Update on SIBO and IBS with Dr. Mark Pimentel: Rational Wellness Podcast 227

Dr. Mark Pimentel provides an Update on SIBO and IBS with Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on September 23, 2021.

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Podcast Highlights

6:52   The REIMAGINE study is the project in which Dr. Pimentel and colleagues mapped out the microbiome of the small intestine.  The Human Microbiome project was published in 2007 and they declared that they had mapped out the microbiome of the gut, but it was based on stool studies, so it did really only represented the microbiome of the colon.  [Here is the first paper published by Dr. Pimentel and others on this REIMAGINE study:  Mapping the Segmental Microbiomes in the Human Small Bowel in Comparison with Stool: A REIMAGINE Study.]  This study required a lot of work and resources to be able to collect accurate samples and sequence the microbiome of the small intestine.  It is difficult the sequence the small intestine for a number of reasons, including that the mucous is so thick that they had to add mucolytics to liberate the bacteria and they had to develop special tools and validate them before conducting the trial, so it took years to prepare and then to conduct it.  And they discovered that the microbiome of the small intestine is quite different from the colon.  They also discovered that the small bowel is fairly uniform from the duodenum till the end of the ileum, whereas it was thought previously that you had more and more bacteria as you get closer to the colon.

9:28   Now we know that the bacteria in the small intestine have not overgrown from the colon up into the small intestine through an incompetent iliocecal valve, as was previously believed by some SIBO researchers. The small bowel contains more proteobacteria and much less bacteroidetes than the colon.  What happens in SIBO is that because of damage to the motility of the intestine, E. coli and Klebsiella grow like weeds and crowd out many of the other commensal bacteria.

12:13  Ehler’s Danlos Syndrome (EDS).  There was a thought that patients with EDS who have ligamentous laxity have hyperlaxity of the ileocecal valve leading to an increased risk of SIBO.  Dr. Pimentel explained that what happens with patients with EDS is that they have visceroptosis, which means that their gut sags into their pelvis, which creates bends and twists in their small bowel, creating obstruction, leading to SIBO.

13:48  Dr. Pimentel’s group published data from the REIMAGINE trial that shows that PPIs (proton pump inhibitors like Prilosec) don’t cause SIBO, though they are a risk factor for C. diff colitis.  They also published a paper showing that in postmenopausal women, their microbiome gets shifted in a very bad way, but if they’re on hormone replacement therapy, their microbiome in their small intestine looks like they’re premenopausal.

15:24  This data that PPIs don’t cause SIBO means that taking PPIs will not likely affect the results of the SIBO breath test.  On the other hand, PPIs by reducing stomach acid will reduce methane production, since methanogens feed on hydrogen that is contributed by hydrochloric acid.  You should stop probiotics for about a week before taking the test.  Patients should not take laxatives within 24 hours of taking the SIBO breath test. This also goes for herbal laxatives and magnesium. Patients should also stop antibiotics and antimicrobial herbs prior to taking the test.  On the other hand, if the patient is still bloated with whatever they are taking, then we can conclude that it’s not working and likely will not affect the test result.

23:00  About 25% of those who have a flat line on a two breath test, which we previously diagnosed as being positive for hydrogen sulfide SIBO, are positive for hydrogen sulfide on the three breath test.

23:50  The organisms that cause hydrogen sulfide SIBO is more complicated than those that cause methane SIBO.  With methane SIBO we have Methanobrevibacter smithii, Methanobrevibacter stadmenii and then a couple of other minor methanogens, and we’ve actually shown that M. smithii correlates with constipation, correlates with the methane on the breath test, and so forth.  Dr. Pimentel said they have shown that M. smithii correlates with constipation, correlates with the methane on the breath test, and so forth.  In the case of hydrogen sulfide, though, there’s multiple organisms that can produce hydrogen sulfide, including pseudomonas, Fusobacterium, Desulfovibrio, and Bilophila.

26:16  Dr. Steven Sandberg-Lewis, who spoke at our meeting a couple of months ago, he said that he’s been finding a number of patients with hydrogen sulfide SIBO positive with constipation.  Any time you have a patient that does not fit the pattern, such as a patient who is positive for hydrogen sulfide SIBO who has constipation, Dr. Pimentel recommended that you work them up with a colonoscopy or a CT scan to see if they have a tumor or a blockage in their colon.

27:49  Treatment for hydrogen sulfide SIBO often includes bismuth, which dates to a study from 1998 from a gastroenterologist, Michael Levitt, who wrote an article in the New England Journal of Medicine about flatus and how bismuth inhibits sulfate reduction pathways, thus reducing gas production.

29:24  Biofilms.  Some of the microorganisms that cause SIBO, like Methanobrevibacter, reside in the mucous layer, which is essentially a biofilm, so busting this mucous layer a bit may be helpful in erradicating them and maybe bismuth is helping with this.

30:54  Hydrogen SIBO.  The organisms that cause hydrogen SIBO are mainly E. coli and Klebsiella and sometimes Aeromonas. 

32:10  Methane SIBO.  Dr. Pimentel explained that they will be publishing how many methanogens are found along the small intestine in different sections, as well as in the stool. In terms of treatment, he recommends rifaximin and neomycin based on the double blind study, rifaximin with metronidazole as a substitute. He also finds Allicin to work well and he also still likes lovastatin, and the veterinary literature is strong, but the problem is that it gets absorbed, so he is still working on a formulation that will not get absorbed.

33:23  While the type of E. coli that causes hydrogen SIBO is not the pathogenic, E. coli that has the gene for CdtB endotoxin, there are still lipopolysacharides (LPS) that other chemicals that may be getting released that can cause inflammation and pain.

37:02  Dr. Sam Rahbar is an integrative gastroenterologist in LA and he’s recently published on some patients who have tick-borne illness such as Lyme disease and it often seems to be correlated with patients with methane SIBO or IMO.  Dr. Pimentel said that they have not analyzed the genetic material that they found to look for spirochetes or other parasites yet.  Dr. Pimentel also said that he agrees that sometimes fungal overgrowth (SIFO) is a factor in IBS, but it is not as common as bacterial SIBO and he refers to Dr. Satish Rao, who is part of his research group, who has done more work on fungal overgrowth. 

39:48  Are elevated levels of Methanobrevibacter on a stool test indicative of IMO?   Yes, as long as the levels are above 10 to the 4 and they are associated with constipation. 

41:06  Lovastatin has been used successfully by some doctors off label for IMO at a dosage of 30 mg at bedtime.

42:24  Some doctors have suggested using 120 minutes as the cutoff time for evaluating a breath test instead of 90 minutes for patients with slow motility, such as those with constipation, but the problem is that if the patient has gastroparesis or is a narcotic user, you don’t know what their transit time is and even 120 minutes may not be enough.

43:26  Mycotoxins. 

45:26  The relationship between IBS and IBD, (Inflammatory Bowel Disorder like Crohn’s and Ulcerative Colitis).  Dr. Pimentel thought at one time that IBS was a possible precursor to IBD, but he doesn’t think that anymore.  Food poisoning causes IBS but they’re not associated with IBD.  Patients with IBD may have SIBO but they rarely have IMO and if they do, it is because of strictures and other structural blockages.



Dr. Mark Pimentel is a Gastroenterologist who is head of the Pimentel Laboratory and Executive Director of the Medically Associated Science and Technology (MAST) program at Cedars-Sinai, which is focused on the development of drugs, diagnostic tests, and devices related to condition of the microbiome, with a focus on IBS. Dr. Pimentel has published over 100 scientific papers and he speaks around the world at conferences, esp. about SIBO and IBS. Here is a list of some of Dr. Pimentel’s key publications: https://www.cedars-sinai.edu/Research/Research-Labs/Pimentel-Lab/Publications.aspx

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 and nutrition experts and researchers in the field to bring you the latest and cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates and to learn more, check out my website drweitz.com. Thanks for joining me and let’s jump into the podcast.

Welcome, everyone, and thank you for joining our functional medicine discussion group meeting tonight, and we’re very excited to have Dr. Mark Pimentel joining us for a discussion on the latest updates on small intestinal bacterial overgrowth and irritable bowel syndrome.  I’m Dr. Ben Weitz. If you have any questions, please type them into the chat box and I’ll either call on you or ask Dr. Pimentel when it’s appropriate. If you’re not aware, we have a close Facebook page, The Functional Medicine Discussion Group of Santa Monica. I’m recording this event, and I’ll post it on my YouTube page, and I’ll also include it in my weekly Rational Wellness Podcast.  If you’ve not listened to it, please check out the Rational Wellness Podcast, subscribe on Apple Podcast or wherever you listen to podcasts. If you joined, please go to Apple Podcast and give us a ratings and review.

We have two sponsors for this evening, Integrative Therapeutics and Vibrant America Testing. I know that the representative from Vibrant is here. So go ahead and tell us a little bit about Vibrant America Testing.

Margot:                                Hi. My name is Margot. I work at Vibrant America in Los Angeles. We work with Dr. Ben Weitz. So Vibrant is a CAP and CLIA-certified full service lab in Northern California with everything from basic blood panels to autoimmune diagnostics. So today, I wanted to bring up one of our most popular panels. It’s the Total Tox-Burden. It includes 31 mycotoxins, 20 heavy metals plus 39 environmental toxins all for under $400. So if you guys are interested in learning more, please email me at margot.h@vibrant-america.com or you can check out our website at www.vibrant-america.com.

Dr. Weitz:                            Okay. Thank you. It looks like Steve Snyder is not here. So let me tell you something about Integrative Therapeutics. They’re one of the few professional manufacturers of high quality nutritional supplements that we carry in our office. They’re sold through practitioners. They have some great products for SIBO. They have the leading brand of the elemental diet, and they have it in the dextrose and non-dextrose version. That’s one of the treatments for SIBO. If you’re not aware of the elemental diet, you should definitely find out more about it. You can talk to Steve Snyder from Integrative Therapeutics.  They also have a great natural pro-kinetic motility activator, which is a really excellent product and we use that all the time. So I want to thank Integrative Therapeutics and Vibrant America very much for helping sponsor tonight’s podcast, tonight’s functional medicine meeting.

Now, I want to introduce Dr. Mark Pimentel, who’s head of the Pimentel Lab, an executive director of the Medically Associated Science and Technology Program at Cedars-Sinai. Dr. Pimentel really needs no introduction, but he is a prolific researcher having published over 150 scientific papers. His lab researches the microbiome and the irritable bowel syndrome. As most of us know, irritable bowel syndrome is probably the most common gastrointestinal condition affecting between 10% and 15% of people in the United States and around the world.  For many years, prior to Dr. Pimentel’s research, IBS was thought to be a diagnosis of exclusion. Once inflammatory bowel disorders, Celiac disease, parasites, and all the conditions that could be diagnosed with a stool sample or looking through a scope, you are then left with IBS. IBS was and still is seen by an unfortunate number of gastroenterologists as a condition of either unknown cause or caused by stress or anxiety. In fact, antidepressants were once one of the most popular medications to treat IBS.  Dr. Pimentel is the first researcher to demonstrate that small intestinal bacterial overgrowth is a cause of IBS in the majority of cases, and that SIBO could be diagnosed with a lactulose breath test. Dr. Pimentel also pioneered the use of rifaximin, a non-absorbed antibiotic as a treatment for IBS. He’s developed an autoimmune model of IBS being caused by an episode of acute gastroenteritis. He’s developed a blood test looking at antibodies vinculin and cytolethal distending toxin to diagnose this autoimmune cause of IBS.  He’s discovered that the methane-producing organism, Methanobrevibacter, causes constipation. Dr. Pimentel and colleagues have recently renamed the methane version of SIBO as IMO, which stands for intestinal methanogen overgrowth. Most recently with his REIMAGINE study, Dr. Pimentel for the first time ever has mapped out the microbiome of the small intestine, which is a monumental achievement.  Most importantly, Dr. Pimentel has given hope to millions of patients with IBS that they might be able to feel better and stay better. So thank you, Dr. Pimentel, and thank you for joining us tonight.

Dr. Pimentel:                     It’s my pleasure. Thank you for inviting me.

Dr. Weitz:                          Absolutely. So how do you want to start?

Dr. Pimentel:                     Well, you tell me. You usually do an interview? Is that what you’re hoping to do tonight?

Dr. Weitz:                          Sure. Absolutely. That’s just fine.

Dr. Pimentel:                     I got to tell you, you always ask the best questions. So I love this podcast for that reason. You’re always well-prepared.

Dr. Weitz:                          Exactly. Well, thank you, thank you. So let’s start off with your mapping out the microbiome of the small intestine. Why don’t you tell us about how you were able to do that and what’s some of the latest information that you’ve gotten out of that?

Dr. Pimentel:                     Well, the human small intestine, what I’d like to say is that the Human Microbiome Project was published in 2007. One of their declarations was, “Well, we published the Human Microbiome and this is what the gut represents based on stool studies.” I was always shocked by that because I felt like, well, stool is stool, but what about the small intestine? What about other parts of the gut? Maybe it’s different. It took us a decade to start to get our act together in terms of getting the REIMAGINE study off the ground because we needed a lot of resources and some of the sequencing equipment. Now, we’ve got everything here at the MAST program.  The problem with the small intestine is it’s not easy to sequence. The mucous is too think. So we realized you couldn’t do what you do with stool. You couldn’t process the stool the same way or the small bowel the same way as stool, and we have to add mucolytics and other things to liberate the bacteria before you get their DNA, but we did all that. We’ve published validations of how you’re supposed to handle the small intestinal microbiome.

While we found a ton of stuff since starting, we found bacteria that produce all sorts of things that humans produce manipulating the human body, and you’re going to see some of that. There’s a paper, again, September, sorry. Ben, I can’t tell you things, but next week there’s a paper coming out. I feel like I’m teasing you too much, but there’s a paper coming out that is the next iteration.  Your point was last year we published and made the cover of the journal what the small bowel looks like. The small bowel is completely different than the colon. A couple of pearls. It’s interesting. The duodenum, jejunum, the ileum, they look identical. We used to think, “Oh, the closer you get to the colon, the more dirty it is, the more colonic it looks like.” It wasn’t what we saw. It was, literally, duodenum, jejunum, ileum looked the same. Then it’s like a cliff. The microbiome completely changes once you hit the colon. I think that’s really so poignant. We have other pearls like people don’t-

Dr. Weitz:                          Can’t I ask you a question about that fact?

Dr. Pimentel:                     I’ll do it for that one.

Dr. Weitz:                          So I want to get right back to it, but does the fact that the level of bacteria you’ve seen throughout the small intestine, does that tell us anything about whether the bacterial overgrowth comes from below up or from above down? In other words, we originally were thinking that the bacteria from the colon were overgrowing into the small intestine. Does the fact that there’s not more bacteria at the distal part of the ileum, does that indicate that that’s not the case?

Dr. Pimentel:                     So all of this notion, believe me I’m guilty of saying the same thing, all of this notion that overgrowth is the colon bacteria coming up into the small intestine is from older data that says, “Well, if the ileocecal valve is incompetent then the stool is reflexing into the small bowel and that contaminates the small bowel,” but as the REIMAGINE study is telling us, that’s not exactly how it happens.  What happens is the small bowel contains generally more proteobacteria than the colon. The small bowel contains no bacteroidetes, hardly at all, but that’s half of what’s the colon. So it’s the composition that’s different, but what we find with SIBO, in sequencing I mean, is that there’s weeds that develop, E. coli and Klebsiella. When they start growing because the flow of the small bowel is not correct, then you get SIBO. E. coli and Klebsiella are just rampant. They run up like weeds and then they crush everything else around them. So it’s not really that the colon bacteria are coming up. It’s that E. coli and Klebsiella are taking the opportunity to become those weeds that they want to be.

Dr. Weitz:                          Is this largely because of decreased motility? We still think that’s one of the main factors?

Dr. Pimentel:                     Yeah, decreased motility. One of the slides I finally added to my new slide deck is there’s a paper that came up because people were saying, “Well, you say, Dr. Pimentel, that adhesions slow motility and maybe you get SIBO from adhesions, but where is the paper that’s published that shows this?”  Well, a paper just came out with sequencing the small bowel, again, in patients with partial bowel obstructions, and sure enough, it’s E. coli, it’s proteobacteria, and so SIBO in that. The point of that paper is anything that slows the gut down, we are correct, it does generate SIBO and allows these E. coli and Klebsiella to take the opportunity to be the weeds.

Dr. Weitz:                            So along the same lines, we sometimes see patients with Ehlers-Danlos syndrome and they have a higher incidence of SIBO, and we would think now it was because of laxity, maybe, in the ileocecal valve. I wonder why patients with that condition looking at hyperlaxity would have an increased risk of SIBO if it’s not coming up from below.

Dr. Pimentel:                     Yeah. So I mean we published one paper on EDS where we’re looking at visceroptosis. So I don’t know if you know the term visceroptosis, but it means that the gut is sagging into the pelvis, and by doing so, it creates all sorts of bends and twists in the small bowel. So I think physically, it creates impairment like your hose bent in the garden and the water doesn’t flow through it. I think that’s what’s going on is just everything is crushed on top of each other down on the pelvis.  That’s a characteristic sign. So the way you do a visceroptosis is you give the barium, you get them to stand up and take a picture front and all the bowel should be nice all over the place, but in the Ehlers-Danlos, it’s all flat down on the pelvis. It’s sad to see it because it’s not a pleasant thing to have for the future for that patient.

Dr. Weitz:                            Okay. If you want to continue on your telling us about some of the findings from the REIMAGINE study.

Dr. Pimentel:                     This is what I get excited about every day. Well, what I was going to tell you is that one of the other things we published, so not everything is in September and I can’t talk about it, but we did publish that PPIs, proton-pump inhibitors, don’t cause SIBO. The sequencing data does not support that, but PPIs do do something really interesting. They reduce clostridial species in the gut. You probably know this, Ben, but PPI is a risk factor for C. diff colitis.  So it’s like you have this neighborhood that’s supposed to be full of clostridium but for some reason, PPIs make those clostridia go away, but that gives an opportunity for some houses to be support another type of clostridia that isn’t good and that might be C. diff. So anytime you leave an opening, other organisms take the opportunity to come in there and take over. So maybe that’s why C. diff grabs hold in these PPI-treated patients. So there’s that paper.

We showed in another study presented at DDW that women who are postmenopausal, if you look at their small bowel, postmenopausal women, their microbiome gets shifted in a very bad way, but if they’re on hormone replacement therapy, their microbiome in the small bowel looks just like they’re premenopausal.  So it’s stuff like that that we’re finding. Again, another paper next week that will get some press, I think, that’s going to be another impactful paper on just getting the knots and bolts of what’s going on in the microbiome.

Dr. Weitz:                            So you mentioned PPIs don’t affect SIBO. That brings up, I’ll jump to a question, which I wanted to ask you about. How important are the pretest procedures before somebody gets a breath test and what are the recommendations? Does that patient stop taking PPIs? Does that mean that’s no longer important?

Dr. Pimentel:                     Well, this paper suggests you shouldn’t have to worry about it. So now, there’s a caveat to that. Patients with methane, for example, when you reduce acid in the stomach, you’ll reduce methane production. We showed that in another paper. We don’t see a lot of methanogens in the upper duodenum. So we can’t actually see that methanogens are being affected by PPI in that PPI study. So there’s reasons for not being on PPI, but to be honest with you, I don’t think PPIs do much to the breath. That consensus was three years ago, so we didn’t have the luxury of that data at the time.

Dr. Weitz:                           Interesting. So does that mean possibly for functional medicine practitioners supplementing with hydrochloric acid for patients with methane SIBO or IMO might be beneficial?

Dr. Pimentel:                     The opposite because methanogens can use hydrogen of any sorts.

Dr. Weitz:                           Okay. Okay. Okay. Okay.

Dr. Pimentel:                     Yeah. So it’s possible that you could be making or putting more gas on the fire with acid.

Dr. Weitz:                           Okay. Yeah, yeah, yeah. So since I asked the question about pretest procedures, what other pretest procedures do you think are most important to get an accurate result and what things need to be stopped over what period of time? How about probiotics?

Dr. Pimentel:                     Yeah. I think most probiotics that you take don’t produce hydrogen, but we generally recommend not beyond those for about a week before the test. Where we get into trouble, and this is a question I got earlier today on another call is, “What about my constipated patient taking laxatives, “Are you telling me I can’t take a laxative for a week before the breath test? I’ll die,” because it’s really hard for these patients.  The North American consensus is meant to be a rule of thumb. It’s not meant to be a gospel, but it is true that I have patients where they come in, I was sure they had SIBO, they do the breath test, it’s negative, and then I talk to them and they say, “Yeah, I had a massive diarrhea the morning of the breath test just before I came to the office to do the breath test because I took all my laxatives last night.”  So if you flush the gut, you’re going to have a negative breath test and that screws up the test, obviously. So you just got to be careful in some of these patients with constipation that they didn’t just take a monster amount of laxatives the night before because they were worried about how bloated they get with the breath test.

Dr. Weitz:                          Okay. So they’re supposed to stop laxatives.  What about herbal laxatives?  What about magnesium and vitamin C? Is that the same thing?

Dr. Pimentel:                     Vitamin C, not as much, but, yeah, herbal laxatives, I mean, anything that’s going to cause you to be purging within 24 hours of the test can have an influence, for sure.

Dr. Weitz:                          Including magnesium citrate.

Dr. Pimentel:                     Yes. Yes. Absolutely.

Dr. Weitz:                          What about herbal antimicrobials?

Dr. Pimentel:                     Yeah. Well, any herbal antimicrobials are antimicrobials, but the way I deal with that is, for example, if a patient says, “I’m still bloated with whatever I’m taking,” then they’re still bloated with whatever they’re taking.  A, it’s not working and B, they must have SIBO.  So it shouldn’t affect. Then the other thing is a lot of times patients will do a breath test after antibiotics to make sure it’s gone.  So I have no problem.  You don’t have to wait a month to do a second breath test.

Dr. Weitz:                          Now, has the new Trio breath test, which measures all three gases, has that recently been recalibrated so that fewer patients would test positive?

Dr. Pimentel:                     So the new breath test is the sensors are supposed to be more accurate down to 0.1 or 0.2 parts per million. If you look at the readings and how it’s reported, you don’t just get 49, you get 49 point something because the sensors are certified to be sensitive to that level, not that you need that extra sensitivity, but the bag system is designed to retain all the gases very well and it’s validated that those bags filled with your air, your lung air, can last a week and hold hydrogen sulfide, methane, and hydrogen correctly as it was on day zero.  So that’s all certified by the CLIA Lab. So in that sense, you’re getting a more accurate result.  Also, the CO2 tends to be higher than other testing because of the way the system works.  So it’s a closer to true alveolar gas and, therefore, you could say you don’t have to adjust the gas.  The biggest problem with breath testing is when you get a bad sample and you get a low CO2 and you have to … So what you do is you correct the CO2 up to 5.5. If you have to correct it from one to 5.5, then you got to multiply every number by five and a half. The more you correct, the more error you impose on the breath test. So it’s important that you get good samples.

Dr. Weitz:                          Has the test been changed? In other words, were they getting too many positives and did they have to change the calibration of the test?

Dr. Pimentel:                     I don’t know.  For hydrogen, methane, hydrogen sulfide?

Dr. Weitz:                          No, for hydrogen sulfide, yeah.

Dr. Pimentel:                     Well, no.  So hydrogen sulfide, okay.  So I understand your question now. I’m sorry.

Dr. Weitz:                          Yes.

Dr. Pimentel:                     So hydrogen sulfide, so when we did our first validation of hydrogen sulfide, we selected functional chronic diarrhea patients. The functional chronic diarrhea patients were finding that their hydrogen sulfide was over five parts per million compared to constipation, compared to healthy.  Just recently, and this has not been published, but it’s been used for validation of the test. We completed a group of D-IBS patients. So you have D-IBS and then the diarrhea patients who are functional diarrhea. So they’re more severe. They’re having diarrhea every single day. Whereas DIBS is on again off again diarrhea. The DIBS is almost often over three parts per million. So now that we have that data, it drives a change in what we think is positive, so anything over three now because constipation is almost always less than three. So as data come in, the science dictates how you interpret the test. It’s the same thing as … Sorry. Was somebody asking?

Dr. Weitz:                          No. I just didn’t mute them as they were coming in.

Dr. Pimentel:                     Okay.

Dr. Weitz:                          Okay. Let’s see. What was the question? Have you gone back and seen if patients who got a flat line on the two breath tests, does that correlate with a positive result for hydrogen sulfide on the three breath test?

Dr. Pimentel:                     Yes. We’ve shown that up to a quarter of patients. Up to a quarter of patients are testing positive for hydrogen sulfide in general, and we’ve seen that, but what I mean is up to a quarter of patients with flat line are testing for hydrogen sulfide. There are still some flat liners that could be unexplained as either poor transit, gastroparesis, maybe even bowel. There’s many reasons why you could have a flat line besides hydrogen sulfide, but, yeah, about a quarter of patients are hydrogen sulfide.

Dr. Weitz:                            Can you talk about the organism Fusobacterium varium that you have found to be … This is a question that Alison asked me to ask you. That appears to be linked with causing hydrogen sulfide SIBO.

Dr. Pimentel:                     Yeah. Thanks, Allison for that question.  So the methane story is simpler.  The methane story is you have a couple of methanogens, Methanobrevibacter smithii, Methanobrevibacter stadmenii and then a couple of other minor methanogens, but we’ve actually shown that M. smithii correlates with constipation, correlates with the methane on the breath test, and so forth.  In the case of hydrogen sulfide, though, there’s multiple organisms that can produce hydrogen sulfide. For example, pseudomonas can produce hydrogen sulfide.  Fusobacteria can produce hydrogen sulfide.  Desulfovibrio can produce hydrogen sulfide, and there’s Bilophila can produce hydrogen sulfide.  So there’s a little bit of a laundry list of hydrogen sulfide producers.  I think Allison is referring to a study we did where we took Fusobacterium and we gavaged or inserted it into the bowel of rats in a rat study.  The purpose for this study was to show putting a bacteria that makes a lot of hydrogen sulfide, will in the animal create the animal to produce hydrogen sulfide and we can detect it.  So we were able to detect an increase in the animal’s production of hydrogen sulfide in their body.  The second part of it is as they grew this Fuso in their body and produced hydrogen sulfide, the animal started to have diarrhea, but then the animal, because this organism wasn’t natural to them, eventually cleared the organism.  The hydrogen sulfide resolved. The diarrhea resolved.  So it’s essentially trying to fulfill Koch’s postulates of cause and effect.  An organism that produces hydrogen sulfide, you put it in, it produces hydrogen sulfide, you get the diarrhea, the organism goes away, the hydrogen sulfide goes down, the diarrhea goes away.  So we’re just trying to prove the point that hydrogen sulfide production causes diarrhea.

Dr. Weitz:                          Now, Dr. Steven Sandberg-Lewis, who spoke at our meeting a couple of months ago, he said that he’s been finding a number of patients with hydrogen sulfide SIBO positive with constipation.

Dr. Pimentel:                     So anything we do has an overlap. There’s no black and whites in medicine. So if you were to look at our graph with a dot plot, you have patients who are constipated, for example, that have, and I could show a graph, but there are occasional constipation patients where their hydrogen sulfide is high and we don’t understand why, but just remember this that if I put a blockage in my colon, let’s say I had a tumor in my colon, and the bowel is obstructed. I would be constipated, and then bacteria in the colon would build up. If you happen to have sulfate-reducing bacteria and they build up, you’d get hydrogen sulfide, but you’re constipated because you have a tumor in your colon.  So anytime in my practice when I see something that doesn’t fit, outliers like that, I go to further workup to be honest, something doesn’t fit, because 90% of people with hydrogen sulfide don’t have constipation. So if I see a constipator, I’m going to work them up further, maybe a colonoscopy, maybe other things.  So these are all clues to something else possibly affecting them.

Dr. Weitz:                          So what do we know about, since we’ve been talking about hydrogen sulfide SIBO, what do we know about treatment for hydrogen sulfide SIBO? I noticed that you tend to use bismuth as part of your protocol and I’ve talked to a number of functional medicine practitioners who also use some form of bismuth. Why do you think bismuth might be helpful?

Dr. Pimentel:                     Well, it was a study from 1998 from a guy, Michael Levitt. I don’t know if you’re familiar with him, but he was a gastroenterologist in the ’70s, ’80s, and ’90s, and he has a New England Journal of Medicine article on flatus. If you can imagine a bunch of flatus article on New England Journal now unless COVID causes flatus, then you’ll get that published.

Dr. Weitz:                            … or if vitamin D causes flatus then that would get published, too.

Dr. Pimentel:                     Yeah, but to be honest, what he was studying was intestinal gas production and it was seminal work at its time. He actually described what he thought was the mechanism is that it inhibits sulfate reduction pathways within the organism and then that reduces their energy and they can die from that. So it was paper of 1998 that I use in my presentation that describes that, but, yeah. I mean, this is all we got to go on at the moment, but stay tuned for more studies that are coming.

Dr. Weitz:                          So here’s some speculation. I think that there’s some data to show that bismuth may be helpful in breaking up biofilms. Have you, in looking at the bacteria in the small intestine and SIBO, have you seen biofilms present and do you think that might be a factor when we treat SIBO?

Dr. Pimentel:                     Yeah. So I mean, the difficulty with biofilms is the way we see it in the REIMAGINE study is you’ve got a layer of thin liquid right on top, then you’ve got mucous, and then when you biopsy the mucosa in between the villi, there’s another layer of mucous. So there’s various biofilms, and each of those layers has a different microbial composition, but we see some of those organisms in the deeper layer.  So, for example, Methanobrevibacter loves the mucosa. So we don’t see a lot of the Methanobrevibacter up in those higher layers of the liquid layers, but busting the biofilm or the mucous can help you in treating some of these patients. So maybe bismuth is working by busting up the mucous and helping you get at these organisms, but we haven’t layered out H2S yet. So I can’t give you an honest answer as to where H2S organisms are residing most commonly.

Dr. Weitz:                          So let’s go to hydrogen SIBO. Which organisms are primarily involved with hydrogen SIBO?

Dr. Pimentel:                     Oh, this we know a lot about. So the REIMAGINE study, we did publish last year a very important paper and we’ve had these debates on these calls as well previously, but E. coli and Klebsiella, those are the two weeds in the garden, but we also showed that the breath test correlated with all the sequencing, and that the hydrogen production pathways are increased in the small intestine of patients with hydrogen SIBO because of the E. coli and Klebsiella.  The reason that’s important is because there are people who said, “Oh, the hydrogen is coming from the colon. It’s coming from colon bacteria and lactulose getting to the colon.” What that paper showed was that that’s not the case. This is happening in the small intestine, and it’s E. coli and Klebsiella. You remember those two, and a little bit of Aeromonas, which I’ll sprinkle in there because we do see a little Aeromonas going up as well.

Dr. Weitz:                            What was I just going to say? I can’t remember what I was just going to say. So I had a thought there. So when it comes to methane SIBO or now it’s called IMO, what’s the latest? What have we learned from the REIMAGINE study on that?

Dr. Pimentel:                     Yeah. So the one thing we’re going to be presenting or submitting to DDW in December is now what we’re doing is we’re mapping intestinal methanogens along the entire intestine. So we’ll show you how much is in the duodenum, the jejunum, the ileum, and then subsequently in stool, and we’ll be able to map it out. In terms of treating IMO, things haven’t changed all that much. We still give rifaximin and neomycin based on the double blind study, rifaximin with metronidazole as a substitute.  Obviously, there’s no FDA-approved drug for IMO because it doesn’t work that way, but that’s what the data and the literature supports at the moment. There are other treatments. Allicin is another product from garlic that seems to work well with reducing methane. We still like lovastatin. Lovastatin, the data in the veterinary literature is very good, but it’s tricky with lovastatin because it gets absorbed.

Dr. Weitz:                            Oh, I know what my question was now with the hydrogen. So do you think that E. coli can produce endotoxins? We know endotoxins are produced by Campylobacter with food poisoning that can often be the cause of SIBO to start with. Do you think that endotoxins secreted by the bacteria that cause hydrogen SIBO or the other forms of SIBO are playing a role in some of the pain and symptoms patients are experiencing?

Dr. Pimentel:                     Yeah. So okay, first of all, hydrogen is something we’ve looked at for years. Hydrogen, no matter how high it is, doesn’t predict the severity of the symptom, whereas hydrogen sulfide does. So the higher it is, the more diarrhea you have, the more pain you have and the more urgency you have, but in terms of the toxin, I think you’re referring to the CdtB toxin.

Dr. Weitz:                          Yeah.

Dr. Pimentel:                     E. coli, pathogenic E. coli has that gene for CdtB, but native E. coli to the gut, which is what’s producing the SIBO, it generally doesn’t. It’s not a pathogen. It’s more of a colonizer, and now it’s blooming, and that’s what’s causing the SIBO, but Campylobacter definitely has CdtB and that’s what triggers your antibody production, CdtB antibody, and then the anti-vinculin antibody, which is the blood test for IBS.

Dr. Weitz:                          Okay. So we don’t think that endotoxins is playing a role other than the endotoxins from Campylobacter that leads to the autoimmune reaction.

Dr. Pimentel:                     I wouldn’t say it that way. I mean, I think I know where you’re going with this, but, for example, E. coli has lipopolysaccharides and other things, other wall chemicals that don’t make you very happy. So having all that E. coli and Klebsiella around does create a bit of an inflammatory response, we think, and in addition to the hydrogen and all these gas dynamics that we’ve been talking about for the last little while.  What lipopolysaccharides or these endotoxins are doing exactly is unclear. Again, we have a study that we just finished. It’s a very large animal study and we see a lot of effect of these endotoxins on the cytokines in this animal, but, again, I can’t really talk about it at the moment, but you’ll see some of that data in a few months.

Dr. Weitz:                            Somebody asked a question about the biofilms. So in the functional medicine world, there are various compounds, nutritional compounds that we’ll use to try to break up biofilms, and some of them are enzymes. There are some products that use a combination of bismuth with some other substances. If we were to use agents that we think might help break up biofilms, would that be something that we would do prior to using antimicrobials or at the same time or what would you think would be the timing of the use of that protocol?

Dr. Pimentel:                     I think some of the data we have that’s published on E. coli is that a lot of these E. coli and Klebsiella are swimming through the mucous. So breaking up the mucous is something we’re very interested in in terms of trying to improve our treatments.

Dr. Weitz:                            Okay. Okay. Good. So let’s go back to IMO. So Dr. Sam Rahbar is an integrative gastroenterologist in LA and he’s recently published on some patients who have tick-borne illness such as Lyme disease and it often seems to be correlated with patients with methane SIBO or IMO. I wonder in your research, have you seen any evidence of spirochetes or other parasites in the small bowel?

Dr. Pimentel:                     So the REIMAGINE study, we have the genetic material from the small bowel. We haven’t actually done this. You have to take the sequences and throw it in a database that looks at parasites or fungi or other things. So we haven’t don’t the parasites yet, but, I mean, there’s data from Sweden and other countries in Europe on the role of spirochetes, for example, in IBS specifically, and they’re finding increased spirochetes in the colon, but the connection to IMO, I don’t have any data for that yet. I’d be curious to see exactly what the data looks like from Dr. Rahbar.

Dr. Weitz:                          Okay. A lot of us have found that the methane SIBO or the IMO is more difficult than hydrogen SIBO, and a lot of times when the patients don’t resolve, we try using different antimicrobials. We look for other possibilities. I think Dr. Rahbar has also spoken at the fact that sometimes he’ll see fungal overgrowth. So the question for you is in your data, did you see candida or other fungus in the small bowel related to IMO?

Dr. Pimentel:                     I think Satish Rao is the ultimate expert on this from Georgia. He’s published a lot of the work on this, but we do see fungal overgrowth occasionally, maybe a handful of times a year in my practice. Dr. Rezaie sees it in some of his refractory patients also. So where he thinks it’s overgrowth or bloating, he treats them, they’re not getting better, and then uses an antifungal and it seems to be effective. He’s also cultured candida in some of these patients as either part of the REIMAGINE study or through the clinical lab and then treated them. So it’s definitely there. It’s definitely present in some of these patients, but I would say it’s not as common as the bacterial SIBO, for sure.

Dr. Weitz:                          Okay. Since IMO occurs throughout the entire digestive tract not just in the small intestine, right?

Dr. Pimentel:                     Right.

Dr. Weitz:                          So would elevated levels of Methanobrevibacter on a stool test could just possibly be indicative of IMO?

Dr. Pimentel:                     So Methanobrevibacter smithii in a stool test, if you go back to a paper we’ve published now a number of years ago, 10 to the four, up to 10 to the four or 10,000 smithii per milliliter is considered physiologic, meaning you don’t have any symptoms, you don’t have constipation, but anybody over 10 to the four was constipated. Anybody over 10 to the six then you start to see it in the breath.  So, yeah, there is some merit to doing stool M. smithii, but you have to use that trial, but we’re getting better at evaluating M. smithii in the stool using QPCR and some of the new refinements are going to have some surprising results, but the point I’m trying to make is, if you see M. smithii in the stool, often that’s normal as long as it’s very low in number.  So you just have to be careful how you interpret those stool tests.

Dr. Weitz:                          Okay. Somebody asked a question about using lovastatin. It sounds like she’s considering possibly using lovastatin.

Dr. Pimentel:                     Yeah. I mean, the dose we use for lovastatin, again, it’s an off label use, is 30 mg at bedtime, and we do see methane reduction, but it’s a little bit, it’s challenging because if you just use plain old lovastatin, there’s always a risk of muscle aches and other side effects of lovastatin.

Dr. Weitz:                          I’m not sure where that echo is coming from. Have you looked into the use of red yeast rice as a possible alternative?

Dr. Pimentel:                     I haven’t personally used it, but I know some people who have and have gotten some decent responses from it because red rice yeast does have lovastatin, natural lovastatin in it.  So that could be effective.

Dr. Weitz:                          Yeah. There’s actually products on the market that we tend to use that make sure that there’s no lovastatin, but they seem to have the same effect, and we see much lower side effects of muscle problems using it versus statins.  So for patients with slow motility such as those with constipation, should we consider a cutoff of 120 minutes instead of 90 minutes for interpreting a positive test?

Dr. Pimentel:                     Yeah. The problem is you don’t know who and what they have. So, for example, there are patients who might have diabetes for a few years and for all intents and purposes they just have bloating. You do the test and they have gastroparesis and you see a flat line because the lactulose or glucose never left the stomach. So it’s those things that create trouble because you don’t know they have gastroparesis and then you get a flat line test, but waiting 120 minutes, waiting three hours, you don’t know how long to wait for each of those individuals because you don’t know what their transit is. Narcotic users have the same issue.

Dr. Weitz:                          Okay. A number of us in the functional medicine world who have difficult to treat IBS slash SIBO patients sometimes will look at the possibility of mycotoxins or exposure to mold and we have found a certain amount of benefit from this pursuit and have had, I know personally have had a number of patients with difficult to treat SIBO who got better after we looked at the possibility of mycotoxins, found that they had some exposure to mold. Do you think that there might be in some way that SIBO might make patients more likely to experience either be more sensitive or to experience symptoms with exposure of mycotoxins?

Dr. Pimentel:                     Yeah. So I mean, my understanding of the literature of mycotoxins is very limited, so I’m going to have a very muted response to that because I don’t know enough about it, but what we are seeing and Mike Camilleri from the Mayo Clinic just is publishing a paper now where there is increased intestinal permeability in some of these patients and in IBS patients.  So the worry is that you have some increased permeability to whether it’s food, food allergies, food antigens. There’s another nature paper that came out of Europe saying that patients with IBS, for example, are more susceptible to allergens maybe because the tight junctions are more open.  So as we start to see maybe the anti-vinculin antibody is allowing these tight junctions to be more open, all of that work needs to still be done, but the pieces are coming in to place. We just don’t have all the answers yet.

Dr. Weitz:                          What about the relationship between IBS and IBD, inflammatory bowel disorder?  I know I’ve seen patients with IBD who also had IBS, and when we treated the IBS, their IBD improved.  What do you think might be the relationship?

Dr. Pimentel:                     I’ve had an on and off relationship with IBD in the sense that there was a period of time where I thought IBS may be a precursor to IBD or maybe even SIBO was a precursor to IBD, but I actually don’t think so anymore. I think IBD and IBS are completely separate entities. I’ll give you the evidence, I think, and things change with time, but from what I understand currently, food poisoning causes IBS. Anti-vinculin, anti-CdtB antibodies are associated with irritable bowel syndrome, but they’re not associated with IBD. So understanding the pathophysiology of that host infectious IBS tells me, “Well, that develops IBS and SIBO,” but we’re not seeing that in IBD at all, not like that.

The other thing is I would challenge you to find me an IBD patient with IMO. They don’t happen almost ever. We did a study where we looked at breath test in IBD patients and out of a huge list of IBD patients, only three had IMO and all three of them when you called them, they were constipated. They weren’t having diarrhea. They weren’t having IBD-like symptoms.  So I don’t know, but what we do see with IBD is that if they have strictures, they’ll have stasis, and if they have stasis, they’ll have SIBO, and if you treat the SIBO, they will get better, but the reason for the SIBO is not IBS. The reason for the SIBO is a mechanical issue due to the strictures and the narrowings and other things that the IBD produce. So that’s how I see it currently.

Dr. Weitz:                          Many of us will use a low-FODMAP diet for SIBO and I know you have the low-fiber diet from Cedars-Sinai. Do you think that there should be a different diet for patients with hydrogen versus methane versus hydrogen sulfide?  A number of practitioners will use a lower sulfur version of the low-FODMAP diet for patients with hydrogen sulfide, for example.

Dr. Pimentel:                     Yeah. I’m getting this question a lot, and I’d like to enthusiastically say that the future is we might have three different diets, but I don’t think we worked out what those diets are yet. I have encouraged some of my hydrogen sulfide patients to go on a low-sulfur diet, but I’m not sure that’s the whole story for them in terms of making them better because I’m giving them antibiotics as well.  So we need more data, more time to unravel that, but what is clear is that from studies done in the past is that people with hydrogen sulfide in their gut that low-sulfur diet does reduce that. That’s been published. So I would imagine that that would, but I don’t have any objective data since the breath test has become available to be able to say, “Aha! This is your diet that you should be on.”

Dr. Weitz:                          Have you seen fasting to be a benefit for patients with SIBO?

Dr. Pimentel:                     I love fasting for my SIBO patients. That’s for sure. I mean, the longer they’re fasted, the more opportunity they have for cleaning waves. The more likely they can naturally clear their bacteria out and so to keep things going. So yeah, I mean, skipping breakfast is something that some of these patients do on their own, but the longer they fast between meals is also part of the low-fermentation diet we developed because it’s not just a diet.  It’s trying to make sure you don’t eat between meals constantly keeping your gut with food and bathing the bacteria with food. It’s not how we used to eat. I mean, thousand years ago, we kill the buffalo, ate the buffalo before it rotted on the field. We didn’t have a refrigerator. We didn’t have potato chips or 7-Eleven. So you eat and then you don’t eat for three days. That’s how life was. Anyway, it’s just-

Dr. Weitz:                          Have you ever recommended patients do an extended fast, maybe a couple of two, three days of water only or something along those lines to calm it down?

Dr. Pimentel:                     I’ve seen patients do that on their own, and that sometimes does work for them, but I don’t generally ask patients to do that because it’s pretty tough.

Dr. Weitz:                          What about the use of the elemental diet? Are you still using that on some patients?

Dr. Pimentel:                     Oh, absolutely. I mean, I’m the one who published that fist trial on elemental diet showing it’s more effective even than antibiotics. So I really like the elemental diet. I think the challenge of the elemental diet is that it is hard for patients to do, but look, we’ve done thousands of patients on the elemental diet, literally. So if we would hit a wall and we want to get rid of the overgrowth, the elemental diet has been quite effective for us.

Dr. Weitz:                          Do you typically do it for two weeks?

Dr. Pimentel:                     So in the study, we have in the past done one, two, and three weeks. So by two weeks, you get your maximum effect and you gain a few percent if you do an extra week, a third week, but I can tell you that there’s two time points in the elemental diet treatment that patients hate me, the first two days and the last three days because in the last three days, they’re like, “I can’t wait till this damn thing is done,” and the first two days, they can’t believe they’re doing this. So the dartboard with my face on it is at the beginning and the end.   You know at the end, what we see is a dramatic response, and then patients, I mean, I have patients who do this three times a year and they just love it. They have the fortitude to do it and it makes them feel better than antibiotics. So it’s not all negative. I don’t mind being the face of the dartboard if it makes the patient feel better.

Dr. Weitz:                          Do you ever see patients who started out maybe as hydrogen SIBO and end up as hydrogen sulfide SIBO or switch from one form to the other?

Dr. Pimentel:                     So we’re still early in the hydrogen sulfide part of things, but I have almost never seen somebody switch from hydrogen to methane, but I have seen if we get rid of methane all of a sudden the hydrogen goes way up because it was always there. It had to be there to make the methane. So I have seen the flip side, but never going from hydrogen as their baseline after treatment to methane, almost never. Maybe one in 10 years that I saw that happen.

Dr. Weitz:                          We got a couple of questions about the elemental diet.  Are you using the integrative product or what product are you using for the elemental diet?

Dr. Pimentel:                     Yes, I’ve used sometimes the integrative diet.  Sometimes I use Vivonex.  So those are mainly the two products.  Peptamen because it’s almost elemental, it may be more palatable for some patients, but those are the two products I mainly stick with.

Dr. Weitz:                          With the elemental, they have a version with dextrose and one without dextrose.

Dr. Pimentel:                     I don’t think it matters to me the dextrose because I think it gets absorbed so quickly it doesn’t really affect the situation. I do have patients who ask me about whether they could have coffee while they’re on it. I always answer, “Well, the study was done with no coffee. If you do coffee and you don’t get better after, don’t blame me,” because I don’t know. I mean, it’s neutral. It’s calorie neutral, but they always ask me all sorts of questions.

Dr. Weitz:                          When I put patients on the elemental diet, I usually give them herbal antifungals because of the possibility that they’re eating a high-sugar diet that can fuel the growth of candida or other fungal organisms.

Dr. Pimentel:                     Yeah. Well, I for sure see candida especially thrush in their mouth on the Vivonex and elemental diets. So, yeah, that’s not an unwise thing.

Dr. Weitz:                          Okay. So I’ve seen where you had a chart of what the microbiome looks like in patients with SIBO and there’s real limitation of a lot of the healthy organisms and you end up with overgrowth of proteobacteria and Firmicutes in particular seem to be really suppressed in patients with SIBO.

Dr. Pimentel:                     Yeah. That’s correct. That’s exactly what we see in the small bowel.

Dr. Weitz:                          So does it make sense to use certain types of probiotics to take up that space that’s been vacated so that we make it more difficult for the proteobacter to continue to occupy the small intestine?

Dr. Pimentel:                     I would love for that to be developed, but I don’t have any evidence to suggest that that would work at this point. The evidence suggests it could work, but I have no evidence to suggest that it does work. One of the things that we’re seeing in another paper is that lactobacillus is a disruptor of the small bowel. It’s doing things like E. coli is doing. So you look at lactobacillus, “Oh, it’s good for your colon. It’s good for your colon.” It’s not good for your small bowel I can tell you that now and you’ll see some data coming out shortly on that. We’ve already talked about that previously. Lots of new things coming in and I’ll be adding that to my slide shortly.

Dr. Weitz:                          Yeah. There’s some new probiotics on the market. There’s now an Akkermansia muciniphila, which is one of the important Firmicutes, which had to be produced in a non-oxygen environment, very difficult, and they finally brought it to market. I wonder if that would be something that would make sense to try to regrow the Firmicutes.

Dr. Pimentel:                     Well, if I know Akkermansia well, it also makes a lot more mucous. So are you making more environment for proteobacteria to hide or I don’t know. I’m not criticizing. I think we have to do more work. I think it’s interesting. I think having it gives us the opportunity to look at those kinds of questions, but, yeah, I’m still not clear yet.

Dr. Weitz:                            Yeah, because I mean, even if we kill the E. coli or the other organisms, we still want to regrow the healthy bacteria in the small intestine. So I wonder if maybe prebiotics would be beneficial.

Dr. Pimentel:                     Yeah. I mean, all of that is on the table. So, again, Ben, I’m not pushing back. I just won’t know what the cocktail will be, but what I think I show and I think the slide you’re referring to or the depictions you’re referring to is the network analysis that we did.  The network is not one organism. It’s not three organisms or five organisms. It’s 100. So what I would love to do is to see the 100 come back and not in a fecal transplant because feces are not the composition of small bowel, but we should do a small bowel to small bowel transplantation, and then we might be talking this stuff. I wish we have that because I think that might be the trick, but single organisms, I don’t know. I have to see.

Dr. Weitz:                          Yeah. Is that something you’re working on?

Dr. Pimentel:                     Not small bowel transplant, not yet. No.

Dr. Weitz:                          Okay. So what’s the best way to reset the motility of the gut?

Dr. Pimentel:                     I really like using prucalopride Motegrity to push motility when it’s down. You can also use low-dose erythromycin. That’s what we old school did. Low-dose naltrexone does some of that, too. I know some people use that, but I like Motegrity now. I’ve had a lot of good success with it in the last couple of years.

Dr. Weitz:                          What do we know about patients who have histamine intolerance and SIBO?

Dr. Pimentel:                     Well, I mean, there are histamine-producing bacteria in the gut. So we have to find those characters and characterize them. Histamine is a really difficult thing. The histamine chemical has a very short half life, hard to measure. So we’re trying to track those characters, but we’re not having a good success with that yet. Stay tuned. We are trying to get at them, though.

Dr. Weitz:                            Okay. I think that’s pretty much all the questions I have. Let me just look through the questions that people have asked here. FODMAP diet, let’s see. Somebody asked, “If you were to use rifaximin plus allicin, would you only do it for two weeks?” which is the way you typically use rifaximin versus when we use herbs, we typically use them for four to six or eight weeks.

Dr. Pimentel:                     So I do use allicin in the form of Allimed is what I generally use. Usually, by itself, and I get some good success with methane. The problem with the allicin is over time the methane returns. Sometimes I keep them on it indefinitely to try and keep it down, but then methane still breaks through. It only goes down for a while.

Dr. Weitz:                          Have you used Atrantil?

Dr. Pimentel:                     I have a few patients on Atrantil and some success there. I don’t use it routinely, but, yeah, I have a few patients who benefit from it.

Dr. Weitz:                          Okay. I think that’s all the questions. Thank you so much for your time, Dr. Pimentel. Any final thoughts you want to leave us with?

Dr. Pimentel:                     No, Ben. You always challenge my brain with the most difficult questions, but I love it because there’s still a lot to learn, obviously, and I can only tell you what I know and I hope that in three months I’ll be able to tell you a lot more of what we’re finding this month and next month and just keep you guys informed, but thank you for all you guys do. I think it’s a challenge to treat these patients, and I know we’re all working together to try and find better treatments.

Dr. Weitz:                          Absolutely. Thank you everybody for joining and we’ll see you next month. Thank you so much, Dr. Pimentel.

Dr. Pimentel:                     All right, Ben. Thanks again. Take care.



Dr. Weitz:                            Thank you for making it all the way through this episode of the Rational Wellness Podcast. If you enjoyed this podcast, please go to Apple Podcasts and give us a five-star ratings and review, that way more people will be able to find this Rational Wellness Podcast when they’re searching for health podcasts. I wanted to let everybody know that I do now have a few openings for new nutritional consultations for patients at my Santa Monica Weitz Sports Chiropractic and Nutrition Clinic. So if you’re interested, please call my office 310-395-3111 and sign up for one of the few remaining slots for a comprehensive nutritional consultation with Dr. Ben Weitz. Thank you and see you next week.


7 replies
  1. Patricia Bonsignore
    Patricia Bonsignore says:

    Do you treat the elderly? Ive had sibo for 50 plus years. My recent compression fractures have motivated me to try and to find the cause of my osteoporosis which i is think may be sibo or imo. Im ready to try treatment under the care of a compassionate doctor such as yourselves. Thank you for all your research and God bless you.

  2. Karen Dobies
    Karen Dobies says:

    One of the most elucidating podcasts I’ve listened to. Thank you to Dr Weitz, and to Dr Mark Pimentel for his endless efforts and research in finding treatments and a cure for SIBO. .

  3. Suzette
    Suzette says:

    Hi, I had a breath test in September that showed both hydrogen and methane. It sounds like that is not possible. I was treated with Xifaxan and Flagyl. My bloating is gone but I still have a yucky stomach feel part of the time, or a tender stomach and I still cannot gain weight. I don’t have any issues with constipation or diarrhea. I was diagnosed with gastritis after I had an endoscopy so am wondering if after an entire year, I still have that? Thank you for any help.

    • drweitz
      drweitz says:

      Hi Suzette, You definitely can be positive for both methane and hydrogen SIBO. I am available for Functional Medicine consultations either in person or via phone or Zoom. Please call my office at 310-395-3111 to set that up.


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