm
• Sx: still low weight, BM’s improved,
bloated/esophagus feelings gone, feels better
overall
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2014
40. Scleroderma SIBO Case 1
• Prevention Treatment
• SCD/C-SD (rice, potatoes)
• Prokinetic: LDN 2.5mg at bed long term
• 3 months out= treatment is holding
• Notes:
• GI sx were not major a complaint
• Qi-Shen/Vitality-Glow is much improved!
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2014
41. Summary
• SIBO is common in Scleroderma
• Symptoms are the same as IBS
• Bacteria ferment carbs into gas> GI sx
• Diagnosis= Lactulose Breath Test
• Treatment= 4 options, 3=quick killing & Diet
• Prevention= Diet + Prokinetics
• Diet= SCD, Gaps, Fodmaps, SCD+LFD, C-SD
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42. Resources
See www.siboinfo.com under:
• ‘Resources’ for:
• Testing Laboratories -Books
• Website Resources -Cookbooks
• MMC videos -You tubes
• ‘Treatment’: ‘Diet’= for more diet info
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43. References
• Marie I, Ducrotté P, Denis P, Menard JF, Levesque H. Small
intestinal bacterial overgrowth in systemic sclerosis.
Rheumatology (Oxford). 2009 Oct;48(10):1314-9. doi:
10.1093/rheumatology/kep226. PMID: 19696066
• Marie I, Ducrotté P, Denis P, Hellot MF, Levesque H. Outcome
of small-bowel motor impairment in systemic sclerosis--a
prospective manometric 5-yr follow-up. Rheumatology
(Oxford). 2007 Jan;46(1):150-3. PMID:16782730
• Parodi A, Sessarego M, Greco A, Bazzica M, Filaci G, Setti M,
Savarino E, Indiveri F, Savarino V, Ghio M. Small intestinal
bacterial overgrowth in patients suffering from scleroderma:
clinical effectiveness of its eradication. Am J Gastroenterol.
2008 May;103(5):1257-62. doi: 10.1111/j.1572-
0241.2007.01758.x. PMID: 18422815
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2014
44. References cont.
• Savarino E, Mei F, Parodi A, Ghio M, Furnari M, Gentile A, Berdini M,
Di Sario A, Bendia E, Bonazzi P, Scarpellini E, Laterza L, Savarino V,
Gasbarrini A. Gastrointestinal motility disorder assessment in
systemic sclerosis. Rheumatology (Oxford). 2013 Jun;52(6):1095-
100. doi: 10.1093/rheumatology/kes429. PMID: 23382360
• Soudah HC, Hasler WL, Owyang C. Effect of octreotide on intestinal
motility and bacterial overgrowth in scleroderma.N Engl J Med. 1991
Nov 21;325(21):1461-7. PMID: 1944424
• Rees WDW, Leigh RJ, Christofides ND, Bloom SR, Turnberg LA.
Interdigestive motor activity in patients with systemic sclerosis .
Gastroenterology 1982;83:575–80.
• Greydanus MP, Camilleri M. Abnormal postcibal antral and small
bowel motility due to neuropathy or myopathy in systemic sclerosis .
Gastroenterology 1989;96:110–5.
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2014
45. References cont.
• Recasens MA, Puig C, Ortiz-Santamaria V. Nutrition in systemic
sclerosis. Reumatol Clin. 2012 May-Jun;8(3):135-40. doi:
10.1016/j.reuma.2011.09.006. PMID: 22197834
• PPI:
• Proton pump inhibitor therapy and hip fracture risk. Geller JL,
Adams JS.JAMA. 2007 Apr 4;297(13):1429; author reply 1429-
30. PMID: 17405964
• Proton pump inhibitor use, hip fracture, and change in bone
mineral density in postmenopausal women: results from the
Women's Health Initiative.Gray SL, LaCroix AZ, Larson J,
Robbins J, Cauley JA, Manson JE, Chen Z. Arch Intern Med.
2010 May 10;170(9):765-71. doi:
10.1001/archinternmed.2010.94. PMID: 20458083
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2014
46. References cont. PPI
• Rebound acid hypersecretion after long-term inhibition of
gastric acid secretion. Fossmark R, Johnsen G, Johanessen E,
Waldum HL. Aliment Pharmacol Ther. 2005 Jan 15;21(2):149-
54. PMID: 15679764
• Rebound acid hypersecretion from a physiological,
pathophysiological and clinical viewpoint. Waldum HL,
Qvigstad G, Fossmark R, Kleveland PM, Sandvik AK. Scand J
Gastroenterol. 2010 Apr;45(4):389-94. doi:
10.3109/00365520903477348. Review. PMID: 20001749
• Proton pump inhibitor use and the risk of small intestinal
bacterial overgrowth: a meta-analysis. Lo WK, Chan WW. Clin
Gastroenterol Hepatol. 2013 May;11(5):483-90. doi:
10.1016/j.cgh.2012.12.011. PMID: 23270866
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2014
47. References: Gluten
• [Antigliadin antibodies in the absence of celiac disease]. Kamaeva
OI, Reznikov IuP, Pimenova NS, Dobritsyna LV. Klin Med (Mosk).
1998;76(2):33-5. Russian. PMID: 9553358
• High incidence of celiac disease in patients with systemic sclerosis.
Rosato E, De Nitto D, Rossi C, Libanori V, Donato G, Di Tola M, Pisarri
S, Salsano F, Picarelli A. J Rheumatol. 2009 May;36(5):965-9. doi:
10.3899/jrheum.081000. PMID: 19332639
• [Celiac disease associated with systemic sclerosis]. Trucco Aguirre E,
Olano Gossweiler C, Méndez Pereira C, Isasi Capelo ME, Isasi Capelo
ES, Rondan Olivera M.Gastroenterol Hepatol. 2007 Nov;30(9):538-
40. Review. Spanish. PMID: 17980132
• Low prevalence of coeliac disease in patients with systemic sclerosis:
a cross-sectional study of a registry cohort. Forbess LJ, Gordon JK,
Doobay K, Bosworth BP, Lyman S, Davids ML, Spiera RF.
Rheumatology (Oxford). 2013 May;52(5):939-43. doi:
10.1093/rheumatology/kes390. PMID: 23335635
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2014
