The document provides an overview of a presentation on Small Intestinal Bacterial Overgrowth (SIBO). The presentation covers:
1) Background, pathophysiology, clinical findings, and differential diagnosis of SIBO from 1:00-1:30pm.
2) Diagnostic testing and clinical approach to SIBO from 1:30-2:00pm.
3) Q&A on SIBO from 2:00-2:15pm.
4) Treatment approaches and algorithms for SIBO from 2:15-3:15pm.
5) Additional Q&A and case studies on SIBO from 3:15-3:50pm.
6) Concluding remarks on
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Small Intestinal Bacterial Overgrowth Update 2015
1. Small Intestinal Bacterial Overgrowth
11/1/2015
Speaker:
Adam Rinde, ND
Naturopathic Physician
Sound Integrative Health, PLLC
Kirkland, Washington
2. Today’s Discussion
• 1:00-1:30 p.m.: Background,
pathophysiology, clinical findings,
differential diagnosis.
• 1:30 p.m.-2:00 pm.: diagnostic testing,
clinical approach.
• 2:00 p.m.-2:15 p.m.: Q and A.
sibo@soundintegrative.com
• 2:15 p.m.-3:15 p.m.: Treatment
approaches/algorithms .
• 3:15 p.m.-3:30 p.m.: Q and A.
• 3:30-3:50: Case Studies.
• 3:50: Concluding Remarks
3. Why is todays talk relevant?
• Likely half of your IBS patients might be dealing
with SIBO.
• Many other patients are dealing with chronic
disease that contains SIBO as a co-morbidity.
• The standard of care for SIBO is lacking long term
efficacy and the route of delivery is not available to
most and not greatly effective.
• Naturopathic Physicians and Functional
Nutritionists are experts in system balancing.
• A better model for care needs to be developed that
is more focused on gut terrain balancing and
recurrence prevention.
• SIBO provides an important model to understand
the gut microbiome.
4. Quick Note Of Disclosure
• I have no affiliations with Designs For Health or any
other companies or institutions besides Sound
Integrative Health, PLLC.
• Cost of ND therapies and alternative labs are
usually out of pocket hence l recommendations will
need to be scaled accordingly to best compliance
and affordability.
• Many other treatments likely exist for SIBO then
mentioned in this presentation .This lecture does
not account for AOM and Ayurveda approaches that
may also be effective
• Much of the treatment process module does not
account for waxing and waning of response and
shifting response from other co-morbidities
• Resource from today talk:
http://www.soundintegrative.com/blog/sibo
5. Key Learning Outcomes
• Understanding of background and clinical
workup related to SIBO
• Understanding of pathophysiology and
pathosequelae of SIBO.
• An appreciation for terrain balancing
approaches and the functional connections in
SIBO.
• Actionable lecture to bedside steps to
evaluate dysmotile or malabsorptive patient or
those at risk for SIBO
• Actionable lecture to bedside steps to treat
and recover patients with SIBO
• Actionable lecture to Bedside Steps to
approach the most sensitive and treatment
refractory patients
6. Germ Theory Vs. Bio-Terrain
Treating a germ vs. Balancing the Terrain
Louis Pasteur Vs. Antione B’echamp
7. Small Intestinal Bowel Overgrowth
Defined:
• Non-native bacteria and/or native bacteria, or
archaea are present in increased numbers in
the small intestine
• Classically defined as a bacterial population in
the small intestine exceeding 105 to 106
organisms/mL upon duodenal aspirate.
• Modernly characterized by a greater than 20
ppm rise in Hydrogen before 180 minutes or
any 2ppm rise or more in Methane above
baseline on LHBT in the setting of upper
intestinal digestive symptoms.
• Can lead to small intestinal inflammation,
maldigestion, malabsorption, and other extra-
intestinal symptoms.
Quigley,2010;Sachev,2013;Dukowick,2007;Bures 2010;Speigel,2011;
Ghosal, 2012)
10. Introducing…the known SIBO gut
microbes.
Methanogens
(Archaea) Hydrogen Sulfide
producers
Hydrogen
Producers
Not detectable on breath
testing
Associated with
constipation
Associated with
diarrhea
Triantafyllou,2014; Sahakian ,2009
11. Features Of SIBO Gut Microbes
Methanogens
• Methanobrevibacter smithii, and other spp.
• Certain Clostridia and Bacteroides
• Odorless
• Normally Produced in Left Colon
• In a gut neutral environment will compete and win with
Hydrogen Sulfide reducers
Hydrogen
• Made up of gram positive and gram negative bacteria
• More likely pain during and after defecation
• More likely large and foul smelling stool
• More likely urgency and weakness after the defecation
Associated with
constipation
Associated with
Diarrhea
12. Features Of SIBO Gut Microbes
Methanogens
Kingdom Archaea
Associated with depletion of gut serotonin
4 H2 molecules are used to make 1 CH4 molecule
Associated with obesity
Play a key role in butyrate production in large Intestine by
reducing hydrogen.
Hydrogen Producers
Mainly produced by gram negative proteobacteria and gram
positive colonic bacteria that have entered the colon
several species involved of oral-colonic flora
Generally sensitive to peptidoglycan layer acting agents
In the presence of methanogens in large Intestine will help digest
polysaccharides and produce Butyrate
Associated with
constipation
Associated with
Diarrhea
13. Duodenal Microbes in IBS
compared to Controls : N=258
Giamarellos-Bourboulis et al., 2015
14. Mark, P., Ruchi, M., & Christopher, C. (2013). Gas and the Microbiome. Current Gastroenterology
Reports, 15(12), 1-6.
15. Anatomic or pathologic risk
factors
• Surgery
• Tumor
• Trauma
• Volvulus
• Ischemia
• Congenital short bowel
• Strangulating hernias, functional short bowel,
• Thrombosis/embolus of superior mesenteric
artery
• Refractory celiac disease,
• Chronic intestinal pseudo-obstruction
• Radiation enteritis
23. N of 1. Proposed unified definition:
SIBO as a heterogeneous disorder resulting as a sequelae of an upstream dysfunction which
effects motility and/or innate gastrointestinal antimicrobial defense
F
u
n
cti
N
eu
G
ut
SIBO
Neuroendocrine
Dysfunction
Gut Immune
Barrier
Dysfunction
Pathologic
Functional
Digestive
Disorder
Drugs
24. What keeps the small intestine relatively sterile?
• Ante-grade
digestion
• Peristalsis
• Adequate serum
IgA
• Migrating Motor
Reflex
• Adequate gastric
acid
• Proper stomach
and intraluminal pH
• Ileocecal valve
patency
25. Normal Motility Process
Segmentation
• Segmented contractions
• Peristalsis
• Occurs when food
enters the digestive
tract.
Inter-digestive period
• occurring between meals
every 1.5-2 hours
• recurrent event moving
from stomach to small
intestine.
• mediated by the
Migrating motor complex
• House cleaning of the
lumen
• Also called the “cleansing
wave”
26. Fasting Pattern of Migrating Motor
Complexes, every 1-2 hours of fasting.
Phase II.
Intermittent
smooth
muscle
contractions
Phase III
continuous
sweeping
contractions
up to 11/min in
the duodenum
A quiescent
stage
Phase I
oscillations of
smooth
muscle
without
contractions
Foxx-Orenstein.2015.
27. Migrating motor
complex Inhibitors of MMC
• Low Small Intestine
pH
• Pancreatic
polypeptide binding
(PPY)
• Eating/grazing
Promoters of MMC
• PH
• Bile Acids
• Somatostatin
• Erythromycin
• 5-HT2 antagonist.
• Serotonin and Somatostatin
• Motilin receptor agonist
• Ghrelin receptor agonist
• Melatonin
30. SIBO Hypothesis of IBS
• Pioneered by Mark
Pimentel, MD from Cedar
Sinai Hospital, Los
Angeles.
• States that the near
majority of people with IBS
have SIBO
• N=320 SIBO was found in
37.5% of sufferers that met
ROME III criteria
confirmed by duodenal
aspirate testing. (Pyleris,
et. al, 2012.
•Recently Reddymasu, et al. 2010.
Showed that 36% of those with IBS-
prominent symptom of bloating and
flatulence had SIBO.
•Pimentel has shown that when SIBO is
eradicated in subjects their IBS symptoms
are significantly reduced. (up to 70%
reduction)
31. Pimentel,2014. Global Symposium on
IBS, Los Angeles, CA
New Autoimmune Theory of IBS
1.Acute
Gastroenteritis
2.Cytolethal
Distending Toxin
(CDT) causes
production of
anti-vinculin
antibodies
3.Damage of
function of
Interstitial Cells
of Cajal and
Migrating Motor
Complex
4.IBS with SIBO
Develops
5.IBS Persists
This takes
about 3
months
to develop
32. Synthesis/new hypothesis of how
SIBO may develop in IBS/dysmotility
Acute Gastroenteritis
Disruption of ICC Cells /MMR
leading to dismotility
Release of CDT Toxin
Leading to anti-vinculin
antibodies which damage ICC
SIBO Develops
dysmotility and highly fermentable
environment in the small intestine
PMID: 15316000; PMID: 22450306, IBS Global Symposium, 2014
35. Subjective Clinical Findings of SIBO
History
Post-prandial bloating and distention.
Feculent breath smell, fish body odor smell.
Generalized abdominal Discomfort that is usually low grade,
non specific, and not described as “Pain”.
May have diarrhea, constipation, or both.
Usually Absence of Red Flags.
Non-specific symptoms: fatigue, joint pain, brain fog,
myalgia's that may mimic somatization.
37. Objective Clinical Findings
• Malabsorption findings rarely observed in
outpatient setting
• Borgborygymus
• Polyneuropathy due to vitamin B-12 deficiency
• Tetany due to Hypocalcemia
• Small intestinal succussion splash
(PMID:23997926)
• Generalized abdominal discomfort or light pain
on light palpation
• Dermatitis due to selenium deficiency
• Rosacea sometimes
• Cachexia due to malnutrition
39. Differential Diagnosis in SIBO
Autoimmune
• Hypothyroidism (can have decrease motility but
also includes other specific findings)
Neoplastic
• Ovarian Cancer (the bloating likely would not wax and
wane)
• Colon Cancer (the digestive symptoms would likely
not wax and wane, and may include middle of the
night symptoms)
Medication/Iatrogenic
40. SIFO Is The new Enteric Candidiasis?
Gastroenterology . 2011. Volume 140, Issue 5, Supplement 1, Page S-810
Investigation of Small Intestinal Fungal Overgrowth (SIFO) and/or Small Intestinal Bacterial Overgrowth (SIBO) in Chronic,
Unexplained Gastrointestinal Symptoms Carolyn Jacobs, Jessica Valestin, Ashok Attaluri, Gideon K. Zamba, Satish S. Rao
Results: 124 (M/F=38/86; ages 17-82) subjects were evaluated; 77/124 (62%) had a positive culture for overgrowth.
Among these 23/124 (19%) had SIFO, 23/124 (19%) had mixed SIFO/SIBO and 31/124 (25%) had SIBO.
All patients with SIFO grew candida
• 36 subjects with SIBO had aerobic flora (enterococcus sp, streptococcus sp, etc.), and 3 had anaerobic flora (bacteroides sp).
Prevalence of symptoms and its severity are detailed in table. Nausea was more prevalent and severe in SIFO whereas abdominal
pain and gas were more common in SIBO. Symptoms do not predict presence/
• absence of infection.
• Conclusion: SIFO and mixed SIFO/SIBO overgrowth is common an occurs
in three of five individuals with chronic, persistent GI symptoms in
tertiary care practice.
41. workup and testing overview
• Blood tests are not often valuable in
detecting or confirming SIBO.
• Stool testing is not often useful for
diagnosis but may be helpful for
monitoring or co-morbidity screening.
• There are no useful imaging tests.
• Jejunal Aspirate is invasive and not
practical.
• Most practical tests is Hydrogen Breath
Testing done in a lab or home setting.
46. SIBO Workup Process
Diagnostic Testing
• Standard: Lactulose
Hydrogen Breath Test
• CDSA or Stool Microbiology
DNA
• Alternatives:
• Glucose Hydrogen breath
test
47. Additional Tests That May Be
Useful
Lactulose/Mannitol test
Intestinal Permeability Screen (Cyrex
Array 2)
Secretory IgA
Urine Hippurate, Benzoate, Lactate.
50. Criteria for Positive Lactulose
Hydrogen Breath Test
Criteria for Positive Lactulose
Glucose Breath Test
• A fasting hydrogen level greater than 20 ppm in a compliant
patient
• The presences of a double peak hydrogen rise with an early
increase (within 90 minutes) greater than 20 ppm OR a
sustained increase greater than 10 ppm.
• Mean methane 2 ppm rise or greater above baseline are
considered methane positive. However methane production
might mean functional constipation compared to SIBO.
Any 10 ppm> rise in hydrogen compared to
baseline
51. Regions of Intestine Accessible by Various
Diagnostic Methods To Detect SIBO
Duod./Jejunum……………/ Lactulose Breath Test
Lactulose Ileum………………………../ Colon
Direct Aspiration
and Culture
Glucose Breath Test
10 X 0
Glucose
Absorption complete
10x11
Absorption Complete
52. Breath Testing for SIBO
(CPT code-91065
Quintron Breathtracker
• Usually requires appointment
with Gastroenterologist.
• Likely more accurate then
home test.
• Better chance to be covered by
insurance.
Quintron Lac Check
• Conveniently performed in
office at home.
• Higher margin for error.
• Insurance coverage varies.
56. Tip Of the
Iceberg
METHANE is only detected on breath test when quantities
of Methanogens are 106 or Greater.
According to Pimental @ IBS Symposium 2014 the 104 to
106 group is likely “ below the tip of the iceberg” but still
relevant.
57. RCCEG: Recommendations for the
Preparation and Performance of
Breath Testing (Saad & Chey, 2014)
Test Preparation
• Avoidance of antibiotics for 4 weeks before
testing
• Avoidance of bismuth for 2–4 weeks before
testing Avoidance of probiotics for 2–4 weeks
before testing
• Avoidance of prokinetics for 3 half-lives before
testing
• Avoidance of colonic purging within 4 weeks
of testing
• Consumption of a diet free of non-absorbable
carbohydrates (pasta, bread, fiber cereal,
beans) the evening before testing . (Most start
this 24 hours before the test)
• Overnight fast before testing
• Avoid cigarette smoking before and during
testing
• Consider mouthwash with chlorhexidine
solution before substrate ingestion
Test performance
• All stationary gas chromatographs have
proven accuracy
• The Haldane–Priestly, Y-piece, or 2-bag
system should be used for breath sample
collection
• Breath sample should be obtained after a
maximal inspiration, 15-second period of
apnea, and prolonged expiration
• Breath sample analysis should be performed
within 6 hours of collection unless stored at -
20C Avoidance of vigorous physical exertion
during testing
58. Consolidation (personal opinion)
• Using Glucose Hydrogen Breath Test (GHBT) may
lead to false negatives in diarrhea subtypes
• Negative hydrogen production and negative methane
production in the context of constipation should taken
in the context that the patient may have prolonged
transit time. OR hydrogen sulfide production. But what
to do for hydrogen sulfide production still in question?
• Vice versa a patient with rapid transit time in lactulose
hydrogen test may produce a false positive because
it may be showing lactulose reaching the caecum in <
90 minutes..
• Baseline elevation in the context of good compliance;
should be weighed for bacterial overgrowth,
especially if its methane elevation due to
constipation/impaction.
• This is subject to change with more data and
improved tests.
PMID :21860825
61. Report Of Findings To Patient
(IFDYR)
• Introduction: materials
and methods used
• Factual observations
and results
• Interpretation
• Discussion
• Your impression
• Recommendations
66. Adapted Cedar Sinai IBS/SIBO Protocol
Cedar Sinai Protocol
adapted from: Pimentel. 2006. A New IBS Solution.Health Point
Press. Van Nuys,CA pg. 90
67. Rifaximin: The Data
• Mechanism of action: Acts on gram positive and gram negative bacteria
transcription by binding to the β-subunit of bacterial RNA polymerase.
• No systemic absorption
• Number Needed to Treat (IBS): 11 / Number Needed to Harm: 8,971
• Overall will normalize breath tests in 40-50% of patients.
• Efficacy in improvement of global IBS Symptoms approximately 40% vs.
30% placebo. A 10% overall therapeutic gain by taking vs. not taking it.
• FDA: approved for Hepatic Encephalopathy, IBS-D, Travelers Diarrhea*
• Cost is $600+.
• Mild Side Effects: Nausea, diarrhea, Headache, Mild, Upper Respiratory
Infection, Abdominal Pain, Nasopharyngitis
• Serious side effects that have been reported: Clostridium difficile,
anaphylaxis, hives
* Travelers Diarrhea approved for 200 mg TID X 3 days
PMID:24004101,PMID 22024520, PMID:21780893, PMID,22298980,
PMID:24004101, PMID:24891990
0
69. Antibiotics treatment of methane+constipation-
predominant irritable bowel syndrome.
• N=31 breath methane positive with ROME II criteria IBS
• 16 with neomycin vs. 15 with Neomycin+ Rifaximin
• Neomycin 500 mg BID X 14 days plus Rifaximin 550 mg
TID for 12 days
• Rifaximin/Neomycin group significantly better
improvement in constipation, straining, and bloating. But
not significantly better improvement in abdominal pain.
• Subjects who achieved <3 ppm methane after treatment
had less constipation then patients who had persistent
methane elevation.
(PMID: 24788320)
70. Antibiotic Choices in SIBO
7-14 day course
• Ciprofloxacin (250 mg twice a day)
• Norfloxacin (800 mg/day)
• Metronidazole (250 mg 3 times a day)
• Trimethoprim-sulfamethoxazole (1 double-strength twice a
day)
• Doxycycline (100 mg twice a day)
• Amoxicillin-clavulanic acid (500 mg 3 times a day)
• Tetracycline (250 mg 4 times a day)
• Chloramphenicol (250 mg 4 times a day)
• Neomycin (500 mg twice per day for 14 days)
• Rifaximin (800–1200 mg/day) * standard is 1650 mg/per day
71. SIBO reoccurrence
• The relapse rate of SIBO after successful treatment is
high.
• 44% (35/80) of patients relapsed within nine months
after successful treatment with Rifaximin.
• NOTE: these patients were treated with 1200 mg of
Rifaximin for 7 days and retested negative for SIBO.
• Higher risk of re-occurrence in older age, long term
history of PPIs, and history of appendectomy.
(PMID : 18802998)
72. Secondary Prevention:
Prokinetics
• Preventing Reoccurrence by improving motility
thereby increasing Phase III Migrating Motor
Complex using prokinetic agents.
• For IBS-C Increase Motility Phase III migrating
motor complex increasing bacterial clearance from
the duodenum distally.
• Erythromycin has been shown to increase Phase III
MMC activity in the antrum of the duodenum: Some
protocols use erythromycin at bedtime 50 mg for 3
months post eradication) Symptom reoccurrence
reduced by to 138.5 +/- days 132.2 days with
erythromycin as prevention strategy compared to
59.7 +/- 47.5 days with no prevention.
• Low dose tegaserod has been used at 2-6 mg
bedtime has been used as a 5-HT4 agonist
however it has been blackboxed.
(PMID:20574504) (PMID:20574504) (PMID: 22450306)
73. Other Pro-Kinetic Agents
• Cisapride: relieves constipation-like
symptoms by indirectly stimulating the release
of acetylcholine in the muscarinic receptors.
HOWEVER IT removed from the market
because its effect on long QT syndrome,
possibly contributing to arrhythmias.
• Octreotide induces phase III of the migrating
motor complex that causes a propagating
peristaltic wave through the small intestine.
• Prucalopride: activates 5-HT4 receptors as a
prokinetic. Available in Canada, but not US.
1mg-2mg daily). Promising Data in women
with idiopathic chronic constipation who failed
laxatives.
.(PMID:24732867)(PMID:24106924)
74. Other emerging medication
groups in the IBS World
• Secretagogues: Lubiprostone: for IBS-C
• Opioid Agonist: Eluxadoline for IBS-D:
• Others: Low Dose TCA’s
75. Emerging issues related to
Rifaximin
• How many times can it be used without patient
developing a resistance?
• Does it “kill-off” colon Flora?
• If used with Neomycin, how does it change the
pharmokinetics and resistance of Neomycin.
78. Assess And Stabilize Adrenal and Immune Function: 2
weeks to 1 month and ongoing.
• Clinical Evaluation.
• Metabolic Detoxification
Questionnaire ™ .
• Idenit-T™ Stress Assessment
• Diagnostics Adrenal Stress
Index, Or Bio health
Laboratories Functional Adrenal
Tests, others.
• If relevant support for at least 2
weeks prior to treatment and
reassess. Continue on support
as needed throughout SIBO
Treatment
Reassess periodically
79. Assess And Stabilize Adrenal and
Immune Function
Treatment
• Appropriate HPA support based on stage
of dysfunction and findings
• Buffered Vitamin C–mixed Ascorbates
1000mg-2000mg to support glutathione
and to reduce Herxheimer reaction:
Cost: $20/month
• Adrenal Supportive Diet
• Reduced Glutathione Supplementation
as appropriate 1 gram daily in divided
doses to reduce Herxheimer reaction.
• Milk thistle 250mg twice per day to
reduce Herxheimer reaction: Cost
$20/month
• If not stooling 1x per day give daily
Morning Glory. Treatment beverage or
appropriate over the counter medicine.
slowly build.
• Continue on this treatment ongoing as indicated
throughout treatment
80. Assess And Stabilize Adrenal and Immune Function
Morning Glory Treatment
Bedtime Fodmap Friendly Bulk, Moisten, Soften
Mix ¼ teaspoon-1 T green banana flour (RS2) + ½
-1 tablespoon of Acacia Powder (soluble fiber) +
Vitamin C (2 grams) + Magnesium Citrate 350mg
¼ teaspoon maple syrup. Adjust dose
accordingly
Morning Stimulate
Mix 2 grams Vitamin C with 350 mg of
Magnesium citrate .
Followed by a chaser of 6-oz of black coffee if
allowed.
Bowel movement should happen within 20
minutes of being awake.
Warn patients that flatulence might increase at first but adjusts over. If
this is unsuccessful consider OTC or Rx options
81. Other acceptable Fiber Sources
• Soluble Fiber
• Guar Gum 5-15 grams per day
• Ground Flax Seed
• Resistant Starches (RS2)
• Potato Flour Starch
• Resistant Starches (RS3)
• Cooked and Cooled and reheated potatoes
and Rice
Response may vary . Start very low and build
slowly!!!!
83. Modify Dysbiotic: Lifestyle:
Treatment Ongoing
Pick The Most Relevant
• Meal Spacing (3-4 hours)
between meals.
• Mastication.
• Dietary trigger awareness.
• 10,000 steps per day
• Control Stress Eating and
Overeating.
• Correct abdominal gut
clenching and gas holding.
• Correct constrictive clothing or
accessories
• Stool Squatting..
84. Abdominal Release inspired by
Katy Bowman:
Release the Gut Shame!
• Start on Hands and Knees
• Release the stomach all the way.
Be proud of that thing! Give it a
name!
• As you are releasing un tuck your
pelvis. If your pelvic stays stuck
you are sucking in.
• Your tailbone should rotate up as
our pelvis rotates toward the floor.
• Don’t push it out. Release it out.
• Once at a good spot . Hang out
and perform deep belly breaths
• Notice thoughts of negative self
talk like “I am fat “ or “ I look fat” or
“ I hate my belly” or “my spine is
weak”.
Bowman, Katy (2014-09-25). Move Your DNA:
86. Implement Microbiome Balancing Diet
Multiple Options.
• Most researched in
FGID is Low Fodmap
Diet
• Most Popularized in
ND world is SCD/Low
Fodmap Combination
• Other common
approaches are:
• Paleolithic Diet
• Cedar Sinai Low
Fermentation Diet
87. The Low Fodmap Diet, edition 3,
Reducing poorly absorbed sugars to control gastrointestinal symptoms. 2012
Monash University
88. Low Fodmap Diet
• Originated largely from research done by Dr Peter
Gibson, Professor of Medicine and Victoria at Monash
University, Sydney, Australia
• Stands for Low Fermentable Oligosaccharide
Disaccharide, Monosaccharide And Polyols
• Additional Research coming out of Kings College in
London
90. What are Fodmap’s? What is the
Science
• Fermentable, Oligo-, Di-, Mono-saccharides and PolyolS
(FODMAPs) are short chain carbohydrates (e.g.
fructans, galacto-oligosaccharides, polyols, fructose
and lactose) that are poorly absorbed in the small
intestine
• FODMAPs: short chain sugars and water soluble
fibers with low degree of polymerization (DP1-10)
• Starch/polysaccharides: long chain carbs DP 10-
1,000+
• Small size makes FODMAPs
• Osmotically active
• Rapidly fermentable
92. High FODMAP Absorption is poor by default
• The absence of luminal
enzymes capable of
hydrolyzing the glycosidic
bonds contained in
carbohydrates
• The absence or low
activity of brush border
enzymes (eg, lactase)
• Or the presence of low-
capacity epithelial trans-
porters (fructose, glucose
transporter 2 [GLUT-2],
and glucose transporter 5
[GLUT-5])
95. Carbohydrate: chain length/digestion
Sugars (DP1-2) Site of absorption
Sucrose proximal sm intestine*
Glucose proximal sm intestine*
Fructose along entire sm intestine
Lactose along entire sm intestine
Polyols along entire sm intestine
• *Well absorbed
96. Randomized Fodmap Trial
• N=30 with IBS and 8 controls
• Low Fodmap Group (<.5 grams Fodmap) vs. Austrailian Diet Group Vs.
Control on typical diet
• Low Fodmap Group had lower overall gastrointestinal symptom scores
(22.8; 95% confidence interval, 16.7-28.8 mm) while on a diet low in
FODMAPs compared with the Australian diet (44.9; 95% confidence
interval, 36.6-53.1 mm; P < .001) and the subjects' habitual diet.
• Bloating, pain, and passage of wind also were reduced while IBS
patients were on the low-FODMAP diet.
• Symptoms were minimal and unaltered by either diet among controls.
• Patients of all IBS subtypes had greater satisfaction with stool
consistency while on the low-FODMAP diet
• However, diarrhea-predominant IBS was the only subtype with altered
fecal frequency and King's Stool Chart .
(PMID: 24076059)
97. Carbohydrate
Intolerance in SIBO-positive patients
• SIBO-positive patients further showed significantly
higher prevalence of malabsorption by lactose breath
test (83% vs 64%), fructose breath test (70% vs 36%)
and sorbitol breath test (70% vs 36%) when compared
with the SIBO negative IBS patients.
• Eradication of SIBO increased tolerance to fructose,
Lactose, and Sorbitol.
• Fructose, sorbitol and lactose breath tests could become
a useful diagnostic approach in SIBO-negative patients
with refractory symptoms.
(PMID:24976698)
PMID:
24976698
99. Implications of long term use of Low
Fodmap Diet requires elucidation
• Monash Study indicated
that a long term low
Fodmap diet may reduce
butyrate production in the
colon, thereby effecting
protective factors of large
Intestine.
• Probably applies other
low fiber diets
PMID:25016597
101. Step 4: Stabilizing Microbiome
Balance: 4 weeks to 3 months
• We are reducing and
stabilizing not
removing/eradicating.
• Plant antimicrobials vs.
conventional
antibiotics
102. Antibacterial activity of essential oils in
disc diffusion assays.
Significance levels obtained from two-
tailed t tests are denoted by stars:
* = significant (P < 0.05); ** = highly
significant (P < 0.01); *** = very highly
significant (P < 0.001).
BMC Complementary and Alternative
Medicine 2013, 13:338
103. Researched Natural Antimicrobial
Treatments
• Enteric Coated Peppermint Oil reported
benefit and improved breath hydrogen
breath test in a case report; of 0.2 mL
three times daily for 20 days. (Logan &
Beaulne, 2002).
• Peppermint Oil has 5 RCTs that showed it
was better then placebo for abdominal
pain (Grade 2b evidence)
104. • Original Retrospective
Chart Review showed:
• 23/67 Patients who took
1200 mg of Rifaximin
Daily had a negative LBT
after therapy
• 17/37 patients who took
either 2 tabs BID of
formula a+b or 2 tabs BID
of formula c+d for 4
weeks had a negative LBT
after therapy.
ormula A Formula B Formula C Formula D
Company A Company A Company B Company B
inospora
ordifolia dill seed Red Thyme Oil
Coptis root and
rhizome
Equisetum
arvense
stemona
sesilifolia Oregano Oiil
Indian Barberry
root exsract
Pau D'Arco
Artemesia
absithinium
Sage Leaf
Extract Berberine Sulfate
Thymus
ulgaris
Pulsatilla
chinesis rhizome
Lemon balm
extract Chinese Skullcap
Artemisia
dracunculus Brucea Javanica
Phillodendron
bark
ida
ordifolia
Pircrasma
Excelsa bark Ginger rhizome
Olea
europaea
Acacia Excelsa
bark
chinese licorice
root
Hedyotis diffusa
chinese rhubarb
root and rhizome
Yarrow leaf and
flower
chinese rhubarb
root and rhizome
105. Group 1 (triple Antibiotics) Group 2 (Biotics Group) Group 3 (Metagenics Group)
Clindamycin: 300mg TID x 4
weeks
Metronidazole 250 mg TID X 4
weeks
Neomycin 500mg TID x 4 weeks
FCcidal 2 cap BID X
4 weeks
Dysbiocide 2 cap
BID X 4 weeks.
Candibactin-AR: 2 cap BID
X 4 weeks
Candibactin-BR:: 2 caps
BID X 4 weeks.
Rescue Protocol Group 1 (triple
Antibiotics (n=10)
Herbal Remedy (N=14)
Negative LBT after therapy 6/10 (60%) 8/14 (57.1%)
Controlled for : age, gender, SIBO risk status, IBS Status
Rescue Protocol In Patients Who failed Rifaximin
106. Findings
• It again proved that
botanicals are decent
antimicrobials
• Did not control for diet
• Study did not show any
markers of patient
improvement or lack of
improvement other
then breath results.
107. • Start slow and work up to the maximum tolerable
dose
• Approach should have one Berberine based formula +
one phenolic monoterpenoid formula or 1 thiol
reducing formula.
• Should be taken with biofilm Eradicator
• All supplements should be taken 30 minutes before a
meal or 2-3 hours after a meal.
• Review side effects and drug interactions of all herbs
and disclose with patient.
• Prepare patient for Herxhemier
• Reassess after 4 weeks with Patient History/PE/maybe
LHBT.
• Use this with Digestive Wellness Questionnaire section
3-4 to Guide treatment and CDSA.
• Retesting LHBT is reasonable but not always necessary
• With no or moderate consider dosing and rotating
herbal blends/antibiotics
Basic Principles: Step Four: Stabilize Microbiome Balance.
2 weeks to 3 months
108. Foundations of treatment:
An foundational Berberine-based formula in
combination with 1 or more
Biofilm Eradicator (Interfase or Interfase plus, or
NAC)
Plus 1 Additional complementary herbs formula
Phenolic monoterpenoid formulas (i.e. Oregano,
Thyme (Carvacol/Thymol)
And/or
Thiol Reducing Agent formula: (i.e. Allicin)
Other agents that might be helpful:
Undecylenic acid and/or Caprylic Acid
Cinnamomum stem bark oil (Cinnameldhyde)
True/Purified Colloidal Silver/Silvercillin
Artemesia (sesquiterpene lactones)
Basic Principles: Step Four: Stabilize Microbiome Balance.
2 weeks to 3 months
109. Target Doses of Single Herbs. Will be Less when used in Combination!
Most from : (Bone, The Ultimate Herbal Compendium, 2007)
Berberine: 1.4-1.8 grams per day.
Origanum Vulgare : 230-450 mg daily of 30% Carvacol
Thymus Vulguaris Oil: 40-50 mg per day
Allicin: 5 mg of enteric coated Allicin divided throughout the day.
Biofilm Eradication
Interphase or Interfase plus* : 2 caps to 8 caps between meals
Other agents that might be helpful:
Undecylenic acid :450mg-740mg in three divided doses daily
Cinnamomum stem Bark oil (Cinnameldhyde): 100mg of Cinnamon
Stem Bark daily with (60% cinnameldhyde)
Purified Silver/Silvercillin 10-ppm silver nano-particle solution .
NOTE make sure you are using correct form and only temporarily)
.See PMID:15111684
Artemesia (sesquiterpene lactones): 300-600mg daily in divided
doses.
*Caution in highly sensitive and constipated patients due to metal
mobilization
All supplements taken 30 minutes before meals or 3 hours after
meals
Basic Principles: Step Four: Stabilize Microbiome Balance. 2
weeks to 3 months
110.
111. General Principles:
• Reinforce Dietary Hygiene principles of meal
spacing and mastication and MOVEMENT(10,000
steps)
• Utilize prokinetics to try and promote regular
and restorative MMC’s that clear the gut of
fermentable debris and bacteria
• Therapeutic Targets: 5HT4, CCK, Motilin in
attempt to create Phase III contractions of
motility
• Macrolide antibiotics erythromycin low dose but
effect has been shown to wear off after 3
months. Safe on Biome however. Researched
heavily in Gastroparesis.
• Prucalopride (Resolor) has been used in chronic
constipation. Only available mail order through
Canada.
• Naturopathic approaches include:
• Herbal Bitters/Cholagogues/carminatives (Ginger,
Bitter Blends/Iberogast)
Step Five: Restore Digestive Clock
112. MMC treatment guidelines:
If antimicrobials need to exceed 1 round, you might want to
start this stage in conjunction with antimicrobials.
Reinforce meals spacing
Choose 1 of the following
Herbal Pro-kinetic Blend (Iberogast or Liquid Ginger). Taken as
directed before meals
Plus 1 of the following night medication
Low Dose Naltrexone ( tapered up to 2.5 mg at bedtime for
diarrhea and up to 5 mg at bedtime or split for constipation
Erythromycin 50mg-75 mg taken at bedtime
Read up on side effects of LDN to prepare patient. Start slow.
Uses Hx, PE, Digestive Wellness Questionnaire, and FGID diary to
guide retreatment. , also consider retesting for LHBT to guide your
treatment.
If bloating and abdominal pain have reduced/stabilized then
proceed to next step with caution. If Bloating, Abdominal, Pain,
and digestive irregularity have all stabilized proceed to next step
Step Five: Restore Digestive Clock
114. • General Guidelines:
• Most patients tried these treatments before coming into your
office but now is a time when they should likely help.
• Goal is Balanced Upper intestinal PH, adequate
digestion/absorption without bloating, stool regularity.
• Use Hx P/E, Digestive Wellness Questionnaire (especially
sections A,B, E), and FGID stool Diary to guide your decisions on
how much or how little support is needed here
• Might consider again CDSA or Heidelberg test at this stage
• Slowly Graduating From a low Fodmap Diet to a Paleo Diet is
likely better long term for flora of colon while still being gut
friendly.
• These treatments (digestive enzymes, Betaine-HCL,
Immunoglobulins, and Pre/Probiotics) generally help with
stabilizing gut flora, optimizing gut pH, mucin production, and
protein, fat, carbohydrate digestion, as well as the multitude of
benefits of probiotics
• In these patients they will likely not need antimicrobials but may
require a pulse dose with symptoms of re-flaring.
• These patients should continue these treatment with Migrating
Motor directed treatments as long as mild symptoms exists
Step Six: Replenish Immune and Digestive Factors
(1-2 months)
115. • Replenish Gut Flora Friendly Diet:
• Reinforce Dietary Hygiene and Exercise
• FODMAP Challenge: Slowly graduating from a low Fodmap Diet to a
Paleolithic Diet. Establish personalized diet that is more flexible, more
diverse, and sustainable.
• Incorporate paleo friendly carbs: Plantain, Cassava, Taro Root, Sweet
Potatoes, Parsnips, and Beets.
• Replenish: Immune/Digestive: Core plan
• Betaine HCL (650mg-1.3 mg) with 130-260 mg of Pepsin with each meal.
• 306-623 mg of acid stable digestive enzymes including amylase,
protease, lipase, phytase, cellulase, sucrase, maltase, and lactase with
each meal
• Probiotic formulation for current replenishment. Amount varies with
each formula. Species such: L. Plantarum 299v h, L. Cassei,
stretptococcus faecalis. Lactobacillus GG, Bifidobacterium brevis.
• Replenish: Additional Supplements that are helpful
• Spore Containing Probiotic for long term (Bacillus
• Ox Bile extract 650mg-130 mg TID with meals.
• Pancreatin 8X USP concentrate 650mg-1.3 mg TID with meals
• IgG Immunoglobulins/Colostrum/Enteragam
• If Diet remains low Fiber (<30 grams per day). You might consider adding
a combination of soluble fiber (i.e. Psyllium) with RS2 starch like Banana
Flour Starch (1/2 tsp to 1 tsp day).
Step Six: Replenish Immune and Digestive Factors: 1-2 months
116. Probiotics for SIBO
• Most studies have been done for IBS not specifically for SIBO
• Bidobacterium infantis seems to outperform strains of Lactobacillus.
• At present, the strongest evidence is for Bifidobacterium infantis 35624
at a dose of 13108 cfu/day taken for at least 4 weeks. However
Lactobacillus GG has performed well in children
• For SIBO specific studies of Probiotics
• Lacotbacillus fermentum KLD 10 Billion BID no better then placebo
(PMID: 9060066)
• Lactobacillus plantarum 299V and Lactobacillus GG benefited children
who had SIBO associated with short bowel syndrome in uncontrolled
studies
• Abstract of N of 25. Probiotics (lactobacilli casei, Lactobacillus
plantarum, streptococcus faecalis, Bifidobacterim brevis) –Bioflora at 5
ml twice per day for 5 days outperformed Flagyl in symptomatic
improvement 80% to 50%) Although full paper seems to be unavailable
and the design questionable
• .
(PMID:21381407) ;(PMID:22730468)
118. General Guidelines:
• At this stage patient should be relatively stable.
• At this stage a gut healthy lifestyle should be in place. You
can always keep re-enforcing this.
• Use Section B,C and D on Digestive Wellness Questionnaire
to Help Drive decisions
• Might want to consider additional testing at this stage like
Lactulose Mannitol testing .Cyrex testing for Zonulin/LPS ,
food allergy/sensitivity testing.
• Treatments are directed at tightening gap junctions ,
reducing inflammation, restoring barrier, and limiting gut
permeability
• At this stage most patient will have graduated from most
other supplementation except will likely stay on Stage 6 diet
and supplementation.
• In these patients they should notify you at first sign of a re-
flare and come in for a visit.
Step Seven: Restore Gut Barrier (Ongoing)
119. • Supplementation
• Continue on lower dose maintenance probiotic (5 billion per day)
• Take gut lining supplementation including daily and ongoing.
Minimum criteria of formula
• 750 mg to 1000 mg of L-Glutamine
• N-acetyl D-glucosamine 375mg -1000 mg daily
• Slippery elm (bark) powder: 200 mg to 400mg daily
• Althea root powder: 120 mg to 250 mg Daily
• DGL 400mg daily
• Zinc Carnosine 75 mg daily
• Some combination of astringing and ant-inflammatory herbs
• Other helpful additions
• Bone broths drinking frequently throughout the week
• Beef Gelatin dissolved in food/drink frequently throughout the
week.
• Treat mild reoccurrences with symptoms lasting > 1 week with 2
round course of herbal antimicrobials
Step Seven: Restore Gut Barrier (Ongoing)
120. Prevention
GI stabilization Supplementation
Lifestyle Maintenance
Address other health issues (pain, mental health)
Specific Dietary plan based on re-challenge
Weed and Feed (pre/probiotic/plant-antimicrobials)(2 weeks cycles on
2 weeks off )
Fiber Goals!
121. When treatment fails to help
• If you refer them away , make sure you invite them
back to discuss what they learned!
• Consider other modalities AOM , Ayurveda.
• Consider psycho-emotional components if not
improving.
• Consider Mind/Body interventions including EMDR
or Hypnosis.
• Consider Pelvic Floor Dysfunction evaluation
• Ongoing surveillance and sensitivity to eating
disorders.
122. Items in Development and more
experimental to add to resistant
patients and improve outcomes
• Elemental Diet to Stabilize the Gut
proceeding Low Fodmap Diet
• Quarom Sensing Inhibition
• The use of bacteriophages. That target
E.coli (highly involved in SIBO)
• The use of biofilm eradicators in
conjunction of treatment (NAC, Interfase)
• Combination treatments of Naturopathic
and Conventional Treatments
• Pulse Dosing
127. Multifactorial. Too much too soon
HPI: Diarrhea (10 bowel movements per day), Weight loss, abrupt onset 3 months ago,
abdominal pain, bloating, and gas. Can only control by strict dietary modification. She has a
history of Hashimotos Thyroiditis otherwise no other pertinent health history. Denied treatment
with steroids and instead treated with Ciprofloxacin which helped X 2 days. Mother is aging
which is stressful. Was told by previous physician that she may have SIBO. Does not want to
test but treat instead. Also has issues with insomnia that she treats with Ambien
Labs: lab review from 3 months prior: ANA+ for
Scleroderma/CREST, Celiac Panel negative, Lyme Panel
Negative
Stool testing: + for Lactoferrin
Diagnostic Imaging: colonoscopy + for Microscopic Colitis.
Lifestyle: continue exercise
program
Continue emphasis on sleep
restoration
Diet: low fodmap diet
P/E: unremarkable, except
for excessive bowel sounds
and mild discomfort on
abdominal exam
Berberine 500 mg three times
per day
Activated Charcoal PRN with
die-off reactions
Discontinue FOS supplements
128. Too much too soon
Return Visit 1@7 days
Reports improvement
Bowel movements down to 3 per
day
Bloating reduced with low fodmap
Had 2 days of die-off controlled by
Activated Charcoal
THINKS WE HAVE EMPIRICALLY
PROVEN SIBO, leaning towards a
trial with Rifaximin if not completely
resolved in 1 week
Return visit 2@14 days
Still at about 3 bowel movements
per day on the looser side
Still having some fatigue
Stopping Ambien wants to switch to
natural sleep alternative
Start Rifaximin 550 mg Twice per
day with food for 10 days (do note
the recommended dose now is
550mg three times per day)
Added Glychrrizza for for fatigue
Return Visit 3 @ 10 days
2-3 formed bowel movements daily
Staying on Low Fodmap
Digestively stable
129. Too much too soon
Return Visit 5 @10 days later
Diarrhea stopped after starting
Budesonide and VSL#3.No
bloating /No gas.
Diarrhea resumed after
stopping Budesonide and
VSL#3. But less severe 3-10
movements per day
Plan: Resume High dose
Probiotic . Adding on
Budesonide again with no
control after 1 week.
Assuming this is a flare in the
Colon.(colitis)
Return visit 30 days
Diarrhea Stabilized with Probiotic
Alone. Digestively stable .Has built up to
3 Digestive Enzyme/HCL capsules per
mea. Starting to go out to eat with
friends again.
Challenged Fodmaps and was positive
for Glactan/Fructans
Plan: Continue Probiotic –High Dose,
Continue Fructan/Galactan Avoidance.
Continue Digestive/Enzyme HCL
Capsules
Start: Gut repair: supplementation.
Begin setting boundaries with family
regarding caretaking roles..
Phone call 60 days later
Added raw veggies and reflared. Is
away on vacation. Not responding to our
standard treatment
Wants a prescription of Enterocort and
High dose probiotics
130. Too much too soon
ROC 14 days later
Budesonide and VSL#3 did not control things
Has been feeling anxious and irritable and overly
stressed
Added Loperamide to control diarrhea until further
investigation
Plan check thyroid: THYROID PANEL
TSH 0.29 L mIU/L, T4/T3 normal
Reduce thyroid dose from 60 mg to 45 mg.
Monitor and repeat labs in 1 week
Return visit 45 days later
TSH stabilized to 2.4. Diarrhea stopped after
changing thyroid dose.
Following Body Ecology Diet, GI Repair
Supplementation. Digestion is stable. Feels good
about plan
Has changed role as a care provider. Is looking at
emotional causes to her health.
Wants to focus on other concerns today such as BIO-
HFRT
131. Case 2: multifactorial, IS SIBO a Symptom
or the Cause ?
Return Visit 4 @30 days
Reflares when veering for from the low fodmap
diet
Has switched to Valerian Root and Kava Kava
for sleep concerns it is helping
Plan to have Lactulose Breath Test to see if
residual overgrowth exists
Breath test shows negative Hydrogen. A 19
PPM rise that happened around 140 to 160
minute mark of test .
Return visit 45 days:
Went on trip to and reflared 10-15 bowel movements
per day
Stools watery, abdomen, and crampy but not bloated.
Plan: CBC, CMP, Electrolytes, (NML)
Treat for microcolitis/scleroderma related
malabsorption
Budesonide 9mg 1-4 weeks
HIGH DOSE prescription Probiotic
She signed up for an online functional medicine
specialist
133. 35 year old Fear of Travel and Eating Out
HPI: Gas, Bloating, alternating constipation/diarrhea, crampy
abdominal pain in supra-umbilical region associated with eating.
Onset 17 years ago. Previous workup at GI ruled out IBD. Notable
for anxiety related to travel and eating due to digestive concerns/
DWQ: A:10 B:9, C: 14, D:10 E: 15
Lab test/Testing: Methane and Hydrogen Positive.
> 30 ppm rise in Hydrogen
>3 ppm rise in Methane
Lifestyle:
Introduced mind/gut
treatment concepts of
meditation
Diet
Low fodmap Diet
P/E: POSITIVE
tenderness noted x 4
quadrants with light
and deep palpation
Berberine/Undelycinic
Acid combination
134. 35 year old: Fear of Travel and Eating Out
Total Gas Production Hydrogen/Methane positive
135. ]35 year old. Fear of Travel and Eating Out
Return Visit 1@30 days
Reports improvement
Only a few days of
constipation, bloating
Increase
Undecyn./Berberine dosage
Continue on low fodmap
Return visit 2@30 days
Feels some occasional
abdominal bloating
Bowel movements 1-2 per
day
Anxiety around eating gone
Start biogest 1-2 caps
Start erythromycin 75 hs.
Slowly begin challenging
fodmaps
Return Visit 3 @ 30 days
Polyol challenge: negative
Fructose challenge: +
diarrhea
Continue bio-gest
Continue erythromycin
Challenge fructans/lactose
Maintain fructose avoidance
136. 35 year old Fear of Travel and Eating Out
Email @45 days
Still digestively stable
Challenged fructans with minimal symptoms
Challenged lactose with minimal symptoms
Plan to avoid fructose
Challenge galactans
Continue digestive enzyme/HCL combo,
stop erythromycin,
Start Bifidobacterium/Lactobacilli
Return visit 6 months later
Has been doing well with plan
Galactans challenged negative
Wants to know what else he can do to
prevent flare
He continues on probiotic and avoiding
fructose but has stopped most other
supplements
Started taking homeopathic remedy for
anxiety flares
Plan:
Continue probiotic: add Gut Repair Formula
Continue fructose Avoidance
Return visit 30 days later, May 2014
Plan is holding
Wants to discuss other concerns
Will continue on current plan
137. Two Tacks, Post Infectious-IBS
43 year old male with constipation,
abdominal pain, nausea, joint pain, and
weight loss that has been flaring for 2
months. He has history of less severe
symptoms following years of international
travels remembers many traveling related
infections. Has lost weight, cannot eat
much. Only eating Ghee, bread, Coconut
butter. Blood work was done and it was
normal at PCP office. Has lost 10 lbs./ in 10
weeks and is worried he has cancer. Had a
colonoscopy in 20’s and has advised to get
another one.
P/E: Abdominal exam: tenderness X 4
quadrants. Otherwise multi-system P/E was
unremarkable
Labs: at presentation: wbc:
3.5 (3.8-11.0), HCT 44.1% normal, Low
absolute neutrophils 1.30(1.9-7.4), TSH
1.23 (.45-5.10), CMP-normal.
Fecal immunochemistry: wnl
Repeat CBC: wnl, CMP: WNL: Sed Rate:
22 (elevated) repeat 1 month later
normalize
RF/anti-ccp antibodies: negative
Amylase: 48 Lipase:21
CRP: <.10
ANA screen: negative
Lactulose breath Test: Methane positive
and weakly hydrogen positive
CDSA: positive to few Blastocystis
Hominis, otherwise completely normal
138. Two Tacks, Post Infectious-IBS
Treatment phase 3
Bitters before each meal
IGG/IgA Colostrum supplementation
Bile Salts 1-2 tabs with each meal for gallbladder support
Betaine + Pepsin with each meals
Continue with VSL #3 or transition on to ProbioMax Plus DF 30 by Xymogen
Supporting liver detoxification processes. Oral glutathione with BCAA’s
Increase proteins in diet to gradually 1.0 gram /kg daily
4-7 servings of phytonutrients daily
141. Two Tacks, Post Infectious-IBS
Treatment phase 1
Homemade Elemental Diet
+ plant based
antimicrobial's
Prescription based
probiotic at night-time
Treatment Phase 2
Neomycin first (14 day
course) and then phase in
Metronidazole after 4 days
on Neomycin (it’s a 10 day
course) + Low Fodmap diet .
Continuing probiotic at
bedtime
142. Case 1a: Two tacks: Post Infectious IBS
• 8/1/2014
“I am doing well and having more vitality and ability to eat
more as well… There is still some rebuilding going on and
I am happy with the progress”
143. Two Tacks, Post Infectious-IBS
Treatment phase 1
Homemade Elemental Diet
+ plant based
antimicrobial's
Prescription based
probiotic at night-time
Treatment Phase 2
Neomycin first (14 day
course) and then phase in
Metronidazole after 4 days
on Neomycin (it’s a 10 day
course) + Low Fodmap diet .
Continuing probiotic at
bedtime
144. Case 1a: Two tacks: Post Infectious IBS
“ This protocol seems to be working very well. I have had a marked increase in
energy and appetite. It was shocking to me to realize that I was hungry for the first
time in four months. I am still eating a very simple diet (that fully fits in the fodmap)
and even have less nausea and often no cramping. My breath seems better as
well. Another interesting change is my stool. It still is good but now it sinks in the
toilet instead of floating. It simply seems more dense even as I am passing it. This
has not been a problem area so I was surprised by this change”
“I am writing to let you know that I am done with the antibiotic and feel a
marked change in the SIBO symptoms. I have more energy and am feeling able to
eat larger quantities of food. My instincts say that I am fairly complete with the
SIBO symptomology and I'm now looking at more focus on the parasitic
components. I am having far less and at times no cramping”
145. Recap
• Understanding of background and clinical workup related to
SIBO
• Understanding of pathophysiology and pathosequelae of
SIBO.
• An appreciation for terrain balancing approaches and the
functional connections in SIBO.
• Actionable lecture to bedside steps to evaluate dysmotile
or malabsorptive patient or those at risk for SIBO
• Actionable lecture to bedside steps to treat and recover
patients with SIBO
• Actionable lecture to bedside steps to approach the most
sensitive and treatment refractory patients
