Recap on the 2017 SIBO Symposium - Day One

Mark Pimentel, MD - SIBO Overview

• Clinicians worked on creating a standard for breath tests - 8-12hrs of fasting, prep diet, no promotility agents for a WEEK, 10g lactulose. "North American consensus on breath testing" on PubMed for free.
• at least 60% of IBS-D is SIBO
• stress doesn't cause SIBO but makes bowel issues worse and reduces the MMC (migratory motor complex).
• IBSChek - high vinculin antibodies means many treatments will be unsuccessful (incl Rif/Neo). High = 3.0
• IBSDetex - doesn't give raw data like IBSChek, it controls for 1, they use a ratio but theres a problem with a formula (not sure what this means other than "use my test" :)
• Methane is only detectable on breath test when it's at 1 million parts per mil. Methane causes constipation at 10,000 parts per mil.
• If you don't respond to Rifaximin the first round you shouldn't use it anymore, it won't suddenly start working. You need to try something else. Also if you rebound quickly after Rifaximin you need to focus on underlying cause (adhesions).
• SIBO is "Changes in flow in the gut causes the wrong bacteria to overgrow in the wrong place". IBS is a disease. SIBO is caused by another disease.
• They are doing the testing for Hydrogen Sulfide at Cedar-Sinai but still don't know what to do with the results so they are reluctant to give them out to providers/patients.
• Elemental diet is most effective.

Melanie Keller, ND - Risk Factors and Environmental Toxins

Risk Factors (essentially EVERYTHING!)

• Gestation/birth/infancy - traumatic birth, condition of mother, abx use as infant, length of hospital stay
• Procedures/surgery - tolerance of anesthesia, what type of procedures have they had done, sinuses, chronic infections, repair of altered anatomy, dental procedures, abdominal procedures
• Injuries - most notably head injuries, abdominal traumas
• Travel - food poisoning
• Infections - various parasites and bacteria
• Dental Hygiene - wisdom teeth extractions, dry socket, all four removed at once, root canals can never be sterilized so may never heal perhaps in greater than 99% of procedures, implants, veneers, amalgam filling removals, carbonated beverages (turns to carbonic acid in your mouth making it more acidic) - must you a straw then rinse after, apple cider vinegar
• Other - gastric acid, medications, eating disorders (why?), IBD with strictures, connective tissue issues, methylation issues (MTHFR and FUT2)
• Environment - US manufactures 5 trillion chemical compounds, fatal food allergies have increased over 50% in recent years, increase in diabetes and obesity related to environment, many toxins in our environment that have a negative lasting impact on digestion
• Q&A - MMC starts in stomach, go to PHCapsule.com to find where you can get a Heidelberg test - need a referral from provider,  

Mark Pimentel, MD -  Methane and Autoimmunity 

• Food poisoning is NOT related to Methane
• Methane comes from environment and family. If you live in impoverished areas where calories are either hard to come by or hard to extract from low quality foods then methane is protective.
• Methane is not an overgrowth, it's a bloom and may NOT be SIBO (WHAT??)
• The older you get the more likely you are to have methane.
• Methane slows transit time.
• Methane makes you hyperglycemic, impacting both blood sugar and insulin (there is data to support this).
• Methane predictive of obesity. Those who don't lose weight after weight loss surgery may have methane complicating picture.
• Combination therapy (Rif/Neo) does not work well for methane, it often comes back quickly and you can't keep people on therapy two weeks out of every month.
• Methane is not an overgrowth, it's a bloom, outgrowing other bacteria. We don't know how much is in colon and how much is in small bowel. Methane is not dependent on lactulose so it doesn't always go up on the test. It may be mostly in the colon.
• F420 enzyme allows M. Smithii to take hydrogen and make methane, lovastatin blocks this enzyme. Methane production drops in days. Hydrogen bugs the get sick and die from the excess of hydrogen.
• Syn-10 (the lovastatin drug in trial) stays in gut and is not absorbed so none of the same lovastatin side effects. Red Yeast Rice is absorbed so likely not effective the same way.
• C-Diff causes post infectious IBS.
• You can get SIBO via FMT
• Fasting helps, meal spacing necessary
• Methane + high fat diet may be recipe for weight gain as methane makes body more efficient with harvesting calories.
• If you have post infectious IBS, NEVER get food poisoning again. Always travel with Rifaximin and take 1/2 a pill with meals (IMO herbals are just as effective and so much less expensive!).
• Scleraderma the only other autoimmune condition that seems to be linked to high levels of vinculin antibodies.
• Allicin works temporarily for methane.
• Phase 3 research for Syn-10 starts in Sept
• Higher vinculin antibodies predict lack of response to treatment with Rif/Neo (Pimentel stated 3 on the vinculin antibodies is high).
• M. Smithii can use acid and ammonia to make methane so keep those lower in diet (ie lemon juice in water, ACV).
• In the process of investigating separate diet for SIBO and Methane.
• Norovirus can cause IBS even though it doesn't release Cdt-B, they are not sure why.
• Cipro does work for SIBO but generally only the first time and then the bacteria becomes resistant and you take a severe hit to the microbiome.

Natalie Gustafson, PharmD - LDN and LDE

Not much new here just explanations of risks and mechanisms of LDN and LDE

• LDN must be taken on an empty stomach
• LDN can be taken at night if it interrupts with sleep
• Always ask compounding pharmacy what kind of filler they use
• LDN upregulates Toll Like Receptor 4 so helps decrease inflammation
• LDE at 50mg does not appear to impact the microbiome
• LDE does have the very rare potential of QT elongation which increases cardiovascular risk
• LDE does block certain liver enzymes so make sure the check crossreactivity.  Will make berberine less effective.
• Enteric coating contains phalates so most pharmacies don't use this coating because they have to have special equipment and ventilation (I don't think she meant all enteric coatings are made from phalates)

Melanie Keller, ND - Managing Treatment Failures in SIBO, IBS & IBD

Many, many rabbit holes in this talk. Dr. Keller clearly deals with SIBO cases that require a much deeper dive into the body to resolve. My guess is is that most people with SIBO do not require such a deep investigation to heal.

• Step one - no more supplements.  She is seeing correlation that certain nutrients feed certain bacteria and if you are low there is a reason. If you simply supplement you could just be feeding the overgrowth of bacteria.
• Test for stomach acid levels - she sees people with both low and high stomach acid.  Both cause issues with digestion.  She believes that people with high stomach acid are actually more sensitive to foods than those with low. (link above to PHCapsule.com to find a Heidelberg test office near you).
• Her theory is that high baseline methane could be in the stomach. H.Pylori used to be erradicated with two medications, now it takes quadruple therapy. Is there some sort of correlation??
• There is a complex communication happening between bacteria, hormones, enzymes, etc. that we don't quite understand yet. Research currently being done.
• Hormones are an important component, need to make sure adequate growth hormone, not too much sex hormone binding globulin, etc.
• Amalgam filling removal - does not like to treat these patients as they don't do well, don't seem to recover.
• She utilizes www.scorecard.org to determine common pollutants in people's area.
• Using Strategene can help answer why some people do well with some things and not others.  She looks at methylation pathways of a person to determine which pharmaceuticals may work best.

I listened to this one twice and still just can even begin to grasp how she noodles all this stuff out.  Dr. Keller is also very interesting in environmental toxins and how they impact the body.  For example, research has shown Agent Orange acts as a xeno-estrogens and caused a rise in endometriosis for women and diabetes for men.  Ulcerative Colitis and Crohn's appear to have doubled from 1996 to 2006.

Next steps for dealing with methane while not actively killing....

While I wait for my antibodies to clear so my nerves can heal and restore function to my migratory motor complex in the small intestine I need to do something to keep the methane at bay.  I tried a 90 day protocol and that clearly didn't do much at all.  So what to do??  I don't want to dive into more killing so I may go back to the (possible) methane inhibitors.

Methane inhibitors
Red Yeast Rice - we know that Dr. Pimental is testing a lovastatin type drug to see if it inhibits methane production.  See here for information, scroll to bottom.  Red Yeast Rice does contain a natural form of lovastatin. I've used it in the past and was able to keep my methane numbers mostly in the single digits.  Once I got them to a certain level they wouldn't go lower but with Primary SIBO (aka the food poisoning induced autoimmune variety), getting the numbers down and maintaining them seems better than having them go up and down. And, it made goats fart less so why not us :) 

"At the genus level, the predominant archaea in the rumen of goats was Methanobrevibacter, 

which was significantly inhibited with the supplementation of red yeast rice. 

In conclusion, red yeast rice is a potential feed ingredient for mitigation of 

enteric methane emissions of goats." 
https://www.ncbi.nlm.nih.gov/pubmed/27467559

The link above is to a brand I used in the past. I might try a different brand this go 'round.

Ideal Bowel Support - this is a probiotic containing only 

Lactobacillus Plantarum which according to Chris Kresser can degrade methane.  I quite literally have a shelf of this stuff in my refrigerator.  Can't hurt!

Atrantil - This seemed so gimmicky when it first came out.  And there were so many "worked like a charm" and "didn't do squat" type comments on message boards that I really was skeptical. But I listened to Dr. Brown on a few recent podcasts and given my current situation (anti-vinculin antibodies negatively impacting motility) I thought I should at least try it.  It made me feel better, lighter.  I don't know how else to explain it.  I should say that I did use it after fasting so I was already feeling lighter and I do have most my digestive symptoms under control but wouldn't it be nice to be able to expand my diet without the usual repercussions. I think yes!  So I'm going to add it in while I focus on boosting motility and supporting healing.

Prokinetics
Cause if things aren't moving you are just generally screwed.  In hindsight I would have started taking these the second I learned I had SIBO.  Keeping things moving through the GI tract is the easiest way to prevent more overgrowth (in my opinion).  And note, not all of these are actual prokinetics, some have a more laxative effect, I realize that.  Slowing anywhere in the GI is just not good, makes you feel toxic, sluggish and ornery.
  
LDN - Low dose Naltrexone, although it really doesn't seem to actually have a prokinetic effect much if at all.  For those with Primary SIBO, LDE (low dose Erythromycin 50mg at bedtime) or Resolor (Prucalopride) seem to be the prescription of choice.  I don't tolerate Resolor because it has a teeny tiny amount of lactose.  Maybe you are luckier than I and tolerate dairy. Resolor is available through Canadian pharmacies.  I may ask for a script for LDE the next time I'm in office but I just hate the idea of more antibiotics even though it is a minidose. So for now I continue on LDN since it's beneficial for autoimmune issues.

Motilpro - Taken at bedtime, helps stimulate the cleansing waves of the small intestine at night.  In the beginning of my treatment it was recommended to take between breakfast and lunch as well but I don't really eat before lunch so I just wait until bedtime. Sometimes I take Ginger capsules in between breakfast and lunch.  The stuff is mega ginger burntastic so make sure to swallow it down with a LOT of water about a 1/2 hour before you actually go to bed.  

Vagal Tone - This shows some promise.  It was recommended by my ND but sadly I am reactive to the chamomile and it gives me a headache within seconds of application. Ugh! Similar to Iberogast in that you use it with meals and at bedtime, only it's external, apply a tiny dab on your occiput.

Magnesium - Most people recommend Magnesium citrate because it's not absorbed well into the system so does the trick. But it's acidic and can burn on the way out. Yikes!  Oxide is also not absorbed well and is not acidic, but I like a blend, that way your body can use some of the more absorbable forms and the rest can do it's job of pulling water into the colon and flushing the system.  I take it at dinner and bedtime so it can go to work in the evening and overnight.

Triphala - My new love.  LOL!  I used to swear this stuff did nothing but made me super constipated (and frustrated).  Turns out you just need to keep increasing to find your optimal dose.  I take 4 capsules at bedtime unless I've indulged and then I take a couple extra. Carbs and nuts do nothing but stop me up but oh how I love the taste of them!

I used Iberogast for a while but it started to not sit well.  It was the chamomile. Now the company has been sold to Bayer and is either being reformulated or completely taken off the market.  Either way pretty sad since I know it's used by many. I also try to use bitters before meals but got out of the habit and now forget a lot of the time.  These things can have a positive impact on motility as well.

Most of us have heard of the physical things we can do to stimulate the vagus nerve.  The vagus nerve stimulates the migratory motor complex so it's important that it's strong and active.  According to Dr. Kharrazian there is (vigorous) gargling, gagging and singing.  I also know from yoga that breathing stimulates the vagus nerve, most notably deep belly breaths followed by restricting and extending the exhale. It's your exhale that stimulate the parasympathic response. It's easiest to do this lying down.

Gut and Liver Support
Zinc Carnosine and L-Glutamine.  That's really all I have found that isn't mucilaginous and doesn't feeds the darned bugs.  I capsule up my own Glutamine because it's cheaper and I can avoid the fillers.  A lot of people drink it in water and it supposedly helps with sugar cravings, I just never liked doing it that way.  I recently added in a small dose of copper when I take extra zinc, apparently you are supposed to keep them balanced and not take zinc longterm on it's own.  Don't ask me where I read this, I cannot recall.

I always taking some sort of liver support because your liver takes the brunt of filtering whatever leaks through the intestinal wall.  If we are permeable and/or killing, your liver could use some assistance cleaning all that garbage out of the blood stream.  I've taken everything from plain Milk Thistle to ayurvedic formulas to herbal combinations.  I rotate formulas. 

Soil based probiotics remain my protocol (I would call it "my stack" but that seems really weird for some reason!).  I still take both PrescriptAssist and MegaSpore. I've done so much killing since my initial diagnosis that I feel it's necessary to support the microbiome in whatever way I can.  

Nerve Support
For those with Primary (autoimmune) SIBO, taking supplements that benefit nerve healing may be helpful.  It may not, who really knows.  I add Lion's Mane and Sunflower Lecithin to my hot chocolate and take Acetyl L-Carnitine in the morning. They talked about using Lion's Mane and Acetyl L-Carnitine at the SIBO Symposium a couple of years ago. 

The other thing I take that may or may not be of any help at all is Fibrenza.  My ND feels it may help remove antibodies in some way.  I have no idea how that would work but the idea of having something that scavenges the body seems good to me.



Please note - I do not make anything off these links I just included them for ease and examples.  All the links are products that I have used and companies I have purchased from.  Make your own decisions with your healthcare provider and buy from someone you trust.  Personally I don't like to buy supplements off Amazon unless I know it's coming straight from the company itself.  There are many rumors of counterfeit supplements out there.

Fasting vs. Elemental Diet

These are two very different things even though both involve no chewing.

Fasting is no calories, just water (and salt or trace minerals) for hours/days.  You can ease into fasting by drinking bone broth, which is what I tried but need to be somewhat careful as consuming too many calories can turn fasting into a low calorie diet of sorts.  Why does this matter?  When you fast, your body will burn through the energy stores in your liver in 2-3 days, with no other calorie options present it will turn to burning body fat for energy.  If/when you get into this magic zone, leptin, your hunger hormone decreases and your metabolism revs up because energy is required to convert body fat to energy.  That's the very, very simple way of explaining what I understand from listening to Jason Fung and reading The Complete Guide to Fasting.  If you are over 300 calories then your body will not switch into this magic zone, you will remain hungry and your metabolism will not rev up and go into body fat burning mode. It will just slow down because you are consuming both too many and not enough calories. This is the zone many dieters end up in after years of calorie counting, exercise and yo yo dieting.  According to the hosts of Fasting Talk this is also what happens to some people who only eat one meal a day.  Your body adapts to the low levels of calories and you do not lose weight.

The elemental diet on the other hand, if done correctly, keeps your calorie consumption up to your normal levels.  If you do the homemade version and keep the fats high and carbs low you will go into ketosis and much of the initial weight that comes off will be water.  It shouldn't slow your metabolism.  The problem comes in that many people with SIBO end up not digesting fat well so they rely more on carbs, which with the elemental means sugars. This is also the problem with many packaged elemental diet formulas, heavy on sugars and nutrients, not much fat.  Thankfully so far I am not one of these people, protein and carbs give me difficulty, fat not so much.  I sucked a tiny bit of honey out of my son's honey stick at the farmer's market today and have had a headache ever since.  I didn't used to be this sensitive but cutting sugars out has reduced my tolerance. It probably doesn't help that I seem to have some lingering insulin resistance issues as well.  Turns out my BS monitor is wildly inaccurate and needs to be replaced so I don't know this for sure.

Given that my body is not digesting well and I have a lot of lingering methane I am considering the homemade elemental.  First I need to finish eating the perishable food in the house that only I will eat, then I'll decide.

In a holding/healing pattern

Instead of being impulsive and diving right into the next killing spree since my small intestine is still overrun with methane, I'm trying a little patience.  Not my strong suit and if you've read any of my earlier posts you know I was more likely to go stronger, longer which has not been to my benefit.  I tried fasting, lasted two days, which makes sense since SIBO can have such a damaging effect on your ability to digest and assimilate.  So I was talking this through with my coach on Wednesday.  She's more of a business/lifestyle coach, not a health coach but she's so darned good at reading me and getting me to really think things through on my own that I broached the subject with her.  You tell me what to do and I'm likely to push back but lead me there and let me think it's my idea and I'm all in :) . Such is the way of my crazy brain!  

So, a year and a half ago after my last major "I'm going to rotate through ever last antimicrobial in the cupboard in a last ditch effort to get rid of every last archaea" episode, I gained 10 lbs, like BOOM!  This has annoyed the hell out of me for a multitude of reasons, one being I can't get my wedding band on, the other being I feel like a stuffed sausage in my clothes.  So while I say that I want to fast to let my digestion rest what I really want to do is lose these stubborn 10 lbs.  So this was the conversation with my coach, am I really fasting for the right reasons??  Maybe I just need to read The Complete Guide to Fasting again, I said.  She responded, stop reading, you are just giving yourself analysis paralysis, what does your body tell you?  I started to respond again from the head.  No, she said, take some time, lay on the floor, hand on heart and belly and really listen.  I don't have to.  My body is soooo hungry for nutrition, which means fasting will continue to be torture and I should really contemplate elemental if I do in fact want to give my digestion a rest.

I have a bag of the Integrative Therapeutics Physicians Elemental Diet but it's so sugary (dextrose and tapioca maltodextrin are the first two ingredients) that I am too chicken to try it.  I'm afraid it's just going to make me itch like crazy since I react so easily to sugars.  Not to mention that I would have to take antifungals as it can feed yeast overgrowth bigtime.  I'm sensitive to both potato and tapioca so there's that too.  I believe the dextrose is from potato since the formula is corn and wheat free. Those are the major sources of dextrose (potato, corn, wheat).  So back to contemplating the homemade elemental....  so nasty.  Still not sure that I want to go that route but really feel like my body could use the love.  In the meantime I'm stuffing my face with mexican food and contemplating beer :P.

Knock, knock?

Is anyone still out there??  

So, yes, it's been forever.  I felt pretty good for about a year, working on motility, gut healing and rebuilding my gut microbiome.  Then the election happened and I won't get political but I just tanked from all the stress.  First, my thyroid took a nose dive and I started pushing into Reverse T3.  Worked to get that sorted out, eventually just throwing in the towel and switching from NDT (natural dessicated thyroid) back to Cytomel.  The muscle cramping didn't go away and the itching came back, which are my body's major SIBO signs.  I'm on so many prokinetics that I have the digestion stuff down so it's the only way my body can cry wolf. On New Year's Day I broke down and did a breath test.  Hello Methane!  

Baseline was so much higher than it's ever been.  Super discouraging and I knew I had to know for sure.  Was my IBS due to the two bouts of food poisoning I had in 2010??  I printed out the lab requisition for the IBSChek and presented it to my ND.  Results came back positive on both measures meaning yes, I have had food poisoning and yes, this SIBO is autoimmune in nature.  Even though the events were nearly 7 years ago I still have antibodies well over the cutoff.  Drat!

We know that when SIBO is autoimmune there's not a heck of a lot you can do until the antibodies clear but I added Lion's Mane and Acetyl L-Carnitine back in to support nerve regeneration.

I opted to do Chris Kresser's SIBO protocol because I've tried many of the others.  90 days of GI-Synergy, biofilm disruptors (lauricidin and Interfase plus), probiotics (Megaspore, PrescriptAssist and Ideal Bowel Support) and hydrolyzed guar gum.

Retest last week...

A big ole...  let down.  Are things better?  Yes!  Have my symptoms reduced?  Yes!  Did I expect more from 90 days of protocol?  Hell YES!

So for now I'm trying Atrantil as I hear for some it can really help with methane.  I'm also playing around with fasting.  Not elemental diet, plain old broth only fasting a couple of days here and there.  I feel pretty darn good.  I have a bag of the ITI ED (Integrative Therapeutics Elemental Diet) sitting in my cupboard but I've heard so many stories of "now I have SIFO" or "now I have a horrible yeast problem and it's worse than SIBO", that I'm seriously scared of the stuff.  I do not tolerate carbs or sugars very well at all so there's that too.  Not sure I could stomach going the homemade elemental diet again and that seems to be the only way you can control the amount of carbs.

Oh and can I just say Biohealth rocks for breath testing - Quintron machine, 3 hr lactulose, I did my test on Monday and had the results by Thursday morning.  I NEVER have to go through NCNM/NUNM again.  Woot! Woot!

Holy Histamines

That's getting a little carried away, but I've never noticed a problems with histamines until recently.  I guess my spinach bread with turkey breast lunch meat and cashew cheeze is a bit heavy on the histamines and I itch after I eat it.  It's so good though.  Guess I'm going to have to do a little research and figure out how to keep my histamines low for a while as I imagine constantly triggering a histamine response doesn't help with gut healing.  Boo!  I've been making Pesto spinach wraps in the dehydrator and it was so fun to be able to eat a sandwich type thing again.  Back to the drawing board!

Stress is such a bugger!

We all like to pretend that stress doesn't matter.  We like to think we are handling it or that we are not stressed.  My husband purchased me the Inner Balance gadget for Christmas with a lovely meditation pillow. Inner Balance is a cord (with an app, of course!) that you plug it into your "i" device, in my case my iPad, and clip it onto your ear.  The sensor on your ear measures your heart rate variability as a way to determine your level of stress and help you learn how to train your mind to bring your heart rate variability to a less stressful pace. There is a lot of science around it, books, etc. none of which I was interested in enough to read.

The first few uses over Christmas break I was easily able to keep it in the green (meaning good heart rate variability, low stress and their term "coherence").  Fast forward a couple of months and I have increase to level 2 and am trying to do around 10 minutes of my HeartMath every day.  Some days, more often than not, it's HARD to get into and stay in coherence.  Dang!  I thought with all my yoga and everything that I was so chill. Apparently not :(  It's amazing how I can be sitting there doing great, in the green, and my mind just wanders to something I have to do or don't want to do and boom! I immediately go into the red.  Then you have to focus again on breath, gratitude, heart thoughts, working your way through blue back to green only to wander and go back to red.  Wow!  It's so much more relaxing to be unplugged and not know :)

I've found when I eat in a rush or under any stress my food just sits in a giant lump in my stomach and doesn't want to go anyway.  I get a little reflux even sometimes.  If it happens to be dinner when this goes down then the next morning can be rough.  So, even though Dr. Pimental has done research that shows that stress alone does not cause SIBO, it can definitely contribute to your symptoms and inhibit your ability to digest.  And remember that the stress hormone cortisol is catabolic, meaning it breaks things down, definitely not helpful for healing!