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.