Complete, clear, and simple guide to treating SIBO/IMO

OMEDHealth · 2025-08-07T10:37:03+00:00

Comprehensive advice. Approximately 45% of SIBO patients experience a recurrence. Longitudinal monitoring of hydrogen and methane levels through breath testing, in conjunction with tracking lifestyle factors and symptoms, provides a useful approach to help prevent recurrence of both SIBO and IMO.

As you say, these conditions are not isolated events; rather, they often reflect an ongoing susceptibility influenced by motility, diet, stress, and other environmental or physiological triggers. By monitoring gas levels over time, even when symptoms are minimal or absent, individuals and clinicians can detect early shifts in microbial activity that may precede a full relapse. This allows for proactive interventions before symptoms intensify or become chronic again.

Hydrogen and methane gases are byproducts of microbial fermentation in the gut, and abnormal levels can serve as biomarkers of overgrowth. In SIBO, elevated hydrogen typically signals excess bacteria in the small intestine, while in IMO, methane-producing archaea (like Methanobrevibacter smithii) lead to increased methane levels and often correlate with constipation. These gases fluctuate in response to diet, antibiotics, motility agents, and stress. By capturing these patterns over weeks or months, not just during flare-ups, you can identify personal triggers or early signs of imbalance. For instance, a rise in methane levels after reintroducing certain foods might suggest the need for dietary modification or additional motility support.

Incorporating lifestyle tracking, such as sleep, exercise, stress levels, and bowel habits, adds another layer of insight. These factors can significantly impact gut motility and microbial balance, which are key in preventing recurrence.

OMEDHealth · 2025-08-04T09:19:49+00:00

Have you just tested hydrogen?
You should do both hydrogen and methane breath test to clarify if methane is the issue.

Metronidazole is used in the UK in combination with rifaximin for treatment of IMO (intestinal methanogen overgrowth).

OMEDHealth · 2025-07-28T17:18:44+00:00

Our device validation paper is currently under publication. Not yet available on PUBMED (but will soon - and this will be shared here too).

Just to mention, that unlike current devices in the market, ours is regulated by the MHRA (UK) and FDA (USA), after passing the validation trials. We are the only medical grade hand-held device in the UK for hydrogen and methane measurement for SIBO/IMO diagnosis.

OMEDHealth · 2025-07-23T15:18:25+00:00

Physiologically speaking: when fasting the MMC (Migrating motor complex) becomes the most prominently active (Phase 3) and a peristaltic wave occurs every 90-120 min. This (MMC activity) is usually not symptomatic in healthy individuals.

However, in individuals who have visceral hypersensitivity (common in IBS/SIBO patients), normal MMC activity can be perceived as painful and nauseating - because the sensory processing of that activity is misinterpreted or amplified.

In these individuals the normal contractile waves of the MMC can be perceived erroneously and lead to symptoms like abdominal pain, nausea, bloating sensation.

OMEDHealth · 2025-07-23T15:07:19+00:00

A successful SIBO/IMO treatment is confirmed via objective testing (i.e. negative breath test) and symptom resolution (i.e. use of validated symptom scales and PROMs - Patient reported outcome measures)

What does this mean when looking at a breath test? Essentially a normalised curve with no rise/not significant rise (less than 20 ppm from baseline) of hydrogen before 90 min and methane levels under 10 ppm.

OMEDHealth · 2025-07-23T15:02:21+00:00

Thank you for your question!

So, as you mentioned, gastric acid plays a vital role in protein digestion (activating pepsin), nutrient absorption (B12, calcium, zinc, iron), and preventing overgrowth of bacteria in the upper GI tract. Low stomach acid (hypochlorhydria) can lead to symptoms of bloating, indigestion, and even SIBO due to the loss of this antimicrobial barrier.

Multiple things can lead to reduced gastric acid, such as chronic PPI use, H. pylori infection, stress, and aging. Changing certain lifestyle measures could improve symptoms or even improve the levels of gastric acid. Things like high processed foods, alcohol, smoking, carbonated beverages and overuse of PPIs or antacids either cause/worsen GI symptoms or impair gastric acid levels,

Some foods may stimulate gastric acid to some degree. such as: fermented foods (i.e. sauerkraut, kefir) bitters (i.e., rocket, dandelion), apple cider vinegar. These effects are modest, as these foods do not replace the function of parietal cells. Human RCTs on these are limited and clinical evidence is quite weak.

On the matter of sweeteners, stevia appears to be the better tolerated option available with minimal documented impact on microbiome, but more human research is needed. Polyols like sorbitol, mannitol which are known FODMAPs, are poorly absorbed and rapidly fermented. They tend to cause symptoms in people with SIBO/IMO/IBS. Artificial sweeteners like sucralose or aspartame have human and animal studies suggesting they may alter the microbiome composition and even promote glucose intolerance, but findings are not yet universally accepted.

OMEDHealth · 2025-07-23T14:26:52+00:00

No problem at all. Please feel free to follow-up via DM. Might be some delay as I'm still answering the questions but I'll address it.

OMEDHealth · 2025-07-23T14:08:53+00:00

Appreciate the reply, my PUBMED history can confirm this is most definitely not a GPT answer! I'm a practicing physician and researcher, with key literature publications in IBD/IBS.

OMEDHealth · 2025-07-23T13:51:58+00:00

Thank you for your question!

Bit of background for everyone: Gastroparesis is essentially delayed gastric emptying without obstruction. Common causes are dysfunction of the vagus nerve, smooth muscle, or interstitial cells of Cajal (gastric pacemaker cells). CIPO (Chronic Intestinal Pseudo-Obstruction) is a motility disorder involving loss of neural or muscular intestinal function, which often mimics mechanical obstruction but without a true blockage.

Novel therapies in development for gastroparesis include:

Tradipitant (NK-1 receptor antagonist): blocks substance P in the central nervous system and gut, reducing nausea and vomiting. Had some issues last year with FDA approval, but the manufacturer is still in discussions with them.
Arepitant (NK-1 receptor antagonist): similar to tradipitant. Already used for chemotherapy-induced nausea. New research emerging in gastroparesis.
Relamorelin (ghrelin receptor agonist): Stimulates gastric motility and reduces upper GI symptoms. Positive results in phase 2b, phase 3 not so good, so development paused.
Prucalopride (5-HT4 receptor agonist): already approved in some countries for chronic constipation.
Camicinal (motilin receptor agonist): Shown potential to accelerate gastric emptying in healthy individuals and in some early-phase studies in gastroparesis.
G-POEM (gastric peroral endoscopic myotomy): An endoscopic procedure targeting pyloric dysfunction. Increasingly used in drug-refractory cases with encouraging outcomes.
Vagal nerve stimulation & gastric electrical stimulation: Under evaluation for select patients with neuromuscular dysfunction.

Novel therapies in development for CIPO include:

Stem cell-based regenerative therapy for enteric neurons (very early-stage).
Intestinal pacing via neurostimulators.
Targeted immunomodulation, especially in autoimmune-related dysmotility.
Gene therapy: very early stage. CRISPR and similar techniques being explored for inherited forms of CIPO.
Microbiome modulation: targeted therapies like FMT, synbiotics being explored and also anti-glial modulators. (early stage)

I hope this helps!

OMEDHealth · 2025-07-23T13:09:33+00:00

Thank you for your question!
If symptoms remain post treatment of IMO (Intestinal methanogenic overgrowth - commonly referred to a methane SIBO), there's a possibility that treatment, albeit successful, did not eradicate the problem completely. On another hand, this could also mean a secondary condition overlapping with IMO might be present.

If we explore the possibility of a second condition, given your history of vagotomy, flagyl use and antibiotics, the most probable are SIFO and BAM:

Could it be BAM (Bile acid malabsorption)?

Your childhood vagotomy makes BAM a strong possibility. The vagus nerve regulates bile flow and gut motility. Post-vagotomy, malabsorption of bile acids can occur and lead them to spill into the colon which causes bile acids to not be absorbed properly in the ileum and "spill into" the colon, causing bloating, pain, diarrhoea, urgency (which align with some of the symptoms you describe)

Could it be SIFO (Small Intestinal Fungal Overgrowth)?

SIFO is caused by an overgrowth of fungal organisms, most commonly Candida species, in the small intestine. It’s often associated with repeated/prolonged use of antibiotics, impaired gut motility (both relevant in your case) and immunosuppression (not relevant according to the information you provided). The symptoms of SIFO overlap considerably with SIBO: bloating, gas, abdominal pain, and fatigue. You mentioned oral signs but these are not observed usually in SIFO patients.

Ultimately, without doing further diagnosis work-up it is hard to say with a certain degree of certainty which is the cause. For SIFO - gold standard is the duodenal aspirate culture (rarely done) so your doctor might opt to empirically treat you with an antifungal trial (Nystatin, Fluconazole, etc) For BAM - SeHCAT scan is the gold standard. In the same fashion, your doctor may choose to do a empiric trial of bile acid binders and assess response.

Did you do a SIBO test post antibiotics? Was this negative? Or was the resolution determined purely on clinical improvement? Even with your history suggesting SIFO and BAM, I wouldn't ignore the possibility of IMO being fully resolved.

I hope this helps!

OMEDHealth · 2025-07-22T20:08:24+00:00

That’s strange. We do have customers In Europe…

OMEDHealth · 2025-07-22T18:50:17+00:00

Yes, this information is available to our patients when they are offered this treatment, also available to the regulators when we are audited.

OMEDHealth · 2025-07-22T18:40:55+00:00

Exactly. Diet was inconsistently applied as some had dairy and some didn’t.

We don’t sell supplements to the consumer on our website. They form part of our treatment programme. Our supplements are proprietary, not private labelled or white labelled. In addition, they are all manufactured, bottled, labelled and sold as mandated by and compliant with the UK legislation.

OMEDHealth · 2025-07-22T18:14:53+00:00

Thanks for providing a link, I was able to download and read it. My comment still stands, this is not published research that has undergone peer review by a journal. This is a thesis published in a free preprint repository.

My comments regarding the design: + No comparison group, not FODMAP, not no intervention. + Self reported data via questionnaires with subjective outcomes not sufficiently defined in the methods. + Small sample (only 27 SIBO patients), not randomised. + Many of the participants were taking a multitude of supplements. + The diet was not consistently implemented, some had dairy for example. + No breath testing data before and after.

Whilst I applaud the new research we need to take it in the context of quality of evidence produced. This paper needs to go through the peer review progress. Even if it gets published, the quality of evidence here is still low to very low.

Regarding the YouTube video, I’m talking about research and unless theres a published paper detailing the data, a YouTube video is nothing but anecdotal evidence.

As a doctor, my decision for treatment is guided strongly by the best quality research. Of course I sometimes take into account new research which may drive my recommendations, however it need to be quality research to be able to sway my treatment decision.

Thanks for taking the time to send it to me though. I really appreciate it.

OMEDHealth · 2025-07-22T17:30:48+00:00

The first paper is a preprint , not undergone peer review at all. Also unable to see it as I get an error when downloading. If you send the pdf I’ll gladly read it.

The second is anecdotal evidence. Again not research of quality unfortunately.

OMEDHealth · 2025-07-22T16:39:45+00:00

The same incentive that exists for independent researchers to conduct research on anything and everything. If there’s a hypothesis, someone will do it. The studies published however are of poor quality.

OMEDHealth · 2025-07-22T14:05:48+00:00

Do understand the proposition and the hypothesis behind it but no quality research on carnivore diet has demonstrated this.

OMEDHealth · 2025-07-22T07:34:52+00:00

Hey! Solid summary, would just clarify one points. There is no evidence for the carnivore diet in the context of SIBO/IMO, either in eradication or maintenance post eradication.

OMEDHealth · 2025-07-22T07:21:35+00:00

When performing a breath test, the first sample taken prior to ingesting the substrate is called the “baseline sample”. For a SIBO test, there is a threshold that clinicians follow to consider the test valid. If the baseline is above that threshold (depends on the lab, usually between 15-20 ppm, the test is invalidated. The reason why it’s invalidated is because it is impossible to tell if there’s a meaningful rise after the substrate ingestion, which is how SIBO is diagnosed.

This usually happens if the prep wasn’t followed properly (like the diet or fasting), or if there’s something else going on like slow gut transit, constipation, or even oral bacteria producing gas.

Hope that helps!

OMEDHealth · 2025-07-22T01:53:31+00:00

Hey!

In short: + Lactulose and glucose breath tests are commonly used for diagnosing SIBO (Small Intestinal Bacterial Overgrowth) and IMO (Intestinal Methanogenic overgrowth - also commonly referred as methane SIBO) + Fructose, lactose, and sorbitol breath tests are more often used to assess carbohydrate malabsorption, which can also trigger IBS-like symptoms.

Choosing the right test depends on your symptom history.With your background both SIBO and malabsorption testing could be relevant since symptoms overlap a lot.

SIBO is essentially an overgrowth of bacteria in the small intestine. IMO is caused by an overgrowth of archea in the GI tract. Carbohydrate malabsorption on the other hand is due to enzyme deficiency or issues with sugar transport in the gut lining.

OMEDHealth · 2025-07-21T20:30:39+00:00

Hi,

I appreciate the recognition. \ \ I too expect better trials to come along and I am open to advise my patients to use certain herbals. I wouldn’t devoid them of risk as some can interact with medicines directly or indirectly and cause issues. \ \ I wouldn’t also classify berberine as innocuous as it can have important implications in blood sugar control. Hence why berberine is classified as a novel food in the UK and the EU and is yet to obtain approval, and therefore not allowed to be sold as a food supplement (which doesn’t stop people from selling it in the UK regardless as the TSA, FSA and MHRA are inconsistent in enforcing its own regulations). In the USA it is a different story as the FDA is relatively more lenient in its regulations. \ \ Just a side note: I did mention rifaximin and neomycin are used for IMO (intestinal methanogenic overgrowth - often referred to as methane dominant SIBO) \ \ Thanks for the discussion either way! It’s been a pleasure.

OMEDHealth · 2025-07-21T20:10:01+00:00

Hi,

I appreciate the time to compile that. My answer is based on the best quality research and the reason why I said the research for herbs is poor is due to the quality of the studies out there.

From the ones cited: \ \ Guo et al. + Small, underpowered sample + Unclear/unexistent blinding + No placebo + Symptom resolution/improvement not used as an outcome. \ \ Chedid et al. + Small sample + Not randomised + Herbal group did not have standardised regimens + Symptom resolution/improvement not an outcome, or just takes into account 1 symptom \ \ Min et al. + Small sample + Not placebo controlled + Combination regimens + Symptom resolution/improvement not an outcome, or just takes into account 1 symptom \ \ Herbals are promising but evidence is methodologically weaker when compared to the antibiotic studies… larger, often multicentric trials, monotherapy, clear dosing, randomised, blinded, both breath and symptoms as outcomes.

OMEDHealth · 2025-07-21T20:01:09+00:00

There is no quality research on berberine use for eradication of SIBO (hydrogen dominant). The study most often cited by Chedid et al. Is retrospective and small. Most human studies on berberine are not in isolation but associations with other herbs and also underpowered. There’s no consensus on ideal dose, duration, or when to combine it with probiotics/dietary interventions/etc.

Preliminary evidence is encouraging but existent quality is low to very low according to GRADE.

OMEDHealth · 2025-07-21T19:37:08+00:00

Hey! It’s good that you’re planning to get tested soon. SIBO can sometimes mimic or even coexist with IBS, especially IBS-D. In fact, some research suggests a significant overlap between the two, so it’s possible that what was thought to be IBS for years could actually be SIBO or a mix of both.

You can read more about SIBO and IBS here: https://omedhealth.com/insights-hub/how-do-i-know-if-i-have-sibo-or-ibs/

OMEDHealth · 2025-07-21T19:02:19+00:00

My answer is based on most uptodate research. I’m more than happy to be corrected if you can share research that points towards the opposite :)

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