SIBO Root Causes, Diagnosis and Treatments

Today on the show, I'm talking all about SIBO, or small intestine bacterial overgrowth, with Dr. Nirala Jacobi. She is a doctor of naturopathic medicine who practiced in the US and then Australia and is currently the senior naturopathic physician at the Biome Clinic Center for Functional Digestive Disorders in Mullumbimby, New South Wales— in Australia. She's a leading expert in Australia on SIBO or small intestine bacterial overgrowth, a common cause of IBS or irritable bowel syndrome. And she is the medical director for SIBO Test, an online testing service where practitioners and patients can order SIBO tests both in Australia and internationally. And she founded the SIBO Doctor, an online professional education platform for practitioners and a podcast for practitioners called the SIBO Doctor. Links to all these sites will be in the show notes. But first, I know there are some folks who love my podcast, and I really need your support to continue offering you this great free resource. So please go sign up for either a $2 or a $5 monthly donation on Patreon. There's a link in the show notes to my Patreon page, or check it out at www.patreon.com/theperfectstool. I was really hoping that my most ardent fans were going to step forward and sign up when I asked on the last episode, but I know you have to ask people at least a few times to consider giving because I used to run a nonprofit, so I know how that is. But now that I'm pointing it out to you, please just do the right thing. And if you're a regular listener, just sign up for a $2 or $5 monthly donation, you won't even notice it coming off your bills. And that can at least cover my $15 a month hosting costs at my server. So thanks so much for that. And my specialty is helping women lose weight without cutting calories or giving up any major food groups. So it's done in a healthy and sustainable way so that the weight you lose stays off for life. So if you're needing help in that area, you can set up a free 1-hour discovery session with me. There's a link in the show notes for that, or go to HighDesertHealthCoaching.com. Now on to the show.

Welcome, Dr. Jakoby, and thanks so much for coming on the show.

It's a pleasure to be here. Thanks.

So can you start out just by explaining what SIBO is and the different types of SIBO?

Yeah, sure. So SIBO is a condition where bacteria that are normally not found in the small intestine are overgrown in the small intestine for a variety of reasons, different reasons for different people, but the symptoms are very classic of IBS, of bloating, bloating, constipation, or diarrhea, or a mixed pattern, abdominal pain. And it's really because bacteria most often are not flushed out of the small intestine. So there's a problem with motility or other problems. So it's a really common condition that we see in people that have previously been diagnosed with IBS.

Okay.

And what about, so I know there's like SIBO-C and SIBO-D and mixed SIBO. Do you consider those kind of different? Oh yeah.

Right. So, I mean, they are, they are different. And the designation is really about the different gases that are produced by the bacteria that are fermenting the food. So we measure these gases with a breath test where you order a breath test, you fast overnight, and then in the morning you consume this test sugar and then measure your breath every 20 minutes for about 3 hours. And depending on the amount of hydrogen gas Typically when hydrogen gas is very high, we see typically more diarrhea than constipation. So that is SIBO-D or diarrhea. And then SIBO-C is where we see a lot more methane produced in the small intestine. And that would be SIBO-C. That's more associated with constipation.

And is that— I have understood that Methanobacter smithii is the archaea that is responsible for that constipation. Is that your understanding?

Yes, yes. So Methanobrevibacter smithii is an organism that's pretty common. It's not a pathogen in and of itself, but in those that are susceptible, it can cause constipation. But it's also normally found in a large number of people that don't have any symptoms. So in and of itself, it's not a pathogen.

And so what would distinguish a person who just has constipation from a person with SIBO, or do you think constipation is often SIBO?

No, not necessarily. So you really want to have— there are different criteria that determine whether or not you're positive on a breath test. You can have methane that's present, but it's pretty steady all the way throughout, and then we can't say that that's SIBO. So you can certainly have constipation and not have SIBO, but if your breath test is positive positive according to the current criteria, then it's likely that you have some element of bacterial overgrowth in the small intestine where it's really not advantageous to have that level of bacterial fermentation because that's your absorptive surface and your immune surface. So there's, there are a lot of symptoms associated with, with bacterial and archaeal overgrowth.

So what I'm getting at though is if a person comes to you and their only symptom were constipation, would you test for SIBO?

Well, no, I, you know, I'm a SIBO specialist, so pretty much I see people that are really advanced. Rarely do I see people now that are just constipated. There's usually a host of other symptoms and very difficult to treat people. But if it's just constipation, you have to still go through, all right, do you have, you know, how much water do you drink? How much fiber? Have you tried these different conditions? Do you have a hypothyroid disorder, thyroid disorder where your thyroid's not functioning? So, you know, the just being constipation alone would not raise necessarily my suspicion that this person has SIBO. A lot of different things can cause constipation, including things like Blastocystis, you know, hominis infection, which is a type of protozoal infection.

You know, I recently was talking to someone who said he, he had that and that it was not curable. Is that true?

So Blastocystis is a, has lots of different subtypes, about 5 or 6 different subtypes, and they have different levels of virulence. So you can certainly have Blastocystis blastocystis and be totally— don't have any symptoms at all. And it depends on the other factors that are going on. But certainly it's inaccurate to say that you can't cure a blastocystis overgrowth. It's just really difficult because it's pretty resistant to all forms of treatment. But you can do it depending on what you use, what kinds of herbal medicines you use.

Okay, so you would say herbal medicines more than— than antibiotics.

Yeah. Well, there are some that are specific for protozoal infections, you know, or pretty much antibiotics like metronidazole are at best 50%, uh, effective. So that's not often a good choice, but there are new ones like nidosoxanide or Linea that have been shown to be quite effective for that. But typically when somebody comes in with blastocystis, I'm not even sure I'm going to treat it. That's how often it is asymptomatic in people.

Oh, okay. So, but if they were symptomatic, then you would treat and—

Yes, you always have to think about it in terms of the entire microbiome. You know, I do a lot of microbiome work where I assess people's stool for different organisms and overgrowths. And just having Blastocystis itself is not sometimes enough for me to say, okay, you need to go onto these antimicrobials. It really depends on what's going on in the, in the full picture, because it's also thought that there are number of people that are, that just have blastocystis and don't have any symptoms at all. And so why treat if a person is not symptomatic, you know? So it goes back to that we do have a certain relationship with different organisms that might be deemed pathological in some people, like people, immigrants, for example, that are coming, or people that are coming from more rural Africa, for example, that come to the United States that have been tested for For parasites, they have a lot of parasites, but when you treat them, they become worse because they're not— they actually have a symbiotic relationship with those kinds of organisms. I'm not saying all parasites need to be ignored, but just saying you have parasites for me is not enough. It's like really understanding the entire microbiome and the role of those protozoans in there.

So I know in the US, testing for parasites is somewhat difficult. Like if you send out for the typical ova and parasites, it doesn't cover all the parasites that are out there. Is it, is it better in Australia?

No, it's not that much better, but it's, it is a dying, you know, being, I've heard that parasitologists are a dying breed because it takes quite a bit of skill to identify parasites on stool tests. And you're right, they're, they typically in a standard stool test, they, they look for about 5 different bacteria and about 3 or 4 protozoans, but they don't look for all parasites.

Okay.

No, you have to go to specialty labs for that.

Okay. So what's going on in the body with mixed-type SIBO? How is it that you can have simultaneously constipation and diarrhea? Like, what's going on underneath?

Well, it's more of a mixed pattern that's pretty classic of IBS, right? And so with IBS, I should say that SIBO is a subset of IBS. It's not separate from IBS. We think that about 60 to 80% of IBS patients actually have this bacterial overgrowth. Now, it's not only the bacteria driving it, it's your enteric nervous system that also determines how well you're propagating a peristaltic wave, meaning that normally in your colon, your peristaltic wave is supposed to push food and then stool out, kind of like a toothpaste tube. And many people with IBS have very non-sequential contractions in their bowels that, that then are very ineffectual in having proper bowel movements. So that's very classic for IBS. And then diarrhea is also very common because bacterial overgrowth by by its nature causes diarrhea.

So what is a typical testing regime for someone who comes in with symptoms like, say, diarrhea or a mix and bloating and that type of thing?

I mean, the easiest is just to do a breath test to understand. Well, actually, let me back up. So if that person has just come back from an overseas trip to, let's say, Bali, which is pretty classic here in Australia. We're fairly close to Indonesia, so a lot of people vacation in, in Bali, and they come back with a classic sort of acute diarrhea. I wouldn't necessarily test for SIBO. I would test for parasites with a PCR, which is basically a stool test that looks for the DNA of these protozoans. Very classic. And typically we're looking for Giardia, We're looking for Campylobacter or food poisoning bacteria. So that's different than somebody who says, you know, I've had problems for 6 months or I've had problems for years and I've tried a number of different products or probiotics and I can't tolerate them and everything I eat, I bloat. And no matter what I do, I have these really mushy stools. So in that case, I'd say, you know, it sounds like, especially if there's a lot of bloating involved, bloating after meals, I definitely think a breath test that patients can easily do at home is a good choice because it's relatively inexpensive and you can, you can glean a lot of information from, from a breath test that can tell you whether or not bacteria are fermenting in the upper gut. So I find that to be pretty useful and I probably start there.

And so what about Candida overgrowth or SIFO, small intestine fungal overgrowth, where does that come in?

So Candida is a really normal organism. Important concept that Candida lives in all of us. There's not a single person that's sterile for Candida. So it loves a warm, moist environment. And when you've had a lot of disrupting medicines like antibiotics that kill the good bacteria like Lactobacillus and Bifidobacterium, which naturally keep Candida in check, then Candida can overgrow. Grow. And especially if you have a diet that's very high in refined carbohydrates like sugars and simple starches, you're just basically feeding an organism that just thrives on that. So Candida is an opportunist. And certainly a lot of people that have functional digestive disorders, meaning there's nothing really— there's no disease state per se, but they have all these problems that are related to either the microbiome or motility or a number of factors, they often have Candida overgrowth as just part and parcel of the overall picture. And so typically we take that into consideration when somebody tests positive for SIBO because roughly 25 to 30% of patients that are positive for SIBO also have a Candida overgrowth. That's been demonstrated by a researcher called Dr. Rao who did, did aspirates, meaning that he sampled fluid from the small intestine and he found that a large large number of SIBO patients also were infected with Candida or overgrowth of Candida in the small intestine.

So will you test for it, or will you just assume it and treat for both?

It depends on the history. So if people have had a lot of antibiotics and have classic Candida symptoms like sugar cravings, brain fog, rashes, classic Candida rashes, or even recurrent vulvovaginitis, which is the, you know, yeast vulvovaginitis or vaginal infections, those kinds of things I wouldn't need to test because it's really not all that definitive. It's very difficult to really diagnose Candida. It's called the great masquerader for that reason because it often goes undetected on stool tests, on blood tests, on even urine tests. I mean, I usually do— if I really need to know, then I do a urinary organic acids test to look for fungal metabolites. But even that is not 100% accurate. So you have to be a very astute clinician to consider SIBO and Candida at the same time.

So, so then given somebody has a history of, or doesn't have a history of both, is it different herbs that you would treat given, given a SIBO diagnosis alone versus a SIBO/CIFO diagnosis?

Well, the great news about herbal medicines is that many herbs really display an antibacterial and antifungal profile. And A good example of that is garlic or something like horopito, which is a New Zealand herb that's really very effective, or oregano oil, or most of the essential oils really that we use internally for overgrowth. So that's the great benefit, but typically you need to treat quite a bit longer for fungus than you do for bacteria because it really likes to burrow itself into the mucosa, and it creates biofilm, which is a biological substance, kind of slime that it secretes to evade detection and treatment. So it is a bit of a tougher client, but it's like, again, it is not a pathogen unless it really has invaded and it's systemically disseminated, which we see in immunocompromised people. So, but that's, that's a whole nother level of badness, you know, that, that's like a life-threatening illness that you don't normally see in clinic.

Right. And so for the garden variety Candida, how long does it typically take to treat that?

Depends, you know, if I have somebody that has really high urinary markers, I usually think it, uh, classically I'd say an average between 6 and 8 months. So it really takes quite a number of months to completely get it under control, and that means rotating antifungals, doing immune support, doing microbiome restoration work, All of that work has to be done so that it doesn't recur.

Mm-hmm.

So it's a lengthy process.

And will you pulse the antifungals, like, like certain number of weeks on and then off, or will you go straight through?

I go straight through it.

Okay.

And what is the utility of the, of a typical stool test that's not a DNA type stool test, but one of these more like, you know, Great Plains Lab or one of these more, um, like GI-MAP, I guess, or is that, that's a DNA one, isn't it?

Mm-hmm. What is the DNA one? Yeah.

Yeah.

So what, but, but of a stool test that, do you use those at all? Are those useful now that we have DNA and we have OAT and we have breath tests? Is there a functionality for those tests now?

It's, well, it's just evolving technology, you know? So it's, um, I mean, you know, most of the labs that I use that used to only provide culture-based sampling. Versus DNA assessment of your microbiome are now offering the 16S DNA assessment of your microbiome, which is— most of those organisms that are in your colon, you cannot culture out. They're anaerobes. As soon as you bring them to air, they're not there anymore. So they die. So that's been the dark matter for all those years preceding the microbiome project that really aimed to map out these types of organisms that we've never really understood before. So even now, we're, I think, only just beginning to understand who's there. We don't really know yet what they're saying and what they're saying to each other, you know. So there's a huge interplay between these different species of organisms that we're really only just beginning to understand what the story is. And I think a lot of interpretation, you know, like for example, that whole story of the Firmicutes versus the Bacteroidetes, the ratio and all of that. I think a lot of that was very premature and we're just starting to understand certainly a lot more than we did even 2, 3, 4 years ago.

Right. Because the story originally was if you have more Firmicutes, you're going to be more tend towards overweight.

But yeah, Bacteroidetes typically.

And more Bacteroidetes would be overweight?

Yes, I believe so. So, so actually, you know, I don't actually even remember because I've just— it's discredited now.

Right. That's what I thought.

So I basically threw that little card in my Rolodex out of my mind.

I've heard people still saying that's, that's legit.

Yeah. No, I mean, there were some preliminary studies that looked at these ratios and I think there is some element of that, but I think it's too simplistic to just say too many Bacteroidetes cause you to be overweight because there's a huge problem with having too many Bacteroidetes as well. And whereas your Firmicutes are much more your butyrate producers and are really, you know, so to say that to reduce Firmicutes is sort of, it's way too simplistic for that.

Oh, okay. So yeah, because I think they were originally saying that they pulled more because they could digest the short-chain fatty acids, they pulled more calories out of your food? Wasn't it— was it something like that?

Something to that effect. And they were just extrapolating a lot of that information because there was some loose association with, with weight gain in those profiles. But again, I mean, it's— I think it's too premature to interpret it that way.

Right, right. So are there labs in Australia that will do a DNA sequence that includes parasites Archaea, fungus, and bacteria?

Yeah, we do have, we do have, you know, distributors that, that offer the GI Map and all of that. But even there, you know, I hear in my naturopathic colleague circles and those of us who specialize in gastroenterology that there, it's again, you have to be really astute. You can't just go by just what the labs say because there's been some rumblings about different labs, some markers not being as accurate as first thought. So always you have to, when you're on the cutting edge of the science with laboratories, there's always going to be an adjustment period. So I think that like, for example, the GI-MAP or so, and I don't use the GI-MAP very often. I usually use I use other types of labs that profile other organisms and stuff. I really like to know about sulfur-reducing bacteria and those kinds of things, and they're not really represented on the GI map, so I prefer a different profile. But again, it's being with a practitioner that's humble enough to say, you know what, we are just at the beginning of understanding the interplay of all of these different organisms. And we do know some definites like, okay, if there's too many gram-negative bacteria, we really don't want that to happen. And so what are the natural ways of reducing that rather than always going after bacteria and saying kill, kill, kill, or protozoan? So that's really, you know, with my 20-plus years in practice of doing this, I've really come to respect that there are, there's different ecosystems that It's not just about the one species and getting it under control, if that makes sense. So yes, sometimes you do have to do that, but it's, yeah, it's kind of sometimes you can do more damage than good.

So tell me a little bit more about the difference between a glucose breath test and a lactulose breath test.

Sure. So the reason we use different test sugars, so there's glucose, there's lactulose, there's sorbitol, there's Xylitol. There's different test sugars that different bacteria prefer to ferment. So classically, to do a breath test for— to just to see if you have SIBO, we start with a lactulose breath test. That's, that's probably the most fermentable. Well, actually, no, glucose is the most fermentable. But the problem with glucose is that it gets very rapidly absorbed in the upper gut because we're designed to absorb glucose because the primary fuel for our brain is glucose. So it's a really valuable molecule. So we have all of these different receptors and ways to absorb glucose. So if, if you're positive on a glucose, you're definitely positive, but oftentimes it's missed because glucose won't make it all the way through the small intestine before it's absorbed. And so if you have a bacterial overgrowth that's a bit more closer to the colon, you might not find it on a, on a glucose breath test. So some practitioners prefer to do a double test, so they do lactulose one day and then the next day they do glucose. So that, in that way, we really are much more able to catch people that would have been negative possibly on either. So, and I've had a number of patients that were negative on a lactulose, for example, but very positive on a glucose. So that's all about bacterial preference of substrate and what they will ferment.

And so I know that in the US to get a, to get lactulose, you have to have a prescription, but I saw that you can order the tests on, on your website. Is it, can you send a lactulose breath test to the US?

Yeah, we can, because it's, it's here, you know, ironically in Australia we have a laxative called Actilax and that's pure lactulose because at a certain level lactulose will be an osmotic type of laxative. It draws water into the colon, but not at the dose that we typically use for testing purposes. But you can just buy a bottle of lactulose in the chemist here or in the drugstore for $10 or something. And it's such a controlled, ridiculously controlled substance in America, which I have And I don't really understand why because it's not a dangerous substance at all. And we use it as a prebiotic. It's a great prebiotic. And we give it to patients that have cleared SIBO and it's a wonderful food for good bacteria as well.

That's interesting. Well, that's great.

But yes, people can certainly order it at sibotest.com. We send it all over the world really, you know. But you shouldn't really have to. If you have a practitioner in America that can order it, there's a number of tests that are, or labs that are pretty good.

Yeah, no, the dilemma of course is that most people don't have access to a functional medicine person, so therefore they have no access to these tests. So, so it's great that you offer it for the US because, because that would be really helpful. So I've got this pet theory about xylitol. Tell me if this, this holds any water. So xylitol is a great sugar replacement for me because I have been a sugar addict my whole life, but I found a way to get away from it by replacing xylitol. But I'll come across clients as I help them with weight loss who are saying, oh, I can't do xylitol. They get diarrhea. And for me, that just says you probably have SIBO. Does that hold any water?

Not necessarily. Well, it's not, I mean, it's a good thought. Depends on how much xylitol will give diarrhea. But if it's only diarrhea, it may just be a malabsorption syndrome. Xylitol is what's called a polyol. It's in the, in the category of fermentable carbohydrates, the same category as sorbitol. Anything that ends with an -ol, like erythritol, will be a polyol typically. And so it is just something that many people can't really tolerate in high amounts because it just is still a fermentable thing. And you can get diarrhea with bacterial overgrowth in the large intestine. So it's not necessarily SIBO, but they have some responsive bacteria likely, or it's also because of this drawing water into the colon. But if they have symptoms with it, then definitely go ahead and, you know, consider a breath test for them, but not just purely diarrhea.

Okay.

Well, it's a good thought. I mean, that is along the lines of what happens with people in SIBO.

Yes. Yes. Okay. So do you do the low FODMAP diet with SIBO, or what kind of diets do you, do you recommend while people are getting treated?

Well, it turns out I created the biphasic diet. So the SIBO biphasic diet is, I've created it 5 or 6 years ago. It's been super popular by practitioners, is used by thousands of practitioners worldwide and their patients, and it's downloadable. From thesibodoctor.com.

Wonderful.

And if you just follow the links there, it's beautifully designed diet with some dietary or recipes. So there's even a vegetarian version. So that's the diet that I recommend and I get really great results with that one.

And how does that compare to a low FODMAP? Like what's the general outline of, of the two phases? I assume biphasic means there's two phases of the diet.

Yes. So the biphasic diet is based on the low fermentation diet by Monash University. So FODMAP diet was, was developed by Monash, and so it's based on this low fermentation principle, but it's a lot stricter because we find that people even on low FODMAP diets still are very symptomatic. So classically, phase 1 is— it starts out quite restrictive, and as people improve, they can move over to phase 2, which is more what we call the treatment phase.

Phase.

So the first phase is just sort of having some bacterial reduction already because you're not feeding them very much. And then when you start treatment with antimicrobials, it's a lot less problematic with die-off and so forth. So it's, it's, it's a pretty good diet and pretty good approach.

So do you use Rifaximin at all for SIBO, or do you stick with the herbal stuff?

So, you know, when I was in America, practiced in America in Montana, I certainly had a full scope of practice where I had prescription rights and all of that. And, and sometimes I do miss that, but I've been here about 15 years now and can't prescribe Rifaximin. But I have a lot of practitioners that I work with, or GPs or medical doctors that are happy to prescribe that based on my recommendation. But it is something that is not in my armamentarium right now, but I see a lot of good results with it. But I use a lot of herbal remedies and combination products The issue with that is that you have to typically do it for quite a bit longer than Rifaximin. Rifaximin is the antibiotic of choice and it's a pretty good one because it doesn't disrupt your normal microbiome that's meant to be in the large intestine. It's really only active in the small intestine. So it's good for, for that reason. But even there, I don't like to use it again and again and again unless that's the only option I have because of also fungal overgrowth. And you do have some You do have a microbiome in the small intestine that's meant to be there. It's just supposed to be in very low numbers, but even that would be affected with, with repeated use of Rifaximin. But I certainly have seen it work very well. But I have my own herbal favorites for the different presentations of SIBO.

Can you share what those are?

Well, it's, it's pretty, you know, straightforward in terms of if you have a hydrogen-based type of SIBO, you you wanna focus on berberine-containing herbs, and that's goldenseal, Oregon grape, golden thread, and a number of others. And if you have very high methane, we have garlic combinations. But the, the thing with garlic is that you can't just use whole garlic or aged garlic extracts because garlic contains also a fermentable substance called fructans. And so by itself, garlic is actually not allowed on the diet. So you have to use very specific garlic that has a very high level of the active ingredient called allicin. So we use that, and then we have different essential oils for very recalcitrant type of situations or fungal overgrowth, or the other dark horse that's called hydrogen sulfide SIBO, which we can't really diagnose with a breath test yet, as of yet, but probably by next year we'll be able to. So there's, there's different strategies, and I always recommend people work with somebody that's really been well trained. And that was the impetus for me to create the SIBO Doctor website because I'm an educator and I, you know, I go around the country and also in America and educate people about SIBO. And so this platform allowed me to create courses that are really specific for patients. So there's a SIBO Success Plan course that I created and, and a whole trajectory sort of program for practitioners to become really well-versed in this. Because I always say, if as a practitioner, if you really know SIBO, you know the gut really well, because it has all the greatest hits of functional gut disorders with leaky gut. You know, SIBO— often patients often have leaky gut, they often have fungal overgrowth, they often have food allergies or food intolerances like histamine histamines, salicylates, oxalates. They have microbiome dysfunction. They have a number of problems that you'll see in many different conditions, not just SIBO. So if you know it really well, you can treat a lot of disorders.

And when you clear up SIBO and fungal overgrowth, do the problems with histamines and oxalates and salicylates go away, or do they— are they, are they related to something else?

Yes, in many cases they do. Some people do have genomic genetic variances. It's not a disease, but it's just little glitches in the DNA, in the genes that are involved with poor histamine metabolism, right? But typically when we improve the gut, it's greatly improved, if not resolved.

So do you ever use the IBS Smart Gut Test, the new test that Mark Pimentel developed?

So it's not available in Australia and it's been around for a few years now. So it's something that I keep waiting for to come to Australia because I would definitely use it all the time because it will determine whether or not a patient has an autoimmune type of SIBO, which was caused by a previous case of food poisoning that triggered an immune response and then and subsequently damaged what we call the migrating motor complex, which is a cleansing wave that sweeps through the upper gut every 90 minutes on an empty stomach, and it's really there to clear bacteria. And when that's damaged, people just have relapsing SIBO all the time. So it's a, it's something that I look forward to using a lot more frequently. Until then, I have to rely on my questionnaires and asking when it started, and many cases definitely have had a case of food poisoning in their where they've never improved since, since the case of food poisoning, you know, and that's a classic development of IBS and SIBO.

And what might be other causes of SIBO that are not from that?

So for example, a woman who has endometriosis, right? We know endometriosis, which is a condition where endometrial— the endometrium is in the lining of the uterus, and when that gets translocated adhered to different places in the pelvis, we see scar tissue or adhesion formation. And it's very, very classic. A lot of women with endometriosis know, know what I'm talking about because it's, it's very painful and it can be, it can cause infertility, it can cause a lot of different things. But in the pelvic cavity, when adhesions adhere to the small intestine, it can cause sort of like a kink in the garden hose. Where it's just not a proper flow through the small intestine, and that slowed-down flow can, can overgrow bacteria. So that's also a really common underlying cause. And then there are many other causes, like not enough stomach acid or not enough digestive enzymes due to chronic stress, for example, or hypothyroidism or connective tissue issues or medication. So there's a lot of different things that can cause SIBO, but I'd say the most common common cause is most likely this, this, this history of food poisoning.

So if you did have endometriosis and adhesions and scar tissue and such, other than surgery for endometriosis, what can you do about that?

There are different techniques to address adhesions, and I usually send people to get something called visceral manipulation, which is an extremely gentle technique to very slowly start this process of addressing adhesion trans abdominally. So this is kind of like a very, very gentle abdominal massage, but nothing rigorous at all. And there is a place, I believe it's in Colorado, called Clear Passage, which is a very specific type of visceral manipulation technique where you go for, I think it's a week, and they teach you how to do it yourself. And they do it on you. I think it's like 2 hours a day or so. And apparently they get very good results with that.

So, so is that pretty much you got to go to Colorado to get it or are there practitioners who do this elsewhere?

I think there are practitioners, but there isn't one in Australia. That's why I don't really know. You'd have to check with Clear Passage. They do have trained practitioners in other states.

That's really cool. So going back to the SmartGut test, would the main utility of that then be to determine whether somebody would need a prokinetic going forward? And can you explain a bit about what prokinetics are?

Do you mean the IBS-Smart?

Right. Yeah. Sorry.

You said SmartGut.

Yeah.

Is it called IBS-Smart?

Okay. IBS-Smart. Yes. So if— so what that does is it tests for two different antibodies. And one antibody is called anti-CDTB, which is an antibody to the toxin that the original food poisoning bacteria released, like Salmonella or Campylobacter or E. coli. And the other one is called anti-vinculin antibody. So if you have both tests positive, it's about 90%, 97% accurate that you have this autoimmune IBS. And what that means is you are a prime candidate to to take prokinetic medicines after you've cleared SIBO. So you would clear SIBO with either herbs or Rifaximin, and then you go on prokinetics to prevent this relapse. And prokinetics are different from laxatives in that they really work on the enteric nervous system and this whole resetting of the motility in the upper gut. And examples of that would be procallopride, which is called Motegrity in America, Resotrans here in Australia, and that's a pretty good prokinetic, but it's very, very sensitive. So you start out very, very low at 0.5 milligrams and you work your way up if needed, but typically you can start, stay pretty low. And then in terms of the, the herbal range, we, we really don't have very much. We have a few things like Iberogast or ginger, but even that's quite iffy. But we have also bitters, which I think work really well, but I— we have no data on that because it's not been researched. So there are a few things to consider.

And isn't there a low-dose— it's an antibiotic.

Low-dose naltrexone is not an antibiotic. It's an opiate kind of receptor stimulator. And so low-dose naltrexone is not a great prokinetic, I will say. It's often used in people with other autoimmune conditions, but it is great for pain and autoimmune conditions. So I'm not opposed to LDN. It's just that I haven't seen it work all that great as a prokinetic. Prokinetic.

But I'm trying to think of, there was a, I've heard of an antibiotic that is—

Oh, you're thinking low-dose erythromycin.

That's the one.

Right. So low-dose erythromycin is another, yep, that's right. That's, that's another prokinetic. So a typical dose for erythromycin to be used as an antibiotic would be 250 milligrams and low-dose erythromycin is 50 milligrams. So it's considered to not high enough to have antibiotic properties, but I still sometimes see fungal symptoms when people use that ongoing. I was wondering. So that, that can also happen, but it's a really good choice for many people because a lot of people, you know, really do have a damaged migrating motor complex. And if that's the one thing that'll prevent an overgrowth of bacteria again and again and again, it's a good choice. But what we see is that at some point it's good to switch up prokinetics. Sometimes people become resistant, you know, it'll, it'll stop working. So that, that you only know when you, when you move through the program.

And so will you typically, if somebody is being treated for SIBO for the first time, will you wait to see if it recurs or will you retest right after do they finish in order to determine if they need a prokinetic, or do you just by default give a prokinetic?

I don't by default give prokinetic unless I know that they have this post-infectious IBS or this autoimmune IBS. So I have, you know, in the past 9 years now been specializing in this, and so I've done a lot of different trials and different things, and so I really do think a lot of people people do need them, do need prokinetics, but there are a number— like, for example, people with, with adhesions don't need prokinetics, right? It's not the problem of motility, it's a problem with obstruction or semi-obstruction. So really understanding the underlying causes has been the focus of my education for— with other practitioners, because I find that people overfocus on just treating bacteria. And so it's just this revolving door in their, in their practice of people just having relapses for for various different reasons. And so that's really what I've been focusing on in my trainings and so forth is how to prevent this from happening.

So basically you'll test for SIBO, you'll treat for SIBO, but you'll also be looking for the underlying cause so that you know whether a prokinetic is in order.

Right. So yeah, so if a woman comes in, has adhesions, and it doesn't have to be just endometriosis, any abdominal surgery has been shown to trigger trigger adhesion formation. Could be that you got your gallbladder out or you had your uterus removed or you had a cesarean. They all can trigger scar tissue formation. So I, you know, I do a really thorough history. I look for different conditions and then treat accordingly once SIBO has been cleared.

So if you don't have somebody who does visceral manipulation in Australia, what do you do with a woman who has had endo and We have people that do endome—

that do visceral manipulation, just not this clear passage type. Okay, got it.

Okay, so are you familiar with the Sephora et al. study from 2019, the Small Intestinal Microbial Dysbiosis Underlies Symptoms Associated with Functional Gastrointestinal Disorders, that suggested that SIBO symptoms were not correlated with the SIBO diagnosis but rather dysbiosis in the small intestine intestine that might be causing the symptoms?

Yeah, and to me, it's kind of saying the same thing because we've said from the beginning that SIBO bacteria are not pathogens, right? So what are the SIBO bacteria? It's typically the Enterobacteriaceae family of organisms, which is your Klebsiella, E. coli, Proteus. Those kinds of organisms are very prevalent in that overgrowth. So it is, and they're very common in the large intestine. So it is a dysbiosis. I agree with that. So nothing surprising. But sometimes you just— there's nothing really surprising. No.

Okay. So, but they also had that secondary finding that just switching to a high-fiber diet might alleviate symptoms. Do you ever just switch people's diets and see if that helps prior to treating for SIBO or?

Well, one of the, you know, one of the questions I often ask people in my quest to find out if they have SIBO is, does fiber aggravate you? And the number of people that say yes is astounding. So no, that's not my first-line treatment, is just to give them more fiber. And I find that, that IBS patients first have been ridiculed for, for, you know, for until even now, people are told it's all in your head, just eat more fiber and learn how to live with it. That kind of thing. And so it's, it's peculiar to me that there is this resistance to accept that this is a possible diagnosis for people that have, you know, and I see it all the time in my practice. People get treated for it. They feel tremendously better. They feel cured of their IBS symptoms. And then once it's, once we have reestablished a normal level of bacteria in their small intestine, from then we can start to increase certain fibers. And definitely there is a period of microbiome restoration that I follow up with, right? But it's not a primary place to start for me because most people will be symptomatic in my experience.

And as you're trying to restore the microbiome, do you use just food or do you Do you prescribe prebiotics?

I use, I do use quite a bit of prebiotics and I do use foods, especially foods that are very high in polyphenols, which are the, you know, gives vegetables and fruit the color. So things like berries and green tea and all the rainbow of color, it really speaks to our microbiome and has been shown to be just as important as prebiotic fibers. So I usually use a combination of those things based on their individual microbiome profile. Profile that we've gotten from one of these functional tests that looks at the stool. We can't really do small intestinal microbiome because a stool test is absolutely not representative of the microbiome in the small intestine, but only of the large intestine. And a breath test will not tell us what bacteria are there, only what gases they're producing. And typically, you know, hydrogen gas is more produced by gram-negative bacteria, whereas methane is more from this Methanobrevibacter that we talked about.

Okay. And so what prebiotic fibers do you like to use? Is there a particular kind or is it different ones?

Different ones. I'm pretty, you know, I'm looking or I use a lot of partially hydrolyzed guar gum, acacia gum, lactulose itself, I also use something called Vimeuno. I use a lot of different things.

So that's interesting about the partially hydrolyzed guar gum. I think I remember something from one of these SIBO summits that was related to using that in conjunction with the Rifaximin, right?

Mm-hmm. Yeah.

And that increases the success rate?

Yeah. And that makes sense because it's— I think it probably would also work with other prebiotics because you're actually feeding the bacteria. Like they're poking up their head while you're chopping them off, right? So, so you're feeding while you're killing, to some extent. That's the thought behind it. And I find that it's a pretty well-tolerated fiber, and I use it also in my methane-dominant patients.

Now, I know there is a good bit of concern around emulsifiers and, and things like that in food, and guar gum is one that is often used in foods that I can eat because I can't do, do, uh, dairy, and so you see it a lot in coconut milk and that sort of thing. And I was worried, is this unhealthy? Now, if it's not partially hydrolyzed, is it of concern?

So that's a different type of emulsifier than the P-80 and the, I think it's CMCT, that have been specifically studied that are part of the creamy sauces and things like that. And the other issue is the carrageenan. So those are more directly linked to microbiome disorders and leaky gut, really, those emulsifiers. But guar gum is a bit different, and partially hydrolyzed guar gum is like totally benign and very helpful.

So PA80 was polysorbate 80, and CMC, what's that one?

It's, it's a different kind of emulsifier that I can't remember the whole name of it, but they were both studied in this one particular study that I'm thinking of that have been shown to actually induce also leaky gut. But more importantly, this microbiome dysfunction.

What about xanthan gum? Is that one we should be avoiding?

You know, I, I'm not a specialist in gums and things like that, so I don't, I don't know. I, I haven't seen a particular problem, but I see a lot of sensitive people that, you know, you name it and they can react to it, right? So I, I wouldn't, I wouldn't put it past it that it can be a problem, but I haven't particularly seen xanthan gum to be an issue.

Okay, I asked because it's in a lot of gluten-free products, so I end up Avoiding things with it just to try and stay a little bit more pure. So is there a version of IBS that is primarily stress-related or emotional that is not, you know, that doesn't have a physical basis?

Absolutely. Absolutely. I think that if it's one thing that's universal with a lot of these conditions, or at least highly prevalent, It's people that are not even so much stressed, although many people say they're stressed, but it's more like a sense of overwhelm, not being able, you know, being overwhelmed by, by the tasks of daily living because they've either overcommitted or lots of different reasons. So that is a very, very common thread that runs through a lot of these cases. And I always talk about it because being in a what we call sympathetic nervous system state chronically, or fight-or-flight state all the time, what is, is really damaging, not just to the gut lining. We know that extreme physical stress and extreme mental stress causes leaky gut, right? We know that. So there is always a level of sort of inflammation and hypersensitivity. Also, they tend to experience pain a lot quicker. And so there is this overall nervous system that's just been completely fried, for lack of a better scientific word, that is, is really trigger-happy. And so they, they are much more reactive very often. And one of the treatments for people that are highly sensitive is actually rewiring the brain and using therapies that, that help with really fostering the rest and digest rather than the fight or flight. So things like gut-centered hypnotherapy are great therapies to do. Even home treatments like EFT or Emotional Freedom Technique has been shown to help, but there are different ones that are just star performers, and that would be things like gut-centered hypnotherapy that we do here at the Biome Clinic. Cool.

So are there any things that I should have asked you that I haven't asked you about My God, it's like such a huge topic.

I, you know, all I have to say is it's an exciting time to be in gut health in terms of as a practitioner, because the field is just exploding with information on the microbiome. And it's every day we're getting more information about its connection to not just digestive disorders like IBS, yes, but cognitive issues like Alzheimer's and Parkinson's disease and really inflammatory conditions that we've always— we've never really connected. I mean, us as naturopathic doctors, we have connected that to the gut, but it's just extremely gratifying to see this all be presented in science and in research, what we've talked about for so many decades really and to have the scientific explanation for it. So, you know, pretty much I can tell your listeners that the microbiome is related to everything. So if you really want to be healthy, you start to, you know, improve the quality of your microbiome. And that's one of the tenets of being healthy is eating organic, eating in a relaxed environment and not like not too much. Mostly plants and organic is sort of the message that I echo from Michael Pollan, who wrote his book about— and he— it's a good one, you know, eat food which is not too much, not processed, not too much. And what was the other thing?

Mostly plants.

Mostly plants.

Yeah.

And that's true. And we know that from things like the— or books like the Blue Zones or the research that did studies on people that live to be the longest, and to me that's the most convincing rather than any paleo and all kinds of other diets, including the FODMAP diet is not meant to be long-term, but look at the people that live to be the longest and they all are 80% plant-based diets. So I think that's a good lesson.

Yeah.

Well, I think that's a good note to finish on.

Thank you so much for coming on.

Sharing your expertise.

Great, no problem.

I hope that was helpful to some of you who are suffering with IBS, SIBO, or mystery stomach ailments that you may now have a name for. And if you think you may have SIBO and are not sure what to do next, I do 1-hour consultations where I can educate you about the best testing options, whether you should consider other factors like fungal overgrowth or parasites, and the most economical way to move forward in getting help based on your symptoms and history. You can find this on my website under highdeserthealthcoaching.com/work-with-me/functional-health-and-nutrition-review. And don't forget to show me and the show some love by supporting it through my Patreon page at patreon.com/theperfectstool. And you can also support the show by buying high-quality, vetted, practitioner-grade supplements through my affiliate account at Fullscript. You can find a link there from my supplements and lab test link on my website, highdeserthealthcoaching.com. Thanks for listening, and here's wishing you all the perfect stool.