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Integrative management of SIBO / SIFO / IMO / LIBO
Your patients complain of bloating, transit disorders and chronic digestive discomfort with no clearly identified cause, and many have been labelled "irritable bowel syndrome" without anything really improving. This e-learning training gives you a complete and rigorous reading framework for microbial overgrowth of the…
7 lessons · Lifetime access · Online
These trainings are delivered in French. This page is translated for your convenience; the course videos and materials remain in French.
Overview
Your patients complain of bloating, transit disorders and chronic digestive discomfort with no clearly identified cause, and many have been labelled "irritable bowel syndrome" without anything really improving. This e-learning training gives you a complete and rigorous reading framework for microbial overgrowth of the small intestine, drawing on reference Anglo-Saxon work adapted to French-speaking practice. You will find both the pathophysiological foundations and a concrete approach, directly transposable to consultation.
What you will learn
- Precisely distinguish the entities SIBO, SIFO, IMO and LIBO, understand the respective role of hydrogen, methane and hydrogen sulphide, and know why methane comes from archaea and not bacteria
- Interpret a lactulose breath test step by step, from real cases, reading the hydrogen, methane and CO2 curves, spotting the flatlines suggestive of a hydrogen-sulphide SIBO and avoiding the pitfalls of false positives and false negatives
- Master the pre-analytical conditions essential to the reliability of a test, as well as the complementary place of 16S rRNA metagenomics, short-chain fatty acid measurement and urinary assessments
- Build a management protocol combining reduction of the microbial load, an appropriate dietary model, support of the intestinal barrier and prevention of recurrences
- Adapt your strategy according to the type of dysbiosis, allopathic or natural antibiotics, well-tolerated prebiotics, targeted probiotics, prokinetics, and manage the question of biofilm and the die-off effect
- Identify the most frequent deep causes so as not to limit yourself to symptomatic treatment
On the programme
- Generalities and pathophysiology: definition, gases produced, mechanisms controlling bacterial proliferation, digestive and extra-digestive consequences, associated micronutritional deficiencies
- The different presentations: hydrogen SIBO, mixed SIBO, methane IMO, hydrogen-sulphide SIBO and LIBO, and Candida-related SIFO
- Practical interpretation of diagnostic tests: guided work on a series of lactulose breath tests and the link with metagenomics
- Management: antimicrobial strategies, dietary models (Specific Carbohydrate Diet, GAPS, low FODMAP, SIBO Specific Food Guide, Biphasic Diet), digestive support, treatment of Leaky Gut, management of the die-off effect and biofilm
- The entry-level deep causes: altered intestinal motility and migrating motor complex, organic alterations, functional digestive alterations linked to stress and vagal tone, and pharmacological causes
- A commented quiz, corrected together, to consolidate all the notions
Who it is for
This training is for healthcare professionals engaged in micronutrition and functional medicine, in particular doctors, pharmacists, as well as practitioners supporting patients with chronic digestive disorders.
At the end of the training
You will be able to recognise the clinical situations suggestive of SIBO, SIFO, IMO or LIBO, prescribe the appropriate test and interpret its results with discernment. You will be able to build structured and individualised management, combining antimicrobial, dietary and micronutritional levers. You will finally have the benchmarks needed to look for the most common deep causes and limit the risk of recurrence.
Programme
Total video duration: 6 h 23 min
CCM SIBO V1
- Quiz de début de formation
- Leçon 11 h 39 min
- Leçon 21 h 36 min
- Leçon 31 h 57 min
- Leçon 447 min
- Leçon 524 min
- Quiz de fin de formation
Video Audio PDF handout
Frequently asked questions
In which cases should anti-vinculin and anti-CdtB antibodies be tested, and what do elevated levels mean?
These tests are indicated only when SIBO began after a case of food poisoning or gastroenteritis. Antigenic mimicry between the CdtB toxin and vinculin (a migrating motor complex protein) can then trigger an autoimmune response. Positive antibodies confirm autoimmune SIBO with impaired intestinal motility, which justifies starting a prokinetic to prevent recurrence.
Why might a patient treated for SIBO fail to improve, or even worsen?
In about 25% of cases, SIBO coexists with SIFO (fungal overgrowth of the small intestine). Antibiotics used to treat SIBO can worsen the underlying candidiasis by reducing the competitive pressure from commensal bacteria. If the follow-up breath test shows normalized gas levels but symptoms persist, an associated SIFO should be considered, among other possible causes: non-measurable H2S SIBO, residual motility disorder, food intolerances.
What is the difference between SIBO, IMO and LIBO, and why was the term SIBO-C abandoned?
SIBO refers to bacterial overgrowth in the small intestine. IMO (intestinal methanogen overgrowth) replaces SIBO-C because the responsible microorganisms (Methanobrevibacter smithii) are archaea, not bacteria, and the overgrowth can occur in either the small intestine or the colon. LIBO (large intestinal bacterial overgrowth) refers to overgrowth in the colon, used in particular for hydrogen-sulfide LIBO.
Which dietary model does Dr Anne Lucas, PharmD recommend first-line for SIBO, and why is Low FODMAP not advised in IMO?
Dr Anne Lucas, PharmD recommends Nirala Jacobi's Biphasic Diet first, for its structure of progressive phases (1A restrictive, 1B semi-restrictive, phase 2). Low FODMAP is not suited as a first-line approach in IMO because it does not specifically target methane production; in this context, Dr Anne Lucas, PharmD prefers the Biphasic Diet, adapting the protocol to reduce animal protein and increase well-tolerated fibers (flax seeds, chia, partially hydrolyzed guar gum).
Why is IMO used rather than SIBO when it comes to methane?
Methane is not produced by a bacterium but by an archaeon. This finding led the scientific community to update the terminology: the term IMO (Intestinal Methanogen Overgrowth) is now used instead of SIBO-C to specifically designate this entity. Dr Anne Lucas, PharmD stresses this point in question 6.
How does the Candida albicans biofilm complicate treatment of chronic digestive candidiasis?
Candida albicans is able to build a protective biofilm that makes it resistant to antifungals. Some authors recommend waiting at least one course of antifungals before introducing anti-biofilm agents, in order to first reduce the fungal load and limit the die-off effect (a massive release of mycotoxins causing a transient worsening of symptoms). In practice, most chronic candidiasis cases require several months of treatment.
When is metagenomics (16S rRNA microbiota) useful in this context, and what is it used to read?
Metagenomics (16S rRNA sequencing) cannot diagnose SIBO, but it is useful for identifying LIBO (colonic dysbiosis) or IMO by visualizing the Euryarchaeota phylum (Methanobrevibacter) and H2S-producing bacteria (Desulfovibrio, Desulfuromonas, Bilophila). It also gives an overall view of microbiota balance and short-chain-fatty-acid-producing bacteria, for around 150 euros.
What are the 4 main root causes of SIBO to explore at level 1?
Dr Anne Lucas, PharmD identifies four axes: (1) impaired small-intestine motility (disrupted MMC, hypothyroidism, head trauma); (2) organic/structural causes (ileocecal valve dysfunction, adhesions, digestive or gynecological surgeries); (3) functional digestive impairments (hypochlorhydria, enzyme insufficiency, bile deficiency, mucus, chronic stress); (4) pharmacological causes (PPIs, antispasmodics, opioids, tricyclic antidepressants).
How should a "flatline" result on the lactulose breath test be interpreted?
When both the H2 and CH4 curves remain very low (below 2-3 ppm) and flat throughout the test, this points toward hydrogen-sulfide (H2S) SIBO. H2S cannot be directly measured in France; it is this flatline profile that allows it to be suspected. A glucose breath test is then carried out second-line.
How can IMO be clinically distinguished from mixed SIBO?
In IMO, the patient has constipation exclusively, never diarrhea, often accompanied by nausea linked to methane's retrograde effect on motility. In mixed SIBO, there is alternating diarrhea and constipation. The lactulose breath test will show a marked rise in CH4 from the start in IMO; in mixed SIBO, the rises in H2 and CH4 are generally less pronounced or delayed.
How does the autoimmune mechanism following food poisoning lead to recurrent hydrogen SIBO?
Food poisoning (E. coli, Campylobacter, Salmonella, etc.) causes pathogenic bacteria to produce CdtB toxin. The immune system generates anti-CdtB antibodies, then, through antigenic mimicry, anti-vinculin antibodies, which attack the migrating motor complex. This MMC dysfunction creates bacterial stasis in the small intestine, promoting hydrogen SIBO.
What are the positivity criteria of the lactulose breath test for H2 and CH4?
A lactulose breath test is positive for hydrogen if the rise exceeds 20 ppm between 90 and 100 minutes after ingestion. It is positive for methane if the rise exceeds 10 ppm (some definitions use 12 ppm), with associated constipation. Dr Anne Lucas, PharmD notes that the 90-100 minute window corresponds to the small-intestine transit; beyond 120 minutes, the marker is already in the colon (LIBO).
Why can't 16S rRNA metagenomics be used to diagnose SIBO?
Because the bacterial composition of the colon is physiologically very different from that of the small intestine: bacteria abundant in the colon are normally absent from the small intestine. Metagenomics analyzes the colonic microbiota and therefore provides no information about small-intestine overgrowth. However, it is useful for revealing an excess of Methanobrevibacter in the colon (colonic IMO) or hydrogen-sulfide-producing bacteria (H2S LIBO).
Why must choleretic/cholagogue plants and garlic be strictly avoided in hydrogen sulfide SIBO?
Sulfate-reducing bacteria (Desulfovibrio, Desulfuromonas) are bile-resistant and favored by increased bile secretion: stimulating bile secretion would therefore worsen their growth. Garlic (and the allicin derived from it) is rich in sulfur compounds that directly feed hydrogen sulfide production, worsening symptoms. These are two absolute contraindications specific to this type of SIBO.
What are the positivity criteria on a lactulose breath test for hydrogen SIBO, methane SIBO (IMO) and mixed SIBO?
For hydrogen (H2-SIBO): a rise of at least 20 ppm from baseline within the first 90 to 100 minutes. For methane (IMO): a rise of at least 10 to 12 ppm from baseline, especially when associated with constipation. For mixed SIBO: the sum of H2 + CH4 must exceed 15 ppm between 90 and 100 minutes. A high CH4 level from baseline points toward small-intestine-and-colon IMO.
Should PPIs be stopped before performing a breath test?Full answer inside the training →
Why prefer lactulose over glucose as the substrate for the SIBO breath test?Full answer inside the training →
Why is T4-only supplementation associated with an increased risk of SIBO, particularly IMO?Full answer inside the training →
What is the role of oregano essential oil in SIBO protocols, and what precautions are required?Full answer inside the training →
How can hydrogen-sulfide SIBO be diagnosed in France, where this gas cannot be measured?Full answer inside the training →
How should gastric hypochlorhydria be assessed and treated in the context of SIBO?Full answer inside the training →
What pre-analytical conditions are essential for the breath test to be interpretable?Full answer inside the training →
What are the three official strategies for reducing bacterial load in SIBO?Full answer inside the training →
Which micronutrients should be monitored first in a patient with SIBO?Full answer inside the training →
How is allicin used in IMO (methane SIBO), and why is it preferable to other antimicrobials in this context?Full answer inside the training →
What role do bile acids play in protecting against SIBO, and which supplements should be proposed in case of biliary insufficiency?Full answer inside the training →
What does a "flatlining" profile mean on a lactulose breath test?Full answer inside the training →
When and how should bismuth be incorporated into managing hydrogen-sulfide SIBO?Full answer inside the training →
Why are soy isoflavones valuable in IMO and hydrogen-sulfide SIBO?Full answer inside the training →
Why do SIBO diets mainly target carbohydrates rather than protein?Full answer inside the training →
How does the FUT2 genetic polymorphism influence intestinal mucus secretion and SIBO recurrence?Full answer inside the training →
What is the role of berberine as a natural antibiotic in SIBO?Full answer inside the training →
What is the only prebiotic recommended in IMO, and why are other prebiotic fibers contraindicated?Full answer inside the training →
Why shouldn't a surge in hydrogen SIBO after treating methane IMO alarm the practitioner?Full answer inside the training →
When should the biofilm be treated, and which agents should be used without worsening the Herxheimer reaction?Full answer inside the training →
What is the role of Saccharomyces boulardii in managing SIFO?Full answer inside the training →
What is the role of cardiac coherence in managing SIBO linked to chronic stress?Full answer inside the training →
How does N-butyrate improve IMO-related constipation?Full answer inside the training →
In which cases is a prokinetic essential, and at what stage of the protocol should it be introduced?Full answer inside the training →
When and how should Saccharomyces boulardii be used in managing SIBO or SIFO?Full answer inside the training →
What are the four etiological axes of SIBO to remember for clinical practice?Full answer inside the training →
Why can certain commonly prescribed supplements worsen hydrogen-sulfide SIBO or LIBO?Full answer inside the training →
Which dietary model should be chosen first-line in SIBO, and what is the difference between the Biphasic Diet and the SIBO Specific Food Guide?Full answer inside the training →
What pre-analytical precautions should be followed before a lactulose breath test to detect IMO?Full answer inside the training →
How should an elevated CH4 level already present at baseline (T0), before lactulose ingestion, be interpreted?Full answer inside the training →
What is the difference in action between prokinetics and laxatives in managing SIBO-related constipation?Full answer inside the training →
What specific dietary and supplement adaptations should be planned for IMO (methane SIBO)?Full answer inside the training →
What is the main pathophysiological mechanism of hydrogen SIBO, and how does the Biphasic Diet fit into it?Full answer inside the training →