My notes from SIBO Symposium

I should preface this by saying that on Thursday I received my son's results for the Cyrex Array 3 & 4.  Turns out he was off the charts sensitive to both wheat (interestingly enough the lectins way more than the gluten) and dairy (casein but not whey).  My family loves their bread products and dairy products and they are a staple in our home (I don't eat them of course due to SIBO and dairy sensitivity).  We talked on Thursday evening and Friday morning after they guys left I cleaned all the dairy and wheat out of the house, jumped in the shower and left for the symposium.  Needless to say all this was heavy on my mind during the weekend since I didn't know what the results actually meant in terms of autoimmunity. Our ND can't see us until July.  Thankfully I ran into the Cyrex Rep at the Symposium and she talked me through the results.  Not specific to him or diagnostic but what each value measures, translates to (eg - wheat germ agglutanin is a lectin), and how symptoms may manifest in the body for people.  After talking with her I was able to breathe because I think that Celiacs and IBD are likely off the table. Phew!

Dr. Pimental spoke first about the Underlying Causes of SIBO.  He has teamed up with the military to study IBS because the majority of soldiers get food poisoning on deployment, as if they don't have enough stress!!!  In these studies they have found that 10% of soldiers returning have IBS from one deployment. You can imagine the rates for soldiers going through multiple deployments! They ruled out stress as a cause by asking question such as - did you fire a weapon, did you shoot another human, were you injured, etc. Through these studies he has determined that IBS is not caused by stress (and therefore is NOT all in your head).  His belief is that the majority of SIBO is caused by food poisoning.  Based on a study, 60%+ cases of IBS are caused by SIBO.  They determined this using both duodenal sample and the breath test.  This number is likely low because if the breath test was positive and the sample negative they said negative for SIBO.  Dr. Pimental mentioned that the duodenum is just a small sample of the upper small intestine and often the bacteria is lower down so this percentage is likely low.

Dr. Pimental has done A LOT of work looking at how food poisoning causes SIBO.  He found that when you get food poisoning often from Campylobacter Jejuni, E. Coli, Salmonella or Shigella they can all cause SIBO.  The bacteria produce CDT (Cytolethal Distending Toxin).  The toxin attaches to the wall of the small intestine and the our immune system creates antibodies (Anti-CdtB and Anti-Vinculin), these antibodies go to attack the CDT and in the process destroy the vinculin which in turn damages the Interstitial Cells of Cajal (ICC).  These ICC cells are responsible for motility.  Dr. Pimental found that if you remove CDT from bacteria before injecting it into the mice they still got gastroenteritis but did not get lasting intestinal damage or SIBO.  This is where Dr. Pimental's new test comes in that measures these antibodies. It's his first step in finding a way to cure SIBO. These antibodies - cause SIBO, the greater the antibody the greater the SIBO so can predict treatment length and if we measure antibodies perhaps we can learn how to decrease them and heal the ICC/motility.  Dr. Pimental stated that if you remove the antibodies the body will heal in 3 weeks.  He also said it is imperative for people with SIBO to NEVER get food poisoning again.  He advises some type of antibacterial while traveling with every meal (of course he said Rifaximin but that's only because it's his weapon of choice and he's rumored to get kickbacks, personally I will stick to Biocidin).

Other takeaways from his talk:

• 10 times more people with IBS have an abnormal breath test than normal people.
• Methane slows transit time in the small intestine 69%.
• You are 5 times more likely to get IBS if you have had food poisoning.
• Also, the breath test is not good at measuring methane under 3 so if your hydrogen is elevated and you still have constipation assume it's positive for methane and keep treating.
• If the breath test shows methane in the colon it's still a positive because you shouldn't have methane produced anywhere!
• Stomach acid (and Betaine HCL) slows motility but kills bacteria so take it if you need it!!
• PPIs increase motility but they are NOT recommended because the decrease acid (which kills bacteria)

Dr. Pimental and Dr. Siebecker then presented Elemental Diet Treatment for SIBO.  Dr. Pimental noted that he only has a 50% success rate with methane producers using Vivonex.  Sometimes people don't feel better until 10 days after they stop the elemental diet.  It's important to reintroduce foods SLOWLY, starting out with soups.  Antibiotics don't work during the elemental diet because the bacteria can hibernate.  The elemental diet is effective in 80% of people in 2 weeks, 85% of people in 3 weeks, there is no benefit in going longer.  Thrush can be a side effect of Vivonex due to "all the nutrition being swished in the mouth".  There have been no studies yet on Peptamen but it appears to have the same effectiveness.  Dr. Siebecker has done no formal studies on the homemade formula but she has found virtually the same effectiveness as Vivonex and says she has found it is effective with Methane.  You can find the recipe here.  Can I just say she is so tiny and absolutely adorable?!?!

I skipped Dr. Pimental's presentation on Rifaximin.  Been there, done that, wouldn't do it again, wouldn't recommend it.  I've found herbals much more effective.

Prokinetic Prevention of SIBO presented by Drs. Pimental, Weinstock, Siebecker, Keller.  I didn't take any notes on the prokinetic discussion because I've used most of them :)  The only one I haven't tried is Resolor because it's expensive and you have to get it from Canada.  Dr. Siebecker does a good job outlining prescription options here.  Dr. Pimental likes Resolor the best.  Dr. Weinstock talked about LDN. Dr. Siebecker seems partial to Iberogast (even for kids).  Dr. Keller presented on Motilpro.

Herbals include:

• Iberogast 20 drops with meals and/or at bedtime
• Motilpro - no instructions provided
• Ginger - 1000-1500mg daily

They all seemed to feel that there may not be a benefit to starting prokinetics early.  Often the methane overrides the benefit of the prokinetic and you are just wasting your money.

Steven Sandberg Lewis and Dr. Shaver presented on Beyond the Breath Test: Other tests for SIBO patients.  My takeaway from this was that a provider should never assume it's just IBD, or Celiacs that if the patient doesn't get better they should always check for SIBO (and in some cases vise versa).  Dr. Shaver indicated she likes to r/o celiacs, non-celiac gluten sensitivity, do food sensitivity testing and a stool test.  Celiacs and SIBO often seem to go hand in hand.  Food sensitivity testing helps you identify and remove foods causing symptoms and/or inflammation, stool testing can help identify parasites/pathogenic bacteria/fungus, bacterial imbalance, inflammation, and sIgA ("a key marker of humoral immune status").

Larry Wurn presented on Physical Treatment for SI Obstruction and all I have to say about this is if you feel like surgical scarring/adhesions are an issue for you, you need to check them out.  I have a friend that has been to their clinic and had treatment and it changed her life.  There technique has been well studied and it's no bull!

Sunday was a bit more of a blur.  The conference started at 8am and the presentation was done via video (for an hour and 15 minutes).  It was hard to follow along.  My friend Tim will do a much better job of summing up Dr. Mullin's presentation and I will link it when he does.  Dr. Mullin spoke on a wide variety of topics, one was using D-Limonene 1000g daily as a prokinetic. I don't recall timing but prokinetics are usually at bedtime.  He also talked about use of the Smart Pill to measure PH in various parts of the digestive tract, in addition to measuring motility, pressure and the ICV.  Sound intriguing!  I also wrote down S. Boulardii increases SigA (which is a good thing!).  I think I tossed mine out long ago however so can't add it in now and again.  He spoke about adding in fermented food but I glazed over :(. His uses the garden metaphor, first kill all the weeds (SIBO), support the soil (gut) so good plants can grow, then reseed (pre- and probiotics).  I'm on the probiotics, the prebiotics still scare me a bit!!  Oligosacchararides promote bifido and lacto, discourage growth of clostridia, prevent constipation, etc.  Sounds kind of important.  Oligo's are found in artichoke, asparagus, broccoli, brussel sprouts, fennel, garlic, leek, onion and cabbage. It was interesting, Dr. Mullin seems to be willing to try anything and if I am remembering right he talked about patients ending up in the hospital (one due to use of biofilm buster EDTA) and said "we discontinued use of that treatment" a handful of times. Which is both awesome and frightening.  We need strong SIBO fighters but I'd hate to end up in the hospital!  He has a new book tomorrow!

Dr. Weinstock spoke again about leaky gut and SIBO.  The feeling is that pretty much everyone with SIBO has leaky gut and if your intestinal permeability test comes back negative it's only because the SIBO has eaten all the lactulose/mannitol before it leaked through to the blood and could be measured.  I believe he said they use 10g of lactulose for the breath test and only 5g of lactulose/mannitol for the intestinal permeability test.  Other ways you can look at intestinal permeability is butyrate, lower levels imply impaired barrier, the other ways, measuring LPS (lipopolysaccharide) is difficult, Anti-LPS only shows in acute phases and the endotoxin test requires measurement in the portal vein.  Bottom line, assume intestinal permeability and support repair using the following supplements:

• Serum Bovine Immunoglobin (SBI) - binds and removes microbial components
• Zinc (I use Endozin) - supports tight junctions between cells
• Glutamine - nutrition to support mucosal integrity
• Curcumin - reduces inflammation
• Probiotics - increases zonulin

The Lactulose Breath Test Interpretation was fascinating and we all pulled out our breath tests to follow along.  It went really fast though.  The only takeaway I had was that you want to see a double peak, the dip between peaks indicates that you have moved from the small intestine to the large intestine.  

That pretty much sums it up.  Phew!  Let me know if you have any questions!