SIBO with Dr. Steven Sandberg-Lewis: Rational Wellness Podcast 218

Dr. Steven Sandberg-Lewis speaks about the SIBO and IBS with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on July 22, 2021.

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Podcast Highlights

10:09  Dr. SSL explained that a group of influential doctors that he is a part of that meet once a month to discuss hydrogen sulfide SIBO, including a major researcher, and they have discussed treating patients who either show a flat line on traditional two gas SIBO breath testing or test positive for hydrogen sufide on the new Trio-smart test that measures hydrogen sulfide as well as hydrogen and methane.  A flat line is when you have the results of a two gas SIBO lactulose breath test and there is no peak in hydrogen or methane gas anywhere along the three hours, not even after 120 minutes when you know you are in the large intestine.  You have a relatively flat line all three hours for both gases. This has often been interpreted to mean that you have a case of hydrogen sulfide SIBO, since the bacteria that produce hydrogen sulfide gas and the archaea that produce methane gas both consume hydrogen as fuel. 

14:05  Also, for patients with slow motility, such as those with constipation, we may want to use 120 minutes as the cut off for interpreting a positive test. Dr. Pimentel says that it takes about 15 minutes from the time the lactulose gets to that part of the bowel where the bugs are, before they make the gas. So you’re actually measuring something that’s delayed another 15 minutes.

16:26  Treatment for Hydrogen Sulfide SIBO.  Some practitioners treat patients with hydrogen sulfide the same as they do patients with hydrogen and the same as they treat methane if they are constipated and that often seems to work. 

20:12  It is important that the patients follow the proper pre-test procedures, which includes avoiding taking laxatives for at least four days and they should also avoid high dose magnesium and vitamin C.  Anything that flushes things through the small intestine may lower gas levels.  If they do need something, they can use a water enema. Or they could use a suppository, a glycerin suppository, because that’s just going to affect the outlet down in the colon and the rectum.  They should also not take any antibiotics or natural antimicrobials for at least 14 days and for as much as 30 days.  You should also avoid probiotics for at least a week prior. 

24:34  Anne asked a question that she heard that the folks at Gemelli had changed the parameters for a positive test because they were having so many patients testing positive for hydrogen sulfide. Dr. SSL pointed out that while Dr. Pimentel has said that hydrogen sulfide is a diarrhea-causing gas, but he and Dr. Siebecker and others in his group have a lot of cases of patients with constipation who test positive for hydrogen sulfide. The range for hydrogen sulfide in constipation may be a lower value than five, which is the cutoff for diarrhea.

28:20  Josh Goldenberg in Colorado has treated a lot of patients with hydrogen sulfide SIBO based on trio-smart with an inexpensive product with bismuth called 5 Symptom Digestive Relief. Another option is to use bismuth plus whatever other normal treatment you would use for either diarrhea type or constipation type SIBO.  One doctor who is part of the group of doctors that Dr. SSL meets with who uses uva ursi mother tincture three times a day, as well as colloidal silver and she has found very good results with before and after testing for hydrogen sulfide. 

34:16  The underlying causes of SIBO.  Food poisoning can lead to elevated levels of anti-vinculin and anti-CdtB antibodies, which then attacks the interstitial cells of Cajal, which decreases the Migrating Motor Complex, which can result in SIBO.  If patients have a thickened bowel wall, such as in Crohn’s disease, then this will decrease gut motility. If your Crohn’s patients are not responding to your standard treatments for inflammatory bowel disease, then you may have to treat their overgrowth.  Scleroderma is another condition where you get an increase in bowel thickness.  And any sort of mechanical or pseudo intestinal obstruction will impair gut motility.  Sometimes patients will ask how long SIBO needs to be treated for and that depends upon whether we can correct the underlying situation. If we can normalize bowel thickness, if we can’t restore the pliability of the tissues, if we can’t restore the MMC, if we can’t fix the ileocecal valve, if we can’t normalize their digestive secretions, then unfortunately, this bacterial overgrowth will be recurrent. Patients who have immunosuppression or immunocompromise, such as being on immunosuppressive medications for organ transplants or autoimmune diseases, are more likely to have bacterial overgrowth recurrence. Traumatic brain injury is another condition that can adversely affect gut motility and the health of the intestinal mucous membranes.  Diabetes, and even prediabetes and metabolic syndrome can result in diabetic enteropathy, which can result in delayed gastric emptying, gastroparesis and other enteropathies that slow down or speed up the bowel.  Hypothyroidism can also slow bowel motility.  Bowel adhesions can slow motility, but these can be treated with manual therapy by specially trained therapists.

44:42  Dr. SSL will use one of five different diets for SIBO patients: 1. Dr. Siebecker’s SIBO-Specific Food Guide  2. the Monash Low FODMAP diet, 3. Dr. Nirala Jacobi’s Bi-Phasic Diet, 4. the Specific Carbohydrate Diet, or 5. the Cedars Sinai Diet, which he will use for patients that are traveling or just can’t make extensive changes, which is the least restrictive of all the diets.

46:23  For the treatment phase of SIBO Dr. SSL will usually use diet plus either prescription or herbal antimicrobials.  After the treatment phase, during the prevention phase, Dr. SSL will tend to use diet plus a pro-kinetic, either natural or prescription.  If they have elevated IBS antibodies, Dr. SSL will offer them low dose naltroxen, high dose fish oil, and vitamin D, which he makes sure are in the normal range to promote regulatory T cells to help the autoimmune mechanism.

48:23  Ehlers Danlos syndrome.  Patients like this who have hypermobility due to altered collagen, such as patients with Ehlers Danlos or Marfan’s have a lot of digestive problems and are prone to altered ileocecal valves due to the loss of tone. Also, they are prone to having open ileocecal valves and to prolapse of the stomach, the small intestine, and/or the large intestine, which can cause kinks and pressure that slows motility.  You can use the Beighton scoring system to assess joint hypermobility in such patients.

58:40  SIBO test prep for vegans. Some vegans just eat white rice all day, which is questionable, esp. if a lot of white rice is not part of their normal diet. a vegan could simply fast or they could do elemental diet.

1:00:40  Microbiome Labs has a new product called FODMATE, which contains enzymes that break down inulin, glucans, and fructans.




Dr. Steven Sandberg-Lewis is a practicing Naturopathic physician for nearly 40 years and he teaches at the National University of Natural Medicine and he wrote a medical textbook, Functional Gastroenterology, now in its 2nd edition. Dr. SSL (as he is often called) practices at 8 Hearts Health and Wellness in Portland, Oregon.

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, 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. Phone or video consulting with Dr. Weitz is available.



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. And to learn more, check out my website, drwietz.com. Thanks for joining me and let’s jump into the podcast.

Thank you everybody for joining us tonight. We’re very, very happy that Dr. Steven Sandberg-Lewis will be joining us tonight, and he’ll be giving us an update on some of the latest research on SIBO and IBS. We do have two sponsors for this evening, Integrative Therapeutics and Vibrant American. So I want to sincerely thank both of them. First, I’ll take a few minutes to tell you about Vibrant, and then I’ll play a pre-recorded message from Dr. Steve Snyder of Integrative Therapeutics. Then I’ll introduce Dr. Sandberg-Lewis, and then we’ll get started.


So I’d like to tell everybody about Vibrant America, which is, if you’re not familiar with them, they’re a leading science and tech company at the forefront of modern medicine. They have a wide range of the most clinically relevant testing options with cutting edge technology. On today’s topic of IBS and SIBO, I’d like to introduce you to Vibrant’s comprehensive stool panel, the Gut Zoomer 3.0. Vibrant uses their proprietary silicon micro-array platform to look at 171 gut commensals, 67 gut pathogens plus critical markers of inflammation and digestive insufficiency to offer you the most complete look at the gut microbiome. Vibrant realizes the difficulty in finding reliable stool testing, which is why they came out with this panel that boasts of unheard of levels of sensitivity and specificity as published in the Journal of Gut Pathogens.  Not only is their test extremely accurate, but Vibrant’s Gut Zoomer has incredibly competitive pricing to save your patient money. Check out their site at www.vibrantwellness.com and open your account today. I’ll mention that I also use Vibrant for a lot of our standard lab testing. And for an extremely reasonable price, you can get a really nice panel set up to do all your standard testing. I use them for hormone testing, advanced lipids, metabolic panel, et cetera. And so for like 250 bucks, I can get an incredible amount of testing. And they also have this great micronutrient test that’s sort of like the SpectraCell test, but much better.



Integrative Therapeutics

Anyway, so now, okay, so I’m going to play this short video with Dr. Steve Snyder of Integrative Therapeutics. I want to thank Integrative Therapeutics for sponsoring this meeting. We have Steve Snyder here and he’d like to tell us a little bit about some of the Integrative fantastic products. 

Steve Snyder:           Thanks, Dr. Weitz. We really appreciate the opportunity to sponsor your group. It’s been a privilege and I’m sorry that I can’t get there tonight, but I’ll definitely be listening to the recording. Dr. SSL, he’s been around for a long time. He’s been a big deal for a long time and you guys are in for a privilege tonight. I’m especially interested in learning more about the ileocecal valve release that he does, and I know that’s kind of a passion of his and that’s often a missing part of the treatment for SIBO. So that’ll be cool. Before you guys get started, real quick, I just wanted to mention a couple of our products that kind of target the SIBO crowd.

The first one is the Physicians’ Elemental Diet. This is based on the groundbreaking research from Dr. Pimentel over at Cedars, showing basically that an elemental diet treatment in SIBO for just two weeks resulted in about an 80% negative breath test. Adding another week of treatment got that up to 85. However, the product that they use was a formula called Vivonex by Nestle, and it could quite possibly be the worst tasting thing I’ve ever put in my mouth. And so we were asked by people in the community to develop a product that could replace it.

And actually, Dr. SSL was one of the main people we consulted with. And he provided some invaluable input for it. The result was Physicians’ Elemental Diet and Physicians’ Elemental Diet Dextrose Free. They’re medical foods that provide all the daily nutritional leads in the simplest form. So simple sugars, preformed amino acids and medium chain triglycerides, which provides basically, complete gut rest and a reboot of the gut. It also allows or provides starvation of the displaced bacteria in SIBO. It’s hypoallergenic, it actually tastes pretty good, think pina colada. And it’s free of intact proteins, polypeptides, corn, gluten, soy, dairy, all the stuff that was in Vivonex that was bad.  It’s really one of the only true elemental diet formulas out there. So don’t be confused by any of the pretenders. If you want to hear more about it, reach out to me directly. The other product I wanted to briefly mention is-

Dr. Weitz:                            By the way, Steve, we probably should point out that there are products on the market that are pretending to be an elemental diet, and essentially, they’re a meal replacement, that include like whey or vegetable protein powder. And that is not even close to a replacement for the elemental diet. Because having complex proteins, even if it’s in a liquid form, it takes a lot of difficulty for your gut system to break down. You’ve got to have free form amino acids, not protein powder.

Steve Snyder:            Right, the complete gut rest is basically, just what it says, and breaking down all those other proteins in whey and the things you mentioned, that takes work. And they’re also allergens. So it really isn’t an elemental diet. Thanks for pointing that out. It’s something we deal with all the time. We have to set people straight, I don’t want to mention any names, but we all know who they are. But they’re not really elemental diets. And the other one, real quick, is Motility Activator, is a combination of high potency artichoke and ginger extracts that have been shown to reduce epigastric fullness and pain, GI bloating and nausea. It’s not the ginger and artichoke you get in Whole Foods Market, these are souped up, high potency products. And that’s why we get the efficacy we do.

This formula has been instrumental in the reintroduction of food after the elemental diet treatments. It helps provide a clear playing field for the migrating motor complex. So that can do its job. And it’s just a really, really good adjunct to the elemental diet treatment. And just for everybody’s information, we just recently reduced the price about 20% as kind of a nod to, hey, this isn’t an experiment anymore, this is the real deal. We know it works and we’re selling it. So we’ve recouped our investment and we’re able to offer it at a lower price. So that’s kind of it. If anybody wants to reach me, I’m at 920-492-0343. Also steve.snyder@integrativepro.com. I hope you guys have a great time tonight and thanks again Dr. Weitz.



Dr. Weitz:                       Thank you so much, Steve. Let me introduce Dr. Steven Sandburg-Lewis, so I’m very, very happy that one of the top experts on using a functional medicine approach to understanding and treating gastrointestinal disorders will be able to join us for a discussion on SIBO and IBS, with a focus on some of the latest research. Dr. Steven Sandberg-Lewis is a legendary naturopathic physician for nearly 40 years, and a professor of gastroenterology at the National College of Natural medicine. He wrote an awesome medical textbook, Functional Gastroenterology. And he will soon be publishing his second book on gastroesophageal reflux disorder. Dr. Steven Sandburg-Lewis, you have the floor.

Dr. Sandberg-Lewis:          All right. Well, earlier we talked a little bit about the trio-smart. If you’re going to have Dr. Pimentel come in a couple of months, I think I’ll let him talk about it, since he’s the one that created that test.

Dr. Weitz:                            Well, that’s okay, you have a different perspective being an integrative doctor.

Dr. Sandberg-Lewis:         That’s true. Also, he’s not a clinician anymore. He’s a researcher. He’s stopped seeing patients. But yeah, as I said, there’s a group of us that meets once a month for an hour. And we have the incredible resource of Joshua Goldenberg, whose a naturopathic doctor, who’s, he’s actually a major researcher. And he’s got a lot of papers out there with his name as the principal investigator. He’s helping us to kind of monitor the response of various treatments that doctors choose to treat hydrogen sulfide, SIBO, and testing whether it’s a flat-line two gas test, or an actual trio-smart that measures all three, and then tracking the results over time and how the patient does symptomatically.

Dr. Weitz:                            Just in case anybody who’s joining tonight is not familiar with what you’re talking about, maybe you could just explain quickly, what a flat-line result on a SIBO breath test is, versus a trio-smart.

Dr. Sandberg-Lewis:         Yeah, so if you’ve looked at two gas standard breath tests, we noticed a long time ago that there are some people that look like they’re not alive, once you look at their tests. Because things just go across. Sometimes they’re all zeros, both hydrogen and methane throughout the small and large intestine. That’s less common than very low levels, often, definitely below six, or even below three. So all zeros, ones, twos and threes, all the way through. And we know that if a patient drinks lactulose or glucose as a substrate, they really should have some fermentation of the normal hydrogen-producing flora in the small bowel and the large bowel. And definitely, when it gets to the large bowel, you should see the levels really go up as you get into the millions per mil.

Dr. Weitz:                            And we assume after 90 minutes or 120 minutes, somewhere in there is when you’re getting into the large bowel, right?

Dr. Sandberg-Lewis:         Yeah, if you use the North American Consensus that was put together about three years ago, they decided that 90 minutes was the cutoff for hydrogen. Differentiating what’s small bowel and what’s large bowel as the lactulose moves through. Because lactulose is an unabsorbable sugar. So it goes all the way through and comes out in the toilet. So it shows you what’s happening with hydrogen-producers throughout the entire digestive tract, starting in the small intestine. And it also shows you if you do have methanogens, archaea organisms that can convert hydrogen to methane. It’ll show them as well. Everybody agrees that with methane, you can find an elevated level of greater than 10 parts per million anywhere on the test.

Dr. Weitz:                            By the way, what do you think about 90 minutes as a cut off?

Dr. Sandberg-Lewis:         Well, we do breath testing at our office. And so I’ve asked if we could have a 90 minute sample. Because up till now, we’ve had every 20 minutes, so we only have 80 and 100. And because of the North American Consensus 90 minute cut off, I want to be able to have that too. So we’re going to change the times when we take the samples. So we’ll be able to see what the standard QuinTron guidelines say is a positive test. And also these other guidelines, just to have them both.

Dr. Weitz:                            Do we know that 90 minutes really accounts for patients who may have slow motility?

Dr. Sandberg-Lewis:         Well, that’s the thing I think that makes the test less individualized, the idea that everybody has the same transit time through the small bowel. We know that’s not true. And if you do a smart pill, or you do a test with the plastic markers that go through, the sitz markers, you can actually measure the small and large intestine transit time. And we know that it varies with different patients. Especially if you have a patient who is constipated and seems to have slow transit, I think using the 120 minutes makes a lot of sense. And the fact that it takes about, I believe, Pimentel will say it takes about 15 minutes from the time the lactulose gets to that part of the bowel where the bugs are, before they make the gas. So you’re actually measuring something that’s delayed another 15 minutes.

In any case, that’s the test that we’re talking about, is there’s this new test since September of last year, that one lab does, Gemelli Biotech, it’s called a trio-smart test. It’s the only lab that’s doing it right now. Pimentel sort of licensed it to them initially. And finally, they came up with a machine that could measure all three gases. So you can either use that flat-line on a two gas test, meaning a lot is going towards hydrogen sulfide, and it doesn’t measure it. So it all looks flat, like nothing’s happening. Or you can use the trio-smart and check all three gases. And that’s what this group is doing. We’re kind of comparing the two with a group of doctors who do a lot of testing. And then we have this researcher doctor, who’s also a clinician that’s working with us.

Do you have specific questions? You want to talk about treatment for hydrogen sulfide, or…

Dr. Weitz:                            Yeah, for sure. I mean, I would love some of your insights. Hydrogen sulfide, I think for a lot of us is a bit of a mystery, having treated differently. I’ve interviewed doctors who say, you have to use a completely different set of nutritional products and/or drugs. Other practitioners say you can use pretty much the same set of nutritional products.

Dr. Sandberg-Lewis:         Yeah, well, the thing is hydrogen is the source of hydrogen sulfide and methane. You have a second set of bugs that then convert the hydrogen that’s made by the hydrogen producers into hydrogen sulfide, or methane. And you can kind of think of it as if hydrogen sulfide and methane organisms condense the gas into a new gas, which has more than one constituent besides just hydrogen. And so some of us have treated hydrogen sulfide just exactly the same as we would treat hydrogen. Or if the patient is constipated, we treat it the way that we would treat methane. And I’ve certainly seen that work. In fact, when I was using flat-line tests to diagnose it, if we gave a treatment, whatever normal treatment, I can tell you what my normal treatments are for hydrogen and for methane.

Dr. Weitz:                          Yeah, why don’t we do that? Why don’t you tell us what your typical treatment approaches are?

Dr. Sandberg-Lewis:         I would just say that though, using those typical approaches, sometimes what would happen then, and very often what would happen is, that flat-line test started looking like a regular positive test. And then the second test that we did after treatment would look like a more normal SIBO positive test. And then we would treat based on what that looked like. So it was a second phase.

Dr. Weitz:                          By the way, somebody just asked, is there an age limit for when the SIBO breath test can be used?

Dr. Sandberg-Lewis:         Yeah, just today, my last patient today, 23 months, the parents wanted to do a breath test. I said, you cannot get a two year old to properly breathe into the machine to get the samples, you just can’t. Interesting thing to know, in veterinary medicine, doctors that treat SIBO, you can’t get a dog or a cat to breathe into the bag either. So what they do is they use serum folate. If the serum folic acid level is elevated and the dog or cat has symptoms that fit it, they consider that a positive test.

Dr. Weitz:                          A couple of people asked, are there false negatives? And I think what happens is, and I’m just speculating here, is you have a patient with what seems like SIBO and then they get the breath test and it’s negative.

Dr. Sandberg-Lewis:         Yeah, well, sometimes that’s because they have hydrogen sulfide SIBO, and you’re not measuring hydrogen sulfide.

Dr. Weitz:                          Right, but now we’re talking about the trio-smart test.

Dr. Sandberg-Lewis:         Yes, so you have that option. If you really think the patient has overgrowth, you can always check the third gas, if you’re not seeing a classic flat-line, that tells you it’s hydrogen sulfide.

Dr. Weitz:                          Now, I’ll just put in here, one of the things you got to make sure is that the patients A, follow the proper pre-test procedures, and B, that they actually perform the test properly.

Dr. Sandberg-Lewis:         Well, yeah, one of the things we found, and Pimentel talks about this too, is that if the patient is taking any kind of laxative for four days prior, that can make the levels look much, much lower. So as long as it’s not going to kill the patient to not take their laxative, they’re not so constipated that they’re going to get blocked, we try to get them to avoid even high dose magnesium or vitamin C or any kind of laxative. If they do need something, they can use a water enema. Or they could use a suppository, a glycerin suppository, because that’s just going to affect the outlet down in the colon and the rectum. But we don’t want anything that’s actually going to flush things through the small intestine and perhaps lower the gas levels.

Dr. Weitz:                            Well, what about other nutrients and/or drugs? Because I had seen that the different breath testing companies seem to have different rules for when patients should stop taking certain drugs or nutrients, like, say, probiotics, or there’s a series of prescription medications that could affect it as well.

Dr. Sandberg-Lewis:         Yeah, so this is especially important the first time you’re doing a test. So you’re doing a virgin test, you’ve never tested the patient before. You really want to follow all these things. So that means no antibiotics for, some say 30 days, some say 14 days, whether that’s any anti-microbial natural products or prescriptions. We mentioned the four days before the test for the laxatives. Probiotics, most will say a week prior, you want to avoid those. And if they’ve had a procedure, such as a barium swallow, a CT with contrast, those kinds of things where you’re putting a contrast media into the gut, often they’ll say 30 days to wait before you do the test, to get an optimal, accurate result.  And your question about are there false negatives, there are false negatives with every test. And there certainly are for this too. But again, if the patient comes to you with a test already, and said, this was my test, you can ask these kinds of questions, how did you prep?

Dr. Weitz:                          Can you comment on the diet, because the trio-smart, they have a little booklet in there. And what they say about diet is different than what Nirala says, which is different than the recommendations given by Genova.

Dr. Sandberg-Lewis:         Yeah. I think probably the important thing is to be consistent. I mean, we’ve had doctors from Italy who do a lot of this work and a lot of research in SIBO, come and speak at seminars. And one of them who’s really knowledgeable, he’s a gastroenterologist and teaches, and he is also a pharmacologist. He says that they don’t even use a prep diet when they test patients in their office, clinically. When they do research, they use a prep diet just to keep things very status quo. But he says they don’t even use a prep diet in their office. So there’s all kinds of variants. I think if you always do the same thing, if you keep it consistent, then you can look at your results and they’re valid.

Dr. Weitz:                          I think Anne wants to ask a question. Did you want to ask a question, Anne, to follow?

Anne:                                 Yeah, I’m sorry. This is Anne, can you hear me?

Dr. Sandberg-Lewis:         Hi Anne.

Anne:                                 Hi, how are you?

Dr. Sandberg-Lewis:         Good.

Anne:                                  I have a patient today that, I swear she has some kind of SIBO, we were just hunting and hunting and hunting and she did the trio-smart. I checked every way about prep or whatever. So I just had heard from some online thing that they were changing the parameters a little. She did about five or six months ago. And there was some question about whether or not everybody was testing positive for a while, then they switched things. I’m just trying to track this down for this patient.

Dr. Sandberg-Lewis:        Yeah, we talked about this today at our meeting, hydrogen sulfide meeting. And yeah, apparently they were getting too many positives, and they’ve changed their cut off. And the details, you’ll have to ask Pimentel, when he comes in two months about that. But there’s also, at this point unpublished, some research that they’re doing at Gemelli, because a lot of us out in the field said… Pimentel was saying that hydrogen sulfide is a diarrhea-causing gas. That these cases are all going to be diarrhea. And what Dr. Siebecker and I and many others in this group were finding is that, a lot of them are constipated. And they’re still showing hydrogen sulfide. So we mentioned that to Pimentel. And he apparently got Gemelli to look at some of their data. And they’re not sure yet, but they’re thinking, well, we’re onto something here with this constipation.  And that probably, the range for hydrogen sulfide in constipation is a lower value. So instead of five as the cut off, it may be somewhere between two and four. That’s not official yet, but it’s something that they’re really looking into. Because we’ve seen so many constipation cases that don’t fit their normal model.

Dr. Weitz:                          Okay, now, what do you tell patients about diet prep?

Dr. Sandberg-Lewis:         Well, did I answer Anne’s question?

Anne:                                 Yes, you did. Basically, it’s almost worth retrying with a regular test and seeing if I get the flat-line, with her, I think, rather than trying to do trio-smart again with her. She’s thinking about retesting.

Dr. Sandberg-Lewis:         Yeah, again, ask Pimentel about this when he comes. But at this point, we’re trying to get our sea legs on this and really try to understand the difference between them. And whether it’s apples and oranges, whether you can compare the hydrogen and methane from a regular test to the trio-smart. And whether a flat-line really does equal hydrogen sulfide. So we’re putting this together.

Anne:                                 So I guess really the reason I keep pursuing this, is she’s having a lot of sulfur intolerance, and she’s been trying for a number of months to work with the CBS pathways and other pathways like that, and getting nowhere. So we’re trying to figure out what’s the driver? And does SIBO fit the clinical picture the best? So anyway, please go on. I’m interested in hearing what you’re doing treatment-wise, too.

Dr. Sandberg-Lewis:         Sure. So interesting thing, Josh Goldenberg in Colorado, he has treated a good number of patients with hydrogen sulfide SIBO based on trio-smart. And what he’s using is dirt cheap to treat these patients. 30 days of a bismuth formula, which kind of goes with the guidelines that Pimentel talks about. He talks about using his standard antibiotic protocol for either hydrogen or methane, depending on whether the patient, he says mostly he was finding patients with diarrhea, and then he would add bismuth to it at the same time during the two-week course.  Josh Goldenberg is using a really inexpensive product from Target drugstore called 5 Symptom Relief formula, I guess it is. Or 5 Symptom Digestive Relief. And it’s just a bismuth, it’s basically Pepto Bismol. It’s a bismuth subsalicylate. And two TID for 30 days. And he’s seen before and after test can be very effective. What’s that?

Dr. Weitz:                         No, I think we just heard some noise.

Dr. Sandberg-Lewis:        Okay, okay.

Dr. Weitz:                         So they had muted themselves.

Dr. Sandberg-Lewis:        And again, you can also use either bismuth subsalicylate or bismuth, what’s the other one, folks? Instead of the salicylate, bismuth subnitrate at 262 milligrams, three times a day, 30 days. Or you can add that to what you would normally use to treat either hydrogen or methane, based on the stool type.

Dr. Weitz:                         That’s kind of what I’ve done. I added the product from Priority One that Paul Anderson developed, that’s a biofilm buster that contains bismuth.

Dr. Sandberg-Lewis:         Yeah, BioFilm Phase Two.

Anne:                                Can I say something about that product, though?

Dr. Sandberg-Lewis:        Sure-

Dr. Weitz:                         Yeah.

Anne:                                Paul Anderson says that if you mix the bismuth with the disulfides, you actually end up with a separate molecule. It’s not bismuth anymore, it doesn’t act as bismuth. So I’m not sure that is a good delivery system for bismuth.

Dr. Sandberg-Lewis:        Meaning if you add the disulfides, meaning in-

Anne:                                The thiols that he puts in that product for the, so, the bismuth-thiol combination molecule for BioFilm is no longer bismuth or a thiol, according to Paul Anderson.

Dr. Weitz:                         But the [inaudible 00:31:23]. So if everybody’s not familiar, he has one version that’s a prescription made up by a compounding pharmacy, and then he has an over-the-counter product that simply, it’s lipoic acid as the thiol.

Anne:                                Well, yes, it’s lipoic acid and Nigella sativa. But he is saying that that combination makes it no longer a bismuth molecule. I mean, that’s what he said to me four or five times, like it changes.

Dr. Weitz:                         Really?

Anne:                                Yeah, it’s not bismuth anymore.

Dr. Sandberg-Lewis:        So your option is to just use a straight bismuth.

Dr. Weitz:                         Okay.

Anne:                                Yeah.

Dr. Sandberg-Lewis:        There’s all kinds of other approaches that doctors have, some strange things that doctors have done with different prescription antibiotics and things that we probably wouldn’t use. But I’d say the basic idea is either bismuth by itself, which seems to be working quite well in the initial group of patients, not dozens and dozens and dozens. Or bismuth plus whatever other normal treatment you would use for either diarrhea type or constipation type SIBO.

Dr. Weitz:                          Yeah, there’s a doctor in Canada, Dr. Preet Khangura who I interviewed who treats a lot of patients with hydrogen sulfide SIBO. And he adds to the mix uva ursi, because he says that some of the bacteria that are often involved in UTIs, are also involved in hydrogen sulfide SIBA.

Dr. Sandberg-Lewis:         Well, yeah, and there’s a doctor that we meet with once a month. And her approach has been to use uva ursi mother tincture three times a day, as well as colloidal silver. And she has found very good results with before and after testing for hydrogen sulfide. And she does quite a bit of it. So that’s her-

Dr. Weitz:                          I think Dr. Khangura mentioned that mother tincture, it’s actually mother something, right? Or I think it’s short for mother something. Mostly it’s this super strong product or something.

Dr. Sandberg-Lewis:        Well, there are extracts and there are mother tinctures, mother tinctures are actually what you start out with to make a homeopathic remedy.

Dr. Weitz:                         Oh, really?

Dr. Sandberg-Lewis:        It’s not as concentrated as a fluid extract, that’s much more concentrated.

Dr. Weitz:                         Oh, okay, I got.

Dr. Sandberg-Lewis:        In any case, I was hoping we could also talk about some of the underlying causes for SIBO.

Dr. Weitz:                         Yeah, that’d be great.

Dr. Sandberg-Lewis:        Okay, so I’m going to share my screen.

Dr. Weitz:                         Okay.

Dr. Sandberg-Lewis:        So this is my little quick and dirty chart that I made for PowerPoint, that that shows some of the major etiologies for SIBO. And of course, you’re probably familiar with the food poisoning, travelers diarrhea, leading to elevated levels of anti-vinculin and anti-CdtB antibodies, which then attacks the interstitial cells of-

Dr. Weitz:                         Hey, Doc, you want to make it the full screen? I think you’ve got one more thing to click to make it the full screen.

Dr. Sandberg-Lewis:        What do I need to click to do that?

Dr. Weitz:                         I think the thing on the bottom that’s quick, three things to the right of that.

Dr. Sandberg-Lewis:        Oh, okay.

Dr. Weitz:                         No, to the left of that. No, no, no, right there-

Dr. Sandberg-Lewis:        There it is.

Dr. Weitz:                         There you go.

Dr. Sandberg-Lewis:        Yeah, that’s it. So the food poisoning and then the autoimmune reaction that attacks the interstitial cells Cajal and slows down the migrating motor complex, promoting bacterial overgrowth. But in addition, really keep this in mind that if your patient has a thickened bowel wall, they’re going to have loss of motility. So, your Crohn’s patients, because Crohn’s by definition is transmural thickening of the small bowel, in most cases. Few cases are somewhere else in the gut or might just be in the colon, but most are in the small intestine. Crohn’s ileitis is a real big cause of people who have both IBS and IBD. And you really have to consider that when your Crohn’s patients are not responding to your standard treatments for inflammatory bowel disease, that you may have to treat their overgrowth. Scleroderma is a really classic example where the tissues thickened, and then you’re not going to have normal motility. And then, of course, if you have any kind of pseudo obstruction or loss of actual motility in the bowel.

But when these things are present, if you can’t get back that that pliability of the tissue, you’re basically going to have to tell the patient, this is a case where we’re going to be managing this for most of your life. We we can keep you in remission from some of these symptoms, with the right treatments, but this is not a one and done kind of situation. Unless you can really normalize the bowel thickness. So keep that in mind. Sometimes patients will ask, “Hey, Doc, I’ve heard SIBO is just something you have to treat forever. Is that right?” Well, it’s right if you can’t treat the underlying cause. If you can’t get the migrating motor complex back, if you can’t fix the ileocecal valve, if you can’t normalize their digestive secretions, whatever the underlying cause is, then it will be recurrent. If they have adhesions.

Dr. Weitz:                            By the way, Doc, I just want to mention that you teach a manual therapy visceral manipulation technique, to help with the ileocecal valve, isn’t that right?

Dr. Sandberg-Lewis:         Yeah, yeah. And I have a whole chapter in my textbook about that as well. But yeah, it’s something I like to teach. I teach it at the National University. And in a course and other weekend courses. Immunosuppression or immunocompromised patients is another important thing to consider, that if you don’t deal with that, you’re going to have bacterial overgrowth occurring over and over. Because the immune system is in-part responsible for keeping the normal flora in check so they don’t overgrow. So your patients that are on immunosuppressive medications, that have had transplants, you really have to take that into account. And you’re probably going to have a more long term condition where you have to keep it under control and prevent recurrence.

Traumatic brain injury is another one, is one of the first things that happens when the brain shakes and gets injured, is that motility and secretion and the health of the mucous membrane changes in the gut. I mentioned the secretion, so acid, pancreatic enzymes, brush border enzymes and bile. Any deficiencies of these things will really tend to allow for overgrowth. The bugs don’t like these things, and that’s what keeps the small bowel having fewer than 1,000 organisms per gram normally.

Next to that is diabetes, and I would include pre-diabetes and metabolic syndrome as well. There’s a group of conditions called diabetic enteropathy. It includes things like delayed gastric emptying, gastroparesis and other enteropathies that slow down or speed up the bowel. And in small bowel, it tends to slow down very commonly, which allows overgrowth to take place.  Hypothyroidism, the thyroid is very much associated with motility. And when it’s not properly treated, everything slows down in the gut and allows for overgrowth. So these are all conditions you have to kind of screen for when your patient has SIBO, especially if it’s recurrent.

Blind loops and adhesions are really important. And the good news with adhesions is, often, they can be treated with manual therapy by people that do visceral manipulation. They can be, of course, brought on by surgery and a real common one is after appendectomy, especially with appendicitis that perforated before they removed the appendix. Because they have to wash out all that pus from the peritoneal sac when they’re doing the surgery. And it can really lead to pretty massive adhesions. Another one would be endometriosis, with monthly bleeding into the peritoneal sac, can create a lot of spot type adhesions, that cause twists and turns and narrowing of the small bowel and make it a perfect place to grow bacteria, because they can hide in those twists and turns, just like the [inaudible 00:41:56] blind loops such as diverticula. Or surgical blind loops, such as in bariatric surgeries.

So remember, if you have a patient who’s had bariatric surgery, you want to really talk to them first about whether or not they want to treat their SIBO. Because SIBO is a desired response to bariatric surgery. Bariatric surgery is designed to reduce the amount of food that the person can take in by making the stomach smaller. And depending on the type of surgery, leading to malabsorption. And the malabsorption and the blind loops, the loops of bowel that just kind of suddenly end and they have a dead end, those are great places for bacteria to overgrow. And when you have SIBO, we know you tend to get malabsorption. So it helps the weight loss. Most patients with SIBO are underweight in our practice, they’re not overweight. Occasionally, you find an overweight patient, but it’s much less common than the underweight patients.  So talk very seriously with your patients that have had bariatric surgery before you treat their SIBO, because they may gain weight. And that’s going to undo all of that misery they had with the surgery. So know what you’re doing before you work with those patients.

Dr. Weitz:                         Of course, Dr. Pimentel talks about the methane patients perhaps being overweight, because it slows the digestive and motility, they absorb more calories from their food.

Dr. Sandberg-Lewis:        Yeah, methane producers, the archaea that make that have been associated with overweight status. So yeah, there are different kinds right there. SIBO, it says SIBO here, SIBO really nowadays refers to hydrogen sulfide and hydrogen. Methane, when the methane is elevated, we now call that IMO or Intestinal Methanogen Overgrowth. Because they’re not bacteria, so call it Small Intestine Bacterial Overgrowth is a misnomer for methane. And elevated methane levels in the colon cause just as much trouble as in the small bowel. So it’s not small bowel only, and it’s not bacteria. So we use the term IMO or Methane Bloom, to talk about elevated methane.

Dr. Weitz:                         By the way, a question came in, not to change the topic. We’ll get right back to this, but somebody was asking, you talked about treatment and you talked about using antimicrobials. Do you normally also put the patients on a specific diet at the same time?

Dr. Sandberg-Lewis:        Yeah, I use one of five different diets. The most common diets that I use, which is also, I have a chapter in my textbook about this, would be Dr. Siebecker’s SIBO-Specific Food Guide. Or I’ll use the Monash Low FODMAP. Or I’ll use the Bi-Phasic Diet which Dr. Jacobi created, based on Dr. Siebecker’s diet. Or I’ll use the diet that Dr. Siebecker originally got the ideas from, the Specific Carbohydrate Diet. She married the specific carbohydrate diet with the Monash FODMAP Diet, and put those together to make the SIBO-Specific Diet. So those are the most common diets I use. If I have a patient who has an eating disorder, and they really want to make just the minimum amount of changes, so that they’re not stimulating any upheaval of their eating disorder, we would probably use something like the Cedars Sinai Diet.  And also with patients that are traveling or just can’t make more extensive changes, we’ll have them use the Cedars Sinai Diet, which is the least restrictive of all the diets.

Dr. Weitz:                          Actually, since we’re on it, why don’t we just hit a couple more things? Do you also use a pro-kinetic, a natural or prescription? And do you ever address biofilms as part of the treatment?

Dr. Sandberg-Lewis:         Yeah, so the pro-kinetics are part of the prevention phase, that we go into after the treatment phase. The treatment phase will involve diet plus either prescription antimicrobials, or herbal antimicrobials. The option, other than that, would be the elemental diet. And the advantage there, of course, is it can bring down gas levels by over 100 parts per million in two to three weeks, which you can’t usually do with the others. And then in the prevention phase, which we start right as they finish the treatment phase, we’ll use diet plus pro-kinetic. And if they have elevated IBS smart-test, if those antibodies for vinculin or CDT are elevated, I will also offer them low dose naltrexone, high dose fish oil. And I’ll make sure that their vitamin D levels are in the normal range to promote regulatory T cells to help with that autoimmune mechanism.

Dr. Weitz:                         I mean, vitamin D in the optimal range?

Dr. Sandberg-Lewis:        Well, it depends who you listen to. Alan Gaby, one of the real experts on vitamin D, he wrote an article a couple years ago saying that for many years, he tried to get people to optimal levels, say 50 to 60. And he found, over time, that it really didn’t have any advantage over just getting them into the normal range. So you can do it either way.

Dr. Weitz:                         Okay.

Dr. Sandberg-Lewis:        I’ll just mention these last two things, so I can cut this slide off. But altered collagen such as hypermobility type Ehlers-Danlos syndrome or other types of Ehlers-Danlos syndrome, or patients with Marfan syndrome or other collagen variants, these patients have a lot of digestive problems, whether or not they have bacterial overgrowth. They have a higher tendency to have sliding hiatal hernia, up to 60% of them have either diarrhea or constipation on a chronic basis. They’re very prone to open ileocecal valves, because of the loss of tone. And prolapse of the stomach, the small intestine and/or the large intestine, which again can cause kinks and pressure that slows down motility.

So this is something I screen every new patient for, by doing a Beighton score. And then also if that’s positive, I’ll do what’s called [criterion-2 00:49:40] testing. A lot of it you can do, initial testing, you can do over the internet too, if you’re doing a telemedicine visit, which is a good way to initially assess. And then the last one, as you mentioned, is the ileocecal valve dysfunction, which can allow cecoileal reflux from the colon into the small bowel, bringing a huge amount, millions per ml of bacteria into the small bowel.  I can take other questions if people have them.

Dr. Weitz:                            Which do you think are the most common causes for SIBO?

Dr. Sandberg-Lewis:        I’ll tell you, I keep thinking I’m going to make a little button that people can walk around with it says endometriosis equals SIBO, chronic SIBO. In females, I would say it’s absolutely the most common thing that I run into for recurrent chronic SIBO. So you have to have a good index of suspicion for endometriosis. If your patient has severe dysmenorrhea, if you know they already have adhesions from it. Patients that are incapacitated by their dysmenorrhea. Patients that have a fixed uterus, I screen my new patients that I see in person, female patients for adhesions. So I’ll check in the mid abdomen, I’ll let my fingers sink down into the abdominal tissue with the patient supine, and I’ll slowly rotate in both directions. And see, if you do that on every patient, male and female, you’ll get a sense of what feels normal. How the organs move underneath the muscles and the subcutaneous fat.

There’s often a very free feeling to it. As opposed to someone who’s got a lot of adhesions, you may actually feel areas that, if you felt somebody with more superficial scarring and adhesions, you can really feel the hardness of it. But there’s also, for the deeper adhesions, you may be able to feel the organs kind of being stiff and not wanting to move. And then I’ll put my fingers on either side of the uterus, and I’ll move it laterally; to the right and to the left. And I’ll see how much mobility the uterus has. Very commonly with endometriosis, or after a patient’s had one or more caesarian sections, they’ll have adhesions that actually fix the uterus to either the pubic bone, to the colon, or to the small bowel.

And it may move nicely in one direction. Or normally, the uterus will move so that you can go actually all the way to the midline with the lateral edge of the uterus. If the uterus was really held in place well, when a woman had a pregnancy, she would rip herself apart. You’ve got to have a really mobile uterus, so that it can grow and enlarge all the way up to the diaphragm, basically. So it’s great to feel women that have never had endometriosis, have never had surgeries in the abdomen, that have never had appendectomies or C-sections and feel what that normal movement is like. It’s quite dramatic. And then when you feel one where it’s locked, you’ll really feel the difference.

Dr. Weitz:                         You just mentioned Ehlers Danlos syndrome. How do you manage SIBO in patients with that?

Dr. Sandberg-Lewis:        Well, I’ve got to tell you, I don’t know, and I’ve looked at a lot. I don’t know any cures for that genetic condition. I know things not to do. So for instance, I’m not going to use high velocity, low amplitude manipulation for them, because it’s going to make them even more unstable. If they do have problems with their joints, which often they do, because their check ligaments are looser and they have hyperextension of joints, I will probably refer them for injection therapies like PRP and prolotherapy. Or even stem cell injections. And I’ve had patients just thank me profusely when they’ve had that done. It can be a real lifesaver for these patients. Even when I do my myofascial release with them, I’m not going to do it the full extent that I would do it with a patient who’s not hyper mobile. Because I don’t want to make them more mobile. Sure, I want to release things that are fixated, but muscle tension and adhesion formation is part of the way the body deals with hypermobility.

It’s a natural response to it. So you have to kind of set up some kind of agreement with the body, how much you’re going to allow. We do tend to tell those patients, it’s worth trying bone broth, if you tolerate it, if you don’t have a histamine problem, or collagen extracts, if you do, collagen powder, grass-fed collagen powder. Two scoops a day is a common thing that we’ll use. We’ll use MSM, if they don’t have a sulfur problem. As a way, first of all, good for pain, good for the liver, but also the sulfur moiety that helps with the collagen formation. And then moderate doses of vitamin C to help that process as well. But I can’t say that I have a cure, and I’ve never had anybody tell me a cure for this genetic condition. But you can work so that you don’t make it worse. And you can try some things that might make it more stable.

Dr. Weitz:                         When patients have hydrogen sulfide SIBO, do you put them on a low sulfur diet at the same time as a low FODMAP diet?

Dr. Sandberg-Lewis:        I have found that that can really get a person’s symptoms way down. But whenever you add another layer of avoidance to a diet, it gets more and more impossible to follow. Especially for your underweight patients to begin with. So it’s a real balancing act. And I often rely on my nutritionist and other nutritionists that I recommend to really help people to individualize the diet, and try to make it the least restrictive as they can.

Dr. Weitz:                         So with the patient with hydrogen sulfide, would it be better to do a low FODMAP or low sulfur diet, if you’re going to pick one?

Dr. Sandberg-Lewis:        Well, the FODMAP is helping to reduce fermentable carbohydrates, and that’s going to be important to prevent relapse. Whether you use that or the minimal Cedars Sinai diet, or any low fermentation diet. And then the low sulfur diet is really more of a way of trying to get symptom relief in patients that are really suffering, until you can get them to tolerate sulfur more effectively. So you do what you have to do and what the patient can tolerate, but it can get pretty dicey. And then you’ve got patients coming to you on a low sulfur, low oxalate, low histamine, low fermentation diet. They’re basically eating meat. And it’s not a healthy thing, maybe for a short period of time, if they’re really suffering, but try to correct whatever you can.

Dr. Weitz:                         What about SIBO test prep for vegans?

Dr. Sandberg-Lewis:        For vegans, so I just had a patient today, who, she was new to me, she’d had a breath test. And I asked her what she did for a prep diet, she’s vegan, she said, “I just ate white rice.” So she just ate white rice all day. Questionable, if white rice weren’t a major portion of her diet to begin with, and then just for the prep diet, she just ate white rice all day, that possibly could skew things. It just really depends how much. We try to tell people, if you don’t normally eat a lot of white rice, don’t live on it the day before the test. Or don’t even introduce it, just eat other foods. If you’re vegan, it gets tough. And they can fast. They could do a water fast, or they could do elemental diet powder. That’s a prep diet. So that’s another option. Because it has nothing in there that feeds the bacteria, or the archaea.

Dr. Weitz:                         What if they were any really, really soft vegetables, like they just overcooked them?

Dr. Sandberg-Lewis:        It’s still not recommended. Now, you could take the approach that Dr. Carmelo Scarpignato in Italy takes, and that’s no prep at all. No diet prep. Just a 12-hour fast from the night before, before they do the test. That’s your other option, if you have a patient who really just can’t do the prep diet. But the PED or other elemental diet, fully elemental diet is a great option for one day, if they have diarrhea tendencies, and two days if they’re constipated.

Dr. Weitz:                         Somebody has a question about a product from Microbiome Labs called Foodmate, which is supposed to break down FODMAPs?

Dr. Sandberg-Lewis:        FODMATE.

Dr. Weitz:                         FODMATE, okay.

Dr. Sandberg-Lewis:        Yeah, this has just been available since May, I think. And it’s the brainchild of a new graduate, MD. She’s just in her first year of practice, but she’s brilliant. I worked with her a lot, putting on courses up at Bastyr where she graduated. And she came up, she thought, well, if we could make an enzyme that would break down inulin, glucans, and fructans, then people could eat a lot more food, if they were on very restricted low FODMAP diets. And we’ll see how it works. I’ve only given two or three patients that enzyme so far, because it’s so new. But I have a lot of positive hopes for it. It’s called FODMATE, F-O-D.

Dr. Weitz:                         Okay. Do you see any correlation between Lyme disease and SIBO?

Dr. Sandberg-Lewis:        Especially Lyme disease, and methane IMO, not so much SIBO. When I see a breath test that the methane begins high, like today I worked with a patient who had a methane, baseline was 28. And then it was high at every test, every sample, throughout the entire 10 samples. And in the last specimen, it was 84. We lovingly call that mega meth, and I didn’t come up with that term, Dr. Rahbar came up with that, which I think is very cute. But anyway, that kind of mega meth, where it’s always high, including at the baseline first sample, I give them the Horowitz questionnaire for Lyme and tick borne related diseases. And I see, if they’re higher than 46 on it, then I’ll probably refer them to another doctor in my office who’s a tick borne disease expert.

Dr. Weitz:                         Do you find IMO harder to treat than hydrogen?

Dr. Sandberg-Lewis:        I think it depends on what kind you’re talking about. So this mega meth, probably more complicated. Because there might be kind of an occult infection behind it, and whether or not you uncover that, you may have trouble.

Dr. Weitz:                         I think that’s how Dr. Rahbar came up with it, because he found that the IMO patients didn’t respond as well to the treatments that were working for hydrogen. And so he found them to be more resistant. So he started looking for other reasons whether they-

Dr. Sandberg-Lewis:        Yeah.

Dr. Weitz:                         Sometimes he finds parasites, sometimes he finds Lyme.

Dr. Sandberg-Lewis:        Yeah, and compare that to someone who has elevated hydrogen, but also has maybe a baseline methane of zero, and then it peaks at 14, which is a positive for IMO. But it’s very different than that patient who has no elevation of hydrogen, but their methanes are sky high at every reading during the test.

Dr. Weitz:                         By the way, do you think that seeing elevated methanogens on a stool test is a potential indication of IMO?

Dr. Sandberg-Lewis:        You mean the PCR testing that shows methanobrevibacter’s elevated?

Dr. Weitz:                         Exactly.

Dr. Sandberg-Lewis:        I don’t know, I’ve been looking at it. And I’ve seen sometimes it correlates. I think it depends whether it’s in the colon. If your methane level peaks in the colon on the last three specimens, it probably will show up high with PCR testing of methanobrevibacter smithii in the stool. But if it’s more in the small intestine, and not so much in the large intestine, you might not see that.

Dr. Weitz:                         Right. But since IMO could be anywhere, if we see elevated methanobrevibacter…

Dr. Sandberg-Lewis:        Yeah, the problem I have with that, with PCR testing, it’s just my personal thing, PCR measuring DNA of organisms, half of the organisms in the colon are dead. Stool is made up of dead bacteria sloughed off cells from the lining of the gut, and fiber that hasn’t been fermented by the bacteria. And then other waste materials. And so, when you’re looking at DNA, it doesn’t say, this methanobrevibacter is alive. It’s saying, it’s there; dead and alive. It’s like those old wanted posters, wanted dead or alive. That’s what you’re seeing when you’re looking at stool, PCR. If you do a culture, you can’t culture anaerobes. So they won’t show up at all. But that’s living bacteria when you culture it. But when you’re doing PCR, it’s dead and alive. So I don’t really, at this point, I don’t put a lot of faith in that.  Sure, if there’s a pathogen on a stool test, that’s important. I find the PCR testing fascinating and nerdy for me and other doctors, but I think a lot of doctors are probably making missed diagnoses based on that, because you don’t know how much of that you’re reading is dead. And who wants to treat dead bacteria? They’re coming out anyway.

Dr. Weitz:                         Do you think that a stool test is only looking at the colon?

Dr. Sandberg-Lewis:        Stool test is colon, when you’re looking at the organisms. If you’re looking at elastase, that’s that small intestine, pancreatic levels. If you’re looking at calprotectin and lysozyme or lactoferrin, you’re also seeing if there’s small intestine inflammation, those will go up. Especially calprotectin. But the other tests are large intestine.

Dr. Weitz:                         Well, according to Tom Fabian from GI Map Diagnostic Solutions, a number of organisms that come up on the GI map are actually typically-

Dr. Sandberg-Lewis:        Small bowel flora-

Dr. Weitz:                         … small bowel, and also, they measure H. pylori, which is more in the stomach.

Dr. Sandberg-Lewis:       Yeah, again, they’re measuring PCR of H. pylori, which is not a standard H. pylori test. Sure, if you have H. pylori, dead or alive, it may eventually come out in the stool. It’s part of the digestive tract. But I don’t think it’s reliable to say that organisms from higher up, checking in the stool is a good way to check for it. Now we know that stool antigen for H. pylori is a valid test. So that’s actually a protein that H. pylori makes. But to actually be using PCR and looking at stool H. pylori, you don’t know how much of that is viable. So that’s why the stool antigen is a more typical test. And the GI map, I think, is the only test that really does a stool H. pylori.

Dr. Weitz:                        But they also look at virulence factors. So doesn’t that increase the potential accuracy, especially if there’s a couple of virulence factors that tend to be more significant, according to some of the data?

Dr. Sandberg-Lewis:       Yeah, I mean, it depends what research you read. Some research says the virulence factors really don’t tell you whether they need to be treated or not. But certainly, I think it gives you a more credence for it, if there are virulence factors, as opposed to not. The interesting thing, I do a two-hour lecture on H. pylori, so don’t get me started. But the interesting thing is that virulence factors such as VacA, they actually have some beneficial effects. And H. pylori, of course, is a commensal organism that’s very important for priming the digestive immune system in children. And VacA and CagA, many studies have shown that a mixture of VacA and CagA-positive strains are actually very beneficial for preventing food allergies, eczema, asthma, Crohn’s disease, long list of things.  So, you really have to decipher between H. pylori that really deserves treatment and that which is commensal. And that’s what I lecture about, is how we might consider the various factors, because it’s protective against more conditions than it is causative of conditions.

Dr. Weitz:                         And you think the antibody test for H. pylori is the most accurate way to test for it?

Dr. Sandberg-Lewis:        The antibody test, IgG, in the blood tells you if you’ve been exposed to H. pylori in high numbers. And actually, if I have a patient with a positive, who doesn’t necessarily have GI problems, I give them a high five. I say, “All right, you have commensal H. pylori.” Now, if you do an H. pylori antigen, stool antigen or a breath test for H. pylori, that tells you the H. pylori is there now, in high amounts. And if you treat the patient, if you choose to treat them, you can use that within a couple of weeks after treatment, to see if you were successful. But the antibody test isn’t as reliable. It could stay high for many months or even years after you treat them. So it kind of depends how you test.

Dr. Weitz:                         So you consider the stool antigen or the breath test the most accurate?

Dr. Sandberg-Lewis:        Yeah, because when those are positive, you know it’s there now and it’s viable. Yeah, that was fun. Always nice to talk with you and your group.

Dr. Weitz:                         Absolutely.

Dr. Sandberg-Lewis:        And I didn’t get to see Anne, because she had her camera off. But I’ve known Anne from way back when she was student at NUNM.

Dr. Weitz:                         Oh, cool. Okay, thank you, Doc. Thank you to everybody. And we’ll see you next month.


Dr. Weitz:                            Thank you listeners for making it all the way through this episode of the Rational Wellness Podcast. Please take a few minutes and go to Apple Podcasts, and give us a five-star ratings and review. That would really help us, so more people can find us in their listing of health podcasts. I’d also like to let everybody know that I now have a few openings for new clients for nutritional consultations. If you’re interested, please call my office in Santa Monica at 310-395-3111. That’s 310-395-3111 and take one of the few openings we have now for an individual consultation for nutrition with Dr. Ben Weitz. Thank you and see you next week.


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