Treating IBS & SIBO: The Root Cause of Leaky Gut & How To Prevent Disease | Dr. Mark Pimentel

If you have tummy troubles, if you are bloated, if you have a food baby after eating, you know, like that ain't normal. People don't realize this, but the number one reason that people go see the doctor is gut trouble. There's over 70 million Americans who have SIBO, which is small intestinal bacterial overgrowth, irritable bowel syndrome, or one of a number of other diseases related to gut health. And 74%, which is crazy of Americans, say that they have some type of digestive discomfort. So, can you kind of just start at the beginning and help us understand what is IBS, what is SIBO, and what are the different subtypes that exist with each? Because it's kind of like a bit of a mishmash, but it's kind of basically people who are having tummy troubles.

People get confused because of the terminology, Irritable Bowel Syndrome, SIBO, and are they the same or different? And so, let me try to dissect that. But Irritable Bowel Syndrome on the face of it, this was a term that was touted in the 1980s. But can you imagine telling a patient, you,'re irritable, it's your bowel, and you're a syndrome, which means doctors don't know what it is. It's not a disease, it's not legitimate. And so that's where we started in the 1990s, that it's, as you say, superintentional or it's in your head because it's a syndrome. And you can only tell me you have symptoms, but I don't know why. And irritable bowel syndrome is characteristically abdominal pain, changes in bowel function and bloating. And everybody was focused on abdominal pain and changes in bowel function. And we said, but everybody's bloated in this disease. And how do you get all that gas in there? Well, you either swallow it or it's made there and it can only be made there by bacteria. And enter SIBO. SIBO is small intestinal bacterial overgrowth. And back in the day, 20 years ago, when you and I were corresponding about patients, we thought, oh, it's just a bunch of bacteria coming up from the colon and now colonizing the small bowel. We'll get to that, but we know that that's not exactly how it works. But in essence, it's too much bacteria in your small intestine. So when you eat food, the bacteria digest it, they start fermenting, they produce gas, it makes you have diarrhea, and then you have all these symptoms and abdominal pain and so forth. But as the years progressed, we learned that the type of buildup of bacteria or organisms in the gut dictate the symptoms. So if you're of a particular type, hydrogen on the breath tests, that's one way to characterize it, then you tend to have a little more diarrhea, more bloating, and that type of symptom. If you're methane and methanogens, those bugs are not bacteria, they're a different, more ancient type of organism called archaea, then the methane makes you constipated. And the new kid on the black is the hydrogen sulfide organisms, which make you have a lot more diarrhea. And so that's sort of in a nutshell, some of the aspects of how these interrelate. But to bring it back together, SIBO is IBS and IBS is SIBO. And what I mean by that is out of 100 IBS with diarrhea patients, 60% roughly have SIBO. So we can explain 60% of irritable bowel syndrome not all of it, but similar to H. Pylori and peptic ulcer disease, not everybody with ulcers has H. Pylori, maybe 60 to 80%.

So, it's the same kind of story evolving here. Yeah, and it's the whole ecosystem of bugs in there that determines the quality of our digestion, our bowel movements, symptoms, and it's been a black hole, which we never learned about in medical school. And now we're in the era of the microbiome and there's just explosion of research, understanding, discovery, it's like, you know, getting a telescope for the first time and looking into outer space and we're actually able to see what's going on and you know, to differentiate things. And before it was just like one big lumped in category of people who had tummy trouble called irritable bowel and it could be, you know, irritable bowel with diarrhea or bowel with constipation or mixed and that doesn't really tell you anything except what symptoms you have. So it's really just a, we'll call a syndrome. And in medicine, everything is a syndrome like chronic leak syndrome or premenstrual syndrome, fibromyalgia syndrome. It means we don't really have a clue what's going on. But now for the first first time, in part largely due to your work, we began to understand what are the underlying mechanisms and what goes wrong and how do we fix it. So maybe we can kind of take a step back and go, what is the root cause of bugs growing where they shouldn't be in your gut? In other words, like most of the bacteria should be in your large intestines, but then it migrates up to the small bowel where it's not supposed to be, and then you get all these symptoms. Why does that happen? Because It's not clear. It's not like a human 74% of people have like a defective, you know, gene or some bad human design design that God designed us poorly. Like something's going on with our modern diet, lifestyle, something that's causing this epidemic of GI symptoms.

That's a lot to unpack, but we have a lot of answers. We don't have all the answers, but we have a lot of answers. So we now believe that and you sort of brought this up as part of the introductions is that we now believe that food poisoning starts the whole process. and eating is part of it. Back in the day, meaning like 40-50 years ago, when we were in kindergarten, we would sit in a sandbox and eat the sand. Now we eat salad out of a bag until we go to Club Med and for the first time in our life we see salmonella or we go somewhere and we get traveler's diarrhea. or we get food poisoning or whatever, we start to explore the world of food. But food poisoning triggers this. And we now have identified the toxin in food poisoning, the CDTB toxin that trips off some antibodies in the human body that then cause your nerves of the gut to fail or to be impaired. And so when the flow of the gut is slowed by this impairment, bacteria build up. and there's two bacteria that just flourish when it's a little more swampy. So I used to watch Survivor shows on TV and Discovery Channel. You probably watch those. And they always say, They're like the loss.

I used to watch loss, which is kind of like Survivor.

It's a little bit different. It's a little more raunchy. With Survivor, you're just kind of trying to make it to a road somewhere. But the point was that he always, this guy on the Survivor show would always say, if the water's not moving, don't drink it. If the water's flowing fast, drink it because it's cleaner. And the same thing with the small bowel. If the small bowel stagnates, it becomes swampy and bacteria grow in it. And the same thing is happening in the human small intestine. And so it's a sequence. So food poisoning, the antibodies, and then you develop the bacterial buildup.

So you're almost saying it's like an autoimmune disease of the nerves of the gut that develops that kind of sluggish. That is an autoimmune disease. so this is a kind of a radical idea that irritable bowel is an autoimmune disease, isn't it? I mean, this is kind of not what most doctors typically think of when they think of IBS. They think of IBD or inflammatory bowel.

Disease, but they don't think of irritable bowel being auto. The interesting, the interesting thing about contrasting IBD to IBS. So the antibody that we discovered is an auto antibody that is directly related to the pathology. So the higher that antibody is, the sicker you are. The antibodies in IBD are markers of IBD. They're not directly implicated in the pathophysiology. The antibody to vinculin that we discovered is directly related to the pathophysiology. We can make rats have IBS just by giving them this toxin. And so that's very cool because it allows us to study new drugs and new therapies coming in the future.

Not so cool for the rats though. so this is fascinating. So you were saying there are different kinds of bacteria. Can you explain, you know, what are the kinds of bacteria? And then, and then what type of food poisoning is it? Any, like, if you get Giardia or if you get salmonella, Shigella, Campylobacter or entamoeba or like, you know, what, what are, are the kinds that typically cause the problem?

Well, the four horsemen of the apocalypse of IBS are Campylobacter, salmonella, Shigella and some E. Coli, food poisoning type of E. Coli, pathogenic E. Coli. Giardia can do it too. It turns out it has vinculin in its structure and so maybe that's how you get the antibodies from Giardia. The viruses are less likely to precipitate IBS. So the four horsemen, Campylobacter, Salmonella, Shigella, and E. Coli. So that's, and it starts to occur about three months after you get sick. Patients will remember. Some don't remember and they'll say, well, you know, they have a couple of days of diarrhea and they don't pay much attention to it, but they remember going on a trip to Hawaii and.

They end up in the hospital with bloody diarrhea. And then ever since then, nothing's been the same. I have heard that story so many times. You know, I went to Thailand or.

India or, you know, Jamaica and like, and sort of tripped the whole thing going.

Yeah.

Or the taco truck in Venice.

Yeah. So, a lot of possibilities. Wow. So this explains like sort of 60%, you say, but not all of it, right? What are the other things that may be driving irritable bowel syndrome? And are they also related to SIBO or is it all something else?

Well, so based on culturing the bowel, we've been able to isolate that 60% of IBS is SIBO. The other 40% is a mixed bag. So for example, and you probably talk about this now, Ehlers-Danlos syndrome, POTS syndrome, we're starting to recognize those illnesses as characteristically GI centric, at least in their early presentations as well. So some of the leftover 40% have Ehlers-Danlos syndrome or POTS or some of them are celiac that we've missed. Some of them are food sensitivities, some of them are histamine sensitivities, some of them, so it's a mixed bag of a number of other disorders. and some of them are fungal overgrowth. So we see that in about 6 to 10% of that 100 pie. So there's still more to unpack. We're not ignoring the other 40. We're trying to figure the rest out, but it's a little bit harder to unravel.

So let's pause there for a minute because you just said something that I think might slip by, which is this whole idea of fungal overgrowth or what often is referred to as C-FO, small, intestinal fungal overgrowth. And in my coming of age as a functional medicine doctor, basically people would laugh when we talked about yeast overgrowth or anything like that and candidiasis and it was just like a quacky alternative concept. But it seems to be now understood as potentially playing a role in some of these cases. Can you talk about the current understanding of this and actually some of the treatment? And then I'll sort of loop back to the how do we start to treat and think about IBS differently.

Yeah, I mean, Satish Rao, Dr. Satish Rao in Georgia has done a lot of the seminal work in this, but more recently we've done shotgun sequencing of the small intestine and we've been seeing this fungal overgrowth.

That doesn't mean you shoot somebody in the gut with a shotgun.

Shotgun sequencing means we sequence every single piece of DNA we can find and then characterize it and see what organisms it represents. And it represents fungus about 10% of the time. And that when the fungus is higher, the patients are experiencing more abdominal pain and more diarrhea. So there is a subclass of these patients that it is fungal, but it's smaller than some would like to believe, but larger than those who are naysayers, as you've probably heard. And so it is there, it's real, but it's a little more challenging to identify. There's no breath test for it, you gotta go in and chase it. and that's the challenge.

Chase it by doing stool cultures or?

Well, chase it, it could be by stool, but if you wanna find small intestinal fungal overgrowth, you gotta get into the small intestine and that's really sample it. Because you have to have endoscopy and all that. That's how Dr. Rao identifies it.

Yeah, and any particular species of fungus or is it sort of a broad array?

So, what we found in this quote shotgun sequencing is Candida albicans is a big part. and a little bit of Candida glabrata. And there's a few other Malassezia and all these other organisms that are very minor, but they generally aren't at a high number that we think are as consequential as the first two I mentioned.

Yeah, no, I definitely have seen that on cultures. And, you know, in my experience, maybe it's not universal, but it tends to lead to more constipation. And so people tend to have more constipation. And also I can tell, 'cause they might have other fungal symptoms. They might, you know, eat tons of sugar and starch. They might actually have fungal rashes their skin or dandruff or other kind of clues that they have kind of a yeasty kind of situation going on. But, I think it's important that it's been identified. And, going back to kind of the treatment of that, how would that normally be treated?

Well, yeah, generally in allopathic medicine, we try an antifungal. There are natural antifungals as well, and you're probably better versed in those than I am. But, we do use fluconazole. We do use nystatin. occasionally we use more radical, more advanced antifungals, but those are the typical first two choices. Yeah, sometimes you can take what we.

Used to call Amphotterable, which is a horrible first generation antifungal, but it's not absorbed. So, if you take it orally, it's not absorbed and that can turn into... Exactly. Yeah. And then in terms of the bacterial stuff, you talked about these three different bacteria, right? You've got methane producing, hydrogen producing, sulfide producing and they all are a little bit different. And, you know, said the methane producers are not really bacteria, they're archaea. But, you know, for, you know, simplicity's sake, let's call them bacteria. And, and I don't, I don't think most people know what our case is. It's arcane. Right. So, yeah. So what, what is your approach to starting to kind of differentiate these and then how do you determine what the right treatment is for a patient and can kind of, kind of guide us through what to do both in terms of lifestyle, diet, and any kind of supplements that might be helpful and medication. Yeah.

So, first of all, we helped develop the first three gas breath tests. So, just full disclosure. But, it's changed my practice because there are patients who fell through the cracks without knowing hydrogen sulfide. So, unpacking each, the hydrogen positive breath test patients are generally, we actually just published this paper, it came out literally yesterday, There are two bugs, that's it, that cause the hydrogen overgrowth. It's Escherichia coli, the non-pathogenic one, and Klebsiella pneumoniae. Those two characters, when they come into town, everybody leaves because they're so opportunistic and bullies. And we think they produce even toxins to the other bacteria around them to try and get rid of the inhabitants. So it's like you've got a gang that comes into the small town and everybody leaves. So it's a disruptor of the microbiome and and then they rise very high in number. So that's the hydrogen one. The second category is the methane or methanogens. And those characters live both in the colon and the small bowel, and we have a paper coming out showing exactly where they're living, and it's pretty universal in a lot of these patients. So hence we call it intestinal methanogen overgrowth and not sebo-methane because it's not just the small bowel, it's colon also. When they produce methane, it gives you a lot of constipation, a lot of gas, and you can't pass the gas, and these people are quite miserable. Then, the third is the hydrogen sulfide, which is the new kid on the block, which has changed my practice because some of those patients, we didn't know. Breath test is normal, everything looks fine, and then the hydrogen sulfide is positive. We get rid of it, and all of a sudden they feel better than they have in their life. and for some reason, when you get rid of hydrogen sulfide, it doesn't come back so quickly, which, which is beautiful. I have patients who've gone a year, just one treatment, and they're done. And so I'm really excited about that.

So, I mean, I could talk about the treatments if you like now or. Yeah, yeah, yeah. Go through the treatments because I think they're real different. And this is important to understand for people because, you know, just because you have real bowel, it's not like a one size fits all approach. You've got to differentiate what type it is. And, and these tests that Dr. Pennington developed, the tests for anti-cdtb and anti Viculin antibodies are really important. And then the breath test that allows you to look at hydrazine, methane, and sulfur. So, can you talk about what are the different treatments for each of these? Yeah.

So, I mean, if I have an IBS patient with diarrhea or a patient with diarrhea and bloating, my practice now I do the antibodies because I want to be able to say was it food poisoning or not. And, if the antibodies are really high, it makes it harder to treat. But, also, you travel. you better take prophylaxis because you could get into further trouble with these antibodies going higher. So, I universally do that.

Like prophylaxis, like what? Like Zifagen?

I give Zifagen prophylaxis. That's what I do in my practice and a lot of the GIs now do that because if the antibody goes higher, the damage to the nerves of the gut is more intense or the effect on the gut is more intense and at least that's what we're seeing in our clinic. So, we're very careful with those patients who have the antibodies positive. When it comes to then we do the three gas breath test in all of our patients. And if it's hydrogen, and we all know Rifaximin got FDA approved for IBS with diarrhea, on the basis that IBS was in part a microbiome disease and now we understand that microbiome condition is SIBO. So I give Rifaximin for that. If it's methane, we have one double-blind study that we can lean on, and it's Rifaximin plus either neomycin, which is what the double-blind study covered, or rifaximin and metronidazole. And then the third category is hydrogen sulfide. And we give rifaximin, but we give it with bismuth, because bismuth is an anti, it blocks some of the synthetic functions of hydrogen sulfide in the sulfate reducing bacteria. Point is the hydrogen sulfide goes down, the bacteria are reduced, and therefore the patient's normal bacteria take over and things get better. the more permanently in that group it looks like.

And, that's basically Pepto-Bismol.

Yeah, Pepto-Bismol.

Yeah. Interesting. So, in terms of diet, is there a different approach to each of these in terms of what you would recommend from a food perspective?

We haven't sorted out or had time to sort out the different diet approaches, but I envision smarter people in the diet will come up with a way, what we do now is what we call low fermentation eating. so we don't use low FODMAP in our practice because you can't do it indefinitely. But low FODMAP will reduce the amount of calories you're providing to bacteria and therefore they'll ferment less and that might help. But long-term low FODMAP hurts your microbiome and can cause nutritional deficiencies. So you can't stay on the full low FODMAP indefinitely.

And FODMAP is like fermentable oligo, saccharides.

Fermentable oligosaccharides, monosaccharides, et cetera. And basically it's too restrictive. But most people have probably read about low FODMAP diet. It's very popular in the last few years. But we use what's called low fermentation eating, not as restrictive. And the philosophy of that was with a low fermentation diet you can go to any restaurant in the country and you'd find a meal. So, it's, you don't want to be the person at the table just because you have IBS that spends 10 minutes with the 10 minutes later. Trying to explain your dietary restrictions on a low FODMAP diet. So, that's part of the reason. We want our IBS patients to feel as normal and as socially non-isolated as possible and that's part of it.

What is a low fermentation diet?

So, it's basically restricting non-digestible carbohydrates, so low fiber, no dairy, and then none of the artificial sweeteners because of course they're easily fermentable. And then spacing your meals so you don't eat for five hours between meals because the damage of the nerves, we talked about that earlier, the damage to the nerves causes a reduction in cleaning waves of the gut. So the cleaning waves only occur when you're not eating. So your gut is sort of like two computer programs, eating mode, cleaning mode. If all you do all day is spend time in the break room taking a bite of a bagel that's in the break room, you never go into cleaning mode. So in addition to the construct of what to eat, we tell you when to eat and to try and space your meals up. so anyway, it's interesting.

You know, the typical dietary recommendation when I was in medical school for IBS was more fiber, like Metamucil, basically. What you're saying is that you want to restrict soluble fibers that are digestible. And that, and low, low fiber diets seem to be kind, you know, it seems like a contrary notion when you want to create a healthy microbiome because good bugs also live on fiber. So how do you, how can you navigate that?

Well, you know, I may be punished for saying something like this, but everything has fiber in it now. Even Cheerios, they put fiber in it because it prevents colon cancer and it's colon health and all this stuff. For 20 years, how many, how much have we heard about colon health and fiber?

A lot.

And what have we, what have we got now? We've got colon cancer happening in the 40s, and we're doing screening colonoscopy at 45 now. I'm not saying it's fiber causing that. But all the fiber we've been pounding and the cardboard we've been eating hasn't really done as much as we thought it might. So I'm a little unclear about fiber. But from the point of view of bacteria, you put more fiber, you're gonna have more of the bacteria. If you had bad bacteria to begin with, there's gonna be more of them. For a healthy person whose microbiome is healthy, no problem. But not for these patients with these microbial conditions.

Now, if you've gotten these antibiotic treatments, you've gotten diagnosed, you've gone through the testing, you've gotten the personalized treatment, you do the course of antibiotics. What prevents the bacteria from coming back? And in my experience, it often does. So how do we manage the sort of recurrence that occurs? Because you don't want to keep giving people antibiotics because intuitively people go, Wait.

A minute, antibiotics are bad for the gut. So why are we giving antibiotics to someone who's got a gut problem? Seems counterintuitive. Well, I can answer in two or three ways, but I'll try to touch on a little bit of each. we looked at rifaximin before and after treatment, the small bowel. And when you get rid of the bullies in the town, all the inhabitants of the town come back. So it goes opposite of what people think. We're not, you know, being cataclysmic. It's getting rid of the E. Coli and the klebsiella and sibo that allows the regular bacteria to re-flourish, repopulate and take over again for a period of time. But remember, the problem is those cleaning waves are not working. So it is possibly going to come back. It depends how badly damaged. And that's where that antibody comes in because if the anti-vinculin, which is that auto antibody for the autoimmune disease of IBS, is very high, the neuropathy is more high or more intense and you're going to relapse or reoccur more frequently. So that's where we were able to have some further strategy. But first of all, take the antibiotics. they actually repopulate the town counter to what you think. We've never seen antibiotic resistance to rifaximin so far, knock on wood. It's a very unique chemical drug. And then we get them on the low fermentation eating diet, that's what we do. And for those where the antibodies high or those who relapse, we do put them on a prokinetic. So they space their meals, everything's going right, but we want to stimulate those cleaning waves at nighttime because that's the longest time you're not eating. and make you clean up as much as possible at night so that the bacteria don't have a chance to come back. So we don't do all three things for everybody. It depends on, you know, if somebody relapses in two years, we don't need to put them on a drug every day to prevent. But if they relapse every three months, then we can stretch it out to a year by adding the prokinetic or doing more aggressive diet strategies.

So this is something that's a chronic condition that has to be kind of re continually retreated in some ways, is that what you're saying?

That's right. It's sort of that way for now, but that's the point of the antibody. If the antibody is causative, get rid of the antibody, get rid of the disease. So, the focus of our lab right now is get rid of that antibody.

And how do you do that?

Well, I can't tell you, first of all, because we haven't worked it all out, but there are ways to do these kinds of things. and we're exploring multiple ways or avenues to do this because the ultimate goal is to cure this and not just go, you know, what I'm telling you today, hopefully if everything goes according to plan 10 years from now, we won't be doing what I'm telling you today. We'll be doing something much more permanent.

Now, is it a pharmacological solution or is this something else?

It would have to be. It would have to be something and it might even be a biologic agent to try and drag that antibody out of the bloodstream. But then it's cured and you don't have to worry about anything.

You can go do whatever you want, go wherever you want. Interesting. I was just thinking about, from my perspective as a functional medicine doctor, I think of things like how do we deal with autoimmune neuropathy, right? One, we look for the cause. Well, if it was some infection, we try to get rid of that. But it could be other things like nutritional deficiencies or toxins or other things. And even certain things might be helpful like lipoic acid, just kind of theorizing that there's any evidence about this. Lipocic acid is great for diabetic neuropathy, could it help the gut? Plasmapheresis is often used for chronic neuropathies, peripheral neuropathies, or things like Guillain-Barre. Could that be helpful? So I'm just sort of wondering are.

There other kind of novel things that we haven't thought about that might be helpful? So just anecdotally, and so I don't like doing anecdotal medicine. We like to do our, you know.

Publish our papers and do good randomized control trials as you know. But, by the way, all feces of medicine come from anecdotes. So, I start with, like, an observation.

I'm going to—no, what I'm saying is I'm going to tell you things that we do that have been very, very successful. So, I'm— that wasn't meant to be critical, more critical of what I'm going to just now tell you, because I don't want people to go out there and start doing plasmapheresis in IBS patients. But we have in five patients, and for one month, their IBS is gone.

Wow.

Until the antibodies repopulate. So we know what you're saying is actually absolutely the list of things that should be tried. And so you're spot on is what I'm saying.

But I just made that up. I just was guessing because based on the theory of how he would normally think about these things.

Now, as I know, I've known you for 20 years, you generally don't riff. Yeah. And, and that riff is based on a lot of scientific knowledge. Yeah.

Yeah.

And you riffed at least two things that we've tried that have worked very, very successfully. But we need to do something even more advanced than that because you can't put a catheter in the neck and do dialysis like plasmapheresis on an IBS patient, 70 million people in the US as you start a program.

No, not clearly not.

So, it's not an answer, but it proves the hypothesis, right? As you mentioned.

Amazing. Now, one question I have is, do you worry about giving antibiotics and then seeing fungal overgrowth? 'cause right, it's all about like the weeds, right? If you kill, you know, one plant, then other plants grow. So if there's, is there any kind of necessity to deal with, you know, kind of cleaning up after the antibiotics with herbal or natural or non-absorbed antifungals or even like nystatin or, or even.

Things like Diflucan, is that ever needed? Yeah. So, I mean, as you probably are aware, I've treated thousands of patients with Rifaximin and it's not zero, but it's extremely rare. that we see people get worse. We did a study where we looked at the number of people who got worse with rifaximin had to stop the drug from taking it and you have to treat 8,000 plus patients for one person to feel bad enough to stop rifaximin. That's how safe it is. However, but in the old traditional thinking, like yeast should get more if you give antibiotics. But as we're dissecting the microbiome, they're almost mutually exclusive, so they don't always happen together. And so maybe the ones that don't, rifaximin doesn't work, it's not making it worse, but you need to go to the antifungal. And that's what we're trying to sort out is, you know, odds are you have overgrowth of bacteria because it's 60% start with that. And maybe the ones who fail start to think about fungal if the symptoms continue to be typical of an overgrowth of some kind.

Yeah, interesting. The other thing I think about is probiotics because typically people think, oh, I have tummy problems, I'm going to take probiotics, but they can make IBS worse and they can make SIBO worse, right?

Yeah, yeah. A couple of things with probiotics that you love to hear. Probiotics do make IBS worse because you already have an overabundance of bacteria. Fun fact, and this goes back to the beginning of the program, you were talking about the microbiome. but the beginning of the microbiome was only looking at stool. Nobody looked in the small bowel, the darkest area of the gut. And that's when we started looking. So lactobacillus, very nice to have in your stool. You know who gets a lot of lactobacillus? People who age very badly. They have a ton of lactobacillus in their small bowel. So when we just published our aging paper, lactobacillus in the small bowel was a sign of unhealthy older people. and so different regions of the gut, different benefits or harms to different whatever you're taking as a probiotic. So I'm not so big a fan of lactobacillus. We didn't see that for bifido or some of the other probiotics, but lactobacillus, I'm not sure. Maybe it's a, it's not so great to take if you're older.

But interesting. If you, you know, if you think often, I'll, you know, empirically just kind of try to reset the gut after a treatment with rifaxim or antibiotics and. and I don't give probiotics before, but I'll give them after and I'll, you know, and I'll give things to help sort of support gut health, like, you know, fish oil or vitamin A or, you know, GLA, other nutrients that are important for helping the digestion kind of repair. So that's my sort of hope that it wouldn't come back. There's not a lot of, you know, great evidence about that, but it's, it's sort of a framework we have in functional medicine of just putting, like, the.

Whole package together of restoring the gut ecosystem. Yeah. I mean, some of the things that I've seen done, and I've done it in a few patients, is, first of all, if you're going to use a probiotic, you could try Bifidobacterium because Bifidobacterium actually has been shown to stimulate cleaning waves and also isn't associated with sort of a bad microbiome. But some of the other things you're talking about to restore, so it's sort of like you've gotten the bullies out of the town. Now let's get limousines and drive all the people back into town, which is what you're doing instead of letting them gradually come back. sort of push them back into town quickly so that everything normalizes. And I think some of the things you've proposed, even fiber, which I was sort of negative against, giving it in the right timing to nurture the normal flora back could be beneficial. So all of these things need further, you know, it's on the inflation and study.

Right. It's all about timing. If you give prebiotics to someone with SIBO, it's disaster. If you do it with someone after you treated them and give some probiotics, often it's fine. I wanted to talk about methane SIBO because it's a bit different. It isn't typically caused by the food poisoning, right? So what causes it? And you mentioned a little bit of the different treatment using different antibiotics, but what seems to cause the intestinal methane overgrowth?

Yeah, so we know a lot about how the hydrogen overgrowth, which we just talked about, the blood test is really important there. the blood test isn't very helpful here, as you said. The food poisoning isn't usually the cause of this. We think you get colonized with these methane producers from your mom, your parents, sharing the bathroom and so forth at a young age, and then they supposed to be there a little bit. Why they, as we call it in the microbiome community, bloom or expand their population so broadly and then cause illness, is not clear. We don't see a trigger. We don't know of a trigger. We seem to see that it is more gradual over time rather than some kind of event like a food poisoning. And then it reaches a threshold where it just crosses over and then you're really unwell. But the people with intestinal methanogen overgrowth or this methane, they're more sick than the patients with diarrhea. So just to put it in perspective, if you never go to the bathroom reliably, and you're bloated and you can't get the gas out. At least the diarrhea patients, they go to the bathroom and they feel a little relief after and some of the gas comes out and they feel something benefit even if it's only for a few hours. The methane people never feel relief. They always feel bloated, they always feel distended and they just can't get a break. They're pretty miserable folks.

One of the things I found also helpful you know, if there's much data about this, but is, you know, after all treat with antibiotics, I'll often give an herbal course of treatment as a way of keeping the bacteria down. So there's things that are typically helpful, like oregano or thyme or, you know, there's a product that's for methane zebu called a trantel. And there's other products out there on the market that seem to be effective in helping keeping things under control, you know, hopefully until you come up with a permanent care over there in your lab. But I, I think I find these very helpful. Have you found those? helpful as well?

Yeah. I mean, one I gravitate towards a lot is Alison.

Garlic. Yeah. That's garlic.

Because it does have an antimethanogen property. I probably shouldn't say this on your podcast, but there is a seaweed from Hawaii that they're using in cows and it reduces methane dramatically. But, they don't know the safety in humans and they don't know what dose exactly. I've been doing a little work on that recently. Yeah.

Yeah, I was going to say that actually, they're talking about cow cause contribution to climate change because of their methane burps and farts and everything. And actually, they're giving them different diets changes the methane production like the seaweed diet.

Yeah, the seaweeds do reduce methane by about 60%, at least that's what I read in the last couple of days on the newest literature. So, that's fascinating. If we knew what chemical agent in the seaweed was doing that, that would be helpful. Maybe it's a new product, a natural product that could be beneficial. But, yeah, I mean, Berberine, oregano oil, things that you mentioned do have effects that, and we try all of the above when we have these really tough, desperate patients.

Yeah, it's been such a learning curve for all of us as we've sort of gone from, oh, it's all in your head to actually there's something going on. I remember this paper you probably remember too, it was in JAMA. I can't remember the author. I think it was an Indian author. And it was 20 plus years ago. And essentially it said how in medical school, we all learned that people who were anxious and had anxiety disorders, basically mental health issues, were the ones who would get irritable bowel, and that was the cause of their irritable bowel. In other words, their emotional irritability would cause an irritability in their gut. And the author was like, hey, wait a minute. No, it's actually the opposite. It's like when there's a change in the gut flora, when there's an increase in inflammation, when there's dysbiotic bacteria, when there's a leaky gut, because there's this deep connection between the brain-brain and the gut-brain, you've got this whole enteric nervous system that feeds back to the brain, irritable signals that makes you have an irritable brain. So, the irritable bowel causes the irritable.

Brain, not necessarily the other way around. What are your thoughts on that? Well, they're now terming this disorders of gut-brain interaction is what they're now the new term for IBS. But, if I take a knife, and I make a one-inch cut on your arm and you feel pain. Is that a problem with your brain or your arm? Because the brain is experiencing the pain, but the arm is having the problem. So, I'm trying to wrestle with this terminology and the whole thing of stress. The other fascinating thing about bacteria in the gut, some of the bacteria produce serotonin, some of them produce insulin-like peptides, some of them produce glucagon-like peptides. Some of them produce, I mean, we're just right here trying to unpackage all the chemical possibilities of what the bacteria are doing. But going back to the original part of your comment, in 1972, if you had a heart attack, you were in the hospital for a month because you can't walk, you're going to have another heart attack, you're going to die. We didn't put stents in back then. We just didn't want any aggravation.

And.

If you were a CEO of a company, you're too stressed. your job is killing you. That was what they were saying in 1972. Your job is killing you, not the stakes, the smoking, the alcohol, the hypertension, the cholesterol. We didn't know any of that then. So medicine evolves. Whenever there's a disease we don't understand, doctors use stress as an excuse to explain it until we know more. So, and maybe I'm being too aggressive with my comments, but that's the point. the truth will eventually unfold. And I do believe these patients have anxiety, and I do believe these patients have stress, and I do believe the disease makes many of those things worse in them. But I don't believe that stress is the cause of IBS.

Yeah, no, I agree. And I hear this over and over from my patients. Gosh, when you treated my gut, my psychological symptoms went away. Or when my gut's really bad, I get more cranky and moody and I have all this anxiety. So it's actually something I quite a bit from my patients. And I'm like, well, that's interesting because it sort of makes me think that it's actually the microbiome that's going on. And now we know that, you know, the change of the microbiome can lead to depression, anxiety, all neurodegenerative diseases. So it's like the microbiome is quite an important, you know, container for an ecosystem of bacteria that are intimately connected with the rest of your health and pretty much every known disease now that we can think about this a chronic disease unless you get hit over the head by the hammer. But basically, it's integral to our health and we've ignored it for so long. And that's why I was so excited to see your book, the Microbiome Connection. And it's really how we need to sort of learn to take care of our inner garden a little bit better. And I'm wondering if you could sort of share as a GI doc who specializes in this, how do you help people restore their intestinal ecosystem? What are the sort of tricks of the trade that you found most effective?

Well, I think what we now understand in the microbiome and this shotgun sequencing again, and all the exploration we've done in the small intestine particularly, remember, the small intestine is not just your garden, it's your grocery basket. Because the small intestine is where you absorb everything. your food. So the bugs in there are dictating what they get, what you get, how they help you, they produce vitamins, et cetera. And so they're really special in the small intestine. And so keeping those normal is important. But what we've seen in the small intestine is there are bullies that take over. I've mentioned the SIBO bullies. Lactobacillus is a disruptor, too. The higher it is, the more destroyed the small bowel microbiome is as well. we sort of touched on that, but I didn't go into a lot of details. So we're looking for the bullies. Interesting fun fact is that we just found a bug in the small intestine that is associated with polycystic ovary syndrome, the number one cause of infertility in women because it produces testosterone. We just presented that at a meeting. Dr. Mathur in our program is an endocrinologist who just knows this stuff and she discovered this in the mast group. And so we're starting to see amazing things that are happening in the small bowel that could be associated with a number of diseases we were not expecting.

Fascinating. Fascinating. Wow. PCOS, I never would have thought of that. But it makes sense because the hormones are regulated in part by the microbiome. There's certain piece of bacteria like Clostridia that make an enzyme called beta-glucuronidase that actually uncouples estrogen from its package that's excreted from your liver and then lets you reabsorb it. And those women tend to get more cancer. And, you know, antibiotic use has been associated with more breast cancer. So it's all, all these things seem to be really connected. You know, one of the, one of the things I'd love you to comment on is, is, you know, some of the sort of really important bacteria that I see very low in patients, which is akkermansia. And I think this is like a keystone species that important for keeping the mucus layer and the lining of the gut and preventing you from having this leaky gut issue. So I want to sort of explore that a little bit and also this sort of idea that maybe when we see irritable bowel syndrome, it's sort of on this spectrum of bowel diseases that goes from irritable bowel all the way to full-blown colitis and Crohn's. And that even systemic autoimmunity, that if your gut's not healthy and you have a damaged gut microbiome, it can cause damage to the gut lining and then create this phenomenon we call leaky gut or increased permeability that creates, you know, a flood of antigens and bacteria and toxins and food toxins or food antigens into your bloodstream that then you react against and creates generalized systemic inflammation. And I think a lot of these IBS patients have this kind of stuff, and that's why when you fix it.

They feel so much better. Yeah. No, I mean, you're, you're touching on this, these Keystone species. I think that They are there and that's true. Akkermansia may be one of them. Prevotella is another one. Anytime we see super healthy people, we see a lot of Prevotella. The older you are, meaning you survived to your 90s, the more Prevotella you have. So Prevotella seems to be sort of a super bug for good health and good aging and less diseases. And so, yeah, that's more in hunter-gatherers, right?

We see those more in the hunter-gatherer species.

It's true, yeah, it's true. And so the question is, you know, whenever you have, maybe I always do these stupid analogies, but so bear with me. But if you have a bad king, this country suffers. If you have a good king, people love the country, the country flourishes. And I think, you know, in Sibo, there are bad kings that are just, people want to leave the country, right? And then you have the good king who's giving all good food and maybe some chemicals that cause the right things to flourish. And so they kind of the country's stable, the country's flourishing and the population's doing really well. So I think that's how we have to look, at least in the small bow, is that we want to have the good kings or the good kingdoms of things that keep the balance. And diversity and balance are critical.

And, and with akkermansia, you know, one of the things that I've learned, and I think this is something that, you know, I definitely missed along the way, is that, is that a lot of these bacteria that got that are good guys actually love polyphenols. So it's not just Prebiotics and Probiotic, but they actually love these, these plant chemicals, these, these dark, colorful compounds and plants that are the medicines and plants. And we're just beginning to understand these relationships. Can you talk about what you know.

About how to sort of include things in your diet that actually help?

The good guys flourish?

So, it's so complicated. But, yeah, polyphenols can be beneficial to some of these species, keystone species. I don't specifically give specific chemicals in that way, but there are things that patients take. We see that in the reimagined study where people are taking certain herbal preparations or certain products and they have more of the keystone species. and what that tells me is we need to do more research in that area. We need to study that more definitively because it's not just about killing the bad ones as our approach now. I think what you're suggesting is that bringing up the good ones may kill the bad ones or prevent the bad ones. And that's a side of medicine that you all are familiar with your clinic is very familiar with, but we don't approach it that way as much. And, I think we need to both come together that way and understand from each other.

Yeah, something you were talking about some of the compounds produced by the microbiome, like Akkermansia, produces GABA, which is basically a natural valium. So, that might help deal with the anxiety or it produces GLP-1 agonist, which is like Ozempic. so, you know, we know that you can swap out the microbiome from a thin mouse into a fat mouse, and the fat mouse gets thin, like, even the same amount of calories. So that's just, it's just kind of mind-blowing when you think about how these relationships are, how complicated they are and how important they are to our overall health. It's not just your real balance. All of us need to be thinking.

About how to take care of our.

Gut a little bit better.

Yeah.

Amazing. Yeah. So, you know, I want to, I want to sort of talk about some of the workup on this because you're kind of at the apex, right? You're the OG guy in SIBO that I learned from decades ago and read your stuff and read your papers and applied it and helped thousands of patients. But there's just kind of one of you. Now, most doctors that I know of don't check for the three gases that you mentioned on a triple breath test, right? This hydrogen, methane, and the sulfur. And they don't check for the anti-avicular or the anti-CD TP antibodies, which is available actually, you can get it online through this website called IBS Smart where you can order without a doctor and it'll get interpreted and sent to you. So how do people start to access this kind of testing and get to the right treatment? Is this widely available? Are GI doctors now understanding this? The average internist or family doc who treats IBS probably not too aware of it. Where do we go from here?

Well, these two tests are available anywhere in the United States. So, you can just go to the websites and order them as you've described. So, it's freely accessible. Even the patient can arrange it themselves.

Even the hydrogen, can you get those triple breath tests from Quest or LabCorp?

No, it's only from the Triosmart website because that's the only company that has it at the moment. But again, I'm part of that and so at full disclosure, but people are doing it. It's more and more and more people are recognizing the importance of SIBO, the importance of doing three gases because three gases gives you more information and that third gas has been a super important addition. So it's available. What the problem is, is there's a gap in education. Look at how much information is coming out every day. As an internist, how do you keep up with everything? I have a tough time keeping up with gastroenterology and IBS, let alone everything as an internist. I feel bad for some of the doctors out there who are treating these patients. Patients are frustrated. They say, Doc, why don't you know about this? The internist is saying, well, I've got a lot to learn. There's so much out there. It's really tough for them. This helps podcasts, it's amazing. I'm so grateful to be on your podcast and if it helps a few patients, that's amazing. But disseminating the knowledge and then having the doctor take an interest in trying to understand how to apply the knowledge because you have to take the test and know what to do with it. And that requires a little more work or effort by the physician.

Now is all this in your book? Is all this described in the microbiome connection?

It's in the book.

Yeah. So often, you know, I find that medicine goes from the bottom up, that patients will bring stuff to their doctor and have to be their own advocate. And, I think, you know, it's important for people to learn about this. For those, we're gonna put a link in the show notes, but the website for the antibody test that Dr. Pimentel talked about is called ibssmart.com, and the one for the gases is triosmartbreath.com, T-R-I-O-S, smart breath. www.smartbreath.com and, and you can learn about them there and learn how to get them and advocate for yourself with your doctor to get these tests. If you have tummy troubles, if you are bloated, if you have a food baby after eating, you know, like, that ain't normal. It's not something you have to live with. It's something you suffer with. And I can tell you, it's one of the, for me, the one of the most satisfying areas of medicine, because I'm able to help so many people. Now, there are those cases that are tough and that, you know, recur and come back. But, but it's, it's really remarkable how many people you can help just following this approach that has really kind of reshaped our thinking about irritable bowel and digestive health. And I think, again, we're just sort of at the beginning and we're developing new tests all the time and new ways of analyzing what's going on. Like you said, you know, the physician who discovered there was, you know, doing small intestinal sampling with an endoscope was able to see fungal overgrowth and treat that and sort of sort of differentiate things. And, you know, I always say, you know, if you know the name of your disease, it doesn't mean you know what's wrong with you, right? Saying irritable bowel doesn't really mean anything. You have to figure out what is it and what type and then personalize the treatment. And this is just sort of taking us on this advent to this era of personalized medicine, which is coming fast and furious. If you love that last video, you're.

Gonna love the next one. Check it out here. 45% of adults and 25% of children, not obese adults, not obese children. All adults, all children now have a disease that didn't even exist 50 years ago.

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