Q. How can IBS related to SIBO be managed?

Answered by
Dr. Sultan Zeb Khan
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Jun 14, 2019

Hi doctor,

I realize I have IBS symptoms and they seem to be related to SIBO. I need your advice on how to treat it effectively. Here are some symptoms and test results.

Leaky gut or intestinal permeability with multiple food intolerances. Seems to have hydrogen sulfide based SIBO, severe farting with a foul smell of eating foods like cabbage, broccoli, cauliflower, high protein foods. I may have an overgrowth of sulfate-reducing bacteria. Rifaximin seems to help with SIBO but it is temporary. I have to eat rice as I cannot eat gluten or wheat. Some experts on SIBO say that MMC or vagal nerve dysfunction is the root cause of SIBO. I have heard a lot of patients get better when they increase gut motility. So I wanted to ask if taking prokinetic or cholinergic support will help SIBO from reccuring.



Welcome to

The best is to avoid eating foods that cause trouble. Secondly, for SIBO (small intestinal bacterial overgrowth), it is better to use a combination of Tetracyclines plus Metronidazole for two weeks. Effective probiotic will also help.

Take the following medications:

1. Tablet Tetracycline 500 mg thrice a day two weeks.

2. Tablet Metronidazole 400 mg thrice a day for two weeks.

3. Take a good probiotic for two weeks at the end of the previous two drugs.

4. Take fresh homemade yogurt twice daily in a small bowel.

Thank you doctor,

I have tried Metronidazole but it caused me side effects. So I had to stop it. A lot of the serotonin gets created in the gut and I do have OCD. How about taking a prokinetic that is a 5HT4 receptor agonist that can stimulate gut movement.



Welcome back to

Yes, you can use tablet Itopride 50 mg or Levosulpride 25 mg thrice a day before meals for 2 to 4 weeks.

Hi doctor,

Thank you so much. I am on SSRI. So, is it fine if I take the tablet you mentioned? Hopefully, there is no interaction or increase in serotonin levels.



Welcome back to

Yes, you can use these drugs along with SSRI.

Thanks so much doctor. Very good response and good advice
# Yes you can use that if it's giving relief. Use fluconazole 100 mg for 2 weeks
Doctor Khan,
I had consulted you for IBS/SIBO issues.
I want to take your opinion again, here are my main issues:

- IBS symtpoms, severe gas and farting
- IBS-Constipation
- Sometimes I suddenly feel cramps in stomach and my palms sweat
- last few days I have sounds in the stomach, irritation in the stomach, accompanied by increased anxiety
- I am on SSRI's but that does not seem to help when I have IBS flare up
- seem to have lactic acid when I eat carbohydrates or rice
- cannot tolerate fermented foods, probiotics, sulfur foods as it increases my symptoms
- I read some research articles where it says that SSRI's block the Serotonin transporter in the gut and cause constipation.

Please advise if I can take antibiotics for the bacteria overgrowth and anything that can regulate serotonin in the gut.
# Vishal SSRIs are good choice in patients with IBS constipation. You need to take some anti spasmodics along with them plus acid suppression drugs as well.
First of all drink plenty of water atleast 10 to 12 glasses per day. Take fiber diet as much as possible. Regarding bacterial overgrowth you can use tetracyclines and Metronidazole but Metronidazole will increase your constipation. But one thing to remember is that in bacterial overgrowth there is usually Diarrhea not constipation, so forget about Sibo.
Take following medications which will help with IBS constipation.
1. Tab. Mebeverine 135 mg thrice a day before meals for 4 to 8 weeks
2. Tab. Rifaxamin 550mg twice a day before meals for 2 weeks.
3. Tab. Clearlax 15 mg once daily at night. 1 month.
I hope you will feel better .
Thank you doctor.
Is it possible to have a phone consultation please?
# Yes. At 10 pm Indian standard time.

Sorry 10.30 pm

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