How PCPs can deliver relief to patients with this chronic GI condition today

GI issues tend to be overlooked, causing patients to suffer from uncomfortable symptoms. In many cases, primary care physicians are the first step in care made by patients. They’re a familiar and trusted resource, so it’s natural that they would look to their PCP for help first. Yet, some PCPs may think that certain symptoms or digestive problems indicate a medical problem outside of their expertise.

While there are certainly many instances that patients should be referred to a specialist, the reality is that several common gastrointestinal issues don't require a gastroenterologist as a first step of care. And with today’s resources, PCPs have the tools available to them so they can confidently and effectively act as the first line of care for patients’ digestive concerns.

GI conditions on the rise

The prevalence of some gastrointestinal disorders has risen significantly since COVID, meaning that more PCPs may be seeing patients with GI complaints. One of those conditions is inflammatory bowel syndrome. This is already one of the most common GI conditions with 10-15% of U.S. adults living with the condition.

IBS is a functional GI disorder that affects the large intestine and it has traditionally been characterized based on symptoms because its cause hasn’t been clearly identified. Patients may experience abdominal pain, diarrhea, constipation and bloating, or they may only have a couple of these symptoms. But bloating can be a key indicator that IBS may not be the proper diagnosis.

I was part of a pivotal study in 2000 that found about 78% of patients with IBS actually have small intestinal bowel overgrowth (SIBO). SIBO affects the small intestine and is caused by an accumulation of bacteria, which ferment and eat the food in your digestive tract, causing symptoms similar to IBS. Because of this, SIBO is commonly mistaken for IBS without further exploration.

Bloating is the primary symptom to watch. Most commonly, E. coli and Klebsiella are the bacteria characterizing SIBO and they can increase the small bowel’s fermenting capacity by 63 times the normal rate, creating gas in the gut and causing bloat. More often than not, it’s consistent diarrhea that prompts PCPs to be worried, as it can indicate a wider range of conditions from Celiac disease, Crohn’s disease, and more. However, a diagnosis considering bloat will most likely still be IBS or SIBO, and if it’s not, there’s an easy way to rule out the latter.

Tools available to PCPs

Over the last decade or so, there have been some incredible advances in the SIBO space that now offer valuable support to PCPs. Most importantly, the innovations around diagnosing and managing SIBO enable PCPs to care for patients with more confidence than ever.

First, diagnosing SIBO is as easy as a breath test, a non-invasive approach for examining a patient’s digestion of certain sugars by measuring the amount of hydrogen exhaled. This can be done either in the PCP’s clinic or in the comfort of a patient’s home rather than having that patient wait on average 40 days for an appointment with a gastroenterologist and likely paying an additional out of pocket expense for an exploratory diagnostic procedure which the patient may ultimately decline or delay while the condition worsens.

With the development of a three-breath test that measures a complete fermented gas profile of a patient’s microbiome, including hydrogen, methane and hydrogen sulfide levels, more patients have a means for a proper diagnosis within reach. When looking at breath tests to stock in the clinic, it’s important to select one that measures all three gases to help capture the different types of SIBO or a combination of SIBO and intestinal methanogenic overgrowth (IMO) or intestinal sulfide overproduction (ISO).

When it comes to patient care options, elemental diets have been well documented over the last 50 years as the most effective method for managing SIBO and other GI conditions. However, they aren’t heavily taught in medical school and the historically sulfuric taste led to low patient compliance in prior decades—a combination leading to very few doctors recommending elemental diets to patients in recent years. Popular antibiotics have been the recent standard for treating SIBO and IBS, in theory reducing a portion of the gut bacteria population, however new advances in food science now offer patients the option of a palatable elemental diet. Where antibiotics eradicate SIBO in 44% of patients, a two-week protocol of palatable elemental diet eradicates SIBO in 83% of patients.

Lastly, once a patient has eradicated their SIBO, either with antibiotics or an elemental diet, GI-supportive diets can help to maintain relief from symptoms. Diets such as Low FODMAP and Low Fermentation Eating (LFE) are designed specifically to reduce the chances of relapse by limiting the fermentation of certain carbohydrates in the gut. Low FODMAP is known to be very restrictive and a short-term diet, but LFE offers patients a long-term diet that extends relief without sacrificing the joy of eating. It is important to note that the restrictive nature of both diets does require patient monitoring to address any potential nutritional deficiencies.

Offering relief earlier

On average, it takes patients six years before they receive an IBS or SIBO diagnosis, often with a specialist at that point. Imagine if they received diagnostic tests or treatment recommendations at their first point of care from a trusted resource and familiar face. Patients could relieve debilitating symptoms significantly earlier and cut around less effective solution methods like antibiotics. This can be a reality today.

More than ever before, PCPs are better equipped to more immediately help their patients with GI symptoms and chronic diseases and with the advances in SIBO research and care, they have access to numerous tools that they can add to their toolbelt to help patients sooner.

Mark Pimentel, MD, is a gastroenterologist and Medical Advisory Board member of mBIOTA Labs.