SIBO INFO Blog

Dr. Pimentel gives a presentation, followed by Q&A.

Summary:
How Food Poisoning Starts IBS/SIBO
Dr. Pimentel explains that food poisoning is a major cause of IBS/SIBO. About one in nine people who get food poisoning will end up with IBS/SIBO. This is often called post-infectious IBS.

Mechanisms
With food poisoning, the body can react to a toxin called cdtB. This toxin is made by common food poisoning bacteria like Salmonella and Campylobacter. The immune system tries to fight the toxin. Sometimes, the immune system gets confused and starts to attack a protein in your own body called vinculin.

The Role of Anti-Vinculin Antibodies
Vinculin is very important for gut nerves. It helps the nerve cells connect and talk to each other. These nerves control the "cleaning waves" (migrating  motor complex) in the small intestine. When the body attacks vinculin, these nerves get damaged. This leads to several problems:

• The gut stops moving correctly.
• Food and waste stay in the small bowel too long.
• Bacteria start to grow where they do not belong.

This process meets all the rules of science to prove it causes the disease. If you have these antibodies in the blood, you likely have post-infectious IBS. This is a big step because it gives patients a clear answer. You can now take a blood test to see if this is why you are sick. ​(IBS-Smart)

Understanding SIBO and the Bad Bugs
Small Intestinal Bacterial Overgrowth (SIBO) happens when too many bacteria live in the small bowel. In a healthy person, the small bowel is relatively clean. In someone with SIBO, the bacteria ferment food and create gas. This gas causes the bloating and pain that IBS patients feel every day.

Dr. Pimentel found that SIBO is not just "any" bacteria. It is usually two specific types: E. coli and Klebsiella (hydrogen SIBO). These bugs are very good at eating sugar and making gas. They can produce gas 63 times faster than normal bacteria. This is why you might feel bloated just 15 minutes after eating.

The New Rule for SIBO Diagnosis by culture (for research)
For a long time, doctors disagreed on how to diagnose SIBO using a culture. New research has settled the debate. A patient has SIBO if they have more than 1,000 bacteria per milliliter in their small bowel juice. This is also written as 10 to the 3rd power. Using this count helps doctors be more accurate. It ensures that patients get the right diagnosis and the right care.

Methane and the Struggle with Constipation
Not all IBS is the same. Some people have diarrhea, while others have constipation. If you struggle with constipation, you might have IMO. This stands for Intestinal Methanogen Overgrowth. This is caused by a tiny organism called M. smithii.

Methane gas is different from other gases. It acts like a brake on your gut. It causes the muscles in your intestine to spasm. This prevents waste from moving through. The more methane you have, the more constipated you will be.

Why Methane is Unique

• It is produced by organisms called methanogens - archaea, not bacteria.
• It eats hydrogen gas to create methane.
• It is often found in both the small and large intestines.

Because methane eats hydrogen, a standard breath test can be tricky to read. You cannot just add the gas numbers together. You need a doctor who understands how these gases interact to get a good plan.

The Discovery of Hydrogen Sulfide
For years, some patients had all the symptoms of SIBO but their breath tests looked normal. Scientists have now found a third gas called hydrogen sulfide. This gas is linked to diarrhea and urgency. It was hard to find because the gas is very reactive. It disappears quickly.

Researchers had to build a new machine to measure this gas. They found that certain bugs like Proteus and Desulfovibrio produce it. This is a huge win for patients who felt ignored. Now there is a test that measures all three gases: hydrogen, methane, and hydrogen sulfide. (Trio Smart) If you have diarrhea and your other tests were negative, this might be the answer.

Better Ways to Test Your Gut
The best way to check for these gases is a breath test. But you must do the test correctly. Dr. Pimentel suggests using a lactulose breath test. Lactulose travels through the entire small bowel. This allows the test to find bacteria even at the very end of the small intestine.

New Treatments on the Way
Treating SIBO is about more than just killing bugs. It is about restoring the balance of the gut. Rifaximin is the most common antibiotic used for IBS with diarrhea. It stays in the gut and does not enter the blood. This makes it very safe.

Rifaximin and NAC
Some bacteria hide in a layer of mucus in the gut. This makes them hard to kill. Dr. Pimentel is testing a new way to use Rifaximin with NAC (N-acetylcysteine). NAC helps thin the mucus. This allows the antibiotic to reach the bacteria and kill them. A large study on this new treatment is starting soon. This could be a huge help for people who do not get better with Rifaximin alone.

The Power of the Elemental Diet
If antibiotics do not work, some doctors use an Elemental Diet. This is a liquid diet where the food is already broken down. The body absorbs the nutrients quickly. This leaves no food for the bacteria, and they starve.

In the past, these diets tasted very bad. A new version called mBiota is now available. It tastes much better and is easier to finish. Research shows it can clear hydrogen and methane gases very well. It is a tough two-week plan, but it works for many people.

Hormones, Menopause, and Gut Health
Women often notice their gut issues change during menopause. New data from the Reimagine Study shows a link between hormones and the microbiome. Women on hormone replacement therapy (HRT) had better gut bacteria. Their microbiomes looked like those of much younger women. If you are going through menopause and have IBS, this is an important topic to discuss with your doctor.

The Impact of GLP-1 Drugs like Ozempic
Many people are now taking drugs like Ozempic for weight loss. These are called GLP-1 drugs. These drugs work by slowing down the stomach. This makes you feel full longer. However, they make SIBO testing very difficult.

If your stomach is too slow, the test liquid never reaches the bacteria. This results in a "flat line" on the test. Dr. Pimentel recommends stopping these drugs for at least one week before a breath test. He also warns that these drugs are so strong that they can cause new gut symptoms that look like SIBO.

Optimism for the Future
The world of IBS research is moving faster than ever. We have gone from thinking IBS was "all in your head" to finding the exact bugs and toxins involved. We have better blood tests to find the cause. We have better breath tests to find the gas. And most importantly, we have better treatments coming every year.
​
If you have been suffering, do not give up. Talk to your doctor about the three-gas breath test (Trio Smart) and the new antibody tests (IBS-Smart). Science is finally catching up to your symptoms. The goal is to get your gut moving again and get your life back. Better days are ahead for everyone with IBS and SIBO.

This video delves into the role of Atrantil in managing methane-SIBO (IMO), addressing common questions about its use, effectiveness, and potential side effects.

Key Discussions and Takeaways:

• Atrantil Mechanism of Action:
  • Atrantil is described as having a mild killing effect but primarily works by inhibiting the production of methane by archaea and bacteria in the gut.
  • The focus is on reducing methane itself, as it is the gas that causes symptoms and aggravation.
• Usage and Combinations:
  • It is commonly combined with herbs that target hydrogen, such as oregano, berberine, or neem, as hydrogen is typically present when methane is produced.
  • Atrantil can also be used effectively on its own for methane SIBO (IMO).
• When and How to Continue Use:
  • If Atrantil proves successful in controlling symptoms and/or shows good results on a SIBO breath test, it is recommended to continue its use.
  • It should be continued at a low dose (e.g., one to three capsules per day) on an ongoing basis to maintain the inhibition of methane production. This approach is taken because the herbs are needed to inhibit methane formation and the bacteria may not be entirely eradicated.
• Potential Side Effects:
  • While Atrantil can cause individual reactions, a potential reason for worsening symptoms could be "die-off," a mild killing effect that herbs can sometimes induce.
  • The tannins present in Atrantil can also be bothersome for some individuals.
  • Identifying what is causing a 'reaction' can take time. It's important to recognize that many factors can influence reactions, and it may take several attempts (three times) to accurately attribute symptoms to a specific substance versus confounding factors.
• Atrantil vs. Prokinetics:
  • Atrantil is not a prokinetic.
  • If gut motility is a concern, a prokinetic would need to be used in addition to Atrantil.

This discussion provides guidance on leveraging Atrantil for methane management, emphasizing its primary role in inhibiting methane production and the importance of individualized assessment and follow-up.

Product Mentioned:

• "Atrantil": https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript), https://amzn.to/3Gwd8Yh (Amazon)
  
• Allicin "Allimed"/"Allimax Pro": https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript), https://amzn.to/3Tg4bdb (Amazon)
  
• Berberine: https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript), https://amzn.to/4a6pmEI (Amazon)
  
• Oregano "ADP": https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript), https://amzn.to/3T94BSO (Amazon)
  
• Neem: https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript), https://amzn.to/3RaPPIH (amazon)

This video discusses strategies for weight gain in SIBO, especially for those who are underweight and struggling with weight loss.

Addressing SIBO Directly

• The primary recommendation is to focus on treating the SIBO itself.
• Once the SIBO overgrowth is reduced, the body's ability to absorb food is likely to improve.
• This improvement occurs because the bacteria will be less active in competing for nutrition and causing damage that hinders absorption.
• If you are not currently treating SIBO, starting this process is the first priority.

Dietary Adjustments for Caloric Intake

• A significant aspect of recovery involves increasing overall caloric intake.
• Increasing Fat Intake:
  • Incorporate more fats into your diet.
  • Examples include eating more pork, such as bacon and rib dishes.
  • If dairy is tolerated, use lactose-free options like cream, sour cream, or make homemade yogurt using half-and-half for increased fat content.
• Sweetened Beverages:
  • Consider getting calories from sweetened beverages, choosing sweeteners that do not cause adverse reactions.
  • Homemade lemonade and eggnog are suggested options.

Optimizing Meal Spacing and Timing

• Frequency of Meals: While food can cause symptoms for SIBO, consider eating more often as a general strategy for caloric intake.
• Meal Spacing:
  • Reduce the strictness of long meal spacing (e.g., 4-5 hours).
  • The goal is to maintain a 12-hour overnight fast to allow for the migrating motor complex, which is crucial for gut health.
  • You might consider a shorter spacing of around three hours between breakfast and lunch.
  • Eating snacks through the afternoon and evening can help increase caloric intake.
    

This video addresses challenges encountered with SIBO treatment protocols and explores potential underlying issues and alternative approaches.

A Patient's SIBO Treatment Experience

• A patient has undergone 4 treatment protocols, including elemental diet, antibiotics and herbs.
• Each treatment cycle has unfortunately worsened SIBO and food sensitivities.
• She is experiencing severe symptoms such as brain fog, making work impossible, joint pain, and insomnia.
• The patient is seeking to understand if she's missing a root cause or what other strategies she could try.

Addressing Difficult SIBO Cases

• Dr. Allison Siebecker notes that more information is needed for a proper analysis, including test results (before and after) and details of past treatments.
• However, for individuals experiencing severe symptoms from SIBO treatments, common considerations include:
  • Yeast overgrowth (which can cause worse die-off vs bactaria)
  • Histamine sensitivity (MCAS or histamine intolerance)
  • Mold exposure
• These conditions can complicate SIBO treatment due to adverse reactions to the treatments.

A Success Story with Cromolyn for MCAS

• A participant shares her positive experience starting cromolyn.
• She takes 200 milligrams orally three times a day for MCAS.
• Within 20 days, all her symptoms have reportedly disappeared, which is highlighted as a significant positive outcome.

Alternative Approach for Histamine Intolerance (MCAS)

• A colleague who treats many MCAS, Lyme, and mold cases, utilizes an interesting protocol.
• This approach involves using traditional over-the-counter antihistamines.
• The doses are adjusted to be lower, such as cutting pills in half or using child dosing, taken three times a day.
• This method has shown excellent results for her patients.

Key Takeaway

• Mast Cell Activation Syndrome (MCAS) is frequently an underlying factor for individuals dealing with difficult-to-treat SIBO.
  

Product Mentioned:
~Cromolyn Sodium prescription Rx for histamine intolerance/MCAS
~standard antihistamines  

For more on treating Tough SIBO see: Tough SIBO Masterclass by Dr. Siebecker

The video addresses the common desire to avoid food poisoning and stomach flu.
Key Discussion Points:

• Recommendations for Food Poisoning:
  • Dr. Pimentel's suggestion involves rapid testing to identify the specific organism responsible for food poisoning, followed by targeted antibiotic treatment. This approach is noted as not always practical due to time and accessibility constraints.
  • An alternative recommendation mentioned by colleagues, particularly for travel, is the regular intake of certain remedies with meals, such as Allimed, though this is considered impractical for daily life.
• Practical Prevention and Intuition:
  • A key takeaway is the importance of careful food handling and selection, such as being mindful of how long perishable items like mayonnaise-based dishes are left out.
  • The video highlights trusting one's intuition and gut feelings as a valuable "early warning device" for potential food safety issues.
• Enhancing Gut Health with Probiotics:
  • The discussion emphasizes the benefits of probiotics, noting that they can be obtained from dietary sources and supplements.
  • Examples of foods rich in probiotics include sauerkraut, sauerkraut juice, yogurt, and various other fermented vegetables.
    
  • Consuming these fermented foods is suggested to help strengthen the gut's immunity.

Product Mentioned:
~ Allimed/Allimax Pro: https://amzn.to/3Tg4bdb (Amazon) https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript)
~ Probiotics: (discounted at Fullscript here)

This video delves into the intricate process of treating multiple gut health conditions concurrently, specifically focusing on gastritis, SIBO (Small Intestinal Bacterial Overgrowth), and leaky gut, especially when treatment tolerance is a concern.
Key Discussion Points:

• Prioritizing Treatment for Tolerance: When faced with gastritis, mixed SIBO, and leaky gut, the initial consideration is to choose treatments that are better tolerated. Pharmaceutical antibiotics are generally preferred over herbals due to their better tolerability, particularly with gastritis.
• Pharmaceutical Antibiotics:
  • Rifaximin is highlighted as a strong option. It is well-tolerated, especially with gastritis, and possesses significant anti-inflammatory properties, making it suitable for addressing multiple issues.
  • For mixed SIBO, treatments like neomycin and metronidazole can cause stomach upset.
  • Alinia [Nitaoxanide] (known by other names outside the US) is suggested as a gentler alternative that typically does not upset the stomach. A combination of Rifaximin, Neomycin, or Metronidazole (or Alinia) could potentially treat gastritis, leaky gut, and SIBO simultaneously.
• Herbal Support for Leaky Gut:
  • Berberine is mentioned as a historical treatment that helps tone, strengthen, and soothe mucous membranes. It is recommended as a good option for leaky gut and for tolerance with gastritis.
  • Other supplements that can support leaky gut and may help gastritis without aggravating SIBO include colostrum, fish oil, zinc, zinc carnosine, and vitamin D. These are generally non-mucilaginous and non-fibrous.
• Overall Strategy: The recommended approach is to address the most bothersome conditions with well-tolerated options first, aiming for a comprehensive treatment that can resolve gastritis, leaky gut, and SIBO concurrently.

Products mentioned:
~ Antibiotics: Rifaximin (Xifaxan), Neomycin, Metronidazole (Flagyl), Nitazoxanide (Alinia).
~ Berberine: https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript), https://amzn.to/4a6pmEI (Amazon)
~ Allicin - Allimed/Allimax Pro: https://amzn.to/3Tg4bdb (Amazon), https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript)
~ Atrantil: https://amzn.to/3Gwd8Yh (Amazon), https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript)
~ Leaky gut: https://us.fullscript.com/plans/asiebecker-leaky-gut (discounted at Fullscript)

This video addresses patient's experience with SIBO symptoms and the interpretation of their recent Trio Smart breath test results using glucose.
Listener's Situation and Test Results

• The listener reports classic SIBO symptoms such as bloating and gas.
• They underwent a Trio Smart test using glucose, which showed normal results except for a slight increase in hydrogen approximately four hours into the test.
• Confusion arose as the standard test duration is only two hours, and the observed increase was beyond this timeframe and not considered positive.

Expert Analysis: The Glucose Breath Test

• Dr. Siebecker advises against using glucose for SIBO testing, deeming it an ineffective substrate for diagnosis.
• The primary reason cited is that glucose is absorbed very early in the small intestine, specifically within the first three feet. This rapid absorption may prevent it from reaching areas where SIBO bacteria could ferment it and produce measurable gases, leading to potential false negatives or inconclusive results.
• A reference is made to Dr. Hawrelack's insights on this topic, with a resource shared for further viewing.

Recommended Next Steps for Testing
To achieve a more accurate diagnosis, the following alternatives are recommended:

• Redo the Test with a Different Substrate:
  • Fructose: Suggested as a more effective substrate than glucose.
  • Lactulose: Recommended if available. Dr. Allison Siebecker notes that lactulose is often easier to obtain via prescription from a primary care physician because it is commonly recognized and prescribed as a laxative.
• Consider FoodMarble: an at home hand held device
• Utilize Trio Smart Again: The expert specifically suggests redoing the Trio Smart test because it has the capability to test for hydrogen sulfide, in addition to hydrogen and methane. This provides a more comprehensive assessment.

The core takeaway is that the choice of substrate in a breath test is critical for accurate SIBO diagnosis, and glucose may not be the most suitable option for all individuals.

Tests mentioned:
- Lactulose SIBO tests can be ordered directly by anyone, via the following:

• True Health (all U.S. states, Canada, Europe)
• Direct Labs (U.S. [excluding NY, NJ, RI] Canada, Europe)
• Rupa Heath: Genova (U.S. excluding NY, NJ, RI)
• Trio-Smart (all U.S. states) 

- 25g Fructose can be used with Foodmarble SIBO test

This video focuses on the challenges and methods for diagnosing intestinal yeast overgrowth, including Small Intestinal Fungal Overgrowth (SIFO).
Key Diagnostic Approaches:

• The Gold Standard Procedure:
  • The most accurate method involves an inpatient or outpatient procedure using endoscopy to place a tube into the small intestine.
  • While considered the gold standard for studies, this method is not practical for typical circumstances.
• Practical Diagnostic Tests:
  • Urine Organic Acid Test:
    • This test can indicate yeast overgrowth within the intestinal tract, whether in the small or large intestine.
    • It does not differentiate between the two, but it is useful for detecting yeast overgrowth in the small intestine, which is relevant to SIFO.
  • Stool Test:
    • This test is limited to identifying yeast overgrowth specifically within the large intestine.
  • Blood Test (Candida Immune Complex Test):
    • This test evaluates the immune system's reaction to yeast.
    • It checks if the body perceives a problem with yeast, even if there might not be a significant overgrowth. The immune system may be reacting to the presence of yeast.

Recommended Practice:

• The speaker typically recommends running two, or often all three, of these tests to gather comprehensive information for a diagnosis.
• The choice of tests can also depend on practical considerations such as cost and patient preference regarding the number of tests performed.
  

This video addresses patient's concern regarding treatment options for high methane SIBO after initial attempts with Xifaxan (Rifaximin) and Neomycin were unsuccessful.
Key Discussion Points:

• Initial Treatment Assessment:
  • It's noted that rifaximin alone may not be sufficient, as combination therapy is typically required for effective eradication.
  • The patient is understood to have effectively undergone only one round of necessary treatment, and more rounds are likely needed.
• Addressing "Very High" SIBO:
  • Cases with "very high" readings often require a more intensive approach.
  • Typically, four rounds of - two-week antibiotic treatments (like rifaximin and another agent) are recommended, or four weeks of herbal treatment.
• Recommended Next Treatment Options:
  • Antibiotic Combination: The suggestion is to begin a second round of treatment, potentially using rifaximin in combination with metronidazole. This is recommended as the patient previously used rifaximin and neomycin.
  • Herbal Alternatives: An alternative is to transition to herbal treatments. This would involve combining one of the following with Allimed (also known as Allimax Pro) or Atrantil:
    • Berberine
    • Oregano
    • Neem
• Importance of Retesting:
  • Given the likelihood of needing multiple treatment rounds, retesting is crucial to monitor progress and determine the effectiveness of the chosen therapy.
    
  • It is advised to compare test results consistently (e.g., using the same type of breath test, like the lactulose breath test) to accurately track changes, especially if a doctor is not facilitating necessary retests.

Products mentioned:
~ Antibiotics: Rifaximin (Xifaxan), Neomycin, Metronidazole (Flagyl)

~ Berberine: https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript), https://amzn.to/4a6pmEI (Amazon)

~ Oregano "ADP": https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript), https://amzn.to/3T94BSO (Amazon)

~ Neem: https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript), https://amzn.to/3RaPPIH (Amazon)

~ Allicin - Allimed/Allimax Pro: https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript), https://amzn.to/3Tg4bdb (Amazon)

~ Atrantil: https://us.fullscript.com/plans/asiebecker-herbal-antibiotics-for-sibo (discounted at Fullscript), https://amzn.to/3Gwd8Yh (Amazon)

~ FoodMarble SIBO test: https://foodmarble.com/shop?discount_code=SAVE16 (16% off Foodmarble at checkout)

This video delves into the nuances of prokinetics and their effectiveness, particularly in the context of SIBO (Small Intestinal Bacterial Overgrowth).

• Individual Variability of Prokinetics: The discussion highlights that prokinetic treatments differ significantly in their effects from person to person. What works wonders for one individual may have little to no impact on another.
• Low Dose Naltrexone (LDN) as a Prokinetic:
  • While not technically classified as a prokinetic, LDN has demonstrated prokinetic effects in studies, largely due to its influence on opioids in the body.
  • For some, LDN can be "phenomenal," leading to no relapses and offering additional benefits such as anti-inflammatory properties, immune system balance, and mood improvement.
  • However, for others, LDN may not be a strong enough prokinetic.
• LDN and Severe SIBO:
  • LDN is often not sufficient for individuals with severe or recalcitrant SIBO, especially when underlying conditions like Ehlers-Danlos syndrome or scleroderma are present.
  • In such cases, a combined approach using LDN alongside another prokinetic, especially pharmaceutical, is recommended.
• Pharmaceutical Prokinetic Options: When LDN is insufficient, stronger interventions are necessary:
  • Prucalopride (marketed as Motegrity in the US).
  • Low-dose Erythromycin
• Conclusion: The effectiveness of any treatment, especially prokinetics, requires individual assessment. Trying different options is key to finding what works best.

Products Mentioned:
Prokinetics (pharmaceutical):
~ LDN (low dose Naltrexone - low dose has very different effects vs regular dose)
~ Prucalopride (Motegrity)
~ Low Dose Erythromycin
​
Herbal Prokinetics list: (Fullscript here)