SIBO with Dr. Allison Siebecker: Rational Wellness Podcast 110

Dr. Allison Siebecker discusses Small Intestinal Bacterial Overgrowth with Dr. Ben Weitz.

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Podcast Highlights

2:20  Dr. Siebecker got interested in digestive disorders and SIBO in particular because she had IBS since she was five years old.  She started getting constipated and bloated and it got her interested in researching about health and medicine.  This also led to her starting her website 14 years ago, SIBOinfo.com to provide a comprehensive source for information on SIBO. 

4:45  If SIBO is the cause of IBS in 70% of cases, what about the other 30% of patients with IBS?  IBS has a set of non-specific symptoms that include bloating, constipation or diarrhea, or a mixture of the two, and abdominal discomfort or pain, at the minimum.  Figuring out the causes of IBS besides SIBO is where the differential diagnosis comes in and the causes include about 40 different conditions, including yeast overgrowth, parasitic infection, large intestine overgrowth or infection, H. pylori infection, celiac disease, non-celiac gluten intolerance, inflammatory bowel disease, IBD, carbohydrate malabsorption, like lactose or fructose, food intolerances, histamine intolerance, salicylate intolerance, hypchlorhydria (too little stomach acid), cancer of the adbomen, pancreatic enzyme insufficiency, diabetes, hypo or hyperthyroid, insufficient chewing, gastroparesis or stomach emptying, bile acid malabsorption, VIPomas, or Zollinger-Ellison Syndrome, any kind of obstruction in the small intestine, Parkinson’s, scleroderma, systemic sclerosis, Ehlers-Danlos Syndrome, mast cell activation, MCAS, mast cell activation syndrome, POTS, Lyme and co-infections, various immune deficiency diseases, and endometriosis.

8:35  And some of these can be co-existent with SIBO, which is why it may be a good idea to have patients with gut problems to do both SIBO breath and stool testing.  And for many patients who have several different conditions co-existing, like SIBO and candida, it is part of the art and science of medicine to figure out if you treat one first and then the other or try to treat both at the same time.

11:11  It is often thought that in SIBO you have an overgrowth of bacteria from the large intestine into the small intestine, made possible by decreased motility.  Dr. Siebecker thinks that while this is possible, she’s not convinced that this is what happens most of the time. She said that it is possible that the bacteria come down from above, up from the bottom, or that the bacteria that are already growing in the small intestine overgrow.  We have to keep in mind that we have bacteria entering into us constantly every day at all times, swallowing, eating, etc.  Dr. Siebecker mentioned that she spoke to Dr. Pimentel about this and he did say that the bacteria that are down in the large intestine do also exist there in the small intestine in very small amounts, and they could just be overgrowing right there. Dr. Siebecker suggested that if they are normal to the small intestinal microbiome, then we should stop thinking about them as large intestinal bacteria. 

16:05  There are bacteria that normally line our digestive tract, though the small intestine is supposed to be relatively free of bacteria (only small amounts of bacteria) since this is where much of the absorption of nutrients from our food occurs.  There are a number of mechanisms that have been discussed in the scientific literature that are supposed to help keep the bacteria count in the small intestine down: 1. Hydrochloric acid, 2. Bile, 3. Pancreatic enzymes, 4. Intestinal motility through cleansing waves via the Migrating Motor Complex (MMC), 5. the immune system centered around the digestive tract (the Gut Associated Lymphatic System, the GALT), and 6. the Iliocecal valve, which is supposed to prevent the bacteria from the large intestine from going backwards up into the small intestine.  I asked Dr. Siebecker which of these mechanisms she thought was most important and she said that the motility is most important, based on the scientific literature, which agrees with what Dr. Pimentel said in his interview.  Dr. Rahbar recently told me that with some of the difficult cases of SIBO, he believes that we are dealing with a dysfunction of the immune system.  Dr. Siebecker said that after motility, any physical obstruction of the intestines, such as scar tissue from trauma or previous surgery, can increase the likelihood of bacterial buildup. She said that after motility and structural, the immune system would be the number three factor resulting in SIBO.  We know that patients with immunodeficiency disease have an 18% increased risk of SIBO, while patients with HIV have a 88% increased risk of SIBO and there is a significant risk of SIBO with a number of other immunodeficiency diseases.  A lot of Functional Medicine practitioners when they see low IgA on a saliva or stool test will assume that this contributes to risk of SIBO and it probably does, but we don’t really know to what extent.  We also know that Lyme is an underlying cause for SIBO and this may be because it can result in nerve damage or because of the immune system deficiency that tends to occur.  Dr. Siebecker said that we don’t know much about the impact of digestive enzymes or of bile.  Hydrochloric acid is hotly debated in the scientific literature with some studies showing that the use of proton pump inhibitor drugs like Prilosec increase SIBO and other studies showing that they don’t.  She feels that PPIs must be a risk factor.  Dr. Siebecker feels that inadequate amounts of HCL allow excessive bacteria to grow in the stomach and some of this bacteria may spill over into the small intestine.  With respect to the importance of a properly functioning ileocecal valve in preventing SIBO, Dr Siebecker said that this too is very controversial.  She pointed out that there are patients who have had their ileocecal valve surgically removed when removing part of the intestine due to cancer or inflammatory bowel disease and they don’t necessarily get SIBO, as long as they have a functioning Migrating Motor Complex and their motility is intact.  They can also surgically create a fake valve and this has been shown to reduce SIBO. 

27:22  Dr. Siebecker often recommends specific herbs for treating hydrogen and methane gas forms of SIBO.  Berberine is one herb that’s often effective, but she recommends a higher dosage than many Functional Medicine doctors recommend–5 grams per day of berberine, split into several different dosages, which could mean taking 9-11 pills per day rather than the 2 or 3 pills per day sometimes recommended.  Dr. Siebecker usually recommends using two different individual herbs and the next herb she will often use for hydrogen SIBO is neem, specifically a product called Neem Plus from Ayush herbs.  She usually recommends six pills of Neem Plus per day. Another herb she will use is oregano, though she tends to use one that does not contain oil in a capsule, since oregano in oil in a capsule can sometimes be hard on some patients mucus membranes. She will tend to use ADP from Biotics at a dosage of 6 per day.  For methane SIBO one of the herbs will tend to be allicin, which is the active ingredient in garlic. She will usually use a product called Allimax Pro at a dosage of 6 per day.  She will use either a Berberine/Neem or Berberine/Oregano or Oregano/Neem for hydrogen SIBO and for methane one of the herbs will be Allimax or Atrantil.   

31:37  The Elemental Diet can also be very effective for SIBO and Dr. Siebecker said that she will typically see a reduction of gas of around 70-100 parts per million of gas lowering in a two week course. She prefers the dextrose version, since she has seen very sensitive patients react to maltodextrin. However, the exception is that this is not good for patients with yeast. 

34:00  Dr. Siebecker said that she finds patients often develop antimicrobial resistance to herbs and she will use different herbs for successive rounds of treatment, so she will usually not use the same herb for more than 6 weeks.  This is also why she likes to use single herbs, so she can reserve some herbs for later use, whereas with combination products that contain many herbs, she may not be able to use any of them for additional rounds of treatment. 

36:14  The most effective natural prokinetic formulas include MotilPro, Motility Activator, Prokine, SIBO MMC, and Bio.Me.Kinetic from the UK.  All of these contain ginger and some other products that are designed to stimulate the migrating motor complex.  As for the best dosage, Dr. Siebecker said that you can experiment with different dosage, but she says you should not go above 2000 mg of ginger per day, esp. since the ginger can burn the throat or cause reflux.  Then we have Iberogast. You can also consider combining them. The prokinetic pharmaceuticals include low-dose erythromycin, procalopride, and LDN, low-dose naltrexone.  The biggest challenge is that we have no way to gauge if the MMC has been stimulated or not by either natural or pharmaceutical agents.  The only way to test the MMC is with antroduodenal manometry, which is costly and invasive and not practical to use in clinical practice.  Taking charcoal and watching how long it is pooped out measures bowel transit, which is different than the MMC.  Several years ago Dr. Pimentel was working with a group that was developing an acoustic test for the MMC, but they decided not to use the device for this purpose, so it’s not available.  How quickly a patient relapses is probably a good way to gauge that their MMC is not working properly. 

44:17  There are some techniques for stimulating the vagal nerve, including manual techniques, which should help the MMC.  Dr. Siebecker said that she experimented with Dr. Kharrazian’s recommendations to gargle and to stimulate the gag reflex and she found no benefit.  There are some doctors who claim that you can use infrared laser and chiropractic adjustments to stimulate the vagal nerve.  Dr. Siebecker mentioned that the medication Prucalopride is a prokinetic that helps to regenerate the nerve.  Since the nerve damage in SIBO is coming from autoimmunity, LDN might help. Dr. Mona Morstein uses Acetyl-L-carnitine to help regenerate nerves, since it has been shown to help regenerate nerves in diabetic neuropathy.  Lion’s mane mushrooms might also help. Frequency specific micro current has been claimed to help. 

47:32  Some prominent Functional Medicine doctors use probiotics for patients with SIBO, often citing the antimicrobial effect of probiotics, while other doctors feel that is a bad idea to add bacteria when you are trying to get rid of too many bacteria in the small intestine.  Dr. Siebecker said that specific probiotics have been shown to help motility and most of the studies on SIBO and probiotics have been positive.  Dr. Jason Hawrelak has shown which specific strains are beneficial for reducing methane or for improving motility or for other effects.  Unfortunately, some of the specific strains he mentions are not available in the US. Dr. Siebecker explained that some Functional Medicine doctors say that no SIBO patient should take probiotics because you don’t want to add more bacteria. Other Functional Medicine doctors say that all SIBO patients should be given probiotics because they help to decontaminate the bad bacteria. Dr. Siebecker says that she is in the middle, a probiotic moderate. She has not really seen probiotics decontaminate the gut like some of the studies say, but she thinks that they could be helpful in some cases.

Dr. Siebecker said that she does not like using the 4 “R” program, since she does not think it’s a good idea to wait until the SIBO has cleared before starting probiotics.  The 4 “R” is a classic Functional Medicine protocol for treating gut disorders where you start with the Remove phase (kill the bad bacteria and parasites and remove foods that cause sensitivities), then Replace (pancreatic enzymes, hydrochloric acid, etc.), then Reinoculate (with probiotics), and finally Repair (using L-glutamine, aloe vera, colostrum, and other gut healing herbs and nutrients).  Probiotics could make some SIBO patients worse by the fact that probiotic bacteria make acids and then the bacteria in the small intestine can take those acids and turn them into gas. So if you wait to recommend probiotics until after the SIBO has cleared and the patients is finally symptom free, esp. after a long course of treatment, you could trigger a relapse.  You should be especially cautious about using prebiotics, so you should make sure that the probiotic product does not also contain a lot of prebiotics, since these can aggravate SIBO, esp. in large amounts.  But if you incorporate probiotics while you are using antimicrobials in the treatment phase and they aggravate the patient, you can stop and the herbs will help to check the symptoms.  Dr. Siebecker mentioned that she has recently started using serum bovine immunoglobulin, which she has found very helpful for her patients to repair the gut.



Dr. Allison Siebecker is a Naturopathic Doctor and Acupuncturist and she is very passionate about education.  She specializes in the treatment of Small Intestinal Bacterial Overgrowth and she teaches advanced gastroenterology at the National University of Natural Medicine. She has the most incredible resource of research articles and information about SIBO on her website, siboinfo.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 and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com.


Podcast Transcript

Dr. Weitz:                   This 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 Rational Wellness Podcast on iTunes and YouTube, and sign up for my free eBook on my website by going to drweitz.com. Let’s get started on your road to better health.  Hello, Rational Wellness Podcasters. Thank you so much for joining me again today for another episode of the Rational Wellness Podcast. For those of you who enjoy listening to this podcast, please go to iTunes and give us a ratings and review. That way more people can find the Rational Wellness Podcast. Also, there’s a video version on YouTube and if you want the show notes, and a complete transcript just go to my website drweitz.com.

Our topic for today is small intestinal bacterial overgrowth, which is the main cause of irritable bowel syndrome in approximately 70% of the cases. Today we plan to focus on how best to understand some of the mechanisms, the latest diagnostic methods, and to hopefully gain some new insights on which integrative treatments strategies work and don’t work. And to help us to take a deep dive into SIBO then with our special guest, Dr. Allison Siebecker, the Queen of SIBO. I feel so fortunate that I recently had the opportunity to speak to Dr. Pimentel, the King of SIBO, and now I get a chance to speak you.

Dr. Allison Siebecker is a Naturopathic Doctor and acupuncturist, and she’s very passionate about education. She specializes in the treatment of small intestinal bacterial overgrowth, and she teaches advanced gastroenterology at the National University of Natural Medicine. She also lectures all around the world at conferences, and she is the most incredible resource of research articles and information about SIBO on her website siboinfo.com. Allison, thank you so much for joining me today.

Dr. Siebecker:          Thanks, Ben, so happy to be here.

Dr. Weitz:                 How did you get interested in digestive disorders and SIBO in particular?

Dr. Siebecker:          Like so many people, it’s because I have the problem. I think, as far as I’ve known, I could recall I had what I now know to be IBS, since I was about five. It was interesting because I wasn’t born with it. My parents and family tell me I had normal function, like normal bowel movements and things like that. But after, somewhere around five or six, I became constipated and also had bloating. I never knew what it was. No one in my family knew what it was and I spent this whole time trying to figure it out. It’s not really why I went to medical school, but it certainly is what steered me in this direction.  I read various things and then I came upon the term, SIBO, and it just all clicked. But there was barely any information out there at the time. This was like 14 years ago or something like that. I can’t remember exactly how long ago. Then I just started researching and researching. Then that’s when I made my website, because when you would Google, or search, nothing would come up. There’s one Medscape article and there was … where you could get the test came up on page four. Then I made my website. Now, of course, my website is like, “Is it even needed?” Because everyone and their brother and their cousin has a site on SIBO. But it’s done its job. It helped people during the pinch when there was no info.

Dr. Weitz:                  No, it’s still a great resource, especially when you update all the most recent studies.

Dr. Siebecker:           Yeah, I’m so glad that you use that, because I work really hard on that. It’s very interesting to me. Every quarter I go through and anything new that’s been published on SIBO I put on my site. Especially, my favorite part of the associated diseases page.

Dr. Weitz:                  Right.

Dr. Siebecker:            God, you just wouldn’t believe the studies. Things you’d never even think of, like acromegaly being associated with SIBO and a study on it. It’s like, “Wow, okay.”

Dr. Weitz:                   Yes. Skin disorders, epilepsy, I had a woman who had seizures, she lost her driver’s license, and you fix the SIBO, and she’s better.

Dr. Siebecker:            Wow.

Dr. Weitz:                   I mean, it’s great. To start off with, I want to take a little bit of a side turn for a second. In 70% of the patients who have IBS, which is caused by SIBO, I wonder what about the rest of the other 30% or so. What do you think is probably the cause of their IBS?  Or is it SIBO that we haven’t been able to diagnose because we don’t have the new breath test, the hydrogen sulfide. Do you speculate about the other 30%?

Dr. Siebecker:            That’s such a good point that you bring up. The other 30% is the differential diagnosis, which just for any lay person listening, that just means what else could it be. This is what we have to go through in our heads. The differential diagnosis for IBS, irritable bowel syndrome, is huge. That’s because the symptoms are what is called, non-specific. The symptoms are bloating, constipation or diarrhea, or a mixture of the two, and abdominal discomfort or pain, at the minimum. At the minimum, right?

Dr. Weitz:                   Right.

Dr. Siebecker:            What causes that? Like so many things, right?

Dr. Weitz:                   Right.

Dr. Siebecker:             Right now, I just brought up in front of me, on my screen, just to remind myself the list that I compiled of the differential, and it’s got 40 conditions on it. I’ll just read a few of them.

Dr. Weitz:                  Sure.

Dr. Siebecker:           And some of them could be causes of SIBO, but some of them they might not be causing SIBO. They just have similar symptoms. We’ve got things like yeast overgrowth, parasitic infection, large intestine overgrowth or infection, H. pylori infection, celiac disease, non-celiac gluten intolerance, inflammatory bowel disease, IBD, carbohydrate malabsorption, like lactose or fructose. I mean people can have that and not have SIBO, and causes the exact same symptoms. Food intolerance, which most people typically think of as a protein type allergy, but there’s also histamine intolerance, salicylate, on and on. General hypochlorhydria, too little stomach acid that can be caused by 15 to 20 things just regardless of SIBO. Pancreatic enzyme insufficiency, diabetes, hypo or hyperthyroid, these have the same symptoms. Something as innocuous as … This does need to go on the differential for IBS, insufficient chewing.  I have all these dietician friends that tell me that’s the first thing they do when someone has IBS symptoms. They coach them on how to chew their food well, and be able to do that. Because, instead you just have the impulse to swallow real quick. And that a large proportion of their patients to IBS, so to speak, is solved by proper chewing. Then all the way on the other side of this differential diagnosis, we have got cancer, any kind of cancer of the abdomen, could create the same symptoms. And we’ve got, from the innocuous, to the very serious. There’s things like gastroparesis or stomach emptying, bile acid malabsorption, VIPomas, or Zollinger-Ellison Syndrome, any kind of obstruction in the small intestine, Parkinson’s, scleroderma, systemic sclerosis, Ehlers-Danlos Syndrome, mast cell activation, MCAS, mast cell activation syndrome, POTS, these are the New Kids on the Block. Everyone’s like, “Whoa, complicated patients might have these.”

These have the same symptoms. Lyme and co-infections, various immune deficiency diseases actually have the same symptoms, and endometriosis that’s a really common one. Lot of patients with SIBO will have that as their cause, the endometriosis, but even if you don’t get SIBO from endometriosis, it has extremely similar symptoms: swelling, bloating, pain, diarrhea, you can vomit from the pain. There you go. That’s not the complete list, but it’s just a massive differential.

Dr. Weitz:                  Right. And, of course, these can be coexistent with SIBO at the same time. You can have several layers of problem dysfunction.

Dr. Siebecker:            Most patients, that I see, have more than one thing wrong.

Dr. Weitz:                   Right.

Dr. Siebecker:            Same with you? Have you ever seen anyone with just one thing wrong?

Dr. Weitz:                  Sometimes, yeah.

Dr. Siebecker:           We have to keep that in mind.

Dr. Weitz:                  Right.

Dr. Siebecker:           The patients, a lot of times, are like, “What’s the one thing?” And it’s often more than one.

Dr. Weitz:                  Right. Yeah, I try to get all the patients with gut disorders, at the very least, to get a stool test and a breath test.

Dr. Siebecker:           Excellent.

Dr. Weitz:                   So we can start to put a couple of layers together.

Dr. Siebecker:            Excellent. The thing about this is that what I think happens to a lot of people with IBS, unfortunately, is it’s not investigated at all. Like this differential I was just reading, which SIBO would be on with the 60 to 70% prevalence. Than all these would have 30 to 40% prevalence. No one looks at any of them or, maybe, they look at one thing. Maybe the doc is advanced enough to check for SIBO, but if that was negative, then they don’t look at all these other things. So it’s, “Oh, you just have IBS.”  I guess the thing is, what really is IBS? I my mind, the way I think about it is, that it’s what would be left if absolutely every single one of these 40 plus things was ruled out. Which, of course, then that’s a burden on everyone, the system, and tests. It might not be practical to rule out all these things, but I’m just saying philosophically what is it? It’s still just a name for when you looked at everything and you don’t know what is causing these symptoms.

Dr. Weitz:                   Right. Then, of course, if you do find several different things, it’s a question of what do you prioritize? If there’s SIBO and there’s blastocystis hominis, or there’s candida, or there’s dysbiotic bacteria, or there’s worms. What do you treat first?  Do you treat both things simultaneously?

Dr. Siebecker:             Questions, just big old questions there.

Dr. Weitz:                   But that’s something that would be interesting to have some guidelines as a continuum, as to, “Okay. If it’s a parasite, treat that first. Then SIBO. If it’s you know.”

Dr. Siebecker:            Yes.

Dr. Weitz:                   But that’s part of the art and science of practice.

Dr. Siebecker:             Yes.

Dr. Weitz:                   When I was speaking to you at the Integrative SIBO Conference in Seattle, you said that you thought that we generally think that the bacteria in the small intestine have overgrown from the large intestine. That’s especially the story that Dr. Pimentel tells, because of a decrease motility and then you get this backwash. You said to me that you think that’s not what happens in a lot of cases. That the bacteria come down from above, is that right?

Dr. Siebecker:             Yeah. I don’t know, it’s just that I’ve read so many articles on SIBO, obviously. I’ve got two file cabinets full. I’ve read them all multiple times. It’s just that there’s this … Something hasn’t made sense to me, and I get a picture in my head. What seems likely to me is that all three things are possible in terms of top-down, bottom-up, or just from the small intestine itself. I do think it’s possible we can have a back migration, but I think it’s just as likely, if not even more likely, that the normal bacteria that are in the small intestine are simply not moved down and are overgrowing. And, also, we have bacteria entering into us constantly every day at all times, swallowing, eating, everything. They’re in the atmosphere. They’re everywhere.

Basically, think about it. How did our large intestines get colonized with these bacteria? Some say from vaginal birth. What if you weren’t vaginally born? They’re going to come from, somehow, the top-down and they’re going to be passing through us. What if then those bacteria just didn’t get the chance to move all the way down? What most experts say is that the way you say it’s SIBO is that the types of bacteria that are in the large intestine are now in the small intestine. That is a very strongly held opinion, but it is debated. It is debated. There are articles currently, in fact, just our symposium, our integrative conference in New Orleans, which was a year ago, we had two researchers discussing that. Discussing the oral upper respiratory bacteria. That being a form of SIBO as well.

Even though it’s what is generally held, I just want people to know that there are other people thinking other thoughts and publishing on that as well. I did talk to Dr. Pimentel about this, and ran some of my suspicions or thoughts by him, and he did say that the bacteria that are down in the large intestine do also exist there in the small intestine in very small amounts, and they could just be overgrowing right there. That’s an odd thing, because they’re really large intestine bacteria but then if they’re always there in the small intestine in small amounts, are they just large intestine bacteria?

Now, he’s just come out … Digestive Disease Week is occurring right now, a big gastrointestinal conference. He’s just come out with a full sequencing of the small intestine microbiota. He’s been working on new technology, and I quickly looked at those articles, but they were abstracts, so I don’t have the full information. Maybe this will become a little bit more clear now.

Dr. Weitz:                  Yes, yes. I had the opportunity to interview him, and he was telling me about that. That he’s mapping the small intestine microbiome.



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Dr. Weitz:                   There’s a number of factors that have been discussed in the literature that help to keep the small intestine relatively free of bacteria. As most of our listeners probably know, your colon is backed with tons and tons of bacteria, and there’s bacteria throughout our digestive tract, and in most of the mucosal surfaces of our body. But the small intestine is supposed to be relatively free of bacteria, because that’s where most of the absorption of nutrients occurs. So getting too many bacteria becomes problematic. There’s a number of mechanisms by which the body typically keeps the small intestine from having too much bacteria, and those include hydrochloric acid secretion, digestive enzymes, bile, motility, the migrating motor complex, the ileocecal valve, which, if it maintains its integrity, prevents the bacteria from the large intestine from growing in. And then 80% of our immune system is focused around the gut. That’s referred to as the GALT, and that also helps to keep the small intestine clear of bacteria.  I asked Dr. Pimentel about this and he’s a big believer motility is pretty much the main factor. He doesn’t think that the others are really important factors. I also spoke to Dr. Rahbar recently and he thinks that a lot, especially the problematic cases of SIBO, were really dealing with this function of the immune system, and that’s one of the underlying problems. What do you think? Do you think these factors can all play roles and which do you think are the most important?

Dr. Siebecker:                      Yeah. I think certainly what everyone else thinks, and what the literature supports, is motility and the anatomy or the structure of the body. The migrating motor complex probably being number one, and number two being the anatomy of the intestines allowing for the passage of bacteria down. The number one problem that would happen there would be obstruction, some kind of partial obstruction. If those things fail, we know it’s really high likelihood someone will get SIBO. That’s very well accepted.  But then when we look at all these other factors, there’s not a lot of studies to support, or there’s a lot of contradicting evidence. I also agree with Dr. Rahbar that, I think, the immune system would be number three, coming after structural and motility, as a very important factor. How important, I’m not sure. I actually brought up a chart. I want to give you the rates I have in one of my slides. The rates of SIBO immunodeficiency that have been published. We don’t have a ton of articles on this.

Dr. Weitz:                   Right.

Dr. Siebecker:                     We’ve got anywhere from about 18%, that’s for common variable immunodeficiency disease, up to 88% for HIV. That’s pretty extraordinary. If a person was to go and look at this article that was written on SIBO and HIV, one thing you would need to keep in mind is that the positive value for … They used culture. They used culture test for the diagnosis. The positive value for that has changed. This article says that it’s not very associated, because it was using the old standard, which was 10 to the fifth, or 10 to the sixth. Now, it’s been lowered to 10 to the three. So taken into account the 10 to the three is 88%.  Then we’ve got chronic lymphocytic leukemia 50%, actually, high. And various immunodeficiency diseases in children 41%. The thing about this is that these are all frank immunodeficiency diseases. I think what a lot of people wonder about is, what about when you see, like on a test, you see low IGA on a saliva test or stool test? What about that? And we just don’t know. I think what we can say is, “Yeah, I think it would be a risk.” I think it would. How much? We don’t know. At least, when we have these frank immunodeficiency diseases in our mind, these percents, we can maybe put it into perspective. But, for instance, with Lyme. We know that Lyme is an underlying cause for SIBO and there’s various theories as to why. One of them is the nerve damage that occurs, probably, from one of the co-infections. But the other is the immune system deficiency that occurs. And I think it’s an important factor.  I would put that as number three, after first motility, and then structural and, particularly, partial obstruction.

Now, bile enzymes, hydrochloric acid, these are … Not much is known about the bile and the enzymes. Hydrochloric acid, that one’s hotly debated. Really where it’s debated is with proton pump inhibitors. Deficiency of hydrochloric acid is actually well documented in studies. That it leads to an overgrowth of bacteria in the stomach, itself. That’s where the acid is missing. For me, the concept with how it would then lead to SIBO is then that overgrowth would just move on over, spill over, into the small intestine. If the migrating motor complex would be working, it could clear it out. We actually have studies that simulate this, where tubes have been put right into the upper small intestine with fetal bacteria, like an FMT type of situation, but those people have been shown to have a functioning migrating motor complex, and all the bacteria was cleared out and they didn’t get SIBO.  That’s the concept, I think, we’re working with here. Therefore, how much would hypochlorhydria effect? I think it would be a significant risk factor, if someone also had deficient motility. I could imagine a scenario like this. You have some deficiency of motility, maybe, not enough to give you SIBO, but you’re heading in the direction. You’re like, “You’re at risk.” Then you have the low hydrochloric acid. Together, it gives you SIBO. See, that’s what I would imagine.  Now, with the proton pump inhibiting drugs being such a highly popular prescribed drug, they, on purpose, create hydrochloric acid deficiency, and that is hotly debated back and forth, back and forth. For every article that comes out saying that they’re a risk factor for SIBO, another one comes out saying that it’s not. Just now, Dr. Pimentel’s team came out at DDW with one saying it’s not. I feel like this is going to go on forever. To me, if you’ve got half the articles saying it’s a risk factor, and half saying it’s not, I don’t know, to me, I feel there’s a risk factor there. I believe it’s a risk factor.

Dr. Weitz:                   Right.

Dr. Siebecker:             It puts at greater chance that’s all.

Dr. Weitz:                   Right.

Dr. Siebecker:             I don’t think it’s a major underlying cause.

Dr. Weitz:                    I spoke to Dr. Rezaie, who’s one of Dr. Pimentel’s associates, who spoke at one of our functional medicine meetings, and he discounted it as a possible factor, because he said that once the hydrochloric acid gets into the proximal part of the small intestine, it gets flooded with bicarbonate, so it would have no effect in the small intestine anyway. In other words, it gets neutralized.

Dr. Siebecker:              I remember you told me that and I thought that was so interesting, because I think he was thinking of a different mechanism here for how it would cause a problem. For me, I’m thinking of actual spillover.

Dr. Weitz:                    I was thinking it had an antibacterial effect.

Dr. Siebecker:              Yeah, right. I wasn’t thinking of it in that way. I had a different concept. But let me just think if there’s anything else. The ileocecal valve, now, that one’s also very controversial, because … You brought that up, right?

Dr. Weitz:                    I did, yes.

Dr. Siebecker:              Okay. Because I actually have … It might be interesting, if I bring this up. Let me just see here. There have been a lot of studies. Well, not a lot, but some that maybe show it’s not so obvious that it is, for sure, a problem. Again, I think what we’re looking at here is the migrating motor complex having the ability to compensate. We actually have some studies like that, where people have their ileocecal valve removed. But they have intact migrating motor complex, and they don’t get SIBO.

Dr. Weitz:                    These are people who had part of their intestine removed due to cancer, or IBD, right?

Dr. Siebecker:                      Exactly, exactly. Let me see if I can bring up the one. There was one that they had controls. Let me just see here. I want to see if I can find it. I’ll just read you what I have, because it’s kind of interesting. In a study of 17 children with bowel surgery, they found that the loss of the ileocecal valve was not associated with an increase risk of bacterial overgrowth. And another study looked at 40 patients with SIBO and concluded there was no significant difference between patients with, and without, SIBO and the presence of the ileocecal valve. Then there was this one that was … Let me find it. Eight resection patients … The ileocecal valve was removed because of cancer. This was the one, they had eight controls. They found then the distal small intestine, ileocecal valve, and proximal large intestine were removed, but the transit was normal. The small intestine transit was normal. The same as the healthy controls. There was no reflux from the large intestine into the small intestine, the remaining aspects.

Now, they didn’t look at SIBO, they looked at reflux, but they did not see it back migrating, and the motility was normal, and there’s more. There’s studies on children and everything. This is not to say it isn’t a risk factor. I believe it’s a risk factor, but I guess the concept to get across here is that risk isn’t a guarantee. It’s that it increases chances somewhat. Here are people that have their whole ileocecal valve removed and they didn’t get SIBO, but then other people do. I have patients who they have an absent ileocecal valve and they have continuous chronic SIBO.

It’s interesting, what they did find, actually, in the study with one of the children’s studies, was it had to do with the length of the small intestine that was removed. The more small intestine that was left in the body the lower the chance of SIBO. And, again, they didn’t say it, but my thought here is because then it could perform the migrating motor complex. It has the chance to do a clearing downward sweeping action. I would say for anyone who’s needing to have their ileocecal valve removed, there’s a couple things to ask for, and that’s to leave as much a small intestine as possible. And, also, there’s studies done where they reconstruct and create a fake valve. That actually also helps. Then there’s studies on which fake valve works better than the others.  If somebody is listening, and heading towards that in surgery, they can look into this.

Dr. Weitz:                    Interesting. Which are the most effective antimicrobial herbs for SIBO, hydrogen methane, hydrogen sulfide, et cetera?

Dr. Siebecker:             Well, there’s a whole bunch that we use that seem to have equal effectiveness. We use berberine containing herbs. You can buy products that just say berberine or berberine complex, things like that. But the herbs that have it are goldenseal, Oregon grape, things like that. That’s an excellent one.

Dr. Weitz:                   Does it matter if the product is from all those variety of different berberine containing herbs, or has the complete herb, or just a berberine extract? Do you think those are equally effective?

Dr. Siebecker:            I do. I’ve tried single herbs and I find them to be just as effective as a combination. The only difference, for me, with a combination is some people are quite sensitive. A lot of people with SIBO are very sensitive to really anything that comes in. So sometimes it’s nice to use just one item and not multiple herbs, because then if they become reactive you just have one thing to remove and figure it out. So that’s excellent. One thing I want to mention about that is that the dose for berberine, I have found, at least in my patient population, which is a bit more of a challenging, we need a pretty high amount. I use, and my colleagues use, five grams a day.

Dr. Weitz:                   Five grams, okay.

Dr. Siebecker:            In split dose, yeah.

Dr. Weitz:                  I was in milligrams.

Dr. Siebecker:            That’s it. It winds up being anywhere from nine to 11 pills. Now, a lot of my colleagues say three grams, 3,000 milligrams is plenty. But, I guess, the key thing I want to get across is, two pills a day, three pills a day, isn’t going to do it.

Dr. Weitz:                  Is that the same if you’re using it with one or two other herbs?

Dr. Siebecker:           It is.

Dr. Weitz:                  Okay.

Dr. Siebecker:            It is. Then the next one would be neem, N-E-M. The one we tend to use a lot is called, Neem Plus, I guess it has Atripla in it, which is really a mild prokinetic. Again, we’re adding extra things here, but people tolerate it very well. We use about six pills of that one a day. Then oregano. I tend to use one that’s not an oil in a capsule, because I find the oil in the capsule is a bit more caustic. Sometimes oregano is hard on people’s mucus membranes and it can hurt. Other people do fabulous with it, no problem. But the one that’s in a dry tablet seems to be tolerated by more people. Of that one, I use it in my-

Dr. Weitz:                  Which product is that?

Dr. Siebecker:            I use Biotics A.D.P. for oregano.

Dr. Weitz:                  Okay.

Dr. Siebecker:            We use six a day, again, of that. Then there’s allicin, the antibacterial aspect of garlic. The product we use is called, Allimed. It’s also sold as Allimax Pro. But that allicin company, they have three levels. They have Allimax, which is the lowest, Alliultra is middle, and Allimed is the highest. So we use the highest one, and that we use six a day of that. Now, that one is the one, the allicin, is specific for methane. The other three work beautifully on hydrogen. And, actually, the Allimed works well on hydrogen, but we don’t typically start with that because it’s more so for methane.

For myself, I will use two herbs at once. I would do berberine neem, or berberine oregano, or oregano neem for hydrogen. And then, when someone has methane, I will choose one of those three, and I will add Allimed. Another one we can use for methane is Atrantil. I can use that one alone sometimes, or I’ll just use it like the Allimed. Those are our main workhorses, and I find them all to have equal effectiveness. But I do just want to say, another point here is, a lot of docs, particularly those who are more primary care physicians, they’ll use combination formulas that also have herbs that work on yeast, and parasites, and viruses, big antimicrobial formulas. I talk to them, and they report good effectiveness with that. I just don’t go that way, because I’m not seeing that population. I’m seeing people that have already failed and I’m getting a bit more specific. But either method works well.

Dr. Weitz:                   What about the elemental diet? Have you found that to be effective either, by itself or in combination?

Dr. Siebecker:             Well, we don’t use it in combination. I mean, I guess there are some people that do, but that’s against Dr. Pimentel’s recommendation. He’s the doc who came up with this as a treatment for SIBO. It’s highly effective, highly, highly effective. I feel, in terms of killing, I guess it has equal effectiveness to herbals or pharmaceutical antibiotics. But it has that one advantage, which is that it can kill more in the same time period. So we’ll typically see somewhere around 70 to 100 parts per million of gas be lowered in one two-week course, a huge amount. It’s a special treatment, because it can safe time. Because a key thing to know, like the little gold piece, I figured out very soon into my SIBO specialty practices that both, herbs and pharmaceutical antibiotics, seem to lower gas, on average, around 30-ish parts per million per treatment course.   A treatment course for a pharmaceutical antibiotics is two weeks. A treatment course for herbal antibiotics is four weeks. It takes longer with herbs to get the same effect. Within those time periods, we tend to get around a 30 part per million decrease. It’s all they can seem to do. I mean, occasionally, of course you get something fabulous and through it. But elemental diet, on average, lowers about 70 in two weeks. It’s not a very pleasant treatment. A lot of people don’t want to do it, but you really have to think about this because if you’ve got high gas, that could be what could convince you. Then you just do that elemental diet.

Dr. Weitz:                  Do you prefer the dextrose or the dextrose free version?

Dr. Siebecker:           I like to use dextrose. Now, this is not for a patient that has yeast, obviously, or a strong history of yeast. This could be problematic. But the only reason why is because I have a lot of sensitive patients, and I’ve had a lot of patients who reacted poorly to the maltodextrin. Most formulas either have maltodextrin or maltodextrin with dextrose, which is glucose. I think those are all wonderful, but if you’re just truly asking … If I was going to pick on out of everything, I would probably pick a dextrose simply because I’ve had a lot of patients react.

Dr. Weitz:                   Right. Do you find some patients are developing antimicrobial resistance the way patients can develop bacterial resistance?

Dr. Siebecker:            You sent me this question ahead. This is to herbs, right?

Dr. Weitz:                  Yeah, to herbs, yes. They can’t tolerate oregano anymore, or they don’t react to it the way they used to.

Dr. Siebecker:            I find this in just about every patient I see. It is absolute norm. Now, this could be, of course, because I’m seeing people farther down their journey and they’re harder cases. So everyone I see is going to have this kind of thing. It is expected and the norm. I see it all the time. I constantly have to rotate my herbs, and this is another reason why I don’t like to use these huge formulas. Because then I’m exposing them to everything. I want to pick and choose, and I want to reserve herbs aside for future use, because most people need multiple rounds because of this high gas.

Dr. Weitz:                   And is the rate around four weeks, six weeks, eight weeks?

Dr. Siebecker:            Yeah, as I mentioned, for pharmaceuticals it’s two weeks, elemental diet it’s two weeks, herbal antibiotics it’s four weeks. Of course, we can stretch that out a bit, so we can go to three weeks for elemental diet, which isn’t the most pleasant, and pharmaceutical antibiotics, and six weeks for herbals. The question here is, well, why not just keep going and get the thing done? It’s because I find that it peters out. I’ve seen this over, and over, and over, and particularly for herbal antibiotics. I will see patients actually start to relapse while they’re taking the herbal antibiotics usually in around six to eight weeks. So I don’t usually go past about six weeks.  I know a lot of docs, standardly, will just give an eight week. In my patient population I can’t do that, because they actually begin relapsing. I certainly have seen some cases where people have been on three months of pharmaceutical antibiotics and it was still working and lowering, but that is not the norm. That is a rare circumstance. You just seem to not get anymore effect. You have point of diminishing returns after about three weeks for pharmaceuticals and six-ish to eight on herbals.

Dr. Weitz:                  What are the most effective natural pro-motility agents?

Dr. Siebecker:           Well, for the natural prokinetics … By the way, a funny thing here is a lot of the SIBO patients have diarrhea, so I specifically don’t say, “Promotility agent,” because they’re going to go, “I can’t take it.”

Dr. Weitz:                  Of course, exactly.

Dr. Siebecker:            Prokinetic, I like to use that term instead, and always try to tell the patients that have had diarrhea, or still do, that they can take it, because it’s not a laxative. It’s possible that it might give them a worsening of diarrhea, because pretty much anything you give could and certainly, as you’re stimulating the upper small intestine motility, it might. But, in general, we don’t see that it does that. For the natural ones, I don’t really see one of our options being more effective than another. I see it’s … We have ginger, which if you just use that alone, ginger root, it would be 1,000 milligrams at night before bed. Then we’ve got all these ginger containing prokinetic formulas. There’s MotilPro. There’s Prokine. There’s SIBO MMC. There’s Motility Activator. And from the UK there’s Bio.Me.Kinetic. Am I forgetting any? Did I get them all? I hope I did.

Dr. Siebecker:            Well, anyway. We’ve got all of those. Then we usually have things like fine HGT and a few other things that can help potentially stimulate migrating motor complex. Then we’ve got Iberogast. I would say they’re pretty equal. Mostly, we just really have the Iberogast, and then ginger or ginger containing formulas. For the pharmaceuticals we have … The main ones we use are low dose-

Dr. Weitz:                  Let me just ask you another question.

Dr. Siebecker:            Yeah, sorry.

Dr. Weitz:                  How easy … It seems to me that with the natural prokinetics, it’s hard to gauge their effectiveness, and a lot of patients don’t necessarily feel anything. I often wonder, “Should I be going up on the dosage?” Especially, maybe you have a 240 pound patient. What do you really think are … Take some of the popular ones, like Motility Activator, or MotilPro, what do you think is the most effective dosage?

Dr. Siebecker:            Well, it’s the same issue with the pharmaceutical prokinetics. No matter what, whether it’s natural or pharmaceutical, how do we know it’s working? This is so frustrating.

Dr. Weitz:                  We need a way to test motility.

Dr. Siebecker:            Yes. Very unfortunately there was this … Fortunately and unfortunately, there was this machine that was being developed. Right when I first talked to Dr. Pimentel, he was helping them run some tests on it. It wasn’t his development, but he was helping and it was acoustic. It was meant to be able to tell us about the migrating motor complex. I spoke to them, and they just decided not to use it for this purpose, at all. Apparently, it’s not even available. Honestly, I haven’t checked back and I should. We were all waiting for this. It was like, “This will be the way. We’ll be able to take a baseline, then give someone a product and check them again.”  Right now, the only way we would be able to know is two ways. One, you would send them for the costly, invasive, have to travel to it, antroduodenal manometry test, which is the way you test for the migrating motor complex. Then that’s performed as a functional test, at least the way Dr. Pimentel does it. You would test the baseline, then you would give them the product. Then you would test again. Can it make the migrating motor complex? Well, obviously this is not very realistic, right? Then what’s the other way we would know? We would know from watching how they relapse. How frustrating, right? When do they relapse? I mean, the best thing I can say about this is I would say for patients that are not doing badly, they probably-

Dr. Weitz:                  What about having them eat some charcoal and see how long it takes to come out in the stool?

Dr. Siebecker:            That’s transit. That doesn’t really have anything to do with migrating motor complex.

Dr. Weitz:                   Okay.

Dr. Siebecker:             Yeah. You’ve got several regions, very different motilities. Anyway, I would say that your relapse rates … If a person’s doing pretty good, they’re probably in the four, to six, to eight month range of relapse, even after a year. When a person is a chronic patient, they often will relapse at about a month or two months. You have to judge like that. If your patient is relapsing, they get better, and then they relapse at two months, that’s pretty average. Now you know, I got to try, and do something to make this better. Then you might increase your dose. You might add a second prokinetic. All the prokinetics, and I didn’t mention the pharmaceuticals, so just quickly, low-dose erythromycin, procalopride, and LDN, low-dose naltrexone. These are the main ones we use.

All of these, that I’ve mentioned, have different mechanisms of action and, therefore, can be used together. One thing, you just want to be very careful erythromycin, because it can prolong QT. But with these particular prokinetics, they can go together. But just anything you’re going to add with erythromycin, check it. Then I will do that. Then I might combine two. To your question, what about if somebody’s heavier weight, should you go up? You can go up. I wouldn’t go higher than 2,000 milligrams in a day of ginger. That’s just from reading studies. And for the low-dose that we use for pharmaceuticals, I wouldn’t go above the standard dose. But for erythromycin, the thing is, with that one, it’s the low-dose that really has the prokinetic effect. When you start going higher it actually doesn’t work as well as a prokinetic. I wouldn’t go above, probably, 100 milligrams two to three times a day on erythromycin.  For the ginger-

Dr. Weitz:                    Has anybody experimented with red yeast rice? Because I know Dr. Pimentel was talking about using low-dose statins, at one time.

Dr. Siebecker:             Yes. That’s different. What that’s about is not as a prokinetic. That’s about inhibiting methane gas formation. Then the idea would be your motility … Because methane gas causes constipation. It slows motility. This is a different mechanism, but people have and when I first did it, it was a little like I had some positive I thought. Then I had some negatives. Then when I really followed it out, I really didn’t have those positives. You know how when you do something, and you’re like, “Oh my God, it’s working.” Then there’s confounding factors. Then as you trace it through you’re like, “Wait, that wasn’t it.”

Dr. Weitz:                   Right.

Dr. Siebecker:             I actually feel better about the Atrantil for this purpose than the red yeast rice. Back to the question of, should you increase your motility activator? You can, just check that dose of ginger, and don’t go above 2,000. Yes, you absolutely can do that. One problem with those is that the ginger often burns people’s throats, so that can be a limited factor or causes reflux. In many patients I’ve had, they just want to drink water, because they like the effect of it. One last thing on this. There are patients that are sensitive enough that they can actually sense and feel a prokinetic working. And it’s an odd thing to describe, but, I wonder, you might have had some patients give you this feedback. It’s different from when somebody has a really excellent bowel movement, and they feel all cleared out, and they’re like, “Wow.”  But, yet, patients will say, “I feel cleared out,” but it’s not like a bowel movement. It’s like an upper clear out. And they’ll say, “Things feel different. Things feel like they’re working better.” It’s like the upper abdomen region and they get a good feeling, some patients. The vast majority, they can’t tell a thing. And one last thing, patients will often confuse this with bowel movement, and they’ll say, “Well, I’m not having a bowel movement anymore than I was before, so my prokinetic isn’t working.” It’s not supposed to give you a bowel movement.

Dr. Weitz:                   Right. Have you experimented with any of the manual or other techniques for stimulating the vagal nerve?

Dr. Siebecker:             I haven’t. Well, actually, I did experiment with gargling and gagging, like the classic from Dr. Kharrazian. And I found no benefit, at all, which has been confounding to me, because Dr. Kharrazian reports these amazing case successes, and I was dejected. It was like, “Why aren’t I seeing this?” Now, I did hear a lecture recently by Neil Nathan. He just came out with the book, Toxic. He was talking about polyvagal syndrome and various vagal issues. He did make this one comment that depending upon the reason of what’s wrong with the nervous system, and the vagus, and everything possibly those exercises just might not be targeted enough. There might be some more targeted treatments that would help. That’s about the extent of my experimentation.  Do you want to make a comment on this?

Dr. Weitz:                  We’ve experimented a little bit with using infrared laser, and chiropractic treatment, sometimes to the thoracic spine or the cervical spine. I’m not really sure if it helps or not.

Dr. Allison S.:             Well, if we’re on the subject of what could help nerve repair. I think there’s a few things that I would be aware of, and you might have others to offer. One is prucalopride, it is a neuro regenerative. That’s the prokinetic. That’s probably my favorite prokinetic that we have to offer, because of this. It actually protects nerves from damage and regenerates them. Then it also stimulates the migrating motor complex. I like that one. I think doing things that help protect from autoimmune damage, because a lot of people are having SIBO from autoimmune damage to nerves, like in the case of food poisoning, the most common cause of SIBO. That’s the mechanism there. Anything we can do to calm down autoimmunity, LDN, that’s another one of our prokinetics could help that. But then my colleague, Dr. Mona Morstein, she uses aceytl L-carnitine. She specializes in SIBO, but also diabetes and that’s been proven to help regenerate nerves in diabetic neuropathy, so that would be another option.  Then myself, and Mona, also have both spoken about Lion’s mane mushrooms has been shown to help do some nerve regeneration.

Dr. Weitz:                  Interesting.

Dr. Siebecker:            Yeah. Then, lastly, frequency specific micro current is something I’ve just recently been learning about. They have an enteric nervous system healing protocol and also a vagal healing protocol. They can heal a lot of tissues with frequency specific micro current. That’s one I’m getting very excited about.

Dr. Weitz:                  I’m loving this conversation, but I think only have time for one more question.

Dr. Siebecker:            Really, only one more? Come on.

Dr. Weitz:                   Unfortunately, the last question is going to be a big question. Probiotics, do you ever use probiotics, part of your treatment protocol, or after the treatment protocol?

Dr. Siebecker:            Yeah.

Dr. Weitz:                  I know it’s controversial. There’s a thought that any kind of probiotics is adding bacteria, and we’re trying to get rid of bacterial overgrowth. It’s a bad idea. There’s some prominent functional medicine doctors who feel like probiotics should be a frontline treatment because of the antimicrobial effects. Some functional medicine doctors say, “Well, I use probiotics, but I don’t use those. I just use soil-based, or I just use saccharomyces.” What are your thoughts about that?

Dr. Siebecker:            Exactly. Dr. Hawrelak, he’s wonderful on showing what strains have been studied, and he’s got some strains that … Or he’s educated an awful lot. Some bring down methane. There are other studies that show probiotics help motility and, maybe, even the migrated motor complex. It is really confusing. I am absolutely not opposed to probiotics. Most of the studies on SIBO and probiotics are positive. They show, actually, probiotics decontaminating, like decreasing the rate of SIBO due to antimicrobial aspects. I can’t say I’ve seen that in my patients. This is a case where, for me, the studies don’t match clinical. Although, I haven’t exactly tried the same strains, because a lot of them in the studies aren’t available, at least in the US.  That’s one of Dr. Hawrelak’s arguments. He’s always arguing for strain specificity and that you can’t just generalize, and say, “Well, I tried probiotics.” You have to try the exact thing that was in the study. I guess what I can say is this, I am not of the belief of one way or the other. There’s some docs who say, “No one with SIBO should have … There should be no probiotics used with SIBO.” And others say, “Everyone should use them.” I’m in the middle, because I just like to go by the case of the person in front of me and ask, because so many patients are very aggregated by probiotics. And my explanation for this with SIBO, would be cross-feeding, because when you give a probiotic it makes acids. Then other bacteria can then take those acids and turn them into gas.  I think that it’s possible for probiotics, through cross-feeding, to increase gas. And it’s the gas that hydrogen, methane, or hydrogen sulfide that causes the symptoms, primarily. You have other pathophysiology stuff, the number one. Sometimes it’s just going to be too aggravating. What I do is, I just ask, “How have you done with them.” I take a look at the brands they’ve had. I always want to see if they had one with a lot of prebiotics in it. Prebiotics can very much aggravate symptoms, especially if there’s a large amount.  I think, also, we can, on a side note here, we can use prebiotics. Certainly some are better handled than others and, especially, if you start very slow and go lowly high … bringing it high up slowly.  But, I guess what I would want to say about this is, my preference is to try probiotics while a person still has SIBO, while you’re giving antimicrobials. Because, if there is a real problem, you can be simply correcting with the antimicrobials. The other reason is because, in the past, I followed the classic thing that everybody does where you-

Dr. Weitz:                    The four “R” …

Dr. Siebecker:              Yeah, right. You mentioned this to me, where you give the probiotics when you’re done. I have a lot of problems with that. I seemed to relapse a lot of my patients. I didn’t forget it.  I felt so horrible and it isn’t my preference to wait and try probiotics after everything’s perfect.  I do not like to rock the boat, because these people are sensitive.  It took us a long hard time to get their tests cleared and get them feeling … I’ve challenged my … We work like eek, eek, eek to get them. Now, you’re at 80%. Now, you’re at 90. We got you to take all this time. I don’t want to rock that boat.  I would rather rock the boat when we’re in the middle of treating. That would be my personal recommendations. Try probiotics when you’re still treating. Of course, you can try them at anytime, but I’m just sharing what happens with me.

Dr. Weitz:                    So, basically, you’re saying the four “R” approach, which is almost like a Biblical verse in the Functional Medicine world. Probably first taught to us by Dr. Jeffrey Bland, maybe, the father of Functional Medicine. That, basically, we want to remove, replace, reinoculate, and repair. That protocol probably isn’t great for SIBO.

Dr. Siebecker:             I don’t think it exactly fits, but it’s not awful. Obviously, we’re doing the remove or the reduce.

Dr. Weitz:                   Right, with that microbials or antibiotics.

Dr. Siebecker:             The replace, I feel, a lot of people can start with the replacement right up front, because it helps the symptoms anyway. You don’t have to wait. I mean, but it’s still good. Then does everybody need that? Also, no, not everybody needs HCL, or the bile, or the enzymes. Again, you can just try, and see. Then the reinoculate and repair. Reinoculate, again, I might like to give that a test a little earlier. Then repair is nice too. The interesting thing is that there was these two studies done on SIBO and leaky gut. What they both showed … They both actually showed about a 50% rate of leaky gut and SIBO, which is surprising. I think most people would think it would be like 100%. I tested a bunch of my patients, and I also found a 50% rate. If we believe our tests.

Dr. Weitz:                  What test do you do for leaky gut?

Dr. Siebecker:            I was doing the Cyrex test, Array2.

Dr. Weitz:                   Okay.

Dr. Siebecker:            Because there’s issues if you use lactulose. That’s funny, because it’s the same test used for SIBO.

Dr. Weitz:                   Right.

Dr. Siebecker:            So you could get a false negative. But, anyway … All right. Anyway, then what these two studies showed is that they did nothing other than clear the bacteria. Then they retested one month after the bacteria was gone, the SIBO was negative. And close to 100%, in one study it was 100%, another it was like 80%, of the patients had their leaky gut … They were now healed. What this really shows us, if you remove the cause, if you really did identify and then remove the cause, the body heals, unless you some wound healing issues it should be able to handle it. Do we have to go in there and throw in all these repair elements?  On the other hand, if we get a cut and we put aloe on it, it heals faster. So, okay, I guess it’s just for discussion, right?

Dr. Weitz:                   Right.

Dr. Siebecker:            But I do think some repair things are nice. And I just want to share one of the ones that I’ve been liking the most recently, because I’ve tried so many things with my patients is actually the serum bovine immunoglobulin.

Dr. Weitz:                  Okay.

Dr. Siebecker:            I used to use colostrum all the time, and I’m finding that the IGG, that a purified IGG, is more effective. One thing colostrum has that purified IGG doesn’t is it has epithelial growth factors. And, honestly, that’s what I was really after with the colostrum. But I’m more excited right now about IGG than the whole product of colostrum. Just thought I’d share that.

Dr. Weitz:                 Okay, awesome. Unfortunately, I have a patient coming up here.

Dr. Siebecker:           Well, fortunate for them.

Dr. Weitz:                 How can our listeners and viewers get a hold of you, or find out about your programs?

Dr. Siebecker:           Yeah, so just my website is siboinfo.com. I would highly encourage signing up for the newsletter, because that’s where I put all the … It comes up quarterly, and then with event updates. Whenever there’s classes, or conferences, or something. That’s where the newest news comes.

Dr. Weitz:                  Awesome, awesome. Thank you so much, Dr. Siebecker.

Dr. Siebecker:            Thank you, Ben.

Dr. Weitz:                   Okay, talk to you soon.


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