SIFO is an acronym for Small Intestinal Fungal Overgrowth.
SFID is defined as an excessive and pathological growth of fungal microorganisms (fungi) in the small intestine associated with gastrointestinal symptoms1.
The human microbiota is composed mainly of bacteria (about 1014 cells) but also of Archaea, viruses, eukaryotes and fungi. In a healthy individual, the different microorganisms cohabit in a dynamic balance among themselves and with the host. In some situations, this balance is disturbed.
Fungi represent a quarter of the species present in the microbiota, but less than 0.1% in number. The “human mycobiota”, that is, all the microscopic fungi that colonize the human body, comprises 150 genera and 390 species, of which only 221 are present in the intestine.
The composition of mycobiote varies from one individual to another.
The most common are the genera Candida (in 80% of the people examined), Malassezia (in 25% of the people examined), Aspergillus (24%), Debaryomyces (21%), Penicillium (20%), Cladosporium (18%), Trichosporon (9%), Galactomyces (9%), Saccharomyces (6%) and Cryptococcus (4%).
Mycobiote is involved in digestive functions. It also interacts with intestinal bacteria and host metabolism. It appears to be very sensitive to environmental conditions, especially food.
Thus, Candida is present in almost all humans in the gastrointestinal mucosa. It is estimated that it is found in the intestines of 96% of newborns2.
Candida albicans is the most common Candida species associated with the gastrointestinal mucosa, while other Candida species such as Candida tropicalis / guilliermondii / krusei, and Glabrata are less common.
Almost all Candida fungal infections in humans are endogenous, that is, their reservoir is the intestine.
Candida is normally observed in the form of yeast, that is, a free and suspended form, also known as “planktonic“. This form is commensal: it lives in harmony with the human host. Under certain conditions, Candida is capable of integrating into biofilms and causing damage to the digestive mucosa.
Some Candida, such as Candida albicans, can change shape to a form of pathogenic mycelium, the mycelium being long filaments similar to those of soil fungi.
At this stage, Candida albicans can pass through the digestive mucosa by “translocation”, that is, transcellularly, into the bloodstream and colonize the entire body.
Candidiasis then becomes “systemic” and is a potentially serious disease. Candida releases a large number of toxins, called mycotoxins, which cause many of the symptoms.
For the sake of simplification, although it is reductive, the rest of the article will talk indistinctly about EIFS or intestinal candidiasis.
Acquired immunodeficiency syndrome is mainly manifested by digestive disorders such as belching, bloating, indigestion, feeling of overflowing stomach, nausea, diarrhea and flatulence.
Frequently associated conditions
In the case of the EIFS, the associated conditions are often as follows:
- …sweet compulsions, cravings for sweet foods or drinks;
- vaginal yeast infections for women;
- food intolerances;
- unexplained weight gain or inability to lose weight despite dieting;
- …severe fatigue;
- certain gastrointestinal conditions: gastric ulcers, ulcerative colitis, Crohn’s disease4.
Systemic candidiasis can have two origins, with very different mechanisms. It can be a consequence of SIFO.
- an exogenous origin: this topic is not part of this article. In this case, it is a known and feared nosocomial (hospital-acquired) disease. A catheter, a surgical operation constitute easy contamination routes between the external environment and the blood or the organs. This form of candidiasis affects immunocompromised people, those undergoing cancer treatment, people with HIV, those with complicated diabetes, or those with other conditions.
- an endogenous origin, that is, the contamination of the blood by the small intestine, which is a consequence of FISO5.
This condition, previously described in hospitals only in immunosuppressed people, is increasingly found in the general population, with varying degrees of severity and symptoms.
These symptoms may include the following, in addition to those mentioned above:
- severe fatigue or asthenia;
- depression, anxiety;
- a brain fog, difficulty concentrating;
- joint pain;
- an immunodeficiency;
- Candidiasis of the mouth*, commonly called “thrush”, which can also extend to the oropharynx and esophagus;
- fungus on the nails, i.e., on the toenails or fingernails*,
- fungus on the skin or hair*,
- of damage to the neuroendocrine system,
- damage to several organs: kidneys, liver, lungs, etc.
- Fever related to a massive blood infection with Candida or Candidaemia This condition is serious and can be fatal. It is mainly found in hospitals in extremely fragile people.
*Symptoms that only affect the mouth, oropharynx, esophagus, skin or nails may be related to a superficial infection
Vaginal and digestive mycosis have the intestine as a reservoir in most cases.
Finally, SIFO (fungal overgrowth in the small intestine) and SIBO (bacterial overgrowth in the small intestine) can coexist, sometimes with similar symptoms6 .
Throughout the world, the prevalence of SFO is unknown. 96% of newborns are carriers of Candida in the intestine7.
25% of people who suffer from “Irritable Bowel Syndrome” (IBS) may have IFS.
In France, the prevalence of Irritable Bowel Syndrome is about 10% of the population8 , that is, more than 6 million French people, which, taking the percentage of 25%, would bring the number of IBS cases to about 1.5 million people. This figure is quite indicative and would merit further investigation.
Immunodeficiency or immune fragility
Intestinal candidiasis is common in immunocompromised people: people hospitalized in intensive care units, people with severe and chronic diseases, people on long-term antibiotic therapy, people with AIDS.
They are also described in malnourished children9.
Prematurity in babies
Prematurity associated with low birth weight exposes newborns to candida infections.
Type 1 and 2 diabetes
People with diabetes are more prone to intestinal candidiasis.
Certain endocrine diseases
Hypothyroidism, Addison’s disease, diseases in which hormone production is poorly regulated, are predisposing factors for candida infections.
The use of certain drugs
The use of antibiotics is known to promote candidiasis. In fact, yeast and bacteria compete for space in the small intestine. After antibiotic therapy decimates the bacteria, the space is left free for fungal microorganisms.
Steroids are anti-inflammatory drugs that act by inhibiting the immune response, which would explain the development of Candida: an inhibited immunity means that the immune system leaves Candida alone.
Prolonged use of proton pump inhibitors has been identified as a causal factor.
Cancer treatments, chemotherapy and radiotherapy, also promote candidiasis.
Finally, the contraceptive pill would also be a contributing factor.
Small bowel dysmotility
As in SIBO (Small Intestinal Bacterial Overgrowth), the motility of the small intestine is altered in the case of SIFO. The periodic emptying of the small intestine is not done properly, and the yeast settles.
The land causes
A diet rich in fermentable carbohydrates
Fungal microorganisms feed on the fermentable food provided by the food bolus. Therefore, they can ferment:
- simple sugars, with a sugar molecule, called monosaccharides, such as fructose, contained in table sugar, glucose-fructose syrup (very present in processed products), honey, fruits ;
- 2 sugar molecules called disaccharides, such as lactose, milk sugar contained in milk, yogurt, low-fermentation cheeses.
- sugars containing a small number of molecules called oligosaccharides (Fructo-oligosaccharides and Galacto-oligosaccharides), contained in cereals such as wheat, barley, rye, legumes (peas, lentils, chickpeas, white and red beans, peanuts) certain vegetables (leeks, garlic, onions, shallots, beets, etc.).
- polyols (mannitol, maltitol, xylitol, sorbitol) contained in certain fruits (apples, pears, mangoes, etc.) and vegetables (mushrooms, cauliflower) and in sweets and gum.
Therefore, a diet rich in carbohydrates will promote SIBO. And the modern diet is particularly rich in fermentable carbohydrates.
Stress acts unfavorably in different ways.
Reduces blood flow to the intestine: the intestine, which is less oxygenated, functions and repairs itself less well. The cells contract, which increases existing injuries.
It reduces the production of hydrochloric acid in the stomach, which no longer destroys bacteria and fungi in the food tract as effectively.
It modifies the intestinal motility, by acting on the vagus nerve and causing insufficiently digested food to reach the intestine, which will promote outbreaks of bacteria and fungi.
It affects the growth of beneficial bacteria, Lactobacilli and Bifidobacteria and promotes the development of pathogenic bacteria and yeasts. In fact, it decreases the production of protective mucus that prevents the adhesion of pathogenic microorganisms.
In addition, it decreases intestinal immunity (decrease in IgA-type immunoglobulins).
There are different methods to diagnose SFID:
- The saliva test is an empirical method. It consists of spitting into a glass full of clear water on an empty stomach in the morning and observing the behavior of the saliva. If it flows in filaments, it probably indicates the presence of a biofilm. This test gives an indication but is not 100% reliable. In fact, the biofilm may be fungal, or bacterial, or mixed.
- Analysis of stool after stool culture is a test used by many medical testing laboratories, but it is not reliable. In fact, Candida is normally present in most individuals.
- The fecal occult test is a more accurate analysis of feces than the previous one, which quantifies the relative populations of bacteria and fungi. But it is also not 100% reliable.
- The urine test for organic acids or “MOU” for Urinary Organic Metabolites. The principle is the determination of the products of sugar degradation by Candida, such as tartarate, in the urine of the second morning. This test is performed by certain laboratories (Eurofins, Barbier, etc.) and is representative of chronic candidiasis.
- The blood test for anti-candidate antibodies (IgA, IgM or IgE or all three) is a test routinely performed by many medical laboratories and characterizes systemic candidiasis.
A positive test means that the strands of candida mycelium have crossed the intestinal barrier and caused the immune system to react, resulting in the detection of antibodies.
The reliability of the test is not 100%. In fact, a healthy person can have a positive test. An immunocompromised person may be infected and produce few antibodies. This test costs about 20 euros and is not reimbursed by social security.
- Differential diagnosis with respect to SIBO in the presence of evocative signs The diagnosis of SIBO is made by means of respiratory gas measurements.
- Crook’s questionnaire (1984) that examines the patient’s symptoms and history.
- Endoscopic aspiration and analysis of the jejunal fluid (the jejunum is the middle part of the small intestine) is the most reliable test and for some authors, the only one. Unfortunately, this test is invasive.
Common medical treatments are antifungal agents that belong to two different classes:
- polyethylenes: nystatin and amphotericin B
- azole: fluconazole, itraconazole, voriconazole
Unfortunately, an increasing number of cases of resistance to these treatments have been observed in recent years19.
Candida associated with biofilms appears to be more resistant than those found in the form of yeast20.
In addition to medications, there are also many natural treatments for intestinal candidiasis.
Natural approaches and treatments for intestinal candidiasis
Diet, a natural treatment, is the first of these measures to reduce infection related to intestinal candidiasis. Micronutrition, the use of probiotics, phytotherapy, mycotherapy, and hygiene care complete the dietary approach.
If necessary, stress management, exercise and sleep are taken into account.
Several feeding approaches can be tried. All are aimed at reducing the sugars that fungal microorganisms feed on.
The anti-candidate regime
It is a very restrictive diet, which consists of avoiding foods that contain carbohydrates that can be used as food by Candida (glucose, lactose, maltose, fructose).
Gluten should be avoided as there is a close link between candidiasis and gluten gliadin.
In genetically predisposed subjects, the immune system would react indiscriminately against the surface proteins of Candida albicans and gluten gliadin, and this reaction could lead to the development of celiac disease.
In addition, gluten increases the permeability of the small intestine, damaging the tight joints between enterocytes, the cells of the small intestine.
This condition facilitates the translocation of the bacteria, Candida.
Fermented foods should also be avoided, as there is a high risk of cross-allergic reactions between Candida and the yeasts contained in these products.
Therefore, the foods that should be avoided in the anti-candida diet are :
- sugar and all sweet foods
- glucose-fructose syrup, maltodextrins, starches
- refined cereals such as white flour, white bread, white pasta
- foods rich in gluten in general: wheat, barley, rye, oats, spelt
- products rich in lactose: milk, yogurt, cream, fromage blanc, cheeses with a maturation period of less than 6 months
- fruit for a few days, and then reintroduce a small amount of fruit per day, among the less sweetened ones: red berries for example.
- the yeast
- Fermented foods: yogurt, cheese, sauerkraut, kimchi
- beer, fermented beverages
- margarines, soybean oils
- the coffee
- Sugary drinks such as fruit juices, soft drinks The anti-candidate regime should be relaxed and individualized after a month or two, depending on the results.
The FODMAP diet may also be advised for its effectiveness in irritable bowel syndrome, a significant percentage of which is correlated with IFS. Its advantage is that it also works in cases of SIBO (Small Intestinal Bacterial Overgrowth). It can be followed up for 4 to 6 weeks.
Therefore, for 4 to 6 weeks, you should avoid “FODMAP” or “Oligosaccharides, Disaccharides, Monosaccharides and Fermentable Polyols”, that is, all the following foods:
- Oligosaccharides: wheat, barley, rye, legumes (peas, lentils, chickpeas, red and white beans, peanuts), certain vegetables (leeks, garlic, onions, shallot, beets), etc.
- Disaccharides: milk, yogurt, cream, low-fermentation cheeses
- Monosaccharides: table sugar, glucose-fructose syrup (very present in processed products), honey, fruit.
- Polyols (mannitol, maltitol, xylitol, sorbitol) contained in certain fruits (apples, pears, mangoes, etc.) and vegetables (mushrooms, cauliflower) and in sweets and gum.
You can consume animal proteins (meat, fish, eggs), cheeses matured for more than 6 months, such as Comté or Parmesan, gluten-free cereals (rice, buckwheat, millet, quinoa, tapioca, sorghum), certain fruits and vegetables that are not very fermentable, oil seeds (nuts, hazelnuts, almonds), etc.
Micronutrition, a natural treatment, is also recommended in cases of intestinal candidiasis.
The micronutrients recommended for SFID are related to the functioning of the immune system, to increase the immune system response and to decrease inflammation.
However, Candida and other fungal microorganisms also need micronutrients such as zinc, copper and iron for their metabolism.
There is competition between the host and its pathogens for micronutrients, resulting in frequent deficiencies in people with ELA. Supplementation is sometimes a double-edged sword: does it strengthen or reinforce the enemy? From a research perspective, it is best to supplement.
In doses of about 500 mg / day, it promotes the action of white blood cells.
In vitamin D3, in doses of about 2000 IU/day, it modulates the inflammatory reaction induced by C. albicans.
It works with vitamin D and plays a role in the integrity of the mucous membranes. It can be provided by food in the form of carotenoids (pro-vitamin A).
It helps heal the intestinal mucosa and plays a vital role in the functioning of the immune system. The recommended dose is 45 mg/day.
It helps to repair the intestinal mucous membrane, in doses of about 3 grams / day.
Magnesium and group B vitamins: B2, B5, B6, B9
They help in the metabolism of the cells’ energy and in the management of stress.
Omega-3 fatty acids
They have an anti-inflammatory effect and are recommended in the form of dietary supplements, especially if the diet is deficient in omega-3s.
The recommended dose is 200 micrograms/day.
In people with poor pancreatic enzyme function, supplementation with synthetic pancreatic enzymes (amylases, lipases, proteases) is beneficial.
The probiotic strain Lactobacillus acidophilus produces hydrogen peroxide (hydrogen peroxide) which inhibits the growth of Candida albicans, the most common Candida species that causes fungal dysbiosis.
The Saccharomyces boulardii strain inhibits the growth of C. albicans in filamentous form and the formation of biofilms.
Aromatherapy or the use of essential oils
Aromatherapy is also an effective natural treatment for intestinal candidiasis.
Many essential oils have anti-candidate and anti-fungal activity in a broader sense. Many are also antibacterial, which may be of interest in cases of SIFO and SIBO combined. Here is a non-exhaustive list of essential oils with antifungal and anti-candidative activity:
- Compact Oregano (Origanumcompactum)
- Oregano vulgaris (Origanum vulgaris)
- Thyme vulgaris (Thymus vulgaris)
- Clove (Eugenia caryophyllus)
- Ceylon cinnamon (Cinnamomum verum)
- Savory (Saturejahortensis)
- Mint (Menthapiperite)
- Tea tree (Melaleucaalternifolia)
- Ajowan (Trachyspermumcopticum)
- Caraway (Carum caraway)
- Geranium Bourbon (Pelargoniumgraveolens)
- Lemongrass (Cymbopogoncitratus)
- Basil (Basilicum ocimum)
- Eucalyptus globulus
- True Lavender (Lavandulaangustifolia)
- Coriander (Coriandrumsativum)
- Lebanon Cedar (Cedruslibani)
- Mugwort of Judea (Artemisia judaica)
- Ceylon Lemongrass (Narduscymbopogon)
These essential oils, to cure the intestine, must be taken orally.
However, they can be caustic to weakened gastric and intestinal mucous membranes and should not be taken cleanly. Specialists recommend at least gastro-resistant capsules or, better yet, emulsified forms or essential oils incorporated into certain supplements.
The cures are of short duration: from 15 days to 3 weeks maximum. It will be renewed if necessary after a period of interruption. The following examples are given as an indication.
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