SIBO Relapse Causes and Management - Dominick Hussey

SIBO Relapse Causes and Management

SIBO relapse is a common occurrence. According to research SIBO relapse rate ranges from 44 to 50 percent.

Those high figures are probably due to using doses that are high enough or durations that are long enough.

One study found a SIBO relapse rate of 13 percent at three months post-treatment, 28 percent at six months, and 44 percent at nine months. The significant caveats of that study, though, were that the probability of recurrence was increased with older age, constipation, a history of appendectomy, and chronic PPI use.

That said SiBO relapse is a significant issue.

Read on to learn about the number one reason why SIBO relapse occurs and some strategies to manage and prevent reoccurrence.

SIBO is as much a symptom as it is a cause.

The authors of the above study wrote that without correcting underlying mechanisms that lead to bacterial colonisation of the small bowel, SIBO would recur.

So, this highlights the point that SIBO is as much a symptom as it is a cause.

The key takeaway here is that if SIBO continues to recur, it probably has to do with not correcting an underlying mechanism.

Not dealing with the underlying cause, in my opinion, is the #1 reason why SIBO relapse occurs.

Guidelines for managing a SIBO Relapse

If you have a relapse of your SIBO symptoms, it is essential you get a retest.

If this is your first follow-up test, then you should try a different treatment.  If you did a botanical protocol, you could try a  treatment with Xifaxan. If you took Xifaxan, you could try a herbal protocol.

You could also consider extending the duration of the treatment depending on the test results.

If the test results were relatively low, a shorter duration is fine, but if they were elevated, you might try a more extended period.

If trying a different treatment fails to produce a negative test result, you may consider an elemental diet.

If your test results repeatedly test positive, you need to start considering the potential underlying mechanism that may be causing the SIBO.

Possible causes of SIBO include gut dysbiosis, parasites, infections, heavy metal toxicity, mould, biotoxins, or other chronic infections like Lyme Disease as well as HPA axis dysregulation (aka Adrenal Fatigue) and past emotional trauma.

If you have ruled out all of the above or if the mechanism cannot be addressed, for example, you have a disease or a mechanical problem that impairs gut motility, and you may need periodic retreatment with botanical or Xifaxan protocols.

Additional steps to reduce the likelihood of recurrence


The first is using a prokinetic, which is an agent that increases gut motility. One theory on why SIBO recurrence is common is that SIBO involves the dysfunction of the migrating motor complex or MMC.

The MMC has a cleansing function in the intestine. A dysfunctional MMC can lead to bacterial overgrowth. Prokinetics stimulate the MMC which would counteract this tendency.

There are three types of prokinetics, herbal, nutritional and Medications.

Iberogast is a herbal prokinetic which has a been shown in research to be clinically valid. It has also been used in Europe for many years.

MotilPro is a nutritional type prokinetic. Motil Pro contains 5-HTP which is a major neurotransmitter in the gut that affects motility.

Drug type prokinetics include a low dose of Naltrexone or a low dose of Erythromycin.

The recommended duration you should take prokinetics is between 3-6 months.


Limiting fermentable carbohydrates is not good during the treatment with antimicrobials, however, it may be a useful measure to prevent recurrence of SIBO.

Possible diet options here would be a low FODMAP diet, or a low fermentation potential diet, which is a diet introduced by Dr Norm Robillard.

One downside to using these diets is that studies show that long-term low FODMAP diets can lead to reduced diversity in gut flora in the colon.

A kind of middle ground approach might be better by doing a low-FODMAP diet and using a soluble fibre like partially hydrolysed guar gum to continue to feed the beneficial gut bacteria.


This article is not intended to provide medical advice, diagnosis or treatment.

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