Your IBS Might Actually Be SIBO – The Cut

In the spring of 2018, my now-husband and I spent a week in Santa Monica, one of my favorite places in the world, and all I remember about the trip is my humiliating farts. Distressed digestion is nothing new to me, a member of the IBS-hot-girl legion since I was diagnosed in 2008. Perhaps because keeping my condition secret felt impossible, my romantic history is weirdly bound up in my constipation. One boyfriend introduced me to enemas — I hate to disappoint, but not in a sexual way — and another lovingly called me his “poop camel,” which I think is self explanatory. At different points, they each massaged my troublesome belly.

I received my initial diagnosis after a boyfriend insisted I seek help from a fancy gastroenterologist who proved as useless as he was handsome. Because I was insured, the good-looking specialist suggested a colonoscopy. But after I acquired a jug of the notoriously foul mixture you’re supposed to drink the night before, I didn’t keep the appointment. The literature he handed me was worthless; it pointed to meats, dairy, and alcohol as triggers, and I’d been a teetotaling vegan for years. For the decade that followed, my symptom severity fluctuated according to no pattern that I could discern, and I (along with my caring suitors) muddled along as best I could.

But by the time of this California trip, my gut had shifted from treating me to occasional bouts of constipation and distention to constant bloating of an unprecedented degree, which came with the worst-smelling gas I’d encountered in the whole of my life. I tried to be strategic about where and when I vented my unfortunate air, but we were in a bungalow, not a mansion.

“Do you smell that?” my husband asked one afternoon as he came into the living room where I had been hideously farting for the duration of his absence.

I was tired of trying to hide how bad the situation had become. He deserved to know the full extent of my shame. “It’s me,” I answered.

“No,” he said. “This isn’t the sort of smell that comes out of a human. It’s like … a chemical leak.” He wandered to the kitchen to investigate the appliances. I shut myself in the bathroom and cried.

Irritable bowel syndrome, the world’s most commonly diagnosed gastrointestinal disorder, is hardly an obscure phenomenon, but in the past few years it’s become trendy thanks to the dovetailing of several factors: a burgeoning class of influencers who mine their bowel issues for content (like YouTuber Emma Chamberlain and TikToker Claudia Kathryn); the willingness of some women on social media to jokingly claim it as a desirable hallmark of femininity (“hot girls have stomach issues”); even the cultural ubiquity and cuteness of poop in general (see: the poop emoji). A Love Is Blind cast member centered her affliction in a recent promo, saying, “If I could tell the love of my life one thing, I would tell them that I have IBS.” The pandemic also exacerbated many people’s symptoms. “The demand at our practice has skyrocketed,” says nutritionist Rachael Singh of the Functional Gut Clinic. She suspects “shutdowns might have given people time to think about what’s important to them” but credits an increased awareness of gut disorders, much of it fueled by social media, for driving some of the inquiries too. Either way, more people than ever seem to be obsessed with making sense of their gut’s functioning, or lack thereof.

The International Foundation for Functional Gastrointestinal Disorders estimates that up to 45 million people in the U.S. are affected, two-thirds of whom are women, and most of whom are under the age of 50. In other words, it’s primarily a young woman’s problem, ripe for cultural reevaluation in light of the $1.5 trillion global “wellness” boom, and a prime topic for influencers who recognize the potential clout value in “bloating positivity.” On TikTok, videos hashtagged #bloating collectively have over 518 million views. Videos hashtagged #IBS have more than 840 million.

Like other predominantly female-afflicting conditions — chronic fatigue syndrome, fibromyalgia, and now, it seems, long COVID — IBS defies concrete definition, making it a category of dubious utility. “It’s a constellation of various symptoms that don’t fit into any other classical diagnosis in gastroenterology,” says Dr. Robynne Chutkan, integrative gastroenterologist and founder of the Digestive Center for Wellness. This list includes diarrhea, constipation, gas, bloating, pain, nausea — basically any digestion-related suffering that’s unpleasant and undesirable but not readily recognizable as serious or life-threatening. “It’s a catchall diagnosis that doesn’t provide much insight into what’s actually causing the problems,” she says. Without a cause, there’s no cure and often little relief. “For a long time, people, especially women, have been told: It’s all in your head, it’s a stress-related issue, go home, relax, and eat more fiber,” says gut-health specialist Dr. Nirala Jacobi. “There wasn’t much doctors could offer these patients.”

It was with my own history of such chronic disappointment that I met with a naturopath who listened to my foggy descriptions of debilitating gas and second-trimester-looking distension and nodded along as if it all made sense. Her response was life-changing: “It sounds like you have SIBO.”

SIBO stands for “small intestinal bacterial overgrowth,” a condition in which bacteria normally meant to be in the large intestine migrate into the small, where they emphatically don’t belong. There, they encounter food that’s less broken down than it would be in the colon, which they eat and ferment into gas that causes horrible bloating. While IBS has long been considered incurable, SIBO is often curable and treatable. Studies suggest that the occurrence of SIBO among patients with IBS commonly ranges from between one in five to nearly half — and that up to a staggering 78 percent of IBS sufferers could have SIBO. That means the syndrome many have endured for years with no hope of permanent relief may actually be an infection that can be resolved in a matter of months.

Perhaps most importantly, there’s an actual test for SIBO. After I explained the extremity of my abdominal distention, my doctor immediately ordered one. It entailed eating a special diet for a day, fasting, drinking a solution (that, unlike the colonoscopy mix, tastes forgettably mild), and collecting my exhalations at timed intervals. Various gases in my breath then indicated the presence of the misplaced bacteria.

Clearing that rogue bacteria is the first order of business for anyone with SIBO, and it can’t be done through meditation or exercise. Nor can it be accomplished with the low FODMAP diet, an increasingly high-profile tool for managing IBS flare-ups that derives its acronym from the carbohydrates that are difficult for one’s small intestine to absorb. Early on in our time working together, my doctor, Maura Henniger, disabused me of the notion that I needed to obsessively monitor and limit my food. “I see so many people driving themselves crazy trying to find the right diet,” she says, “when really they’re going to find relief by getting rid of the infection and working to heal the gut.” Though prescription antibiotics are available for SIBO, I went with an herbal course of antimicrobials that included garlic extract, oregano oil, and berberine, among others. However New Age-y that may sound, follow-up breath tests and improvement in my symptoms confirmed that they worked. (More studies are needed to verify the efficacy of herbal treatments, but many of the practitioners I spoke with have seen success with them among patients.) My course of treatment took many weeks, but after years of unpleasantness, a few months weren’t a big deal. Several rounds of herbs and my infection was gone.

Yet it’s likely most gut-health sufferers have never heard of SIBO. Sexism accounts for some of this. Gastroenterology is among the most male-dominated specialties; in 2020, 84 percent of its practitioners were male. Both Henninger and Jacobi say they see patients who’ve met with gastroenterologists who don’t know about SIBO or who even deny that it’s a real condition, though the research at this point is conclusive. Any advancement takes time to trickle down into doctors’ offices, but there are also specific reasons for resistance to new findings. “Gastroenterology is a field where practitioners are highly incentivized to perform procedures that generate lots of income and take little time to do: 15 minutes to 30 minutes versus sitting with a patient for an hour and trying to figure out what’s really going on,” says Chutkan.

This isn’t to say that an IBS diagnosis should be regarded as a de facto diagnosis of SIBO. “There are so many conditions that can mimic SIBO,” says DIY advocate Shivan Sarna. “Please don’t guess.” That means getting tested for SIBO but also taking advantage of the blood test that can detect certain kinds of IBS. The idea is to just get as much information as you can when presented with the possibility of IBS. “I encourage people to, in some ways, reject the diagnosis” of IBS, Chutkan told me. “It can be counterproductive in terms of getting a read on what’s really going on in someone’s digestive system.”

Which makes me wonder if the memification of IBS might be part of the problem. While the condition’s visibility may suggest a net positive, could it have the inadvertent effect of leaving sufferers resigned to symptom management instead of pursuing a cure, viewing the disorder as a flukey feature of their bodies rather than a distinct condition that merits precise intervention? The more your online community is predicated upon a shared medical problem, shaping what you share and who you connect with, the harder it may be to look beyond it. “I can’t help but fear I will lose myself if I find the underlying cause of my digestive issues,” Reductress writer Damien Kronfeld joked in her piece “My Gastrointestinal Problems Are Part of My Hot Girl Brand, but I Really Would Like Some Relief.” Trust me, we have nothing to lose but our chains (to the bathroom).

Almost every specialist I spoke with was energized and optimistic about the future of gut health. They anticipate increasingly specific diagnoses with a broadening, increasingly successful array of treatments. “SIBO research is evolving almost constantly,” Henninger said, citing the work of Dr. Mark Pimentel, head researcher at Cedars-Sinai’s Pimentel Laboratory, who pioneered the use of a prescription antibiotic for SIBO and developed a blood test for detecting certain types of IBS. Their enthusiasm is contagious and relatable. When you’ve been beset by a mysterious, seemingly inexplicable health problem for most of your adult life, finding the solution to that problem can turn you into an evangelist — just ask some of my indulgent friends.

It’s premature to say my SIBO is permanently cured — reinfection is unfortunately quite common — and it’s inaccurate to say my gut never gives me any grief. There are still nights when I regret gorging on cauliflower bites or eating a lunch with too many chickpeas. But I’m so, so much better than I was before. Perhaps my hotness has diminished, but my quality of life has improved dramatically. And I don’t want myself, or anyone, to cry about their farts ever again.