Reversing IBS Caused by Candida Yeast Overgrowth

IBS symptoms generally come from dysbiosis, an imbalance of microbes in your small intestine. The key players in dysbiosis are parasites, bacteria and fungi. I have other posts on parasites and bacterial overgrowth (SIBO). Now it’s time to talk about FUNGI, a kingdom of critters with superpowers!

Fungi can be opportunistic, quick, shape shifting and ultra-evasive. It can cause digestive problems like belching, bloating and diarrhea, but also has the ability to mess with your brain; to the extent of even making some people legally intoxicated in a single meal!

When any kind of fungi overgrows in your small intestine, it’s called Small intestinal fungal overgrowth (SIFO). The most prevalent is a species in the yeast domain known as candida albicans.

If you’re looking for help reversing IBS caused by candida yeast overgrowth, these tips from doctors can help you fix your fungus!

Fungi and yeast and candida! Oh my!

While these words are often used interchangeably, they are actually on different levels in the biological ranking known as taxonomy. A quick look at the taxonomy of candida albicans will provide a helpful anchor for when our experts offer recommendations using these words.

• Domain – The broadest, most general rank. There are three: Bacteria, Archaea, and Eukaryota.
• Kingdom – Fungi (part of the Domain Eukaryota)
• Phylum (or division) – Yeast are single-celled microorganisms that are “classified into two separate phyla, Ascomycota or sac fungi and Basidiomycota or higher fungi.” Yeast is always a fungus. Yeasts are opportunistic, always ready to jump into replication mode the moment there are favorable conditions.
  
• Class – Saccharomycetes
• Order – Saccharomycetales
• Family – Saccharomycetacea
• Genus – Candida. According to the CDC, “There are over 20 species of Candida yeasts that can cause infection in humans, the most common of which is Candida albicans.” Per Wikipidia, “Over 200 species have been described within the candida genus.”
  
• Species – Candida albicans is thought to have the most virulent potential of the candida yeasts. Zooming back out… there are at least 45,000 fungal species.
  

Candida albicans is a normal part of the human microbiome that hangs around for life. It can exist as a commensal organism, meaning you feed it, but it doesn’t usually cause any harm. However, it is also an opportunistic pathogen. When conditions are right, an overgrowth called candidiasis can develop.

Candidiasis that develops in the mouth or throat is called “thrush” or oropharyngeal candidiasis.

Candidiasis in the vagina is commonly referred to as a “yeast infection.” “About 75% of women experience vulvovaginal candidiasis”.

An invasive form of candidiasis, called candidemia, occurs when candida species enter the bloodstream and spread throughout the body. Candidemia has a reported mortality rate as high as 78% in cases where treatment is delayed as little as 48 hours!

Small Intestinal Fungal Overgrowth – SIFO

From a 2015 study: “Small intestinal fungal overgrowth (SIFO) is characterized by the presence of excessive number of fungal organisms in the small intestine associated with gastrointestinal (GI) symptoms.”  The study also states that candidiasis in the small intestines is known to cause GI symptoms.

C. albicans is not the only species from the fungal kingdom that can grow to overpopulation in the small intestine, but it is the most common.

With that groundwork, let’s meet some of the world’s foremost experts on SIFO and candida albicans.

SIFO and Candida Albicans Experts

Dr. Satish S. C. Rao, M.D., PHD, FRCP (LON), FACG, AGAF

Dr. Rao is a Professor of Medicine at Augusta University Medical Center. Among Dr. Rao’s credentials:

Clinical interests:

• Clinical study of motility, constipation, incontinence, pain and digestive health disorders
• Research specialty in treatment of IBS, constipation, fecal incontinence, visceral pain (particularly esophageal chest pain)
• Pioneered several new techniques of evaluating esophageal, gastric, colonic, and anorectal function (brain-gut axis)
• Received several patents and pioneered the technique of biofeedback therapy for dyssynergic defecation
• Currently, investigating the neurobiologic mechanisms of biofeedback therapy, and pioneering new treatments for fructose intolerance

Recognitions:

• American Gastroenterological Association (AGA) Distinguished Clinician Award
• AGA Masters Award for Outstanding Clinical Research
• American College of Gastroenterology (ACG) Auxiliary Research Award, 2005
• International Foundation for Functional GI disorders Senior Clinical Investigator Award, 2009
• Indian Society of Gastroenterology “Dr PN Chuttani Oration”, 2010
• Editor of several books: Disorders of the Anorectum (2001), Anorectal and Pelvic Floor Disorders (2008) for Gastroenterology Clinics of North America, Gastrointestinal Motility-Tests and Problem-Oriented Approach, and GI Motility Testing – a Laboratory and Office Handbook (2010, Co-Editor).

Dr. Michael Ruscio, DC and Functional Medicine Practitioner

Dr. Ruscio hosts a podcast called Dr. Ruscio Radio where he interviews cutting edge researchers like Dr. Rao. Dr. Ruscio specializes in treating gut dysbiosis (microbial imbalance). He also publishes a newsletter for other practitioners called The Future of Functional Medicine Review.

Some of his background:

• Functional Medicine Practitioner
• Lead researcher in a current IBS study
• Post-doctoral continuing education provider
• Doctor of Chiropractic – Life Chiropractic College West
• University of Massachusetts – B.S. Exercise Kinesiology
• Post-doctoral Functional Medicine study with educational bodies such as; The National College of Naturopathic Medicine, The Institute of Functional Medicine, The American Academy of Anti-Aging Medicine, Kalish Research, and Defeat Autism Now.

SIFO produces IBS-type symptoms

They include:

• Belching
• Bloating
• Brain Fog
• Diarrhea
• Fungal infections on skin and nails
• Gas
• Indigestion
• Joint pain
• Nausea
• Low iron – and low haemoglobin, transferrin, lactoferrin, zinc and ferritin as a result

If these symptoms look like a perfect match for what you are experiencing, don’t get excited just yet. Dr. Satish Rao and other researchers pointed out in a study that, “symptoms were poor predictors of overgrowth.”

They looked at 150 patients presenting with belching, bloating, indigestion, nausea, diarrhea, and gas. Findings:

• 25% had pure SIBO (bacterial overgrowth).
• 20% had both SIBO and SIFO.
• 20% had just SIFO.

The study concluded that about 40% of people with IBS have SIFO. These percentages were replicated in another study also.

One reason the Wellness Repair Plan evaluates for parasites and bacterial overgrowth (SIBO) first is because those imbalances also produce IBS symptoms and create an environment that can foster SIFO.

The best test for SIFO is invasive (sorry)

Fungus doesn’t ferment food like bacteria, so a breath test won’t help. The test options are:

• Small intestine aspirate: Dr. Rao: “…the best objective test is really taking fluid from the small bowel and aspirating it. I know it’s cumbersome. I know it’s invasive and so on. But truly, that is the best diagnostic method.” Dr. Ruscio: “Currently, the best test available to diagnose SIFO is a small bowel aspirate via endoscopy.” 
• Stool testing: Dr. Rao: “…there is a fair amount of candida that one can see in stool even in healthy individuals, and it is heavily influenced by diet. So it probably is not the best way because one can get a lot of false positive tests.”
• Blood antibody testing: Dr. Ruscio: “Not a perfect test, but certainly an option and much less invasive. The main concern with antibody testing is that it doesn’t tell you if you have an active infection. It simply suggests that you may have it or you previously had it at one point in your life. This may be more reliable than the stool test, but less accurate than the aspirate.”
• Organic acid testing – A functional medicine practitioner may look at markers like oxalates, tricarballylic acid and D-arabinose. These are indirect markers because they show byproducts or the exhaust of fungi, according to Dr. Justin Marchegiani.
• Treat based on symptoms: Dr. Ruscio: “Doing a short round of antifungals is not likely to cause any negative problems. If the patient responds well, then you have pretty good confirmation that SIFO is an issue.”

It should get easier in time. Dr. Ruscio estimates, “In 2 to 3 years, we will have simple methods for testing.” He says, “Researchers are currently working on capsules that you can ingest that will sample small intestinal juice every 15 minutes to diagnose SIFO. This will be a very easy, minimally invasive method.”

Acid reducers and antibiotics make SIFO more likely

According to Dr. Rao, “The underlying mechanism(s) that predisposes to SIFO is unclear but small intestinal dysmotility and use of proton pump inhibitors has been implicated.”

Here’s a list of likely predisposing factors identified by researchers and clinicians:

• Excessive antibiotic usage
• Long-term use of proton pump inhibitors (PPIs). Acid reducing drugs, including PPIs and H2 blockers, reduce acidity in your small intestine.
• Metabolic conditions like diabetes
• Inflammatory bowel disease (IBD)
• Intestinal dysmotility
• Neurological issues
• Connective tissue disorders
• Genetic predisposition
• Compromised immune system –  Candida infections are common in HIV, cancer, ICU, surgical, and transplant patients

Candida can morph!

Mild changes in temperature, CO2, nutrients and pH can result in candida shifting from a single cell yeast into a multicellular organism that grows branching filaments called hyphae. Scientists refer to this as a yeast-to-hypha transition. (Hyphae is multiple branches. Hypha is just one.) A 2004 study points out, “Candida albicans can grow in at least three different morphologies: yeast, pseudohyphae and hyphae.”

Here’s a video of what hyphae growth looks like.

One form isn’t necessarily worse than the other. According to research papers cited on Wikipedia, “Filamentous cells share many similarities with yeast cells. Both cell types seem to play a specific, distinctive role in the survival and pathogenicity of C. albicans. Yeast cells seem to be better suited for the dissemination in the bloodstream while hyphal cells have been proposed as a virulence factor. Hyphal cells are invasive and speculated to be important for tissue penetration, colonization of organs and surviving plus escaping macrophages.”

Here are some of the adaptive abilities of candida:

• Adhesion to and invasion into host cells
• Secretion of hydrolases – They steal nutrients. “Fungi are known to produce a range of extracellular enzymes, in particular hydrolases, which will aid in their acquisition of nutrients from the surrounding environment.”
• Contact sensing and thigmotropism – movement or change in orientation of growth as a reaction to touch, like ivy growing up a wall or tendrils from a plant that wrap around a pole. Contact to host cells can trigger the yeast-to-hypha transition.
• Biofilm formation – Also referred to as “slime”. “A biofilm is any group of microorganisms in which cells stick to each other and often also to a surface.” Biofilms protect bacteria from antibiotics and can also attract heavy metals!
• Phenotypic switching – Yet another way fungi can change quickly. This one is genetic and has to do with it’s ability to mate.
• Range of fitness attributes – “…include rapid adaptation to fluctuations in environmental pH, metabolic flexibility, powerful nutrient acquisition systems and robust stress response machineries.”

How functional medicine doctors treat SIFO

The steps in general terms:

• Stop feeding and making a comfy home for it.
• Stop eating and breathing mold.
• Kill it topically.
• Kill it internally. (Details below)
• Give it some competition. Per Dr. Justin Marchegiani, “…add back in quality probiotics and also maybe even competitive yeast like Saccharomyces boulardii.”

Specifics directly from the Textbook of Functional Medicine (2010, page 378):

• “Deal with predisposing factors (such as chronic use of antibiotics, steroids, hormones — stop unless absolutely medically necessary).”
• “Trial of yeast-control diet: elimination of refined carbohydrates, sugar, and fermented foods.”
• “Test for yeast overgrowth.”
• “Nonprescription antifungals include oregano, garlic, citrus seed extract, berberine, tannins, undecylenate, Isatis tinctoria, and caprylic acid.”
• “Antifungal prescription medications include nystatin, fluconazole, itraconazole, and terbinafine.
• Immunotherapy”
• “Identify potential environmental toxic fungi (stachybotrys, strains of aspergillus, chaetomium, and penicillium).”
• “Utilize the 4R Program and institute stress reduction and stress management practices.”

Fungal infections can be extremely serious

According to researchers, under certain circumstances, “C. albicans can cause infections that range from superficial infections of the skin to life-threatening systemic infections.” Microb Wiki points out, “Most patients can recover from oral and genital candidiasis after a treatment with antifungal such as fluconazole. On the other hand, candidemia is much more life-threatening infection. In one study, the mortality rate for patients with candidemia was about 34%. Shockingly, this figure almost doubled when treatment is delayed; i.e., the mortality rate was 78% when therapy was delayed for more than 48 hours.”

If you suspect you have a serious fungal infection you should always consult your doctor immediately.

Herbal and  pharmaceutical antifungal protocols

Regardless of the exact therapy you choose, the prerequisite steps are:

• Eliminate predisposing factors (such as chronic use of antibiotics, steroids, hormones — stop unless absolutely medically necessary).
• Eliminate foods that feed candida (like refined carbohydrates, sugar, and fermented foods).

Herbal antifungal therapy (Credit Dr. Ruscio)

Pros:

• Herbal antimicrobials are more broad-spectrum.
• Herbs can treat SIBO and fungal overgrowth at the same time.
• Herbs may be safer than a pharmaceutical antifungal.

Cons:

• Herbs are not covered by insurance.
• Herbs require a couple weeks longer treatment duration.
• You have to take more capsules compared to a pharmaceutical.
• Herbs are not regulated, so quality can be an issue. Stick with a reputable brand.

Natural antifungals

Many herbs used to treat parasites and SIBO are also effective against fungal infections. If these protocols look familiar, it’s because I copy/pasted them from my SIBO and parasite posts. Note that while the herbs and dosages are the same, the parasite protocol differs in that it requires a week off in the middle.

Take throughout the protocol if tolerated.

• Primal Defense from Garden of Life – This is a probiotic and prebiotic.
• Digestzymes from Designs for Health – a blend of hydrochloric acid, pancreatic enzymes and bile. You can also do a straight hydrochloric acid supplement (cheaper) if you do better on hydrochloric acid. It is critical that one avoids anything that will inhibit stomach acid production like antacids, H2 inhibitors, and proton pump inhibitors.
• Allimax Pro (optional) – An agent to help break down biofilms. More on biofilms later with two options that are far less expensive.

Month 1

• GI Microb-X from Designs for Health (6 capsules per day)
• Oil of Oregano from Designs for Health (6 capsules per day)

Month 2

• OrthoFlora Yeast (6 capsules per day)
• ParaBotanic Select by Moss Nutrition (6 capsules per day)

A protocol used by Dr. Josh Axe

One round involves all of these substances simultaneously and takes about 4-5 weeks

#1 Black walnut (250 milligrams 3x daily)

Use in tincture form. Other experts advise taking the entire daily amount in one dose. Mix into half a cup of water and sip over about 15 minutes or less on an empty stomach. Don’t gulp. If the slight amount of alcohol in the tincture makes you woozy, just stay seated until you are comfortable again. The beneficial compound in black walnut is juglone.

#2 Sweet wormwood (200 milligrams 3x daily)

You can get sweet wormwood in tincture or capsule form. It tastes nasty, so I went with capsules. Some experts go a little higher on dosage (200-300mg) and recommend taking the entire daily amount at once on an empty stomach before a meal (3 x 200-300mg = 600-900mg). Pregnant or breastfeeding women and infants should not take sweet wormwood.

#3 Cloves (500 mg 4x daily or 4 cups of tea)

Other practitioners advise 3x daily, so my takeaway is multiple times per day instead of all at once.

#4 Oregano Oil (500 milligrams 4x daily)

1-3 drops per day if you go with a tincture. Dilute in water because oregano oil is very strong tasting. Oregano is also potent against parasites. I’ve used the oregano oil capsules by Gaia Herbs.

#5 Grapefruit seed extract (take as directed)

A 2002 study showed that GSE inhibited the growth of Candida Albicans. It’s a popular and powerful antifungal, so start with a small dose and dilute in plenty of water. Also be aware that Candida can adapt to GSE, so consider taking it as part of a group of antifungals. GSE is not recommended for women who are pregnant or breastfeeding.

Additional herbal protocol tips (credit Lisa Richards and Dr. Eric Wood):

• “Using a set of antifungals consistently works better then rotating them.“
• In addition to herbs, they recommend caprylic acid in gel capsule form (500-100mg, 3x per day). Reputable products containing caprylic acid include NOW Candida Support and Pure Encapsulations Caprylic Acid.
• Start slowly so you don’t have to endure as much of a die-off reaction.
• Start probiotics at least 1-2 weeks after antifungals. Allow at least two hours between antifungals and probiotics during the weeks you are taking both together.

At the time of this writing, Dr. Rao has not researched herbal treatments but is open to their use. He is, however, one of the leading researchers on treating SIFO with pharmaceutical antibiotics. Here are his picks.

Pharmaceutical antifungal therapy

Pharmaceutical therapy is faster, but will require a prescription. Dr. Rao says, “…a 2-3-week course of antifungal therapy is recommended and may be effective in improving symptoms.”

Fluconazole (Generic. A brand name is Diflucan.)

• The first choice of Dr. Rao.
• Stays intact so the compound makes it to the small intestine.
• The dosage recommended by Dr. Rao is one pill per day (100mg) for 3 weeks.
• If you don’t respond, consider switching to itraconazole or posaconazole.
• Works by interfering with the cell membrane of the fungus.
• Creates small holes in the structure of the fungal cell that allow it to disintegrate into your bloodstream and exit your body.

Nystatin

• May get broken down in the stomach, so not Dr. Rao’s first choice for SIFO.
• A better option for oral and esophageal fungal infections

Additional antifungal drugs include Lotrimin, Spectazole, Nizoral, Monistat, Ertaczo, Exelderm, Terazol, Vagistat-1 or Vfend.

Dr. Rao treats patients with both SIBO and SIFO as follows: They get an antibiotic, such as rifaximin for 1 week. In week-2, he prescribes both an antibiotic and antifungal. Then for the 3rd and 4th weeks, just the antifungal.

Dr. Rao doesn’t use prokinetics very often because we don’t have many prokinetic options in the US. Also, he tends not to use probiotics very often due to a concern that bacteria may over colonize in the small intestine rather than in the colon.

Dr. Justin Marchegiani referring to pharmaceutical antifungals: “They’re also very stressful on the liver.”

Antifungal foods to promote ongoing balance

As always, we would rather prevent SIFO than have to treat it. A 2014 Study stated: “Prevention is the most effective “treatment,” much more than eradication of the yeast with antifungal agents.”

Here are some antifungal foods you can keep in your diet. The intent here is to just use them as normal spices to make your food tasty, not to send you looking for capsules.

• Cinnamon
• Cloves
• Coconut Oil (much more on this below)
• Garlic – Allicin is the active ingredient
• Ginger
• Oregano
• Peppermint
• Radish
• Turmeric

Fatty acids as antifungals – Coconut oil fights candida!

You can get C10 and C12 in your diet:

• Palm oil – 55.8% lauric acid (C12:0).
• Palm kernel oil – 47% lauric acid (C12:0)
• Coconut oil – 42% lauric acid (C12:0).
• MCT oil – Get the less expensive combo of 50% caprylic acid (8:0) and 50% capric acid (C10:0) for this purpose.
• Olive oil – As high as 20% linoleic acid (18:2), and 21% palmitic acid (C16:0). However, olive oil is primarily oleic acid, which did not prove as effective against C. albicans.

Candida infection can make you legally drunk in one meal!

• Video on ABC’s 20/20
• Article on NPR News
• Article on CNN News
• autobrewery.info  – Barbara Cordell’s website

Do ketones feed candida?

Some have raised a concern that ketones from a low carb diet can provide energy for candida. Paul Jaminet, Ph.D. responds to this assumption. “As for Candida using ketones for energy in the GI tract, you mentioned the TCA cycle. But this requires oxygen, which is pretty scarce in the intestines. This recent report suggests that dysbiosis may involve a shift to higher O2 levels. Perhaps this is something to explore, but otherwise, I don’t see adequate O2 levels for aerobic respiration via the TCA cycle.“

Key Takeaways

• SIFO stands for Small Intestinal Fungal Overgrowth. The most common form is candida albicans and it is known to cause IBS symptoms like belching, bloating, diarrhea, gas, indigestion and nausea. There can also be symptoms that are not obviously associated with digestion, like brain fog, skin infections, joint pain and low iron.
• If you suspect the fungal infection is severe, go to a physician immediately. Systemic infections can have a high mortality rate.
• The best test for SIFO is small intestine aspirate via endoscopy. Yep. It’s invasive. But since treatment with herbal antibiotics is usually low risk, most functional medicine docs will skip the invasive test and go straight to a round or two of herbal antifungals.
• The first step in treatment is to eliminate predisposing factors, which include acid reducers (PPI’s), excessive antibiotic usage, steroids, hormones and diabetes.
• Simultaneously, you’ll want to stop feeding the overgrowth. Take out refined carbohydrates, sugar, and fermented foods. You’ll also want to stop eating and breathing mold.
• If all that doesn’t rebalance, you can move on to 4 weeks of herbal antibiotics or 2-3 weeks of pharmaceutical antibiotics (prescribed by a physician). One round may not be enough.
• There are preventative foods such as coconut oil and spices like cinnamon, oregano, garlic, cloves and turmeric.

Additional Resources

Dr. Satish Rao on the Dr. Ruscio Radio podcast