Hydrogen Sulfide SIBO and SIFO with Dr. Preet Khangura: Rational Wellness Podcast 194

Dr. Preet Khangura discusses Hydrogen Sulfide SIBO (Small Intestinal Bacterial Overgrowth) and SIFO (Small Intestinal Fungal Overgrowth) with Dr. Ben Weitz.

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Podcast Highlights

1:34  Dr. Khangura learned about naturopathic medicine when his wife had some significant gastrointestinal issues and after multiple visits to the ER and to her family MD, who prescribed Proton Pump Inhibitors, she saw a Naturopathic doctor who really turned her health around. Dr. Khangura switched his career path from medical physics to naturopathic medicine with a focus on gut health.  Dr. Preet started exploring SIBO (Small Intestinal Bacterial Overgrowth) in Naturopathic college, even though it was not taught very well in Naturopathic school.  SIBO became one of the focus points of his practice from day one.

5:08  IBS (Irritable Bowel Syndrome) is a lazy diagnosis because it is really more of a label and it does not indicate the cause of the symptoms.  Conventional MDs will often say, “You just have IBS.” “You’re just going to have to deal with it.” “You’re just going to have to take a laxative.” “You’re just going to have to take a PPI.” 

7:04  While SIBO is the most common cause of IBS, another cause is pancreatic insufficiency, which involves a lack of sufficient digestive enzymes being produced like lipase, proteases and amylase.  One way to diagnose pancreatic insufficiency is to run a stool elastase test, and while 200 is the lab designated cutoff point, anything less than 500 is potentially indicative of the need for enzymes.

9:43  Some of the cases of patients with constipation, esp. if there is methane, can be some of the most difficult cases to treat till resolution.  While some constipation patients have methane overgrowth on the SIBO breath test, others may have a low level of methane that may not show positive on a breath test, but may still induce constipation.  For example, while on the SIBO breath test, the cutoff for methane is 10, perhaps it should be 3. You may have to get rid of virtually all of the methanogens to resolve the constipation.  One natural product that Dr. Khangura will use is an herbal tincture called the Tincture of Death, which contains a very concentrated combination of the three herbs: golden seal, myrrh and thyme.  Allicin extract can also be very effective.  Oregano can work and he likes the emulsified oregano formula from Biotics, ADP.  He also finds the combination of Candibactin BR and Candibactin AR from Metagenics very effective.  If he uses pharmaceuticals for methane SIBO, Dr. Khangura will use Rifaximin and neomycin or Rifaximin and metronidizole.  He may also use Amoxicillin/clavulanate or trimethoprin/sulfamethoxazole.

17:25  Biofilms. Bacteria biofilm is one of the reasons why we can’t eradicate the bacteria in stubborn SIBO cases. We need to pick a good biofilm disruptor and the best biofilm disrupting complex would be what’s called the Bismuth thiol complex.  It is typically bismuth subnitrate mixed with either DMPA or DMSA along with alpha lipoic acid and this is usually compounded by a pharmacy.  There are phase one and phase two biofilms. Phase two is a very mature biofilm that is much more difficult to disrupt.  There are metalloid lengths within the biofilm, which is what the Bismuth Thiol complex acts on by forming a wedge to open the biofilm.  NAC can be very effective and Dr. Khangura recommends a dosage of 1000 mg of NAC twice per day on an empty stomach.  A lot of practitioners will use enzyme formulas, like Interphase Plus, but these are pretty weak at opening biofilms and are probably better for prevention to prevent relapse.  If you are a practitioner that can’t prescribe DMPS or DMSA, Dr. Paul Anderson developed a bismuth thiol product without DMPS or DMSA that combines bismuth subnitrate with alpha lipoic acid and black cumin seed.  Dr. Khangura will often have patients continue with biofilm disruptors until they get a flareup of symptoms, which indicates that the biofilm is being broken up.  Dr. Anderson teaches that when the biofilm is broken, the bacterial colonies will become more active and they start fermenting more, leading to more symptoms.  It can be difficult to kill the bacteria until the biofilm is broken up.  Once the biofilm is broken, the immune system will more likely now activate to reduce the overgrowth. 

26:29  Erradication period.  To erradicate the bacterial overgrowth, Dr. Khangura will either use Rifaximin or herbals for 2 to four weeks and he expects to see some significant improvement in two weeks or he will not continue.

28:35  Dr. Khangura does not recommend patients to follow a strict anti-SIBO diet at the same time as the erradication process, since the bacteria may go dormant and produce even more biofilm.  It can help to use guar gum with rifaximin, since guar gum will feed the bacteria and make it easier to kill them.  The other reason is that if you have them follow a low FODMAP diet and put them on rifaximin and they feel 50% better, you don’t know which intervention worked.

31:36  Dr. Khangura recommends not giving broad spectrum probiotics to SIBO patients and he finds that most SIBO patients feel worse if they eat fermented foods like sauerkraut or drink kombucha.  The probiotics contain bacteria that can take up residence in the small intestine and studies have found that lactabacillus are hydrogen producers and have been found in 25% of cases of SIBO.  Dr. Khangura sees less issues with using bifido species and with spore based probiotics. 

35:15  Hydrogen sulfide SIBO.  While the flat line on a SIBO breath test might be an indication of hydrogen sulfide SIBO, Dr. Khangura finds that medical history and symptoms can often alert him to this condition. Patients may report a very pungent, rotten egg smelling gas that occurs on a regular basis or they may have an unexplained halitosis.  The new Trio Smart Breath Test, which also measures hydrogen sulfide gas, is not yet available in Canada, so Dr. Khangura has not been able to use it yet. 

The bacteria that produce hydrogen sulfide typically don’t feed on fermentable fiber or sugar, but they feed on foods rich in sulfur compounds, like garlic and onions.  Chronic or reoccurring UTIs occur from hydrogen sulfide producing bacteria.  Drinking well water is an easy way to pickup hydrogen sulfide bacteria if they’re not using UV light to kill the bacteria.  Some of the most common hydrogen sulfide producing bacteria are klebsiella, proteus, citrobacter, E. coli, and morganella.

For treatment of hydrogen sulfide SIBO, Dr. Khangura usually uses Rifaximin or Amoxicillin/clavulanate or trimethoprin/sulfamethoxazole.  Natural treatments for hydrogen sulfide SIBO include Uva Ursi, which is often used for UTIs.  He will have a good herb dispenser in Canada make a one to one or a one to two tincture of Uva Ursi, whereas most health food stores carry a one to four or a one to five, which is less potent. This herb does contain a hydroquinone, which some people worry might affect the liver, but using it for a few weeks he has never seen it cause a problem. Silver can also be very effective against hydrogen sulfide producers either as colloidal silver or silver hydrosol.  He may use a combination of Uva Ursi plus Silver Hydrosol.

47:30  SIFO (Small Intestinal Fungal Overgrowth).  Candida or other fungal overgrowth can occur in the small intestine or the colon or in other parts of the digestive tract. There is no breath test for SIFO for fungal dysbiosis. Stool tests might show yeast/fungus like candida in the colon and this might indicate fungal overgrowth in the small intestines as well.  While Rifaximin only works in the small intestine and does not affect the microbiome, other antibiotics like neomycin, metronidazole, Amoxicillin/clavulanate, and trimethoprin/sulfamethoxazole could make the fungal growth worse. If they have a chronic gastrointestinal fungal issue it may present systemically as oral thrush or fungal scalp problems or recurrent skin fungal infections or athlete’s foot, or recurrent vaginal yeast infections.  You can ask the patient how they feel after eating a candy bar or having a drink?  Fungal overgrowth can lead to the production of acetaldehyde, which can cause brain fog, a hung over feeling, nausea, tachycardia, increased heart rate.



Dr. Preet Khangura is a Naturopathic Doctor with an integrative and functional medicine practice at Juniper Family Health in Victoria, British Columbia, Canada. Dr. Khangura has a practice focus on treating gastrointestinal conditions, including SIBO – the #1 cause of IBS.  Dr. Khangura has also been educating doctors about SIBO at in person and now at online conferences. To learn more, here is a course that Dr. Khangura offers: Beyond Superseding SIBO.

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:                            Hey, this is Dr. Ben Weitz, host of the Rational Wellness podcast. I talk to the leading health and nutrition experts, and researchers in the field, to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness podcast for weekly updates. To learn more, check out my website, DrWeitz.com. Thanks for joining me, and let’s jump into the podcast.

                                                Hello Rational Wellness podcasters. Our topic for today is hydrogen sulfide SIBO and SIFO, and difficult SIBO cases with Dr. Preet Khangura. Dr. Preet Khangura is a naturopathic physician with an integrative and functional medicine practice at Juniper Family Health in Victoria, British Columbia in Canada. Dr. Khangura has a practiced focused on treating gastrointestinal issues including SIBO which is the main cause if IBS. Dr. Khangura has also been educating doctors about SIBO in person and now with COVID at online conferences. My goal for this interview with Dr. Khangura is to gain some insights into treating some of the more difficult SIBO cases. We would like to highlight the diagnosis and treatment of hydrogen sulfide SIBO and small intestinal fungal overgrowth in particular. Thank you so much for joining me, Dr. Khangura.

Dr. Khangura:                    My pleasure, thank you for having me.

Dr. Weitz:                          That’s great. Perhaps you can explain to our listeners how you came to become so interested in SIBO and in functional gut disorders?

Dr. Khangura:                    It’s kind of an interesting story. My wife always takes credit for it, of course. There’s some truth to that. Years ago-

Dr. Weitz:                          You’re not going to win by denying that.

Dr. Khangura:                    Exactly, that’s true. Years ago, before I even went to naturopathic medical school, my wife and I have been married for close to 14 years but we’ve been dating for 20 plus. In our early 20s she came down with some very significant gastrointestinal issues. It kind of came out of nowhere at such a young age and her hair started falling out, she started getting arthritic joint pains but it all started with very significant gastrointestinal issues. I had to take her to the ER a few times, of course they couldn’t find anything. Her family doctor was just prescribing her antacids even though she never had GERD. I was talking to my friend’s mother-

Dr. Weitz:                          That’s the classic treatment for everything.

Dr. Khangura:                    Yeah. Throw a PPI at it.  I was talking to one of my friend’s mothers over Christmas break one time and she said, “Oh that sounds like what our daughter dealt with last year. We saw this great naturopathic doctor that focused on gut health.” That sparked my interest. She saw a naturopathic doctor here in B.C. all those years ago, within three months completely turned her health around. That really sparked my interest in not just naturopathic medicine, functional medicine but gut health. At that time I was doing my degree in physics. I was going to go into medical physics but I totally switched gears. Went to naturopathic medical school and always had a sight on gastrointestinal disorders. When I started practice I started really diving into SIBO even in naturopathic medical school, even today, especially back then. SIBO’s not really taught very well even in naturopathic medical schools. I had to do a lot of it myself. I dove right into it and really focused on it since day one of practice. As you know, whatever we practice more of, that’s why it’s called practice, we get better at.

Dr. Weitz:                            Right. Of course, SIBO is one of those conditions that on the one hand seems like a really simple condition. We do have our cases where everything fits, they have the symptoms, you get the breath test back, you do your normal treatment, whether it be antimicrobials from the natural world or rifaximin or whatever. Then they resolve, end of story. Then we have our 50% or so of cases that don’t seem to come along so easily.

Dr. Khangura:                    Yeah, exactly, that’s exactly it. I see a ton of that in my practice because I do have expertise in SIBO and other GI disorders, dysbiosis disorder especially. I get a lot of these very stubborn cases referred to me. I’d say in my practice, more than 50% are the stubborn cases but that’s where you really learn as a practitioner and that’s why I try to get across in my courses and seminars for other doctors. Keep your fingers crossed that you get a really easy case because it’s good for you and the patient, of course. But where you’re really going to learn, especially the individualistic treatments for patients as opposed to protocols or blueprints are those patients where they’ve already tried this, they’ve tried this. The SIBO is not resolving or it’s coming back quickly or whatever it may be.

Dr. Weitz:                           Right. I heard you say that IBS is the lazy diagnosis, what did you mean by this?

Dr. Khangura:                    Yes. That ruffles a lot of feathers, especially more M.D. colleagues-

Dr. Weitz:                           Conventional GI docs.

Dr. Khangura:                    Conventional GI docs, yeah. Really what I mean by that is kind of tongue in cheek. Obviously it is a diagnosis however it’s more of a label than a diagnosis, kind of like fibromyalgia is a label, chronic fatigue syndrome is a label. There’s obviously always root causes to these conditions and digger deeper to find out that root cause, then you can actually treat that as your therapeutic target and actually not just mask signs and symptoms but actually resolve the case, hopefully, for these patients. The problem is, I’m sure you know this yourself, when the patients get that label of IBS, so many times that’s where the doctor stops. They just the word “just” quite often. They’ll say, “You just have IBS.” “You’re just going to have to deal with it.” “You’re just going to have to take a laxative.” “You’re just going to have to take a PPI.”

Dr. Weitz:                           Partially it’s a diagnosis of exclusion, they’ve excluded IBD, their scope is negative, there’s no parasites. It’s a functional gut disorder.

Dr. Khangura:                    Exactly. It’s becoming a lazy diagnosis because those doctors will stop at that point and give maybe some dietary recommendations. Now a lot of doctors are recommending the low-FODMAP diet and other things. But that’s really the extent they get other things to slow down the diarrhea or slow down the cramping or whatever it might be. That’s basically why I call it a lazy diagnosis. By no means is SIBO always the root cause of someone’s IBS. It’s definitely near the top of the list for a lot of the patients but of course there are cases of “IBS” that SIBO is not the root cause. But definitely SIBO should be there on a practitioner’s DB-

Dr. Weitz:                          What are some of the other causes of IBS besides SIBO?

Dr. Khangura:                    One that mimics SIBO extremely well, definitely a lot more rare than SIBO would be something like pancreatic insufficiency. This would be a condition where the patient’s pancreas is not producing enough of the digestive enzymes like lipase, proteases and amylase.

Dr. Weitz:                          How often do you think that happens?

Dr. Khangura:                    I couldn’t really give you a number but I have seen it a decent amount in my practice whether I suspected it and I prescribed actual prescription strength enzymes to see if it made a significant difference or we ran a stool elastase test which is very diagnostic of pancreatic insufficiency if the number comes back lower than usually a threshold of 200. It depends on what units they’re using. But-

Dr. Weitz:                          Actually I recently spoke to Dr. Stephen Sandberg Lewis. Even though the labs usually give 200 as a cutoff point, he feels that really a normal elastase should be over 500.

Dr. Khangura:                    Yeah, exactly. In that kind of gray zone, if a patient comes back with 300 I’ll still usually prescribe the enzymes just in case because the reason why it’s a perfect mimicker of SIBO is when you boil down SIBO, you get into all the patho-physiology, you can get into all the nitty gritty details of why we develop it, what happens, what bacteria is there. But really what it comes down to is over fermentation from an over pooling of bacteria in the small intestine. Now, pancreatic insufficiency, even if a patient does not have SIBO, they have a regular amount of small, tiny amount of bacteria in the small intestine but if they now don’t produce enough enzymes to break their proteins, carbs and fats down properly, the meals they’re eating are just sitting there in their small intestines much longer than they should be. Even that small, regular amount of bacteria can now over ferment the fibers and sugars that came in that meal because it’s just sitting there. They can produce SIBO-like levels of gas even though the actual community count isn’t at an overgrowth level.   That’s one that I’d say is almost a perfect mimicker of SIBO.  You’ll sometimes hear that, okay sometimes pancreatic insufficiency, they definitely are going to have diarrhea because of the fact that the food isn’t breaking down well, fats aren’t breaking down well.  The gut will send things out. We do see that very often, IBS-D caused by pancreatic insufficiency but I’ve had many constipation cases where pancreatic insufficiency was the big root cause.  Those are things also to watch out for.  It doesn’t always have diarrhea.

Dr. Weitz:                            I’ve found some of the constipation cases are some of the most challenging of cases. They often don’t fit the classic, they don’t have elevated methane and a lot of times getting rid of that constipation seems to be really, really tough.

Dr. Khangura:                    They can be, they probably are the most stubborn cases to crack. I find when we talk about methane, there is that big connection between methane production in the small intestines and slowing of the colon motility leading to constipation. I think the reason why they can be the toughest cases to crack is that if you do not resolve the constipation aspect, it can be very difficult to have the patient feel better even as you’re getting rid of, say, their hydrogen sulfide SIBO because if the colon motility is not very good and they’re not evacuating their bowels very well, they are going to have higher levels of discomfort, gas, bloating, just not feeling well, low appetite. Until you can resolve that constipation, if that means eradicating enough methane bacteria to do that, okay, great. But the problem is, as you probably know and your listeners may know is that there is methane producing SIBO and then there’s something called methane induced constipation. These can be two separate things. Obviously if someone has methane SIBO, they have an overgrowth of methane bacteria that can very easily lead to constipation, not always. It just depends on what else is going on.   But there’s some patients that have what’s called methane induced constipation where they don’t actually need a full overgrowth of the methane bacteria colony. They’re just the unfortunate subset of patients where they need a small amount of methane production to cause their constipation. You as a practitioner and any other practitioners out there may see this in SIBO breath tests where they say, “Okay, the cutoff for methane producing SIBO is between 10 to 12 parts per million of methane.” But then as soon as you see this fine print saying, “But some practitioners see 3 parts per million as a positive diagnosis.” But they don’t tell you positive diagnosis for what. Really, what they’re trying to say is some patients if they have constipation and they have at least 3 parts per million of methane, there can be a big correlation. Those patients can be really tough.

Dr. Weitz:                            When we see those recommendations for how these tests should be interpreted, like the North American Consensus, that’s a consensus of different doctors that had to all agree. I’ve spoken to Dr. Pimentel before, he had recommended a cutoff of three but the consensus was ten.

Dr. Khangura:                    Yeah. That’s exactly it. That’s something I brought up in a lecture I did the past summer I did on breath analysis. Really what the real data shows and how this consensus was just decided by a group of docs based on some research but the research is quite flawed in some ways. I do agree with Dr. Pimentel with the whole three parts per million aspect because I’ve had many patients where we have to eradicate virtually all of the methane bacteria in that small intestinal tract before that constipation resolved. Until we can do that, the patient was getting some benefit in a lot of these cases because we were getting rid of maybe some other problems, hydrogenic SIBO, whatever else. But because they were not able to move their bowels properly until we were able to eradicate enough of the methane bacteria, archaea technically, then these sometimes can be the tougher cases.    What I also will mention to practitioners is that if you have a patient that has methane induced constipation where you need to get their methane levels down to below three parts per million, these are also cases that their constipation will very likely relapse very easily because it won’t, even if you have them on a good pro-kinetic and you’re doing all these good things. The reason being is that it won’t take much over pooling or re-pooling of methane archaea again to get back to three parts per million and all of a sudden they get constipated again. Even if you’re able to resolve one of those cases, you’ve got to be on top of even prophylactic treatments and good prevention- [crosstalk 00:13:51]

Dr. Weitz:                          What are your favorite prophylactic or what are your favorite treatments for breaking the constipation cycle until you eradicate the methane?

Dr. Khangura:                    The way I look at it is, if I do suspect that the methane growth and methane production is the cause of the constipation, eradicating that growth is the treatment that I go with. Of course, you could do things like some pro-kinetics that can help colon motility, like prucalopride for example. You can get their bowels moving in a sense artificially because you’re inducing the contractions or even other over the counter laxatives or high dose magnesium or senna, whatever it might be. That’s not getting to the root cause. The way I look at it is, if a patient needs to be on something as we begin treatment just to get their bowels moving otherwise, only going twice a week or something like that, I’m fine with them remaining on something like that at the beginning but my goal is to eradicate the methane archaea to a point where they don’t have to be on those laxatives anymore, they don’t need the actual pro-kinetic to have a bowel movement. That’s where there’s a lot of confusion on what a pro-kinetic is for. It’s really for retraining the migrating motor complex contractions as opposed to making sure patients have bowel movements. That’s the way I look at it. If that means using pharmaceutical antibiotics, if that means using specific herbal extracts to kill the methane archaea, elemental diet, picking the right agents in that scenario.

Dr. Weitz:                          What are your favorite herbal agents for killing the methane?

Dr. Khangura:                    For the methane? I have this one tincture, I just call it my SIBO tincture.  A lot of docs here in Canada, they know it by the name Tincture of Death.  It goes back to a story of one of the first patients I gave it to, I asked them, because the tincture has a really strong taste. I go, “How did you handle the tincture?” He goes, “Oh, you mean the tincture of death?” and I go, “What do you mean by that?” He goes, “Well, it obviously worked at killing the bacteria because I’m feeling better but it also tasted like death.” I’m like, “Okay.” Basically I just call it my SIBO tincture, calling it the Tincture of Death is a great marketing ploy. Basically this is personally what I use and a lot of docs I taught use it but it’s a very concentrated combination of the three herbs golden seal, myrrh and thyme. Some docs do equal parts, I do a little bit more of the golden seal and myrrh than the thyme in the tincture. But that tincture I’ve seen work over and over for methane overgrowth. Also it can help with hydrogenic overgrowth. Probably not the best choice for hydrogen sulfide overgrowth, which we can get into in a little bit. But that tincture I use quite often.  Allicin extract can be good, I specifically use a product called Allimax.  A lot of docs know about that one.

Dr. Weitz:                          We use the same one.

Dr. Khangura:                   That one can work well in some cases. You’ll hear that oregano is better for hydrogenic SIBO.  It’s definitely not black and white. I’ve seen oregano work well for methane overgrowth. There’s a very specific emulsified oregano that I use called ADP emulsified oregano from Biotics Research. That’s a good one. I’ve seen that one work well. Of course there’s other good formulas that can work, Candibactin AR, Candibactin BR products when used in combo they can work. There’s a lot of options. Definitely the methane archaea will be tougher than the hydrogenic bacteria. But if you use the right agents, then you can hit them pretty good.

Now, the caveat to all of this is whether it’s hydrogenic, hydrogen sulfide or methane producing SIBO. I talk a lot about this when I do my courses is biofilm production. Bacteria biofilm is, in my opinion, the number one reason why we see a lot of those very stubborn SIBO cases out there where you can’t even start an eradication. You either give them rifaximin or neomycin. Rifaximin and metronidizole, you give them all these herbs but the SIBO is just not budging. You retest, the numbers aren’t getting better. They even may be getting worse. Bacterial biofilm is definitely a big problem in a lot of these cases. A good, good biofilm disruptor, no matter what you pick to kill the bacteria, a good biofilm disrupting agent is key for a lot of these cases.

Dr. Weitz:                          What are the best biofilm disruptors?

Dr. Khangura:                    There’s some very simple single ingredient things you can use. But by far, the best biofilm disrupting complex would be what’s called the bismuth thiol complex. Bismuth like the bismuth that’s in Pepto Bismol. But it’s a little bit different version of it. It’s bismuth sub-nitrate as opposed bismuth salycilate. But the Bismuth vial complex is bismuth sub-nitrate mixed together with either DMPS or DMSA. One or the other and also alpha lipoic acid. ALA- 

Dr. Weitz:                          Is this something that’s compounded?

Dr. Khangura:                    This is something that has to be compounded. Here in Canada there’s a couple of pharmacies that do compound it for clinicians. I know in the states there’s some pharmacies that do a lot of this product as well. This product has had some good research on it showing that … There’s two different forms of biofilms.  There’s phase one biofilm, there’s phase two biofilm. There’s a lot of agents that can work on phase one biofilm, especially a lot of natural agents.  But once the biofilm gets to phase two, essentially what that means is, it’s very much matured biofilm. It’s been getting produced for many, many years, at least many, many months. There’s significant amounts of metalloid lengths within the biofilm, you need something better than what can open up the phase one biofilm. That’s where the bismuth vial complex comes in.

                                                When the compounding pharmacy mixes the three ingredients together in the right ratio, the ALA and the DMPS will bind tightly to the bismuth sub-nitrate and this will form one whole new agent. It’s not like taking three separate, really awesome biofilm disruptors, they’re actually all really mediocre at opening up biofilm but when they combine they form this one whole new agent. In an analogy sense, it forms a wedge that opens up the metalloid lengths and it’s been shown to open up phase two biofilm, at least at this point, probably the best compared to anything else. But if you weren’t going to use that or you couldn’t use it, then something as simple as NAC can work very, very well. Very good research on that with inhibiting biofilm protection and also opening up biofilm. There will be cases where it fails, if it’s significant phase two biofilm

Dr. Weitz:                          What dosage do you like for the NAC?

Dr. Khangura:                    I typically will do a little bit higher dose than we normally do for NAC. 1,000 milligrams twice a day empty stomach. Empty stomach for any disruptors is important to get to the gut biofilm including the bismuth vial complex you want to do empty stomach. A lot of people will talk about enzymes. They’ll do enzyme formulas to open up biofilm. They’re pretty weak at actually opening up biofilm. They’re more so for prevention so they can inhibit biofilm production by the microorganisms. In a lot of cases, especially my cases that have been pretty tough to crack or I do see we can solve it but there is a relapse rate that happens, a lot of times we’ll put patients on these enzyme formulas or lower dose NAC long term after we actually resolve the case just to inhibit more biofilm production as time goes on.

Dr. Weitz:                          Which is your favorite enzyme formula?

Dr. Khangura:                    If I was going to use an enzyme formula, I don’t use it often because I’ll typically prescribe the bismuth vial complex but there is, I’m forgetting the actual name of the product now but it’s made by the company Klaire Labs.

Dr. Weitz:                          Yeah, yeah. Interphase Plus.

Dr. Khangura:                    Interphase Plus, yeah. That would probably be one of the better ones and then here in Canada there’s one called BioFilm X by Vita Aid, which is a fairly similar formula to that one. But like I said, if I had to choose and I wasn’t using the bismuth vial complex, I would still pick high dose NAC over the enzyme formulas.

Dr. Weitz:                          I think Paul Anderson developed a bismuth thiol product that just doesn’t have the DMP-S or DMS-A.

Dr. Khangura:                    That’s exactly … Thanks for bringing that up because I was going to say that an alternative if you’re a practitioner that can’t, let’s say, prescribe the DMPS or DMSA, Paul did formulate for the comfortable Priority One and it’s a product called Phase Two Biofilm which has the bismuth sub-nitrate which is just over the counter and then alpha lipoic acid and then black cumin seed. The black cumin seed will bind to the bismuth in a similar way as the DMP-S but just not as tightly and as strong but it’s a very good alternative formula.

Dr. Weitz:                          Okay. You use that for which forms of SIBO? Or all of them?

Dr. Khangura:                    Pretty much all of them because virtually all microorganisms produce biofilm directly including fungal species, candida species. They produce a lot of biofilm when they co-colonize with certain bacterial species. I’ll use a biofilm disruptor pretty much with every SIBO case. Now, not all SIBO cases need it but I like to hedge my bets because if I do a very well rounded treatment on a patient and two or three weeks later they tell me they’ve had zero resolution of any symptoms, zero improvement at all, then the next step would be, “Well, we probably should have done that with a biofilm disruptor. Let’s try again.” I’d rather not do that. I’ll do the biofilm disruption along with the eradication agents. In some cases what I’ll do is, especially if it’s a case that comes to me and I see in their history they’ve already tried everything under the sun for their SIBO and their SIBO is very much there still, I’ll do very good biofilm disruption like bismuth vial complex all by itself for a set period of time before we even go back to eradication. There’s going to be some cases out there that are going to need extensive biofilm disruption before anything is going to work. I have cases where three, four months of biofilm disruption and then we go back to something they’ve already tried. All of a sudden they get full resolution. 

Dr. Weitz:                            How did you decide that three or four months is the right amount of time?

Dr. Khangura:                    Yeah. For some of these cases I’ll have them stay on the biofilm disruptor until they get a flareup of symptoms. Paul teaches a lot about this as well. Basically what happens is when biofilm is produced and these colonies are living within it, it actually can inhibit how bad that patient’s SIBO symptoms are because what happens is the colonies are living within the biofilm and then when that patient eats, only some of the SIBO comes out of the biofilm to feed. The rest stays behind, dormant and protected in the biofilm. It actually limits how bad the fermentation can be. When you put a patient on just biofilm disruption, a lot of times I’ll tell them, “You’re going to stay on this until you get an unexplained flareup of your symptoms.” A lot of these patients, they don’t believe me because their symptoms are already quite significant. How could it get worse? It does. When this biofilm opens up, all of a sudden there’s two things that happen. One is the actual colonies, the overgrowth actually become more active. They’re going to ferment more. They’re going to give you more symptoms.

                                                But the other thing that happens is that the gut’s immune system can now activate against the overgrowth, because that’s one major reason why bacteria produce biofilm isn’t just to adhere to a surface, it’s to protect themselves from your immune system, from the environment, whatever else is out there. For two reasons the patient might get a flareup. Gut’s immune system activates, the actual overgrowth gets more active and I tell them, “We’re looking for an unexplained flareup so it’s not because you change your diet, it’s not because you’re getting sick. You’re doing your every day old thing and all of a sudden for the last two or three days you thought your bloating was a 10 out of 10, it’s a 12 out of 10 now. Diarrhea has increased, constipation has gotten worse, whatever it might be. That’s when I’ll add in the eradication agent. When I talk about those cases that took three or four months, those are cases where the patient had enough patience to stick with that protocol until they got that flareup. It can be tough, I don’t lie about that because the patient is like, “Okay I’ve been doing this for a very long time, I haven’t got that flareup you told me is coming.”   Sometimes practitioners will start the eradication before that flareup. Sometimes it still works because the flareup isn’t always distinct but it can be very distinct. It’s a good hallmark so you know it’s time to start the actual eradication.

Dr. Weitz:                            For eradication agents, rifaximin we know is 10 days or 2 weeks, but what about when you use herbal agents? What length of time do you usually prescribe them for?

Dr. Khangura:                    Regardless if I prescribe pharmaceuticals or herbal agents, I’ll prescribe about two weeks’ worth at a time. Some cases I’ll do up to four weeks because we already have a history, you already had an idea that this body will take more than two weeks. I know that the patient is okay with these agents, there’s no side effects I’m worried about or anything like that. But in general I’ll break down treatments into two week chunks because the way I look at it is, if a SIBO treatment is working, actually working at a significant level, even if it doesn’t completely resolve someone’s SIBO case in two weeks, which is very common that it doesn’t, you want to still see at least moderate to good improvement with that treatment protocol you have set. I know a lot of practitioners will give a patient six weeks of the same combo of herbs and then say, “We’ll chat in six weeks.” Then they find out in six weeks that did nothing in those six weeks. It was a waste of time, also a waste of the patient’s money because if that combo was going to work, they should see some improvements within the first couple weeks. It may only be 20, 30% or it might be 80, 90% or anything in between. You want to see some improvements. I’ll still prescribe in that manner. Then go from there. But there are cases where I do prescribe for longer.

                                                When it comes to pharmaceuticals, typically it is a maximum two weeks at once. Herbs, sometimes I’ll go longer than two weeks. Rifaximin is very, very safe in general when it comes to antibiotics. If you were going to do an antibiotic for more than two weeks at a time, that would be the one that I wouldn’t be too worried about at all. It doesn’t absorb. It’s pretty much inactive in the large intestine. It doesn’t eradicate where you want to keep bacteria. But those other antibiotics, neomycin, metronidazole, amoxi/clav, trimethoprin/sulfa, all those other ones, definitely I wouldn’t prescribe more than two weeks at once. You just want to make sure you’re doing more good than harm, of course.

Dr. Weitz:                           Do you recommend specific dietary changes at the same time as the eradication process?

Dr. Khangura:                    My recommendation is not to do a strict anti-SIBO diet, not to do a strict low-FODMAP diet, biphasic diet, whatever anti-SIBO diet that the practitioner uses. Dr. Pimentel talks about this a good amount as well. It actually has to do with biofilm. If you do a very strict anti-SIBO diet, however you classify it, what can happen is the bacteria can produce potentially more biofilm because you’re not feeding them as much. They start to produce more biofilm, they start to go more dormant. There’s that research that a lot of people cite and quote about rifaximin with guar gum showing that rifaximin works better if you give guar gum with it. Essentially what the research was showing- 

Dr. Weitz:                           I think in the U.S. they call it guar gum. 

Dr. Khangura:                    Guar gum? Tomato, tomato. Basically what the research is really showing is that if you bring the bacteria out to feed by giving that gum, the rifaximin will hit the bacteria better.

Dr. Weitz:                            I think that’s the main reason why Dr. Pimentel actually recommends not restricting the diet-

Dr. Khangura:                    Exactly.

Dr. Weitz:                            … because antibiotics work by acting on the cell walls during replication. If the bacteria happily fed, they’re going to be reproducing so it will be more effective.

Dr. Khangura:                    Exactly, yep.

Dr. Weitz:                            But we don’t know that herbs are going to work the same way. In fact, we don’t think that they do.

Dr. Khangura:                    They might not but the way I look at it is there’s another reason why I don’t have patients do one of those strict anti-SIBO diets, especially if the patient has never done it before. If they come to me saying, “I’ve been doing a low-FOBMAP diet for three months straight. It helps reduce my symptoms by 50%.” Okay, we have that benchmark, we know what that diet is doing. We then know if they only get better with the antimicrobials that they are actually doing something. Whereas if a patient has never done that diet before and I’m starting them on eradication and I say, “You know what? You’re also going to do a low-FODMAP diet.” Then in two weeks they tell me they’re 50% better, at that point I don’t know how much is because they’re not feeding the bacteria or how much is because the eradication is working. Then you just have to figure that out. I’d rather not do that. The thing is, it’s not like I tell patients or Dr. Pimentel tells patients to do the opposite of the low-FODMAP diet. Just go nuts on high FODMAPs. Patients aren’t going to feel well if you do.

                                                It’s really about just having some fermentable fibers or sugars in those meals, especially the ones they take the antibiotics with or even the herbal microbials just to cover your bases, just enough that this can potentially help. If they only get better with antimicrobials and you’ve done nothing to the diet, then you know the antimicrobials are very likely the reason for that. There’s actual eradication occurring. That’s the other reason why. There’s certain things I still tell them not to do. For example, there’s that controversy over probiotics and SIBO. What I will say is it’s not black and white but what I do see is that most patients with SIBO will do worse with broad spectrum probiotics. Not always the case but-

Dr. Weitz:                          Dr. Ruscio is a huge fan of using probiotics.

Dr. Khangura:                    I know.

Dr. Weitz:                          His first line for SIBO.

Dr. Khangura:                    That’s one place I think we disagree on. Really what it comes down to is we can all have theories on it but it also is patient experience. A lot of my patients, when I ask about do probiotics make you feel better, no different, worse? This is before I even mention the word SIBO to patients, the patient might not even know what SIBO is. So many patients that have SIBO will say, “That’s interesting you say that because I’m told to take probiotics and I get worse when I take them.” Or this is the dietary thing I tell them not to do, “I’ll drink kombucha and I’ll feel horrible.” Or, “I started eating sauerkraut every day and I just felt worse, worse and worse.” They’re just probiotic foods. Those type of foods I will tell SIBO patients to actually if they are eating to limit them or completely eliminate because if taking a probiotic is actually making their SIBO worse, we’ve got to eliminate those probiotic foods at least while you’re trying to deal with the SIBO. It doesn’t mean they have to eliminate them forever but at least at that point because it’s counterproductive otherwise.

                                                Now, the reason why probiotics may make SIBO worse, it all comes down to the root cause of developing SIBO. It’s not the same for everybody but the majority of SIBO patients is because their migrating motor complex or their phase three contractions of their migrating motor complex have become weakened. Aka the sweeping action of the small intestines. If they’re putting a bunch of bacteria in through the oral route and they’re not being forced into the large intestine where they’re supposed to go and they’re just pooling in the small intestines, they’re still fermenters. They’re still gas producers. They’ve done separate studies on SIBO patients and one study quite a few years ago found that 25% of the SIBO patients had lactobacillus overgrowing. They’re still hydrogen producers. That’s the side I’m on when it comes to probiotics and SIBO.

                                                Bifido species I’m not so worried about because bifido species, they never really have been implicated in causing SIBO, like in separate studies. They don’t seem to be the species that over pools. The one theory on why that is, is that they don’t really survive well in the small intestines whereas lactobacillus species do. Of that 1% of bacteria that’s supposed to live in the small intestines, it’s supposed to mainly be lactobacillus. If they are not forced out, they can survive there. A bifido-only probiotic, which there’s now more on the market as “SIBO okay probiotics.” I don’t see as much trouble with them but with lactobacillus, with probiotic foods I do see quite a few patients have issues with them-

Dr. Weitz:                           We’ve had good luck recommending spore-based probiotics with SIBO patients.

Dr. Khangura:                    Yes, that’s another one I think I’ve seen less issues with. I don’t use a lot of the spore based probiotics with the practice but not for any real reason like that. I haven’t really included it in my practice too much but that is something I’ve seen with patients that, once again, when they mention spore-based probiotics aren’t so bad but this other probiotic is.

Dr. Weitz:                           Yeah, particular the mega spore products we’ve found to be really helpful.

Dr. Khangura:                    Mm-hmm (affirmative).

Dr. Weitz:                           Let’s get into hydrogen sulfide.

Dr. Khangura:                    Sure.

Dr. Weitz:                           So far we’ve been diagnosing hydrogen sulfide SIBO by patients who have IBS SIBO symptoms. We do the breath test and they have essentially a flat line. We see no significant increase in hydrogen or methane. Of course, now Dr. Pimentel has finally come out with the new breath test, the trio, that also includes not only methane and hydrogen but also hydrogen sulfide, which I haven’t used yet but I just got a couple kits.

Dr. Khangura:                    The flat line test results on the hydrogen methane breath test can indicate hydrogen sulfide SIBO. Not always but it can. The other thing I think that really needs to be known is something I really focused on in that lecture I gave in the summer when it came to the SIBO breath test is that, I see it’s been practiced all the time is that when someone has hydrogen sulfide SIBO, they can still have regular looking SIBO test results. Spikes of hydrogen or elevated methane and hydrogen or elevated methane causing hydrogen flat line. All these are still in the realm of possibility. If a patient has hydrogen sulfide SIBO, don’t only look for the flat lines. I think that’s where we’re going to get a lot of value out of the new trio smart test is that now a lot of practitioners are going to see, “Oh wow this patient actually does have a hydrogen spike and they have hydrogen sulfide SIBO.” If I was only looking for the flat line I would have missed the hydrogen sulfide SIBO aspect. That’s why I always teach about don’t just go based on flat lines, go based on medical history and hallmark symptoms of hydrogen sulfide SIBO.

                                                A lot of us know a couple of those hallmark symptoms. One can be chronic, very pungent, rotten egg smelling gas. Not just once in a while but it’s always there. Obviously that smell is produced by hydrogen sulfide gas. Another symptom that can happen is unexplained halitosis. Unexplained bad breath. If their hydrogen sulfide overgrowth is high enough in the small intestines, hydrogen sulfide gas will come up into the stomach, up the esophagus and cause unexplained bad breath. We know that these can be hallmarks of hydrogen sulfide SIBO because when you treat the hydrogen sulfide SIBO very specifically with specific agents, which we can get to in a few minutes, all of a sudden that bad breath starts to go away. The pungent smell goes away. You can also use that as an indicator of your treatment, even if you aren’t using the trio smart breath test.

                                                For example, here in Canada, the trio smart still is not available in Canada just yet. They’re hoping to get it available here hopefully by early mid next year. But up until that point, if you’re not using the trio smart test, looking for those couple hallmark symptoms but there are other things to look for. For example, a lot of us know that high FODMAPs or fermentable fiber foods and fermentable sugars will trigger a lot of classic SIBO symptoms. But hydrogen sulfide bacteria, I call them hypo-fermenters because they don’t just feed on fibers, they don’t just feed on sugars, they also are sulfate reducing bacteria. Foods rich in sulfur compounds will also trigger a lot of the symptoms. Of course, garlic and onions, they’re sulfur containing foods but anyone with SIBO, garlic and onions could cause symptoms. What I ask a lot of patients when I’m trying to figure out if it’s hydrogen sulfide SIBO is I’ll ask them have they ever noticed just eating eggs causes the same bloating or the same gas smell or cramping, diarrhea? Does eating just red meat do the same thing? If they haven’t tested just eating red meat, go ahead and just have a steak and tell me what happens.  It’s because the sulfur compounds in those foods may still be enough to trigger the hydrogen sulfide symptoms. Things such as that, of course the medical history stuff as well. Chronic or reoccurring UTIs, a lot of times, can stem from hydrogen sulfide dysbiosis. Most UTIs are hydrogen sulfide producing bacteria. Well water use, that definitely is an easy way to pickup hydrogen sulfide bacteria if they’re not using the UV light.

Dr. Weitz:                         Okay. What are some of the favorite treatments for hydrogen sulfide SIBO?

Dr. Khangura:                   Naturally there’s less options than we have against hydrogenic and methanogenic SIBO cases. A big reason why … Same thing with pharmaceutically although there’s some really good options in both realms. Hydrogen sulfide bacteria are notoriously resistant to a lot of different antimicrobials and antibiotics. This is why a lot of the hydrogen sulfide bacteria that live in the human gut and propagate in human gut are actually very dysbiotic bacteria. With hydrogen sulfide-

Dr. Weitz:                          Do we know what some of the most common bacteria are that produce hydrogen sulfide?

Dr. Khangura:                    Yeah. The most common ones and the ones that are most common overgrowing, unfortunately in the human gut would be dysbiotic species such as klebsiella species, klebsiella with a K, especially klebsiella pneumonia, proteus species with a P, citrobacter species with a C. Those three are ones I focus a lot on in my seminars because they don’t just cause hydrogen sulfide SIBO, these guys just overgrowing in the colon terrain where we’re supposed to have a lot of bacteria, they are very enterotoxic bacteria. They’re very much correlated with developing autoimmune conditions including Crohn’s and ulcerative colitis and even things like rheumatoid arthritis, proteus and rheumatoid arthritis go hand and hand. Ankylosing spondylitis and klebsiella go hand in hand. They can be bad for us throughout the gut. Now there are some regular bacteria that produce hydrogen sulfide. E. Coli is one. Not the food poisoning E. Coli but the regular E. Coli is a hydrogen sulfide producer. The majority of the hydrogen sulfide producers in the human gut, especially in these gut cases, are the dysbiotic species. Morganella morganii is another species, that’s a big time histamine producer as well. A lot of these histamine cases that doctors see, for some of them it’s actually stemming from the gastrointestinal tract. Obviously Morganella is not the only histamine producer but it’s a big one. That’s another dysbiotic hydrogen sulfide species.

                                                When you diagnose someone with hydrogen sulfide SIBO, just like if you diagnose them with hydrogenic SIBO and you just do it based on a breath test or just based on symptoms, obviously you don’t know exactly what species are overgrowing. Some docs will talk about running a stool test and trying to determine that but the problem with the stool test is it only tells you what’s going on in the colon terrain. It doesn’t tell you what’s going on higher up. You can maybe use the stool test to say, “Look at that. There’s heavy growth of klebsiella, heavy growths of let’s say proteus, maybe they’re overgrowing higher up as well.” But you can’t guarantee that. To treat them, to go back to that question, is that because these guys are notoriously resistant, that’s why they hang around a lot after heavy antibiotic use. That’s another history thing for practitioners to ask their patients is their antibiotic history. Did things get much worse after that?

                                                What I found that works the best when it comes to pharmaceutical antibiotics, if it’s primarily hydrogen sulfide SIBO, you only need to get rid of them in the small intestines and they’re not overgrowing in the colon, rifaximin is a pretty good option. Rifaximin does have proven activity against most of these species but what I’ve seen work even better than rifaximin from the pharmaceutical side would be amoxicillin clavulanic acid or sulfatrim, the sulfur-based antibiotic. When one of these works, it works extremely quickly. I only typically prescribe a five to seven day course of the amoxiclav or the sulfatrim because when it’s working, the patient should see significant changes in those five to seven days. If they haven’t seen much change in five to seven days, I don’t typically continue the same antibiotic. I’ll switch to something else.

                                                Now, of course, these antibiotics do come with some side effect risk and things such as that. If you want to go natural or you can’t prescribe the antibiotics, what I find works best for hydrogen sulfide SIBO naturally, I do this combination quite a bit but it’s the herb uva ursi which a lot of us know or use for UTIs. The biggest reason why it’s used for UTIs is most UTIs are caused by hydrogen sulfide producing bacteria. Uva ursi is very specific at killing hydrogen sulfide bacteria. If they’re overgrowing in the gut, it will hit them there first. I do use a very concentrated version of uva ursi. I’ll use a one to one or one to two tincture which can be tough to get. Some good herbal pharmacies do carry it but most of the times in health food stores you’ll find a one to four or one to five. 

Dr. Weitz:                            Are there products on the market that are available to practitioners that you could recommend?

Dr. Khangura:                    We typically just get the tincture from a good herbal dispenser here in Canada. There will be some good herbal tincture dispensaries and pharmacies in the States, I’m sure, that make a one to one uva ursi or a one to two. It’s easy to get a one to four, one to five like at a health food store but the patient would have to take boatloads of it to really work for hydrogen sulfide SIBO case. With a one to two, which is the one I typically use, I’ll do about three and a half to four milliliters twice a day with food. About seven to eight milliliters a day. It does contain hydroquinone, which some people worry that will affect the liver and cause liver damage. There’s always a theory that hydroquinone in uva ursi might but it’s never really been solidified. The hydroquinone in uva ursi is called arbutin and yes, I don’t prescribe an extensive amount of it. I’ll prescribe about two weeks at a time but in my opinion it’s not a big thing to worry about. But if you do the three and a half to four mils of a one to two for two weeks, unless the patient has a history of liver issues and liver disease, I don’t think there’s much of a problem.

                                                That’s one agent I use that can work very specifically for those guys. If you give someone that uva ursi and the patient is getting better, you know you’re specifically treating hydrogen sulfide bacteria. That’s really all that goes after. It doesn’t go after hydrogen or methane bacteria. Now, another product that can be used with uva ursi that can work in a lot of cases is silver agent. Old school colloidal silver is out there but the newer version of silver called silver hydrosol, which instead of the silver bound to the water molecule, the silver is part of the water molecule. The hydrosol version, about 99% is eliminated in 24 hours and about 100% is eliminated in 48 hours. It doesn’t actually pose the risk of giving the patient Blue Man syndrome like standard colloidal silver does because that one, the silver can disassociate from the water molecule in the colloidal silver version. Silver hydrosol it can’t do that. But silver is very antibacterial, as I’m sure you know. Hydrogen sulfide bacter is something it can target. A lot of times I’ll do a silver hydrosol product with uva ursi as a combo, kind of natural therapy or sometimes I’ll do one of those with other herbs because the patient has hydrogenic SIBO as well or they have methane producing SIBO as well.

                                                This is another tangent but the thing is, as well, if someone has one form of SIBO, they usually have … Let’s put it this way. A patient usually has more than one form of SIBO. Sometimes they might just have hydrogenic SIBO and very low methane and no hydrogen sulfide overgrowth. That does happen. But usually if someone’s migratory motor complex isn’t working very well, they are going to have an over pooling of bacteria across the board. Not always all three but usually two of the three. Doing a well rounded treatment, even if the patient has hydrogen sulfide SIBO, is recommended. Sometimes I’ll do a very specific hydrogen sulfide treatment first just to see what gets better first and then move on from there.

Dr. Weitz:                            Okay. Small intestinal fungal overgrowth. This is something that comes up when we have a patient with IBS SIBO type symptoms and the breath test is negative. Then we ask ourselves, “Could this person have SIFO.” How do we diagnose that? How often does that happen? What do we do about it?

Dr. Khangura:                    That’s always the million dollar question is how to diagnose SIFO or just fungal dysbiosis in general. SIFO, obviously, is just a good, obvious buzz term that’s been created because of SIBO. But it’s always been, whatever you want to call it, yeast overgrowth, candida overgrowth, fungal overgrowth. Sometimes it is isolated to the small intestines or that’s where the big problems are happening and sometimes it’s in the colon. But diagnosing it, no matter where it is, can be tough because there is no breath test to determine if someone has SIFO because the only gas those fungal species produce is carbon dioxide. We, as humans, obviously breathe out carbon dioxide. We can’t distinguish what’s from what. There are stool tests that will do yeast cultures and microscopic counts of yeast. If there is an overgrowth of the yeast, at least in the colon, that might be a decent test to diagnose at least colon yeast growth. That might mean they do have too much yeast high up in the small intestines as well. For diagnosis, put it this way, I don’t test for fungal growth as much as I test for SIBO but you can definitely look for hallmarks, again.

                                                Prevalence, I would say SIBO at least being the root cause behind someone’s “IBS” case is higher than a fungal dysbiosis being the root cause. A lot of times they happen together. Sometimes, depending on what SIBO treatment you give, it actually might make the fungal dysbiosis worse as well. You’ve got to keep in mind should I do a fungal treatment along with the SIBO treatment or just wait and see. Some hallmarks for fungal overgrowth, of course-

Dr. Weitz:                            For example, if you use the elemental diet, that tends to promote the growth of fungal because there’s sugar in it.

Dr. Khangura:                    Yeah, exactly. Another thing could be even the pharmaceutical antibiotics. Rifaximin I’m not really worried about it causing a problem because it’s not eradicating good bacteria in the large intestine where fungal growth can start to take hold is in the colon. But those other antibiotics, neomycin, potentially Metronidazole, amoxi/clav, sulfa/trim, they all could make the fungal growth worse as well. But elemental diet, yeah, you’re right. That can be a problem as well. There are some keto versions of the elemental diet out there now, without the glucose, which tastes even worse than the standard elemental diet. Most patients don’t go for it anyway. Basically looking for certain hallmarks as well. What I see in practice at least, maybe you see the same thing, is that when someone has a chronic gastrointestinal fungal issue is that it will present systemically in a lot of ways as well. Maybe it’s oral thrush but maybe a fungal scalp problems or recurrent fungal infections on the skin elsewhere. It doesn’t always have to be scalp or it doesn’t always have to be athlete’s foot. If it’s a female patient and they get recurrent vaginal yeast infections. A lot of these things can stem from a fungal dysbiosis as the root to all these systemic issues.

                                                If you have a patient with a lot of that history, consider that they might be stemming from the gut. Then asking patients specific reactions to things as well. The classic would be the sugar in alcohol because that would be the primary fuel source for the fungal species. What I’ll ask patient about sugar is not just does it cause gastrointestinal symptoms but I’ll ask questions such as, I usually just ask first, “If you eat a candy bar, does anything strange happen?” Just let them answer without me leading them. Then if I need more details I’ll ask, “Okay, if you ate that candy bar, would you feel like you almost had a drink or two an hour later? Almost like that buzzed feeling? Or maybe not the buzzed feeling but you feel like you’re getting a little bit of a hungover feeling a few hours later or even the next morning?” Same thing with alcohol. I would ask, “Are you very sensitive to alcohol? Do you have one drink and feel like you had two or three? Or is it that you only have one drink but the next day you feel like you had two or three? Or even more?”

                                                The big reason for those questions isn’t just that they use it as a fuel source, is that especially candida species, they’re probably most harmful metabolite is acetaldehyde. Acetaldehyde is caused by a neurotoxic and it’s also a carcinogenic. Heavy production of it over years is not very good for us. But that metabolite from fungal species definitely can cause things like brain fog, that hung over feeling, nausea, tachycardia, increased heart rate. If patients are getting those kind of strange reactions when they have high amounts of sugar or alcohol, I’ll definitely start to suspect fungal growth and possibly include a fungal treatment.

Dr. Weitz:                            What’s your favorite fungal treatments?

Dr. Khangura:                    Once again, break it down to pharmaceutical and natural because there’s obviously pros and cons. One of the pharmaceutical agents that I do use is high dose nystatin. I’ll get it, at least here in Canada, we can’t get it in capsules anymore, it only comes in liquid with things like parabens in it and all that. I don’t prescribe that version of it. I get a compound into capsules. I do about three million units a day. One million units three times a day. You can go up to five million units a day but the higher you go, the higher chance of gastrointestinal symptoms. That’s one reason why I go with it is that it’s not really a dangerous medication by any means. It’s nonabsorbable. If it’s going to give side effects it’s usually gastrointestinal side effects. At three million units a day, most patients tolerate it just fine. Because it’s nonabsorbable, it can target the fungal species throughout the GI tract, small intestines and large intestine. You don’t have to worry about it being absorbed before it hits, let’s say colon growths. It’s very effective. Nystatin, it’s old school it’s been around for years but it is still very effective at killing most candida species by disrupting their cell membranes. I do use that one quite often.

                                                I don’t prescribe Fluconazole or other azole antifungals that often. In some cases they are the magic bullet but they do come with a higher list of potential side effects, some more contraindications with other medications which could be dangerous depending which medication the patient is on. Short term use, they’re not that bad but I know of docs that will do two, three, four, five, six weeks of it. It’s still a pretty moderate dose but then you’re running into potential problems. I do find good success with nystatin pharmaceutically. I’ll typically start with that. But naturally there’s some very good options as well. They’re all pretty much fatty acids. A lot of them coconut oil derived but not all of them. Obviously a lot of people know about caprylic acid. Caprylic acid and capric acid from coconut oil are definitely very good antifungals. Those acids don’t only disrupt the cell membrane of the yeast, they also inhibit the hi-fi formation of the yeast. Candida species are polymorphic. They can go from a dormant, uni-cellular form to a multi-cellular form. It’s the multi-cellular form that’s the problem. They can even produce hi-fi, these little legs that come off the cell body to be more invasive. Caprylic acid and capric acid can actually inhibit that. It can also arrest the cell cycle of candida when they replicate. It doesn’t just kill the candida, it can actually inhibit the replication efficacy.

                                                Getting that from pure MCT oil is an option. You can get higher doses much easier. The benefit of doing a caprylic acid supplement like a magnesium caprylate or a calcium caprylate is that when they combine it with the mineral, it will get further down the GI tract. If you are worried about that, just the pure MCT oil version of it, which is easy to get the high dose, it may absorb too quick. That’s the one issue. Then there’s another fatty acid from coconut oil which gets not as much attention-

Dr. Weitz:                           By the way, what’s the dosage you use for caprylic acid?

Dr. Khangura:                    If I was doing … Ideally if you’re doing an MCT oil, I’d go up to three grams two to three times a day, up to.

Dr. Weitz:                           Okay.

Dr. Khangura:                    One to three grams, two to three times a day of pure MCT oil. Some patients don’t do well with high amounts of fat for various reasons. You’ve got to be careful with that. But when it comes to the caprylic acid supplements, the ones that can get a little bit further down, I typically don’t do up to three grams three times a day. I’ll do maybe a gram, 1,000 milligrams three times a day. If that’s a pure caprylic acid supplement or it’s one that has other ingredients in it, they might be taking a bunch of pills compared to eating the oil. But up to tolerance, too. If they can go a little bit higher in the fatty acids not causing any sort of strateria or nausea or anything like that, I’ll push it a little bit, especially if they’re getting better.

                                           The other fatty acid from coconut oil, lauric acid, monolaurin is the supplement version of it. I’m a huge fan of monolaurin. There’s a product at least here in Canada that’s available called Lauricidin. It’s monolaurin in a little tub. Monolaurin comes in this little soft, white pellets and it comes with a scoop. You put a scoop of it in your mouth, you swallow it with water. You don’t chew them or anything like that. It will taste like soap. Make sure to tell your patients not to do that. But monolaurin is very, very antifungal, well proven like caprylic acid. It also inhibits the actual replication efficacy of candida species. The bonus of monolaurin, which caprylic acid doesn’t have, is that monolaurin has also been shown to be very effective against gram positive bacteria. It’s not very effective against gram negative. The problem with SIBO is most SIBO cases have gram negative bacteria overgrowing. In some SIBO cases, if it is gram positive bacteria, monolaurin might actually help. It might cross that threshold and an antiviral as well. Monolaurin, for viruses that have a lipid membrane, monolaurin does have antiviral capabilities against that as well.

Dr. Weitz:                           A number of the antimicrobial herbs like [inaudible 00:58:13] and oregano are known to have antifungal properties as well.

Dr. Khangura:                    Yes, that’s exactly it. There are some herbs, too, that can cross over from the SIBO side of things to fungal. A lot of times when you’re prescribing a patient high dose herbs for their SIBO, you’re actually treating maybe a fungal growth that’s there as well and you don’t even know it. But the patient is getting better. That is true. Allicin extract, [inaudible 00:58:36] is a really good antifungal herb and can work in some SIBO cases as well. When you’re talking specific for fungal, these fatty acids are really where it’s at. There’s another fatty acid from castor oil called 10-undecylenic acid. This has been around for decades. It was one of the original over the counter creams back in the 70s has 10-undecylenic in it. It’s still, to this day, extremely antifungal. It’s just gone to the wayside of popularity. You can still get it in supplement form. Thorn still makes it. They have a funny name for the product but it’s called Formula SF722. That’s their 10-undecylenic formula. It comes in little soft gels. You’ve got to take a high dose of it, four soft gels three times a day is what I would dose it at. But 10-undecylenic acid, it can directly kill the yeast but what it’s really, really good at is inhibiting the yeast from replicating, inhibiting the yeast from wanting to multiply. When you treat fungal species with-

Dr. Weitz:                          Castor oil is pretty toxic, right?

Dr. Khangura:                    Yeah, no don’t drink castor oil. Let’s make it clear on that. This is a fatty acid from castor oil. This is totally safe to take internally. Don’t drink castor oil, everyone.

Dr. Weitz:                          Isn’t that where they get ricin from, I think?

Dr. Khangura:                    Yeah. Is it from castor beans? I don’t know. [crosstalk 01:00:05] I think so. Something like that. Don’t drink castor oil but the supplement 10-undecylenic acid, that’s okay to take. It is very, very effective at inhibiting yeast from being opportunistic. That is a big difference between treating fungal overgrowth and SIBO is that yes, some of the bacteria overgrowth in SIBO could be opportunistic, especially some of those hydrogen sulfide dysbiotic bacteria but the majority of bacteria overgrowing in a SIBO case are not opportunistic. Fungal species are totally different. These candida species are very opportunistic. They wait for a chance to replicate and take over. One thing they can do, when you come at them with artillery and I see this mistake in a lot of practitioners is they’ll just throw a bunch of nystatin at it or a bunch of whatever, caprylic acid at it. The problem is, the candida, when you do that, if they’re already in a stronghold, they can start to multiply faster in the presence of you trying to him them with artillery.

                                          What I like to do with a lot of these yeast cases, I’ll put them on things like a 10-undecylenic or the one reason why I use the monolaurin as well or even caprylic acid is a lot of these natural agents don’t just kill the yeast, they inhibit their ability to be opportunistic. They inhibit their ability to replicate quickly. If you come at them with that aspect, you’re probably going to have more success. Even though I do prescribe nystatin very often, I’ll typically still give 10-undecylenic acid with it or monolaurin with it so we can hit it from multiple viewpoints.

Dr. Weitz:                          Cool. This has been a great discussion Dr. Khangura. Any final thoughts? How can practitioners and listeners and viewers get ahold of you? You have a great course for practitioners available.

Dr. Khangura:                   Like you mentioned at the beginning of the chat, I’m up in Victoria, B.C., Canada. Because I’m doing a lot more stuff in the States I’ve been having a lot of U.S. patients wanting to book. Unfortunately I can’t take any U.S. patients. I still have to keep that to Canadian patients but for any U.S. practitioners that are looking for either the comprehensive course in SIBO and dysbiosis in general, my latest course is called Beyond Superseding SIBO. I’ve had a series of them over the years and my latest one is still up for registration. The website is SupersedingSIBO.CA. Seding is S-E-D-I-N-G, not two E’s. It’s about a six hour course, very comprehensive on SIBO and other dysbiosis including some fungal. Next year I’m hoping by spring 2021 I will have an updated version of this course with more specifics on certain areas. Obviously as time goes by there’s more to learn about and more to teach about. This will be my most comprehensive course at this point.

                                          Otherwise, any closing comments, the one thing I like to mention is that I understand where a lot of practitioners are coming from, is that SIBO seems almost like a fad diagnosis in the last few years. A lot of practitioners are starting to scoff at it because of that saying that it’s the new thing, it’s the new flavor for diagnosis of IBS and all that. The one thing I will tell practitioners that maybe think that’s true is that give it a chance with your patients because if you have not gone down the road with SIBO with most of your “IBS” patients and your looking at your practice and wondering why just cutting out wheat hasn’t helped them, just cutting out dairy hasn’t helped them. Giving them a healthier, more fibrous diet has made them worse but you don’t have any answers for it. Definitely start looking into SIBO specifically as the diagnosis. It’s not an end all, be all by any means for a lot of patients, it’s just part of the problem. I talked to Dr. Ruscio about practitioners really need to be careful not getting into SIBO tunnel vision, once you get that SIBO diagnosis a lot of us just look at that and be like, “We’ve got to tackle this, we’ve got to tackle this.” You’re missing something else.

                                                But for the practitioners out there that don’t even consider SIBO, I really do recommend starting to look into it more because for a lot of patients it really is the very, very specific root cause. We talked about the stubborn cases but some cases will resolve in two to four weeks. We’re talking 10, 20 years of IBS, gone in two to four weeks of treatment. If that’s what the patient needs, that’s what they need. Really, just putting it all together. That’s the way I look at it. That’s what all of us, integrative and functional, whether naturopathic doctors or medical doctors need to do is put it all together from all angles.

Dr. Weitz:                           Excellent, excellent. Thank you.

Dr. Khangura:                    No problem at all.


2 replies
  1. Dr09
    Dr09 says:

    May I ask if rifaximin is still recommended in case or H2S SIBO + LIBO?
    And can NAC be taken 600mg tid + rifaximin 550mg tid?

    • drweitz
      drweitz says:

      No problem taking NAC with Rifaximin. Rifaximin plus bismuth for hydrogen SIBO. Rifaximin will probably not help with LIBO as much.


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