North Dakota woman's puzzling digestive problem turned out to be bacterial overgrowth
FARGO—Annika Perkins always had stomach troubles. It was just something she came to accept as normal for her. They largely receded from her thoughts and faded into the background.
"Even as a small girl I always had stomach aches," she said. Then, after years of coping with digestive problems, she came to realize that she had a problem."This isn't normal," she said, remembering the words of her fiance, now her husband. "You shouldn't have to live like this."
His words sank in. Perkins took inventory and realized something was wrong. "I was always fatigued," she said. "Always."
Then came a battery of tests. She had an upper endoscopy and, over time, three colonoscopies. She went on a gluten-free diet. She was tested for celiac disease and Crohn's disease. Nothing could explain her chronic digestive problems.
"For the longest time I did food journals," said Perkins, 26, who lives in West Fargo. "I could never figure it out. We could not find a theme."
But her gastroenterologist, Dr. Kimberly Kolkhorst at Essentia Health, was persistent in the cause. She had Perkins take one more test, what's called a hydrogen breath test.
The breath test revealed the culprit to be Small Intestine Bacterial Overgrowth, or SIBO. It's a condition in which bacteria, normally found in large numbers in the colon, become overpopulated in the small intestine.
"I was happy it wasn't anything more serious," she said, such as celiac disease or Crohn's.
Still, the bacterial overgrowth can wreak havoc, with symptoms including uncomfortable bloating and reflux as well as diarrhea, constipation, or both. Kolkhorst prescribed an antibiotic, Rifaximin, to kill off the excess bacteria.
Die-off caused by the antibiotics made Perkins nauseous during the first week of her treatment. At first, she said, "I didn't feel well."
She also went on a diet that restricted hard-to-digest carbohydrates, which the bacteria feast upon. A carb-restricted diet helps to gradually "starve" the bacteria. "I definitely felt better on that," she said of the diet.
After several weeks—in time for Perkins' wedding—her symptoms began to diminish, and continued to improve during her honeymoon. "Now I can basically eat anything," she said.
SIBO can be stubborn, requiring multiple rounds of antibiotics and restrictive dieting. It's also notorious for coming back.
As Perkins' case shows, SIBO can also be difficult to diagnose, Kolkhorst said.
"The symptoms are so non-specific," she said. "I see a lot of bloating," she added. "It doesn't always turn out ot be SIBO."
Because the symptoms are common and can stem from other causes, Kolkhorst usually examines other possible diagnoses first. "If everything's negative," she said, "I go to the breath test."
SIBO has multiple causes. It can be caused by acid-suppressing medications—stomach acid helps to control bacteria and other pathogens—and food poisoning. SIBO can be associated with celiac disease and diabetes, among other diseases.
The condition typically involves slow intestinal motility, meaning that it takes too long for food to move through the intestinal tract—giving bacteria the opportunity to flourish and overpopulate.
Often people with irritable bowel syndrome have SIBO, Kolkhorst said. "There is an overlap with IBS and SIBO," she said. In fact, Rifaximin now is often prescribed for IBS, she added.
SIBO is becoming more common, but Kolkhorst said it isn't clear whether that's because testing has become more common, or whether the incidence is rising.
Carbohydrates, especially in the form of processed foods, are cheap and readily available, making it easy for people to consume too many, Kolkhorst said.
"Carbs are cheap and easy," she said.
Besides antibiotics and a diet that restricts certain carbohydrates, probiotics to restore balance of the gut microbiome is important to treat SIBO, Kolkhorst said. Exercise also helps by working to improve intestinal motility, she said.
Perkins is enjoying feeling better and being able to eat a greater variety of foods without worrying. She's telling her story, she said, "So that other people don't have to deal with this."
Sanford Health, as well as independent gastroenterologists, also diagnose and treat SIBO.