Small Intestinal Bacterial Overgrowth: Rational Wellness Podcast 049

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Dr. Kenneth Brown describes strategies for treating Small Intestinal Bacterial Overgrowth with Dr. Ben Weitz. 

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Podcast Highlights

1:46 Small Intestinal Bacterial Overgrowth SIBO is caused by an overgrowth of bacteria that normally live in your colon that have gotten translocated and are growing where they shouldn’t be–in the small intestine, esp. in the duodenum. This can be caused by stress, an infection, taking antibiotics, or poor diet. Then when you eat, the bacteria will break down the food, creating gas, bloating, discomfort and change in bowel habits. And this is the main cause of Irritable Bowel Syndrome. This was first demonstrated by Dr. Mark Pimentel. If you have bacteria that produce methane gas, it will cause constipation and if they produce hydrogen sulfide, it will cause diarrhea.  Dr. Brown said that it always bothered him that you had patients with opposite symptoms–diarrhea and constipation–and they were both diagnosed with Irritable Bowel Syndrome and the SIBO diagnosis explains and unifies this.

4:56  We discuss briefly the gut brain connection.

6:02  Dr. Brown talks about Dr. Pimentel’s post-food poisoning, post-infectious explanation for the cause of SIBO in some patients. Your body can produce antibodies to some common bacteria, like salmonella, that end up damaging the neurological control of the intestines, the Migrating Motor Complex. This decrease in the motility, esp. the cleansing waves of the intestines, facilitates the buildup of bacteria in the small intestine and makes it more likely to recur even after treatment. Dr. Brown also also explains that some of the damage to the microbiota that can result from taking antibiotics and how this can cause bacteria to overgrow into the small intestine. The same goes for ingesting pesticides like glyphosate in our food. Dr. Brown also explains how stress can play a role as well. Post-infectious, antibiotic use, stress and diet can all play a role in SIBO developing.

10:51 We discuss whether ileocecal valve dysfunction is a reasonable explanation for the cause of SIBO. Dr. Brown said he has seen a lot of patients with Crohn’s Disease who had their ileocecal valve removed as part of a surgical resection of part of their bowel and he does not see SIBO in the majority of these patients.

13:00  Dr. Brown said that he feels that patients who get a recurrence of their symptoms are looking for an explanation of why.  He said that he spoke with Chris Kresser who told him that he thinks that toxins like mercury might be playing a role in these difficult patients who keep recurring.

14:20  I asked what happens when a patient has had their colon completely removed? Are they then supposed to have a microbiome? Do they not have a microbiome? I mean does your small intestine become the place with your microbiome? Can you live without a microbiome? 

16:45  We discussed SIBO breath testing. 

22:14  I asked Dr. Brown when he treats SIBO with Atrantil, is that the only product he’ll use and does he also place the patient on a special diet? Dr. Brown explained the composition of Atrantil and how it works.  He said that he may add Rifaximin or another herbal antimicrobial and Saccharomyces boulardii. He may recommend a gluten free diet. He also feels that using a motility agent is very important, such as Erythromycin.   

30:22  We discussed the concept that the patient may have several layers of dysfunction or gut dysbiosis, such as SIBO plus a fungal overgrowth, and how candida and SIBO can feed off each other.  Dr. Brown also talked about the significance of leaky gut for patients with SIBO.

 

 

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Dr. Kenneth Brown is a conventionally trained Gastroenterologist and researcher who now takes a Functional Medicine approach and has developed an herbal product for treating SIBO, called Atrantil. He can be reached through KBMDhealth.com or KennethBrownMDHealth.com or just KennethBrownMD.com. You can also go to Lovemytummy.com or go to Atrantil.com.

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure as well as chiropractic work by calling the office 310-395-3111.

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Podcast Transcripts

Dr. Weitz:            This is Dr. Ben Weitz with the Rational Wellness podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness podcast on iTunes and YouTube. And sign up for my free ebook on my website by going to Doctorweitz.com. Let’s get started, on your road to better health.

Dr. Weitz:            Hey you Rational Wellness podcasters, thank you so much for joining me again today for another episode of the Rational Wellness podcast. If you enjoy this episode, please give us a review on iTunes, that helps more people find out about it. And today, we’re going to interview Dr. Kenneth Brown, a functional gastroenterologist and the developer of Atrantil, a herbal product used to treat methane producing Small Intestinal Bacterial Overgrowth. And this is a very interesting product, we’re using it in our office very successfully. Dr. Brown has done several studies showing it to be 80% effective in relieving SIBO symptoms such as bloating, constipation and abdominal discomfort. And he’s also in the process of completing a multicenter trial and we love that kind of scientific approach. So Dr. Brown thank you so much for joining me today.

Dr. Brown:          No, thank you so much Dr. Weitz. I appreciate you having me on. It’s an honor to be on the Rational Wellness podcast.

Dr. Weitz:            So since we’re going to be talking about SIBO. What do you think are some of the most common causes of SIBO?

Dr. Brown:          So when we talk about SIBO, I’m sure most of your listeners-

Dr. Weitz:            I guess we should probably define what it is to begin with, yeah.

Dr. Brown:          Yeah. So when you say SIBO, it’s Small Intestinal Bacterial Overgrowth. And what that means is whenever … What people don’t quite realize is that your microbiome, we’re always talking about the microbiome or the bacteria that live within us, they really should exist primarily in your colon and that’s where you have 100 trillion bacteria, a thousand different species and they coexist with us. I mean it’s an argument, do we exist for them or do they exist for us? But when we treat them right, they can be very beneficial for us. Now, so it isn’t so much that bacteria are good or bad, it’s just that bacteria can start to grow where they shouldn’t be.

Dr. Brown:          So in the upper intestine, specifically the duodenum, what can happen is that bacteria can start to grow there, that can be due to severe stress and infection, taking antibiotics or very poor diet will allow the bacteria to start to grow. And when that happens, you have bacteria growing where it shouldn’t be, so when you eat, the bacteria will break down the food before you can, creating bloating, discomfort, change in bowel habits and all these other symptoms like that. That’s really what bacterial overgrowth is, bacteria growing where it shouldn’t be.

Dr. Weitz:            And basically this is believed to be the main cause of Irritable Bowel Syndrome.

Dr. Brown:          Exactly. So I was doing research … So my background as a gastroenterologist, I have been doing clinical research, pharmaceutical research specifically, for the last 15 years. And when I was working with one of your prior guests, Dr. Pimentel, he came up with this whole model. He had a mouse model that demonstrated that you can actually have bacteria growing where it shouldn’t be and then you can develop these symptoms. So he was the first guy to really demonstrate that, “Hey, this is very similar to that paradigm shift that took place over 35 years ago, when we used to think that ulcers were actually caused by stress and anxiety.” And then an Australia gastroenterologist figured out that it was caused by Helicobacter pylori or H. pylori. So a similar paradigm shift.

Dr. Brown:          So all these people that we’ve been patting on the head saying, “Oh, you have IBS, take this anti-depressant. Oh, you’re just stressed, don’t worry about it.” And these people would come back and go, “Well, if it’s just IBS, why am I so miserable?” All these people we now realize probably have a bacterial component to it. And if you have a bacteria that produce a certain type of gas like methane, it will cause constipation. If you have bacteria that produce hydrogen sulfide, it’ll cause diarrhea. One of the problems I’ve always had as a gastroenterologist is the fact that you have this unifying diagnosis called IBS, but you’ve got opposing symptoms. That’s always bothered me. Either you have back pain, or you don’t, so when you have somebody that has diarrhea and then the opposing symptom, constipation, and we call it the same thing? That’s not right. And now we have a unifying diagnosis, and SIBO kind of explains all of it.

Dr. Weitz:            And it’s kind of interesting that the anti-depressants may have actually had some benefit, but not because it improved their depression or their psychological outlook but because there are serotonin receptors in the small intestine and decreased motility may be a factor in the cause of small intestinal overgrowth, and it may be that the anti-depressant stimulated the serotonin receptors in the small intestine, so some of those patients may have actually got benefit for their small bacterial overgrowth that they didn’t know they had. 

Dr. Brown:          Exactly. What people don’t realize is, you have more serotonin receptors in your gut than you do in your brain.

Dr. Weitz:            Yeah.

Dr. Brown:          This is why as a gastroenterologist dealing with these functional medicine problems, I call it the gut-brain connection. That’s what’s going on. I treat the brain as much as I treat the gut and vice-versa, because the two interact with each other. And you know as functional doctor that you don’t just treat the end organ, you have to treat the whole body. And definitely the brain is almost always involved in everything.

Dr. Weitz:            Right. So what do you think … What are some of the causes of this Small Intestinal Bacterial Overgrowth? I know Dr. Pimentel feels that a percentage of these result from a case of food poisoning that leads to damage to the migrating motor complex due to toxins released by the bacteria that causes food poisoning that damages the nerves that control the motility of the small intestine.

Dr. Brown:          Exactly. So he was smart enough to actually realize that we were calling people post-infectious IBS. Where actually some people would develop inflammatory bowel disease, Crohn’s or ulcerative colitis, and they’re called post-infectious. What he realized is, is that when you get exposed to a certain bacteria, salmonella, shigella or these very common ones, then your body can overreact, produce antibodies to get rid of it, which is important, but then these antibodies hang around, and they misinterpret these cells of Cajal, which are these electrical pulse, think of it that way. So you’ve got a current that goes through, and in your intestines there’s a migrating motor complex, meaning an electrical impulse starts and makes sure intestines move from the stomach all the way to the cecum, which is how we move our food through. Well, antibodies can be produced called vinculin antibodies, and they can actually bind to those things and actually shut them off.

Dr. Brown:          So think of them like cell towers being turned off. And that happens in about 20% of the people that actually have an infection like that. So 20% of our SIBO patients, we look for that, and you can actually get … He actually developed a very eloquent test called the IBS check test, where you can see if somebody has these antibodies. What that tells us is, you’re going to be at risk for having recurrent issues and that’s something that I discuss with my patients. When they say, “Look why every few months I’ll get treated, I’ll feel better, five months later I have this?” I’m like, “Okay, it looks like you have essentially developed an autoimmune disease, to the motility of your intestines.” So that’s one cause, that’s how the infections cause it.

                           The infections also cause it by having your body overreact to it and have it … You don’t have to form the antibodies, but it changes the whole bacterial motility for a little bit, and what you would normally have as a free-flowing stream crystal clear, it shocks it and then bacteria start to grow, and the bacteria themselves can produce gases to slow it down. So now we end up going from a small little stream to a bigger sewer and then the bacteria start growing. And then the other couple reasons that actually can happen, taking antibiotics would do it. We don’t realize the destructive nature of these antibiotics. I try to only use them when it’s completely necessary. And there’s a lot of researchers out there showing that we really disrupt a lot of things by giving so much antibiotics.  And then ultimately …

Dr. Weitz:            And by the way with antibiotics, so anything that would kill the bacteria, so that also includes pesticides that are found in our food and insecticides used around the house et cetera, et cetera.

Dr. Brown:          I love that you brought that up, because that was the other thing. People don’t realize that when they’re eating a lot of refined foods it has all that Glyphosate in it. Glyphosate is Roundup, which is an antibiotic, and it can do the exact same thing. If we eat a lot of meats that are with that. I think you probably saw that recent study where if you work with household cleaners it’s just as dangerous as smoking for 20 years.

Dr. Weitz:            Yeah.

Dr. Brown:          So unfortunately, our people in the industrial cleaning industry are exposing themselves to a lot of toxins and it does very, very similar things. So the bottom-line is where I tell people … And the final thing that gets missed a whole lot is, any time you go through a very stressful situation, you can actually go through this fight or flight process and ten that … And you go through a sympathetic response of fight or flight, it actually slows down your intestines. I like to tell my patients … I get so many people that are like … It’s like having insult to injury.

                       Somebody will go through the death of a family, or they’ll go through a bad divorce, and then they’ll show up at my office, and I have to explain to them that, “Look that was very traumatically stressful for you. Your body was in a constant state of fight or flight, it’s going to reserve its energy so that you can get out of the situation. You know if you’re being …” From paleo times when you’re being chased by a saber tooth tiger, you don’t want to get hungry or stop and have to use the restroom, you want to just get out of the situation. In our society today that stress just stays so high that, that can affect the intestines. So those major things, antibiotics, post-infection, diet and stress can all do it.

Dr. Weitz:            What you think about … A lot of people talk about that the ileocecal valve problem is playing a role. How often do you think that really happens?

Dr. Brown:          That’s fascinating to me because that’s one of those deals where I think more clinically, as opposed to what’s actually being said. So for instance, I was listening to a podcast by J.J. Virgin, she had a functional medicine doctor on and he was citing that as one of the causes of bacterial overgrowth. Very clearly the ileocecal valve is built to be there. For those that don’t know, that’s the valve from the end of the small intestine going into the cecum or the first part of the colon. What it does is, we have these valves, it’s job is to let things into the cecum and prevent the cecum from coming back in. We call that backwash ileitis, when you can actually have some inflammation in the ileum. So it makes sense. Oh, if a lot of your stool is going back into the small value, you can colonize it.

Dr. Brown:          Here’s the problem I have with it. I deal with a lot of inflammatory bowel disease, which includes a disease called Crohn’s. So one of the things in one of the treatments of Crohn’s, since 70% will show up in the ileum, is the surgical resection. This takes out the ileocecal valve in the right colon and my surgeons will hook up the last part of the intestine, a portion of the ileum, directly to the colon, so there is no more valve. And I don’t see SIBO in most of these people. And I’ve got, I don’t know, a couple of hundred people who have had this done.  So yes, I guess it’s plausible but I think we’re giving too much credence to it and I think people want to give a reason as to why they’re developing it.  I was talking to … I don’t remember. It was another doctor and we were actually discussing this, about the exact same concept.

                          And he said, “I think people are trying to wrap their hands around why and patients want to know why.” They want to say, “Oh, I’m having this because my ileocecal valve is this. I’m having this because …” And then what we realized is that maybe there’s other things going on, and it probably comes down to pure motility issues. And I was speaking with … I think you know him, Chris Kresser out there in California.

Dr. Weitz:            Oh yeah.

Dr. Brown:          So we were conversing about this, because he has a lot of patients that are extremely difficult to deal with as far as recurring issues. And he’s realizing that, when you take even a more Functional Medicine approach and look at some people and realize that possibly they’ve got mercury toxicity or different things, and he’s got me thinking that, “Oh, some of these things we need to treat.” I can fix the symptoms, it’s the person that keeps coming back to me they’re like, “I was better and now I’m back to where I was again.”

                         And we keep treating and I guess that’s good for business if I’ve got this company where I’m selling a product, but as a physician I want them to get better. And he brought to my attention that maybe we’re missing a certain amount of environmental toxins, which are actually affecting the motility, which is causing the bacterial overgrowth. If we look at the big picture, I think that the ileocecal valve thing is plausible, but I have so many patients that have had that completely cut out and they don’t show up two months later with bacterial overgrowth.

Dr. Weitz:            I’d like to go off topic for just a second because you brought up this surgical situation. I’ve had a number of patients who had their colon removed completely, how are we supposed to think about that? Are they then supposed to have a microbiome? Do they not have a microbiome? I mean does your small intestine become the place with your microbiome? Can you live without a microbiome? What does that mean?

Dr. Brown:          That’s called a total colectomy. So, when have a total colectomy, it’s usually due to a disease called ulcerative colitis. Maybe due to other things, but the majority of people that are going to continue to live without a colon is because of ulcerative colitis. What the surgeons will do, is they will take the last part of the small bowel, so they cut out your colon put it in a bucket and it goes away. Now, something to keep in mind is that that microbiome is so sick due to inflammation, that they’ve been living without a proper functioning microbiome for a long time. So keep that in mind with these people. So the body is already starting to adapt.

                         Then they will take the last few loops of the small intestine and they cut the middle of it and they essentially build what’s called an ileal-anal pouch or they build a kind of a fake rectum, and then they attach it to the anus. That mucosa starts to become like colonic mucosa. And so it actually develops its own microbiome and people can end up with situations like proctitis … I’m sorry, we call it … Basically it’s the ileum that gets there, it gets essentially inflamed. And so that inflamed area there we can treat. And we have to treat it with typical ways that we treat, probiotics will actually help those people. That’s one of the few places where the literature has really shown that it’s been very, very effective is in people like this … Oh, pouchitis.

                        I’m sorry I had a little brain slip there. It’s called pouchitis. So, which might actually help with pouchitis and we sometimes use antibiotics for those people, which means that the microbiome is certainly playing a role in that. So yes, you can certainly live without a colon, people do and they live very fruitful lives, the body adapts, the body is very resilient through it. I think that we’re just scratching the surface about what the microbiome can actually do but maybe we don’t need the whole colon, because I have all kinds of patients that have sections of it taken out. The whole colon taken out and they’re perfectly healthy for years and years and years, decades perfectly healthy.

Dr. Weitz:            Interesting. Do you use breath testing for diagnosing Small Intestinal Bacterial Overgrowth? And if so, do you use lactulose or glucose or fructose or all of them?

Dr. Brown:          So this comes down to the, what is the best test to diagnose bacterial overgrowth, SIBO?  So when we started looking at these different tests, the one that keeps being referenced in the literature is the very old way of doing it, which is a jejunal aspirate. And the original studies with that … We call that the gold standard. But then we’ve learned in more recent literature that the jejunal aspirate is actually not nearly as sensitive nor specific as we thought. The thing about that is, the old way of doing it was dropping a tube down and then aspirating. And we know that there’s lots of contamination. There’s only a few gastroenterologists in the country, one of them is named Satish Rao, he’s out of Augusta, Georgia and he will do it with a very dedicated sterile endoscopy. And they don’t go to the jejunum. The jejunum bowel. Most bacterial overgrowth takes place in the duodenum.

                          So when people are referencing jejunal aspirate studies, that is an archaic method of doing it. So now if you talk to a guy like Dr. Rao, he’ll explain that he goes into the duodenum and aspirates, and then tries to selectively keep it totally sterile. And it’s a very laborious and hard process. So that being said, that’s what we thought was the gold standard and as time has gone on, we realized it’s probably not. So we’re left with the next best thing, which is a breath test. And this is where you will have somebody take some sort of, we call it a substrate or some sugar, and you measure baseline hydrogen and methane. Then you take this in and if bacteria are growing, high up into the small bowel, the thought process is, they will break it down and then the gas gets absorbed and then you will breathe it out. So by definition that seems like a cool thing, but it’s flawed from the beginning, because there’s so many ways it can be messed with, both the type of test that’s done. So there’s many companies out there.

                            The one that I’m using right now, because I can hand my patient a kit and he’s actually in LA, is the gastroenterologist that started this company, it’s Pivotal Diagnostics. Yeah, this is where I can hand them a kit, so I know my patients are leaving with a kit and I say, “I expect you to do this.” Aero diagnostics is a pretty good one but they have to mail them the kit and they have to do it and I can’t expect that to happen. So there is a rule for breath test, I don’t start with that. And what I do is, if you show up to me and you eat a substrate, in other words, starches and you bloat. And you develop these symptoms, especially when people come to me and they go, “Man I was totally fine, five years ago and then X, Y, Z happened. I went to India and I got really bad food poisoning and I’ve never been right since.”

                         You’re screaming to me those causes that can bring on SIBO, so I’m going to treat you like SIBO, if you don’t get better or if there’re other reasons then I consider doing the breath test. And that’s just because the breath test … There was a recent review in 2017 with Dr. Pimentel, Satish S. Rao, Brooks Cash, sort of the guys in my neck of the woods in the non-functional area, the research area and their conclusion was really funny, after all of this it was, “There is distinct heterogeneity amongst the data, so we can’t make a conclusion.” Basically, it is probably the best thing that we have and really use it judiciously, but don’t hang your head on it.  It will not pick up hydrogen sulfide. If it is methane, some of the experts like Dr. Pimentel will say, “If you are methane positive, it’s probably positive.”

                        So you can trust that as long as you have a rise in methane. Some people start high in methane and that’s a different situation, but if you get a rise then maybe that’s going on. I use it when people don’t get better, if they have recurrent situations, if they’ve got atypical symptoms. And I’ll tell you where I like to use it. I can look at this and I say, “I’m 100% sure you have SIBO.” They’ve got classic symptoms. “Why are you not getting better?” So many times, since I get people that have already seen a lot of other doctors, they’ll come in with a baseline and they’ll say, “This is my test, they treated me for this and I didn’t get better.” I will repeat the test. And for me if somebody is methane positive, if they are normal and then all of sudden like 20 minutes it spikes, and possibly goes down then possibly what’s missing is that the bacteria is living very high up, like the duodenal bulb, and the duodenal sweep.

                        And maybe the medications we’re giving including natural products like Atrantil, herbal antibiotics, Xifaxan and all these other things, it’s not even dissolved yet. So it’s dissolving further now. And then vice-versa can happen, I’ll see these people with peaks later and go, “Oh, we’re not getting enough concentration to where we need to.” So I use breath test to fine tune what I’m already doing. That’s how I use it.

Dr. Weitz:            By the way, Genova Labs will mail you the kits that you can hand to your patients now and they also have a three hour kit.

Dr. Brown:          I forgot you also know the hazard also, yeah.

Dr. Weitz:            Yeah, so when you treat with Atrantil, is that the only thing you’ll use or do you use other herbal products at the same time? Do you also use an agent for motility? Do you also put the patient on a special diet as well?

Dr. Brown:          All fantastic questions so Atrantil is basically a combination of three polyphenols that work together. And the way it works is we use a little bit of the peppermint leaf, not the oil, but the polyphenol component of it and that calms the area down. Then the second ingredient, which is the one that I get a lot of questions on, is called Quebracho. It’s Quebracho colorado. It’s a beautiful polyphenol known as a proanthocyanidin and it’s a tenant. It doesn’t get absorbed. So we put that one in there because it is a very old ancient tree that has specific defense against archaebacter. An archaebacter is the type of organism that produces the methane. So in the intro you mention methane producing, that’s a route that we initially started because that was the tough group to treat.

                           So we know that the Quebracho can get rid of the methane and then the Conker tree works … It’s a saponin and basically works by getting rid of the bacteria and that shuts the enzyme off in the archaea species. So in our clinical trials with two published studies, one randomized, one where we treated people with the worst of the worst. We were able to show that really four out of five people definitely get better. So, that being said, because of the type of practice I have, I get the people, I get that fifth person. Almost always I get the fifth person that has tried different things. So what I do for my … I listen to what they say, first thing is history says so much. When you eat and 20 minutes later, an hour later, you’re bloated like that, the timing of when you get bloated tells me what’s going on. If you’re bloated all the time, I’m really worried that something else is going on.

                         So I get a bunch of people that come in and they said, “I saw Dr. So and so, they put me on Xifaxan and I’ve done some natural antibiotics, I went to a Naturopath. Eventually, I tried your stuff, I’m still bloated.” And I’ll talk to them. Are bloated when you wake up? “Yes.” Are you bloated this? And then you really start looking so I realize that … Well, I’ve been able to find a lot of very interesting things.  Occult celiac disease. I have found Crohn’s. I found five or six carcinoid tumors. We’ve found … Things that I normally when you walk through … I mean the old adage in medicine training is if you hear hooves steps you don’t think zebras, you think horses. Well in this case I’m getting zebras walking through at this point.

                        Then that leaves the people that we’ve ruled everything else out, I’ve done a full work up, what else do I do? I believe that since the starches are a significant problem we’re feeding the bacteria, I like to put people on, at a minimum, a gluten free diet. Now, you’ll hear a lot of people throw around the FODMAP diet, that’s the sort of de jure knee-jerk in my field at least. And there’s elemental diets, SCD diet, GAPs diet, there’s all these other diets out there. The one thing that they all have in common is you really take away a lot of the starches, and you certainly take away the gluten.

Dr. Weitz:          Especially fermentable fibers. Right?

Dr. Brown:         Exactly, yeah. So that comes down to the … Fermentable fibers are essenially prebiotics and bacteria love them, and they’re very good for us when you’re in a normal state. So when you’re in a healthy state, taking those prebiotics or fibers are very good, the polyphenols are prebiotic, your bacteria will break them down and generate energy for you. So coming back to an evolutionary type thing when we couldn’t really have access to all the food we needed, you could actually eat a plant based diet and your bacteria will produce short chain fatty acids that will help feed the tissue around your colonic mucosa and give you energy. So I like to do at least a gluten free diet, I’m not a big fan of gluten in general, I myself I’m gluten free, so I try to only recommend things that I’m willing to do myself.

                        I have a lot of people that have tried these extreme diets and it’s just temporary. When you look at the data, the most recent data looking at this is that, FODMAP map diet is about 28% effective in relieving IBS symptoms, gluten free diet is 28% effective in relieving IBS symptoms. And these are the IBS population–not necessarily the SIBO population. There’s lots of overlap and we can talk about the problems with some of the literature with. So going gluten free. Then I have Atrantil. I look at this and if they’ve got more diarrhea predominant, I do have some success by adding something else. I do have some success by possibly using Xifaxan. I have used other herbal antibiotics to augment this. 

Dr. Brown:          I think that … I met a Naturopath out of Australia. Her research was in Saccharomyces boulardii, which was one of the original probiotics. What’s really cool about this, it’s not a commensal organism, meaning we don’t really have a whole lot of Saccharomyces in us but what it does is it boosts your new secretory IGA, so I’m having good success adding Atrantil plus Saccharomyces, we’re going to stay all natural. There are other herbal antibiotics, which I’m having some fun with also. I mean the typical ones, Berberine, Allicin. I’ve got a lot of people that are really struggling if I can throw anything at them. But the most important thing is the motility agent.

                          I think the thing I can help the most and get a sustained response is the motility agent, because, if you think of it this way, if you’ve got those antibodies that we were talking about, the vinculin antibodies, and they do not allow the small intestine to move, you can treat it with whatever you want, and then when they go to sleep at night, then the bacteria will just start growing again. So I like to use a motility agent when they go to bed. And we used to have some other pharmaceutical agents, which are used for constipation, which were serotonin agonists, but they got pulled off the market, that was Zelnorm.  And Zelnorm was fantastic for that, really low dose. We’ll use Erythromycin when they go to bed to help create that motility.  If they want to stay all natural, then we’ll go with the other motility the agents like Iberogast and things like that. I’ve had less success with that, but if we’re to stay all natural then I’ll do that.

Dr. Weitz:            By the way, that seems to be off the market right now for some reason.

Dr. Brown:          Oh, I don’t know that really. Wow.

Dr. Weitz:            Yeah. Some pharmaceutical company bought the company and nobody knows what’s going on, but it’s not really available. So I’ve been using MotilPro, which has 5-HTP, which simulates serotonin and ginger.

Dr. Brown:          Yeah cool.

Dr. Weitz:            We do get some results.

Dr. Brown:          Make sure that … You only really want that to kick in at night, that’s the most important thing.

Dr. Weitz:            Absolutely, yeah. It’s the migrating motor complex that only comes in when you haven’t eaten for like more than three or four hours.

Dr. Brown:          Exactly, yeah. That’s known as the housekeeper phenomenon and when you go to sleep, you get into a deep sleep, which is a whole separate discussion, but sleep is super important to treatment. You probably use … Probably talk sleep all the time for any other process, but I talk sleep a lot. We need to make sure that all these people get a good night sleep because if you don’t get into certain depths of sleep, you will not activate that migrating motor complex. So make sure you have a good sleep hygiene, take it at night and that housekeeper phenomenon does this very large contractions, which move everything from the small intestine into the colon.  And that’s a physiological process, but for whatever reason, people with SIBO can lose that. And when that happens, it’s just a recurring hamster wheel. You can treat it during the day, and it grows at night.

Dr. Weitz:           I’ve seen a lot of cases where the patient who recur, have several layers of dysfunction. So we’ll do a stool test or find out that in addition to SIBO, they have some potentially pathogenic bacteria, or they’ll have a parasite, or they’ll have fungal overgrowth, and so I usually sequence it into several layers of treatment, maybe one period of time where we’re trying to work on their fungal overgrowth and one period of time where we are focusing on the SIBO. And I wonder, how often do you think that’s the case? Where you have layers of dysfunction?

Dr. Brown:          Well, I think that it probably happens all the time because … I inadvertently mentioned earlier the microbiome, which is the bacteria. But honestly Ben we should be talking about the multi-biome. It’s not just bacteria, we’ve got an interaction with the bacteria and fungus and even viruses and even some parasitic organisms. We don’t think about that a whole lot when disruption happens. So one of the things that gets talked about a whole lot is the fungal overgrowth or the candida phenomenon that was the … Before SIBO came on, I think everybody was using candida as the term. What’s fascinating to that is … I’ve been doing a lot of thinking about this and I’m going to publish something you can download from my website because there’s some misinterpretation of it. And when I really started looking at them at the multi-biome, one of the problems I always had was that people … Patients were coming in and they’re like, “I believe that I have candida overgrowth.”

                          And they would come in and I would explain to them, “Well, tell me what happens.” They would eat and they would bloat. Okay, so it is possible but it really sounds like more of a bacterial issue, bacterial overgrowth, and that’s when the pendulum starts moving over here. So I started to really think about that more, instead of just discounting it, I started looking into it more. And then I realized that when we have Candida albicans, which is the genus and species of the organism, when we had rampant AIDS before we had treatment and when we had chemotherapy, I would do endoscopy on people, And I would see their whole esophagus, stomach, and small bowel, essentially coated with white, white plaques everywhere.

                       Such an overgrowth that it was becoming to the point where it could … Once it crosses in the blood then it’s a systematic disease that will kill you very quickly. They never complained of these symptoms, they never had bloating, they never had this, they never had that. And so this wasn’t a GI situation. But really got me thinking, I’m like, “Well, what is the role of this multi-biome?”  Then I found some incredible literature where it shows that the fungus when it breaks down starches, it is a fermentation organism. It’ll produce the CO2. So carbon dioxide is what we use when I do colonoscopies and endoscopies, we use CO2 because it doesn’t stay in your intestines, it freely goes through the intestinal wall and you just breathe it out. So it can’t create the bloating.

                      And I’m like, “Man, this is crazy.” But then I realized oh, part of the multi-biome, the CO2 is the carbon backbone that the bacteria use to form the methane. So if an archaea actor and a Candida species are side by side, the Candida will produce the carbon backbone and the archaea will produce the methane and allow both organisms to grow more. So that’s where it was kind of the aha moment, I’m like, “Oh, we don’t have to separate it, we have to treat the multi-biome.” So you’ve already figured out that there are layers to this. And yes, if you treat the bacteria and you still have this abundance of Candida maybe they’re not creating symptoms but they’re creating the backbone for the bacteria to have a party and vice-versa. They have shown that when you treat people with antibiotics, obviously you will have this rise in fungus.

                     Just ask any woman that’s ever had the whole yeast infection after they get antibiotics, it’s exactly what’s going on, we disrupt the checks and balances. Same thing can happen, we have shown that if you treat just the fungus then you have a disruption and sometimes you’ll have a rise in the type of bacteria that you don’t want, they keep each other in check. So that whole thing that you’re talking about is brilliant and I think that we’re going to develop some protocols to treat these layers.

Dr. Weitz:            Interesting, we had a functional medicine meeting recently and we had Dr. Rahber who runs the Integrative Gastroenterology Center in Los Angeles, and he feels that a lot of cases of methane producing bacterial overgrowth is actually related to Lyme disease that leads to immune dysfunction.

Dr. Brown:          Oh, wow. Interesting.

Dr. Weitz:            And so as a part of his protocol before he’ll use Rifaximin or herbal anti-microbials, he’ll use a few nutritional agents to try to strengthen your immune system first.

Dr. Brown:          So I think that, that is another great take. So admittedly I am not a Lyme specialist and I always have this in the back of my mind because when I talk to infectious disease guys in Dallas, Texas where Lyme isn’t supposed to exist. Lyme is the candida, the fibromyalgia, the whatever, they …

Dr. Weitz:            The chronic disease de jure.

Dr. Brown:          The chronic disease de jure. And so when I started asking about Lyme … The reason why I started working up with it is because I’ve had several patients that have traveled to the Northeast, they’ll find somebody who’s a true Lyme expert, and they’ll find a different way to diagnosis this. So I always leave Lyme as a possibility, I just haven’t figured out quite, there’s only so many hours in the day, I’ll let those experts figure that out and then treat it. But think about this, so my research is headed this way. We now know that there is this overlap between IBS, food, and leaky gut, so when I talk leaky gut to my partners, and if a patient goes in and says that, they get laughed at. And the doctors stick their head in the sand.

                          So when I bring up leaky gut to my patients they’re always like … Because they’ve already found it on the internet. I mean everybody has information, they can listen to your podcast, they can hear your guests. They can do all that. What I like to address is the fact that leaky gut is intestinal permeablity, a more scientific way to say leaky gut. We know that bacterial overgrowth, infections, a protein called Zonulin and diet, and this gets back to the GMO, glyphosates things like that, they can actually affect the intestinal membrane. So normally you should have this very tight junction, and one of those things happens and it opens it up and allows some movement of energy of antigens, and so the way this works on the immune level.

                        And the reason I’m referring to this is because I think this is exactly what that the doctor you’re referencing was talking about the immune system. When you have a situation that is bothering the body, the dendrite, which is like a security guard, will reach a sample, hand it to a B-cell and go, “What do I do with this?” And the B-cell will look at it and be like, “Oh, that’s a normal bacteria, just ignore it.” Or the B-cell will go, “Whoa, this is Shigella.” And mobilize, sound the alarms, hands it to a T-cell. T-cell turns around, builds up all these antibodies, the antibodies drop and they get rid of the infection, which is what keeps us alive. The problem is that sometimes those antibodies will misinterpret our own body or something and then that’s the autoimmune process.

                       Well, what can happen with bacterial overgrowth, is that the dendrite keeps handing it to the B-cell and the B-cell is like, “I told you it’s normal, ignore it.” And the B-cell is like, “Maybe it’s not normal because it’s been around here so long, now I’m getting really angry.” Then it starts mobilizing the same process to fight infection, and that creates more intestinal permeability. And then all of a sudden you start having the patient show up with the extra intestinal issues, “I’ve got brain fog, I’ve got fibromylagia, I’ve got fatigue. I don’t feel right, something is wrong.” And if you let that process continue, then that becomes an autoimmune situation. All these people with autoimmune disease: thyroid, autoimmune liver, Crohn’s, ulcerative colitis and they’ll say, “yeah, it all started about seven years ago, I got sick and the belly started acting up and then these other things can of started showing up.”

                       That’s the explanation for celiac disease also and so on. So when it comes down to the immune system, anything that’s revving it up, which is what I think your doctor was referring to, if you’ve got Lyme disease, which is an intracellular organism that does a great job of avoiding the immune system but periodically could turn it on, then you have these little hypersensitive immune situations, and that’s my theory as to probably what he’s getting at with the Lyme disease. I’m going to eventually learn a lot more about that, but I think it’s all interplay. I think it’s part of that multi-biome.

Dr. Weitz:            Well, this may also be why there’s a connection between SIBO and ulcerative colitis and Crohn’s, which are the autoimmune intestinal issues, the inflammatory bowel disease. And why patients who have SIBO have an increased risk of getting one of those. And I’ve seen patients with say, ulcerative colitis or Crohn’s and then we treat them for SIBO, and their Crohn’s will get better and I think it’s because it’s probably decreasing that leaky gut and decreasing the additional stress on that autoimmune component.

Dr. Brown:          100%. And almost all my patients with inflammatory bowel disease are on this. I just got contacted last week, there’s a conference in Austin if any of your listeners are on there called Paleo f(x), and they’re going to ask me to give a lecture on this exact topic, with this interaction between all these things, trying to make sense it.

Dr. Weitz:            When is that going to be?

Dr. Brown:          April … It’s late April. Late April this year. April 25th, 30th. Somewhere around there.

Dr. Weitz:            Okay, cool.

Dr. Brown:          Yeah, Paleo f(x) 2018. There’s some … I’m on a little side stage. There’s some really cool speakers this year, J.J. Virgin is speaking, Joseph Mercola is speaking, Ben Greenfield, Rob Wolf, so I’m just honored that they kind of threw me in there also. I don’t think I’m on the main stage but … But I would love to have people learning about this, because I’m passionate about it and it’s an opportunity to sort integrate all that.

Dr. Weitz:            Yeah, that’s great. So it’s been a great podcast Dr. Brown. I don’t have any further questions. Any other pressing thoughts that you had that you want to get out there?

Dr. Brown:          I mean my deal is just keep an open mind, we’re still learning. I think that … My new research right now is getting into this whole aspect of leaky gut and brain inflammation. We do have a Facebook group where I would love to hear people’s opinions on this, it’s a closed group, really want very serious people the Gut Brain connection. And I believe and it’s not just me-

Dr. Weitz:            Is that what it’s called Gut-Brain Connection in Facebook?

Dr. Brown:          Yeah. Gut-Brain Connection Community. Yeah.

Dr. Weitz:            Okay.

Dr. Brown:          I love it because I did … I’m having some other functional medicine guys come on that can offer things. You should join also to go ahead and give your insight. And we’re going to go ahead and eventually we’ll get our podcast up and running and do a few things like that. We’ll have you on. I learned so much doing this, like now I’m going to go back, the layers you’re talking about is fantastic. I love the good that you’re doing for your community, and I think that we just make each other better, kind of iron sharpens iron.

Dr. Weitz:            Cool. And we also have a closed Facebook page, it’s called The Functional Medicine Discussion Group of Santa Monica, if you’d like to-

Dr. Brown:          Oh, really?

Dr. Weitz:            … Add your input. Yeah, yeah. We have a monthly discussion group, we have Dr. Vojdani speaking in a few weeks. So I’m really looking forward to that on autoimmune.

Dr. Brown:          Oh. That’s awesome.

Dr. Weitz:            So for practitioners and listeners who want to get a hold of you, what’s the best way for them to contact you?

Dr. Brown:          Easiest way is to KBMDhealth.com, just KB, KennethBrownMDHealth.com or just KennethBrownMD.com we’ve got both and we’ll be able to connect and do the usual stuff. I learned so much by having questions from people, because it makes me go look it up.

Dr. Weitz:            And where can they go to get hold of Atrantil? Where can that be purchased?

Dr. Brown:          Yeah just go to Lovemytummy.com

Dr. Weitz:            Okay.

Dr. Brown:          Lovemytummy.com or go to Atrantil.com. It’s A.T.R.A.N.T.I.L.com-

Dr. Weitz:            Where did you come up with that name? It sounds like some French cosmetic or something.

Dr. Brown:          We’re here in the studio that’s what it looks like right there. So we developed … I mean we basically developed this, it’s a first thing and so when you go to trademark a name, you will find that pharmaceutical companies have whole divisions where they will trademark thousands of names, and if you are phonetically or visually even close to them, then they will become trademark bullies and sue you. So you have to just do this word lab. So I was at my endoscopy center, we got about 30 employees. And I just put blank piece of paper up and I was like, “Come up with the name of my product.” And nurses would walk by and just write stuff. And eventually it came down to Trantil, just T.R.A.N.T.I.L..  I was like, “That makes me think that, that’s tranquil. I like that.” And we went to file that, our attorney said, “Listen, it’s too close to something. If you throw an A in front.” We’re like, “All right, we’re this far into it, let’s do it.” So now the A became our symbol here. It’s kind of a funny deal. It’s life lessons. I’ve never done a startup before, so we’re two years into it, it’s growing rapidly. I’m having fun but it’s just jumping one hurdle after another, that’s why when you say Iberogast, there’s probably … The CEO of that company is probably wrestling with the idea that a pharmaceutical company is hiding his product, they’re going to trying to stuff. They’re probably behind closed doors and he’s probably thinking, it was a whole lot more fun when he was just producing it helping people but-

Dr. Weitz:            I’m sure.

Dr. Brown:          … It’s life.

Dr. Weitz:            Okay. This is great Ken. Talk to you soon.

Dr. Brown:          All right buddy. Thanks.

Dr. Weitz:            Okay.