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.

Clinical Pearls from the SIBO Symposium

The webinars from the SIBO Symposium have finally been released. They are a bit hard to hear but I spent a couple of hours last night listening to the Clinical Pearls section that we missed. Providers had the opportunity to come up and talk about cases and things they are trying or noticing in their patients. They each had 5 minutes. Some takeaways: Farshid Rahbar, MD presented on SIBO and tick borne illness (Lyme). He found that patient with abnormally high levels of hydrogen or methane often had tick borne illness. 65% of people that he has seen that have tick borne disease also have SIBO. Dr. Morstein (ND) uses the generic Rifaximin from Canada and has great success but she always pairs it with 1 tsp of guar gum in 8oz of water. She never treats SIBO without including Lactoprime Plus. She has the client take them with lunch. She felt that if you just treated the SIBO you would end up creating a dysbiosis in the large intestine and then you would be stuck fixing that next. (I have to say I kind of agree, after last summer's war against the archaea I ended up with a bad dysbiosis in my colon.) She also uses Hercius Erineus and Acetyl L-Carnitine to help heal any nerve damage in the small intestine. (My guess is this is the product she uses.) Whitney and Stephanie Hayes, NDs presented on SIBO and infertility. They found if they got rid of a woman's SIBO she often became fertile again. Pretty fascinating since you wouldn't think they would be linked. They think SIBO testing should be considered in any woman with pelvic pain/dysfunctions. Dr. Elena Guggenheim talked about autoimmunity and how the bacteroides seem to modulate the immune response. She presented a case on RA and said that once she got the woman's SIBO under control (only symptom was diarrhea), her RA symptoms greatly reduced and she was able to resume normal activities without daily use of medications. Kelly Reis (sp?), ND was great. She bought her own Quintron so she could get results fast. She also does thermography and finds that people with autoimmune issues have a cooling spot above their T2 thoracic spine. (I had this done before my SIBO diagnosis and I didn't have anything blue (cold) in this area. Fascinating!) She runs a facebook page for clinicians which is a valuable resource since everyone seems to be guessing a bit on the harder cases. Nora Jacoby, ND talked about diet. She has a diet handout that she gives patients and there is access to it for clinicians only on her website www.sibotest.com. She gave no details to say how it was different that the SIBO specific diet. She strongly recommends Dr. Kharrazian's gargle/gag method, breathing exercises and use of cascara sagrada. She also mentioned Heart Math (which I really want), to help you get into rest and digest mode before meals and to help train yourself overall to easily get into parasympathetic mode. Using a Squatty Potty or step stool will help retrain the bowels. If you like local and sustainable (aka expensive) go herehttp://gostool.com/shop/ Dara Perkins, MD has found that with low weight SIBO patients she often has them eat high quality fermented sourdough bread and organic corn products such as polenta for a starch and most have success. One of her patients found that if you combine LDN with antihistamines you may have nightmares. Dr. Ruscio came up and talked about how he tracked patients taking biofilm agents and some who were not and so far hasn't found any difference in effectiveness. He will release his finding later this summer. BIofilm disrupters are a must if the overgrowth is fungal.  He brought up how the microbiota is the next big thing but that a lot of the information going around on blogs is not based in research. He's not ready to jump on the feed the microbiota carb bandwagon. He said prebiotics need to be taken on a case by case basis and you should be gunshy with SIBO patients. He is beginning a study of prokinetics in the next 2-4 months. To be in this study you have to be ending your treatment and SIBO clear when he starts his research. Information at www.drruscio.com Mark Davis, ND talked extensively about FMT and said that even when people swallow (ewwww!) an FMT capsule it does not cause SIBO. He bases this on a study where they sprayed fecal material into the duodenum of people and the bacteria migrated back down to the colon. Allison Siebecker, ND indicated that any kind of self care whether it be acupuncture, massage, yoga, meditation, colonics, deep breathing, etc improves patient outcome. Dr. Moore, ND uses a food allergy test to see if patients have leaky gut, if there are lots of positives or mildly positives it indicates leaky gut. (other NDs mentioned this as well). Expressed need for mentoring program for clinicians treating SIBO (the new GastroANP.org for providers will provide some of this). A doctor asked a question about how to regenerate nerve function in the small intestine. The same herbs were brought up (as above) by Dr. Morstein, acupuncture, colon hydrotherapy, cranial-sacral therapy. Dr. Ruscio brought up again that ICC cells will regenerate on their own once SIBO or antibodies are gone. Steven Sandberg Lewis, ND brought up the whole gut brain connection. He said if there has been any mild traumatic brain injury - former soccer player, non-diagnosed concussion, black eye, broken nose, whiplash (me two or three times), any of those impacts can affect the gut neurology. Neurofeedback is a great way to address it. The general consensus with all the providers was SIBO is either easily treated or very, very difficult. There doesn't seem to be a lot of middle ground. Guess I know where fall!

SIBO as an autoimmune disease

First of all, can those people with an actual autoimmune version of SIBO get something new to call it?  An actual name, not an acronym.  The bacterial overgrowth is just a symptom of the actual problem.  The actual problem being the damaged vinculin and ICC.  Any thoughts on names?  Just please not Pimental's Syndrome.

Dr. Ruscio podcast on IBSChek

I have to say seeing Dr. Ruscio at the SIBO Symposium was quite fun.  People flocked to him, handsome and smart.  Hilarious!  It was like there was a rock star in the room.  LOL!

He recorded this podcast before the SIBO Symposium.  After Dr. Pimental's presentation I wonder if he has changed his thinking at all??  I'm sure he'll do a podcast about the SIBO Symposium soon. 

I waiver on this one.  Do I want to know if I have antibodies?  Would it actually change my course of treatment? (NO!)  Is satisfying curiousity worth the $$$? Given that I did the Cyrex Array 3, 4 and 10 you probably know the answer to that!!

new-sibo-test-just-released-episode-15/

Breath Test #7

I knew I'd still be positive but it doesn't suck any less, especially since my (methane) numbers are a little higher than in September.  At least the hydrogen is down.  Oh, and based on the Breath Test Interpretation section at the SIBO Symposium, my guess is that the dip at the 180 mark is the dip where the lactulose transitions to large intestine.  You should see a double peak and the dip between the double peak is the ICV (ileocecal valve). Hello slow motility!

Pity party over, time to move on...  Do I choose a protocol or wait to talk to Dr. Keller. Hmmmm, I'm not very good at patience..  Stay tuned!

Another great perspective from the SIBO Symposium

From my friend, Tim.

http://www.dharmaworks.net/Tim/sibo-symposium-recap/

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!

Here's an excellent post from the Symposium

Dr. Keller's ......  office manager (that word just doesn't cover it), she does everything and is so awesome, wrote an excellent blogpost wrapping up the symposium.  Find it here:

 http://sibowithhope.com/2015/06/07/sibo-symposium-2015/

Home again, home again...

Oh how my bowels are happy to be home.  TMI :)  Sorry!  Not sure if it's related but I rolled a ball under my foot while sitting in the symposium this morning and things finally started moving. Phew!

What an amazingly fun weekend hanging out with online friends (in person) who are just like me!  Last night we went to the The Brooklyn House for dinner last night.  They are well versed in dietary challenged people and are rumored to have a copy of the SIBO Specific Diet in the kitchen.  My meal wasn't spectacular, but really what can you do with white fish if you can't use butter, garlic, onions, etc.  I should have tried the rabbit.  The rib eye steak looked fabulous too but my chewing it would have been too difficult.  They messed up and accidently gave me a side of grilled cauliflower instead of grilled vegetables but with the huge amount of fish and the potatoes I knew it would be too much so didn't request them.

Today we went to The Cultured Caveman on the way home.  I chose wrong again!  I'm just not accustomed to eating out.  I had hot dogs (off the kids menu) and they were scrawny things with a pretty tough exterior.  I had zoodles on the side, bone broth and a shot of fermented cod liver oil.  I usually take this fermented cod liver oil but in capsules. They had the same brand in liquid form.  It was so disgusting and I burped fish for the rest of the 3 hour ride home.  But the restaurant was so cool and they had so many paleo products to browse and buy, including cookbooks.

I'll update on everything I learned tomorrow.  It's going to take time to put my notes together and I am exhausted!

On My Way.....

to the SIBO Symposium in the paleo mecca Portland, Oregon.  I can't wait to meet all my facebook friends in person and learn a ton of new information about how to eradicate the scourge that is SIBO.  Stay tuned!  I will be sharing it all here, of course!