“My Breath Smells Like An Open Sewer”

Robert’s breath had become his worst nightmare and as a consequence he knew was starting to isolate himself socially. For three years, he’d tried every over-the-counter remedy. When he walked, Tic Tacs rattled in several pockets.

Robert had seen specialists, had his teeth cleaned every three months, and followed a twice-daily oral regimen that included flossing, brushing, and jet-streaming his gums.  The finale was a vicious tongue-scraping that left his taste buds raw and aching. He’d then blast whatever was left with undiluted mouthwash.

Robert had tried everything.

“The tongue-scraping is especially horrible,” he told me. “I can actually smell that sewer odor coming from that guck I scrape off.”

One doctor said it was all in his mind, that he should see a good psychiatrist because his breath might be a symbol of some deeper issue and that he might be sinking into the terrain of obsessive-compulsive disorder. Robert was intelligent enough to consider this for a moment, but because his wife had recently remarked that his breath was interfering with their lovemaking he skipped checking the mental health benefits on his insurance.

An otorhinolaryngologist (ear, nose, throat specialist) scoped his sinuses and pronounced them clean. A gastroenterologist (GI) scoped his esophagus and stomach and found nothing out of the ordinary. The GI doc was less than hopeful. “My brother has had bad breath since he was 20. He’s 50 now and spent a fortune trying to figure it out. Nothing. Nada. He lives on Certs.”

Robert offered the doctor a Tic Tac and left the office.

My meeting with Robert
When I first saw Robert I was not hopeful. First of all, I couldn’t smell a thing, which isn’t saying much because I have a dreadful sense of smell. He’d already read one of my previous Health Tips citing poor digestion as a possible cause of bad breath, but a month of digestive enzymes and betaine didn’t make a dent.

I reviewed Robert’s entire health history and there wasn’t much. He did have some heartburn (gastroesophageal reflux disease, or GERD) that he’d self-treated on an as-needed basis with Nexium, one of the proton-pump inhibitors that reduce stomach acid. Robert told me he had frequent bloating, but generally his bowels were regular and there were no particular foods that gave him trouble. Except for seeing a dermatologist for some stubborn rosacea, there was nothing really wrong with him that decapitation couldn’t cure (I knew he’d laugh when I told him this).

Since he already had a primary physician (who had pronounced him healthy) and had been pretty thoroughly tested by other doctors, I ordered two tests of his gastrointestinal function.

  • For the first, a Comprehensive Stool Digestive Analysis, he would send stool specimens to Genova Labs to determine if he was digesting and absorbing his food normally. This test would also look for intestinal parasites and determine if there were any imbalances in his intestinal bacteria. Robert’s results were normal. He was digesting and absorbing his food well.
  • The second test would measure the contents of his breath for two gasses, hydrogen and methane. This test would determine if there were an overgrowth of bacteria in his small intestine, called SIBO for small intestine bacterial overgrowth. Some bacteria in the small intestine is allowable. But an overgrowth can produce all sorts of mischief, including bloating and impairing your digestion and absorption of food.

For the SIBO test (done at home), Robert would drink a small amount of lactulose, a harmless sugar that’s like cotton candy to the target bacteria, which promptly respond to this treat by producing more gas than ever. For the next two hours, Robert would collect samples of his breath by blowing into a specially designed balloon and then attaching a vacuum tube to extract an air sample. He’d send off six tubes of air, which looked empty, but definitely were not.

When the test results came back from the lab, I knew we had an answer. This link shows a typical mild-to-moderate case of SIBO. Note how the hydrogen-methane content rises as time passes. Robert’s started rising at the 20-minute point and remained at the very top of the graph for the rest of the two-hour collection period. His was among the highest gas levels I’d ever encountered.

Treating Robert’s SIBO
Robert’s response to Xifaxan, the antibiotic most widely prescribed for SIBO, was dramatic. On the fourth day of his ten-day Xifaxan prescription, the nauseating odor from his tongue scraping had vanished. By the tenth day, neither he nor his wife could detect any breath odor whatsoever and I hoped they were now able to resume their passions.

Just why Robert had developed SIBO is hard to say. Some people get it if they have a chronic intestinal inflammation, like Crohn’s disease. Some get SIBO as a consequence of using the Nexium family of meds, which reduce the stomach acid necessary to keep the small intestine’s bacterial population in check. SIBO has also been linked to anything that slows intestinal motility (movement), like underactive thyroid or constipation-dominant irritable bowel syndrome. But for most people with SIBO, the “why me?” is left unanswered.

Fortunately, as in Robert’s case, treatment can be dramatically successful. The only caveat is that the bacteria are stubborn and a return of symptoms can occur. We reduce this possibility using an antibiotic blend of herbs and a quality probiotic, since nobody needs to be carpet-bombing what helpful bacteria they do have by taking an antibiotic regularly.

Three intriguing points worth mentioning
First, the question of the garbage-y odor itself since the two gasses measured with SIBO testing, hydrogen and methane, are both odorless. The likely reason for the odor is that the bacteria are producing other gasses, especially hydrogen sulfide, the villain behind your odiferous farts. You’re better off not thinking about this too much.

Second, a few weeks after treatment, Robert’s rosacea had disappeared. The link between SIBO and rosacea is relatively new, first described by a group of Italian physicians in 2008. Unfortunately, testing for SIBO has been slow among US dermatologists seeking a rosacea cure, but the connection might explain how Flagyl (metronidazole) works. Flagyl, the top-prescribed drug for rosacea can also be used to treat SIBO if Xifaxan is unavailable. Perhaps dermatologists prescribing Flagyl are inadvertently curing SIBO, which in turn cures the rosacea.

Third, I have to wonder if something as thoroughly annoying as having horrible breath  ever affects celebrities and other beautiful people. There’s a real imbalance in the universe. I mean, if Brad Pitt or Taylor Swift or Princess Kate had socially isolating breath problems, they’d be able to compensate by saying, “Thank god I’m Brad Pitt” or “Wow, at least I’m Taylor Swift” or “I’d be even more miserable if I weren’t a princess.”

Instead, this stuff strikes plebes like you and me. No justice.

Be well,
David Edelberg, MD



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24 comments on ““My Breath Smells Like An Open Sewer”
  1. Simona Garcia says:

    Thank you so much Dr. Edelberg! You saved me and I will forever be grateful!

  2. Tammy says:

    Could not be a more timely article personally for me. Unfortunately I allowed my GI doc to prescribe Rifaxamin before doing SIBO test to determine exactly which gases were causing the left sided pouch and now ready for the delivery room bloat. Now after round 3 of Rifaxamin getting the test done. Here’s my concern possibly have created greater methane gas bacteria now and may be harder to tx. On the fence about doing elemental diet adding flagyl or using herbals suggested by Dr Scieceker from siboinfo.com

  3. Reem says:

    What herbal treatment is recommended?

  4. Tammy says:

    Check out siboinfo.Com
    Dr Siebecker describes what research supports and compares to antibiotic meds.

  5. Mary Gardier says:

    Sort of off-topic, Dr. Edelberg, but I was wondering if Clark Gable may have suffered from SIBO? Actresses who had kissing scenes with him reported that his breath was terrible!

    I enjoy reading all of your articles, and have learned so much. I try to apply them to my own health concerns.

    Take Care,
    Mary Gardier

  6. Dr E says:

    Actually Clark Gable has terrible gum disease which caused his bad breath and when all his horriblle teeth were pulled and he got dentures his breath improved. Check this site

  7. Div says:

    My daughter is 9 yrs old and has severe acid reflux. She is on Zantac but I would like to look for alternative options as these medicines can have long term impact on health. Is Homeopathy treatment a good alternate option for her? She is Asthma too and both triggering each other during Fall/ Winter

  8. cliffmaurer says:

    Homeopathy is a good option to consider. Making certain that her pediatrician is informed of all of her concerns and treatments is also important.
    -Dr. M

  9. Mary Gardier says:

    Interesting, thank you!

  10. Mary Gardier says:

    Interesting, thanks!

  11. Tammie says:

    Hi Dr., how can I get my Dr. to test me for SIBO because they think my bad breath is all in my head? Should I go to my PCP or GI Dr? My dentist told me my breath and teeth were good too.

  12. Dr. R says:

    Tammie. Start with your PCP and just make the request to be tested.

  13. George Rane says:

    Best article I have read on this condition. My breath problem I’ve broken down–oddly, it’s much more apparent when I eat or consume items with sulphite preservatives in them — beer, wine, procesed meats etc. I wondering if you have come across this before? What maybe the underlying cause.

  14. Sarah Reynolds says:

    How can I get a doctor to prescribe this medicine? I’ve seen an ENT, Gastroenterologist and dentist and all the results are the same. I have severe sinus issues and mild gastric issues nothing that nexium wouldn’t cure and my dentist says nothing wrong but otherwise I have suffered for 10 years keeping me from pursuing my dreams.

  15. Dr E says:

    Hi Sarah
    You can order this test directly from the lab.
    If your test is positive, your primary doc or your GI doc will likely go ahead and order Xifaxan
    Also, if you don’t do this already, buy a tongue scraper and clean the surface of your tongue every morning

  16. Candy says:

    Hi Dr. E,
    I loved your article! I have suffered with this terrible breath for almost 4 years, and the only thing that helped was Augmentin 875-125 for 14 days (but the smell returned after finishing) and then again with Flagyl for 14 days, but the smell returned. I have acid reflux and other digestive issues, and I want to know if you think that Xifaxin will still be able to help me in light of my recurrence of smell after I concluded the courses of the above mentioned antibiotics?
    Any help would be appreciated 🙂

  17. Dr E says:

    Hi Candy
    Each of the meds you listed could be used for SIBO but are not first choice and this is why the symptom may be coming back. Get tested for SIBO and if positive get an rx for Xifaxan

  18. maha says:

    Can you translate it to arabic . please

  19. cliffmaurer says:

    Here is a good translation resource.
    .هنا مورد ترجمة لغة جيد

  20. VL says:

    Hello Dr. Edelberg,

    What a relief it is to read this article about Robert. I have been experiencing this same exact thing for a few years now and it feels like an absolute living nightmare. I am a female in my early 30s and this “odor” has been effecting every aspect of my life. It has made me incredibly anxious and depressed and I don’t know what to do anymore.

    It is nothing relating to my mouth/teeth. I get my teeth cleaned twice a year and meticulously take care of my teeth. I have visited with my regular doctor and a GI. Neither of them have helped. My regular doctor told me I have an iron deficiency (which I never had), so I took an iron pill for a few months. The GI did the lactose intolerance breath test and performed an endoscopy. The test proved that I am not lactose intolerant and from the endoscopy he informed me that I have GERD and prescribed pantoprazole. I started taking the pantoprazole back in March and stopped in October once I read about the negative long-term side effects.

    Just like Robert, I have GERD and experience bloating. Generally my bowels are good, but sometimes I can be constipated. Here is an overall list of everything I’ve been experiencing:
    -burping (a lot after meals)
    -I have gained a lot of weight and it’s hard for me to lose weight despite eating healthy and exercising
    -I’ve had toe nail fungus 3 times in the past few years, went to podiatrist over summer to cure (went on generic lamisil)
    -I always have beaus lines on my nails, probably from the iron deficiency?
    -trouble focusing
    -heartburn at random times…there’s no rhyme or reason to it…I get heartburn no matter what I eat, doesn’t matter if I eat something like plain chicken breast or ice cream

    What’s odd is I hardly ever smell this “odor,” but there’s constant reminders that it’s there. I’ve been asked on multiple occasions by different people if I have passed gas. Most recently a coworker of mine came into my office to chat and as soon as they entered, they asked if I farted. At home, sometimes my husband will enter the room I’ve been in and will say something like, “it smell’s so bad in here, stop farting,” and I have to laugh and play it off like I have (but haven’t at all).

    I just got over a cold, but I noticed a few things while I was sick. I noticed that the smell was much worse while I was sick (like a rotton-egg odor that could fill a big room). I took antibiotics and on day two, the odor was really bad. I was in a car with my mom, and she exclaimed that it smelled like something was dying. I tried to play it off like it was coming from outside, but I knew for sure it was me. After I was done with the antibiotics, for about 2 weeks, I had no reactions from anyone.

    These stories sound funny, but they’re honestly a nightmare. There are days where I just want to crawl in a hole.

    I noticed that the odor is much worse when I eat/drink certain things. These include: tea (especially dandelion root tea), ice cream, bananas, milk, kefir (store bought), lemon water, chocolates, sweets, cheese, wine/liquor (really embarrassing when I’m out with friends), beans (I had lentil soup for dinner one night – for that entire night and the next day my husband told me I had a smell following me).

    I’m so sorry this post is so long, I just finally feel like I can relate to someone. I’ve felt so alone and lost for so, so long.

    I’ve never been tested for SIBO, I never even heard of it. From all the researching I’ve done on the internet, I thought it could possibly be candida. I desperately wish I lived near your practice, I am out of state. Is there any way you can work with me remotely?

    Thank you in advance,

  21. Dr E says:

    Hi VL
    Just order the SIBO test kit directly from Genova. If positive, your primary care physician can treat it

  22. VL says:

    Thank you for the link. I will order it and will see what happens.

  23. Maha says:

    welcome . What are the results . I have the same problem . I suffered from it for 12years. I have question . does this problem appear suddenly and you haven’t a control or it is because some food . Thank you

  24. Dr. R says:

    Maha. Thank you for your comment. A more detailed reading of the blog and comments may answer your questions.

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