Discussion on SIBO and IBS with Dr. Sam Rahbar and Dr. Ilana Gurevich: Rational Wellness Podcast 298

Dr. Sam Rahbar and Dr. Ilana Gurevich discuss SIBO and IBS and how to treat difficult cases at the Functional Medicine Discussion Group meeting on February 23, 2023 with moderator Dr. Ben Weitz.

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Podcast Highlights

4:14:  IBS, Irritable Bowel Syndrome, is the most common gastrointestinal condition and it exists in at least 10% of the population.  For many years we had no idea what the real cause of IBS was and it was often considered to be a stress-related condition.  Patients would either be put on antidepressants or if they had constipation, they would get a drug for constipation or if they had diarrhea, they would get a drug to try to control the diarrhea.  Dr. Pimentel pioneered the idea that IBS is caused by an overgrowth of bacteria in the small intestine (SIBO).  When you consume food with fermentable fiber, those bacteria consume that fiber and produce either hydrogen or methane or hydrogen sulfide gas.  By measuring these three gases using a lactulose breath test, we can partition these patients into hydrogen SIBO and methane SIBO and hydrogen sulfide SIBO.  Methane SIBO, which is actually caused by methanogens, which are technically not bacteria but another group of microorganisms known as primitive archaea.  Dr. Pimentel has now changed the name of methane SIBO to IMO both to reflect the fact that the methanogens are not bacteria and that it can exist in the large intestine as well as in the small intestine.  Dr. Pimentel has also pioneered the use of a non-absorbable antibiotic, Rifaximin, for the treatment of SIBO/IBS.  Dr. Pimentel tends to use Rifaximin for hydrogen SIBO, Rifaximin plus Neomycin for methane SIBO (IMO), and Rifaximin plus Bismuth for hydrogen sulfide SIBO. 

7:53:  Dr. Pimentel has mapped out the microbiome of the small intestine for the first time, so we now know that hydrogen SIBO tends to be caused by E Coli and KlebsiellaIMO is caused by methanogens, including methanobrevibacter smithii.  Hydrogen sulfide SIBO tends to be associated with pseudomonas, Fusobacterium, Desulfovibrio, and Bilophila bacteria.  Dr. Pimentel has also discovered that there are two bacteria, Ruminococcus and Christensenella, that help to donate the hydrogen to the methanogens.  And Enterobacteriaceae helps to donate the hydrogen to the hydrogen sulfide producers.

10:18  The clinical picture.  SIBO is very challenging to treat and the biggest challenges are when you have either a recurrent SIBO or a persistent SIBO or methane SIBO, which is particularly difficult.  Dr. Rahbar explained that methane SIBO implies some level of immune dysregulation and he often finds fungal overgrowth concurrent with it.  Fungus facilitates the growth of the methanogens because the archaea need an anaerobic environment and the fungus absorbs oxygen and releases nitrogen, creating an anaerobic environment.

13:14  While he has performed detailed immunological testing on some patients, Dr. Rahbar does not do this routinely.  He often investigates why this person might have immune dysregulation and he often will look for exposure to toxins in either the urine or the blood and he often finds that the higher the amount of toxins will often correspond with the alterations of the microbiome and the severity of the symptoms.

15:42  Dr. Rahbar will usually address the local immune dysfunction with nutritional strategies and part of the immunity has to do with the quality of the mucus layer in the gut and the toxins present in the person will often alter this mucus layer and this makes it easier for the bugs to hang on as they are imbedded in this mucus.  Dr. Rahbar also pointed out that fungus when present will often change their shape into the hyphae form, which is a long branching structure.

18:11  Dr. Gurevich finds that by addressing this mucus layer with biofilm busting strategies, that is part of a strategy that is effective at reducing the SIBO. She agrees that with methanogen overgrowth there is often a fungal component and the analogy she uses is that when you look at the forest floor, fungus is literally everywhere.  She uses some aggressive biofilm strategies, starting with Dr. Paul Anderson’s compounded pharmaceutical formulation containing bismuth and DMSA or DMPS.  After a month she will layer in herbal antimicrobials and then pharmaceutical antibiotics if needed.  The results of testing will also inform clinical decisions, including stool testing and blood tests, including running a Candida Immune Complex and Elisa antigen testing for candida IgG, IgA, and IgM from Quest or Labcorp.  To get rid of the fungus, she layers in antifungal herbal and pharmaceutical medications.  If we have a methane patient, she will also use either natural or pharmaceutical prokinetics to make sure that they are moving their bowels.

20:16  Dr. Gurevich uses what she calls her antifungal parade. She starts with pharmaceutical biofilm disruptors as mentioned, then she will use some enzyme biofilm disruptors, including hemicellulose and Serrapeptase, and then she’ll circle through various herbal antifungal agents so patients don’t develop a tolerance for them. There’s some interesting evidence that the herb Gymnema sylvestre prevents the yeast from budding and going into its hyphae form.  She often uses a Gymnema capsule from Wise Woman Herbals three times per day. She will also use Formula SF722 (Undecylenic acid) from Thorne–5 caps twice per day.  Then she’ll switch to oregano oil or to Kolorex and then she will switch to Y arrest from Integrative Therapeutics.  She will have them use natural antifungals for at least three months and sometimes for up to a year.  Dr. Gurevich also likes to use Nystatin, a prescription antifungal and Dr. Rahbar also often uses this medication.

25:52  Diet for SIBO.  Neither Dr. Gurevich or Dr. Rahbar advocate strict diets for patients with SIBO. Dr. Gurevich noted that has not found strict anti-Candida diets or low FODMAP diets helpful.  Dr. Rahbar finds that diets that are too restrictive in carbohydrates can lead to mood problems and anxiety. Both Dr. Rahbar and Gurevich want their patients to eat organic, clean diets and avoid junk food and avoid pesticides and herbicides like glyphosate.  Dr. Gurevich emphasizes a vegetable-forward diet and she has seen too many patients develop eating disorders from eating a very strict low FODMAP diet.

30:59  SIBO is often difficult to treat because such patients tend to have a complicated picture that besides bacterial overgrowth, they often have gut hypersensitivity, fungal overgrowth, and toxicity. 

32:27  Dr. Gurevich will often run the Trio SIBO breath test and she will have patients collect breath every 17 minutes instead of 15 minutes, so this will last 3 hours rather than 2 hours.

34:42  Treatment for hydrogen sulfide SIBO.  Dr. Gurevich tends to use bismuth and Rifaximin or bismuth and herbs.  As far as herbs, she likes oregano, Allimed, and Chinese herbs like Huang Lian and Huangjiang, Philodendron, Coptis, and Scutellaria. For oregano she will often use oregano oil by Gaia Herbs. Dr. Rahbar tends to use Xifaxan with Bismuth that is compounded without Salicylate. Either bismuth citrate or subnitrate is better to use. Dr. Rahbar also finds Mesalamine is helpful in such patients, which is a medication that is often recommended for treating ulcerative colitis.  He likes the Pentasa brand of Mesalamine and he likes it in the powder form so it opens up in the small intestine.



Dr. Sam Rahbar is an Integrative Gastroenterologist in Los Angeles, California, combining conventional gastroenterology, performing colonoscopies, endoscopies, and Heidelberg pH testing, but incorporating anti-aging and Functional Medicine into his unique treatment approach to digestive disorders.  He can be contacted through his website http://www.laintegrativegi.com/ or by calling his office 310.289.8000.

Dr. Ilana Gurevich is a board-certified naturopathic physician and acupuncturist and is currently co-owner of two large integrative medical clinics, one in northwest Portland and one in northeast Portland, Kwan Yin Healing Arts and the website is KwanYinHealingArts.com.  She runs a very busy private practice specializing in treating inflammatory bowel disease as well as IBS/SIBO and functional GI disorders.  She lectures extensively and teaches about both conventional and natural treatments for inflammatory bowel disease as well as SIBO.  She is one of the foremost experts on the intersection of IBD and IBS and how treating one resolves the other. She can be contacted through her website, naturopathicgastro.com.  She recently started a new podcast, The Turd Nerds with Dr. Rebecca Sand and Dr. Ami Kapadia.  

Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.



Podcast Transcript

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

                                                Welcome, everybody. If you’re participating in this live event, this is the Functional Medicine Discussion Group of Santa Monica, and we have a special program. We’re going to be discussing SIBO, small intestinal bacterial overgrowth and IBS, and we’re going to have a group discussion with Dr. Sam Rahbar, who’s an integrative gastroenterologist, and Dr. Ilana Gurevich, who’s a naturopathic doctor, who’s an expert on gut health. If you’re listening to this recorded, this is part of my weekly Rational Wellness podcast and I hope you enjoy it. It’s pretty high level science here, and we’ll be discussing some innovative approaches on how to treat patients with these particular conditions.

                                                Keep in mind that these are experienced practitioners who often are seeing some of the worst patients who failed some of the basic frontline treatments. For example, a lot of their patients have seen a gastroenterologists or somebody else and have already tried a round of Rifaximin or have tried some of the anti-microbial herbs or have done some of the other strategies that are being promoted out there. They’re seeing some of the most difficult cases. We’re going to have a really high level scientific discussion about how to treat these conditions. I hope you enjoy it and we’ll get started right now. Now, I’d like our two experts who agreed to join us tonight to tell us a little bit about themselves. Alana, can you tell us a little bit about yourself and tell us about your new podcast?

Dr. Gurevich:                     Sure. My name is Dr. Ilana Gurevich, and I am a board-certified naturopathic gastroenterologist and a naturopathic physician who runs a practice out at Portland, Oregon. I am also in the process of launching a new podcast. I teamed up with two other physicians, Dr. Ami Kapadia, who’s a functional medicine medical doctor, and Dr. Rebecca Sand, who has a history of working for the CDC and research and is also a naturopathic physician, and we launched a podcast called The Turd Nerds. It’s just discussing really integrative gastroenterology topics from a research and an anecdotal practice stance.

Dr. Weitz:                          That’s great. I’m not sure about the name.

Dr. Gurevich:                     Either at Google, like tell us it’s offensive.

Dr. Weitz:                          Oh, really? Sam, can you tell everybody about yourself?

Dr. Rahbar:                       I’m a board-certified gastroenterologist, but I practice mainly integrative gastroenterology and I incorporate the traditional with all the alternative method and the functional medicine model into the GI practice.

Dr. Weitz:                         That’s great. I was thinking maybe I could start off talking a little bit to just go into some of the basics about SIBO, in case anybody who’s on the call doesn’t know much about SIBO or IB. Then, I figure we’ll just let the discussion go where it goes and the goal is for all of us to learn from each other and learn a little more about how we can help our patients. The history of IBS is that it is the most common gastrointestinal condition. It’s been around for very long time, probably exists in at least 10% of the population. For many years, we had no idea what was the real cause of IBS. It was often considered to be a stress-related condition. It was that, typically, patients would be either put on anti-depressants or if they had constipation, they would get a drug for constipation, or if they had a diarrhea, they would get a drug to try to control the diarrhea.  Unfortunately, IBS is still treated that way in a significant percentage of the conventional medical community. But Dr. Pimentel, who as I mentioned in case you weren’t here at the beginning, wasn’t able to join us tonight, he’s really pioneered that there is this actual cause of IBS and that’s small intestinal bacterial overgrowth. What that means is that there’s an overgrowth of bacteria in the small intestine and that those bacteria, when you consume foods with fermentable fiber, those bacteria consume that fiber and produce gas. Now, we know that there’s three gases, and so we have hydrogen, which was the first gas we discovered, then methane and hydrogen sulfide. Now, the latest data shows that we have the Trio Smart Breath Test, which allows us to measure all three gases for the first time. That allows us to partition SIBO into three different categories.  We have hydrogen SIBO, we have hydrogen sulfide SIBO, and then we have … we used to call it methane SIBO and now, Dr. Pimentel has changed the name to IMO, which is Intestinal Methanogen Overgrowth, and I think a couple of reasons for calling it IMO is because it’s produced by methanogens, which are actually not bacteria, and because it doesn’t just exist in the small intestine, it also exists in the large intestine. Dr. Pimentel also pioneered the use of a non-absorbable, supposedly non-absorbable anti-biotic called Rifaximin for the treatment of SIBO. He has shown that it is very effective for, especially hydrogen SIBO. Then, for methane SIBO, he uses a combination of Rifaximin and neomycin. For the new hydrogen sulfide SIBO, as of this point, there are no new approved treatments for that. Dr. Pimentel, my understanding is, he uses Rifaximin plus Bismuth, essentially gives the patients Pepto-Bismol along with the Rifaximin.

                                            Dr. Pimentel has been doing a ton of research on mapping the microbiome of the small intestine, so now we know for the first time exactly which particular organisms, particular strains of bacteria are causing these forms of SIBO. We know that with the hydrogen SIBO, maybe you guys can help me out. What are the two bacteria? E-coli-

Dr. Rahbar:                         Klebsiella.

Dr. Weitz:                            Klebsiella, and then with the IMO within methanogen overgrowth, we have Methanobrevibacter. Then recently, Dr. Pimentel has discovered two other bacteria that participate in helping to get hydrogen to the methanogen. The methanogens consume the hydrogen, and then they produce the methane gas. He found two particular bacteria known as Ruminococcus and Christensenella, so these particular bacteria are known as hydrogen donors. He’s also published the paper showing that there are two bacteria that help to donate the hydrogen to the hydrogen sulfide. The bacteria that produce the hydrogen sulfide SIBO are Fusobacterium and Desulfovibrio. Those are the two main ones. Enterobacteriaceae is the bacteria that helps to donate the hydrogen to those. Being able to determine exactly which bacteria is responsible for the SIBO and knowing where they exist in the small intestine is part of allowing us to come up with better treatments and better ways to diagnose and understand it. Sam, where should we go from here?

Dr. Rahbar:                         Let’s go to the clinical stories, I think. I think if the SIBO is easy to treat, we wouldn’t be here.

Dr. Weitz:                            Absolutely.

Dr. Rahbar:                         Okay. Obviously, the challenge is when you have a recurrent SIBO, you have a persistent SIBO or you have methane SIBO. In my experience, when you see methane, it practical involves the entire intestine, the upper part maybe extending all the way to the colon almost, they may have similar numbers for the most part. The question is that, what allows the methanogens to grow in the upper part of the intestine there? I can understand that the colon may be somewhat anaerobic here, but the upper part of the bowel may contain some oxygen and air that we might have swallowed. For these bugs to grow, they probably need an anaerobic environment for this archaea to survive. I think the main question comes up, what has transpired that allows the methanogens to grow in the upper part of the intestine then?   Now, I share my own personal experience and observation, this is not all published, but it’s basically our interpretation of what we see and how these might be related there. The presence of methane, to me, generally implies some immune dysregulation. There is something beyond just the SIBO and the body has difficulty keeping the gut clean. We also have to understand at what allows it to have an anaerobic environment without oxygen. Again, when I looked at some of the data as how they actually grow archaea in the laboratory, in the environment, in the methodology that they use, they add the yeast and fungi to be able to absorb the oxygen and release nitrogen and create an anaerobic environment. This is the Journal of Bacteriology Microbiology, and I believe in one of the conferences, I shared the reference on that one. When I see methane excess, I ask two questions, where is the fungus and what has caused immune dysregulation to allow the body for these bug to grow and the body become like a Petri dish?

Dr. Weitz:                            Now Sam, how do we know?  Is there a way to measure this immune dysregulation?  Can we do a stool test that looks at secretory IGA?  Is there a lab test?  Should we use the Lymphocyte Map test?  How can we determine this immune dysfunction?

Dr. Rahbar:                         You can do detailed immunological studies. Okay, I must tell that we have not done that in all patients, but we did it in those that we felt that the problem was more intractable and we had to go further. But we did ask one question that even though there is some immunological dysfunction or body’s inability to deal with this, what would be causing that? That brings us to the question of how that person or that individual has interacted with the universe, and that brings us to the concept of exposure to metals, to toxins, to chemicals, more toxins, many of these either they affect the microbiome directly and they allow an imbalance to remain in the gut or they somehow deal with the immune system.  Generally, we just go and investigate that one and see if we can find risk factors. At least, in our observation, we have seen many patients, they have a variety of chemicals or toxins or mold or metals showing up in their urine or sometimes showing in their blood there. Interestingly, it’s not always one item. You cannot just pinpoint one single item, and I think we need to look at this cumulatively and maybe give a score to each of these things that we observe. Practically, the higher the score of abnormality that one can find in a urine toxicity evaluation probably would correspond to the alterations of the microbiome and the symptom presentations that patient come to us.

Dr. Weitz:                            Yeah. When I get a SIBO patient, typically I do a stool test as well as a breath test. If I see low secretory IGA, I’ll use something like SBI Protect to try to help beef up the immune system. Do you try to address the immune system dysfunction in some way?

Dr. Rahbar:                         A hundred percent. We do a variety of things to improve the local immunity at the gut level. That is almost granted that there’s going to be some alterations locally. Part of the defense mechanism that the intestines carry is the quality of the gel and the mucus layer that is sitting on the gut surfaced. When we’re dealing with this dysbiotic fluoride, there is clearly alteration of those mucus layers. Based on what I’ve seen from the literature that exposure to the variety of the chemicals from the environment and detergents, they actually alter that mucus layer and it makes it easier for the bugs to hang on and not be so mobile, if you will. The body has difficulty to push them out and they will get embedded into that mucus layer.  My emphasis has generally been on fungal elements because they have an ability to change shape from yeast into HFI format, and HFI has the ability to crack the wall. Those mechanical alterations, they allow bacteria to sometimes remain into those crevices. At least that has been one of my theories, that when we are dealing with recurrent SIBO that, in addition to whatever else is going on, there’s some mechanical changes at the gut level. There’s a whole protocol that we use to deal with that. I’m not going to continue talking as the only person here, see what Dr. Gurevich would like to share. But obviously, dealing with the gut surface and also the immunity locally is going to be crucial to the recovery.

Dr. Weitz:                            I know every time I hear about these bacteria living in the mucus layer, the first thing that I think about is this is a biofilm. That’s probably what’s making it more difficult to get rid of these bacteria, and maybe we need the right biofilm busting agent to help us to do that. I know, like a lot of people who deal with SIBO, we’ve tried various biofilm busting products and strategies and not sure that any of them are all that effective.

Dr. Gurevich:                     I disagree.

Dr. Weitz:                            Oh, okay.

Dr. Gurevich:                     First of all, I could not agree more, I don’t think that meth antigen overgrowth is exclusively an issue with bacteria. I definitely think the more we think about it, the more fungus is one of the key courses of what’s involved. I always put the analogy of looking at the forest floor where the system that the way the forest floor communicates is all of fungus because fungus is literally everywhere, which is why we have such fungal overgrowths. In my experience, very, very intractable methanogen overgrowth is actually pretty resolvable with using some aggressive biofilm strategies. The biofilm strategy that I’m using is, I’ll start with a pharmaceutical compounded medication using bismuth and DMSA or DMPS whatever the pharmacy’s got.

Dr. Weitz:                            Just like Paul Anderson’s strategy?

Dr. Gurevich:                     It is Paul Anderson’s and I’ll start there and then I’ll layer in after a month, I’ll layer in herbal antibiotics and then pharmaceutical antibiotics if needed. Depending on what’s happening with stool tests, blood tests, I’m doing a lot of AMITA antigen testing right now. If I find fungal overgrowth, then I’ll also layer in antifungal both herbal modalities and pharmaceutical modalities. It’s a long protocol, but you can definitely get improvement. Then of course, you can’t ever treat a meth antigen patient without making sure they’re actually eliminating and moving their bowels, and so we’ll use some of our natural or pharmaceutical prokinetics to get it to move as well.

Dr. Weitz:                            What do you use to get rid of the fungus?

Dr. Gurevich:                     I lovingly call it my antifungal parade. I’ll use some pharmaceutical biofilm disruptors, that’s the Paul Anderson one. I’ll use some interesting enzyme biofilm disruptors. There’s some interesting data using Hemicellulose, using Serratiopeptidase, and so I’ll put patients on that, and then I’ll circle them through antifungal herbal agents, so they don’t ever develop a tolerance to it. There is some really interesting data that’s in vitro that shows that using Gymnema prevents the yeast from budding. That’s how I try to-

Dr. Weitz:                          Gymnema is an herb we typically think of as helping with blood sugar problems, right?

Dr. Gurevich:                     Yep. That’s exactly what it is. There’s in vitro data that shows that it prevents the yeast from budding.

Dr. Weitz:                          Can you recommend a product and a dosage for that?

Dr. Gurevich:                     I’m using Wise Woman Herbals. They have a Gymnema capsule and I’ll go one three times a day. I think now also has a really, really affordable product that’s just Gymnema, and so that will be in the protocol.  If I can find candida, I still love Nystatin, and I know it’s not popular anymore, but I think Nystatin is generally very well-tolerated and very safe.  Then, I’ll rotate through that old formulation SF722, they’ve just rebranded it.  I’ll have the patients on that for a bottle, and then I’ll switch them to oregano or I’ll switch them to Kolorex or I’ll switch them to, ITI has a really great formula called yeast arrest or Y arrest, something like that, and I’ll just circle through one product as soon as they finish the bottle, and we’re looking at a minimum three months, but often people were looking at nine months to a year.

Dr. Weitz:                          If you don’t mind, can you give us your entire protocol?

Dr. Gurevich:                     Yeah. Okay. We’re assuming that this patient has both methanogen overgrowth, plus a fungal overgrowth that we found either in stool or more likely a candida immune complex and even possibly candida IGM, IGG or IGA. I don’t do a lot of urine testing, I don’t do the OAT testing, but there are some markers in the OAT test that would also show you fungal overgrowth. What I do is-

Dr. Weitz:                          Let me stop you, sorry. What’s your best test for fungal overgrowth?

Dr. Gurevich:                     I like, Quest and LabCorp have a test called a candida immune complex, which is, this test goes back to I think 1950s or late 1940s, early 1950s, that shows that when that marker is positive, there is actually intestinal candidiasis. I’m going back to way back in the day and I’m using that marker and then I’ll also look for a candida IGM, IGA and IGG. This is an intractable SIBO patient, we’ve tried all the things that should work, they haven’t worked, you’re treating the wrong thing, you start looking.  I’ll do that, and I’ll also probably run a stool assay that’s provoked. I try to break down biofilms before they collect their stool, and I see if I can find some fungus in there. If I find fungus, I’ll start them on the BisThiol complex that Paul Anderson came up with, and it’ll take them a month to get up to therapeutic dose. Then, after that month, I’ll introduce the biofilm, the enzyme biofilm disruptors. Right now, I’m using a product called Biofilm X. Enzyme Science also has a pretty interesting enzyme product that has a high dose of Hemicellulose, which also has some data.

Dr. Weitz:                          Do you like Interfase Plus, which is a very popular one?

Dr. Gurevich:                     I use Interfase Plus to provoke. I don’t love the EDTA, is that what’s in there?

Dr. Weitz:                          Yes.

Dr. Gurevich:                     Yeah. I don’t like that long term if I don’t have to, especially if I’m giving them the biofilm disruptor with the BisThiol complex, and so that’s a DM assay, so I kind of will stay away from interface if I’m using the other biofilm agent.

Dr. Weitz:                          The biofilm buster with the bismuth is, how long are you using that for? Because potentially, using a heavy metal like bismuth could be a problem used for a long period of time.

Dr. Gurevich:                     It seems that when you’re making the BisThiol complex, you’re actually protect protecting the body against long-term use of bismuth on its own. It becomes a bigger molecule, and so it doesn’t cross the intestine as easily even with intestinal permeability patients. There is interesting research that says that it’s actually safer. I think Paul talks about it on your podcast actually.

Dr. Weitz:                          Yeah.

Dr. Gurevich:                     I think I heard it from you. I’m using that at a minimum three months, but with these chronic patients, you’re looking nine months to a year easily. I’ll do that and then I’ll introduce the enzymes and the herbs in month two. I’m starting with SF722, which it goes like oleic acid and nucleic acid, they’ve renamed.

Dr. Weitz:                          Right. Is that the Thorne product, I think, yes.

Dr. Gurevich:                     Thorn product, yep.

Dr. Weitz:                          Okay.

Dr. Gurevich:                     They’re little, little gel tabs. You work-

Dr. Weitz:                          I think you have to take almost a whole bottle in five days or something.

Dr. Gurevich:                     They’re like little, little gel tabs, but it’s five-

Dr. Weitz:                          You have to take 12 of them or 15 or something, right?

Dr. Gurevich:                     Ten, yeah, 10 a day.

Dr. Weitz:                          Okay.

Dr. Gurevich:                     Five [inaudible 00:25:24] a day, and then I’ll kind of circle through the herbs as we go. Honestly, usually the first thing that happens, and I don’t know if you guys can see this as well and then I’ll also put a Nystatin, the minute you start Nystatin, generally, their bowel movements start moving. Not always, but it is 70% of the time, they will immediately have better evacuation just by putting in Nystatin if candida or fungus is the underlying cause.

Dr. Weitz:                          Are you addressing diet as part of this program?

Dr. Gurevich:                     I always say, I always have my spiel like, I’m not one of those naturopaths that give people eating disorders, but I am one of those naturopaths that believe that you shouldn’t eat garbage. Your diet can’t be a hundred percent processed, a hundred percent sugar, and I do think the protocol works faster if you’re not eating a ton of processed sugar.

Dr. Weitz:                          Yeah. I would assume some version of an anti-candida diet.

Dr. Gurevich:                     I have a personal story. I was kicking this road trip with my girlfriend when we were in school, and she decided that that was the perfect time while we’re driving to Canada to go on her anti-candida diet, and I have never sat through so many mood swings in all. I’m not a big fan of that restriction. I’m a big fan of eating a really holistic vegetable forward diet that’s not super processed. Sam, do you agree?

Dr. Rahbar:                         Yes.

Dr. Weitz:                            What kind of dietary recommendations do you give to your patients who you see who have SIBO and then especially those who where you think fungus is an issue? Then, somebody also asks, what about restricting fungus in a diet like mushrooms and things and foods that might be … coffee, which might have fungus on it, et cetera?

Dr. Rahbar:                         I’ll try to keep a little bit of balance. It really becomes difficult more than a month to be in such a strict diet. If you keep the carbohydrate too low, occasionally, then mood problems, anxiety and other things start to develop. I generally try not to take coffee away from people. I ask them to use maybe an organic version and something that probably doesn’t have glyphosate. We are all going to have some exposure to fungi. If they use mushroom and other things, I do recommend that those are cooked or highly steamed, so at least those bugs might be killed if they consumed them. As a Libra, I usually try to keep a little balance there, but I’m interested to see what Ilana is going to say.

Dr. Gurevich:                     Basically, when I’m talking to patients with diet, I think pesticides, herbicides, fungicides, all of those need to be, because those are basically just antibiotics that are making the microbiome more deteriorated. On top of that, I think that, as much as you can give me a vegetable-forward diet, I think that’s going to make all the difference. That’s going to give you your fiber, that’s going to increase your biodiversity, that’s also going to help with elimination if you’re getting both soluble and insoluble fibers. Then, I’d say avoid the garbage, which we all eat a little bit too much of as Americans or at this point, the whole world. Avoid all of the processed. I’m not opposed to grains, I think whole grains are super useful. I’m not opposed to proteins, I think any way you can get your proteins, that’s great. Then, just avoid what doesn’t make you feel good.  I went through the whole FODMAP where everybody got a FODMAP diet when they had SIBO, and I just witnessed the eating disorders. With all due respect, the minute they stop that diet, they’re having exactly the same symptom picture, they just now have a phobia of food. My goal is not, I don’t actually take very much away, I just try to educate them on what eating a holistic diet looks like and lead them in that direction. I’m a really big fan of meal delivery services. I educate patients where, if you don’t want to do the cooking yourself, let’s get you one of these organic meal delivery services where you can actually eat quality food that tastes good.

Dr. Weitz:                          Now, Dr. Pimentel has been working on using lovastatin for methane SIBO because there’s data showing that lovastatin can block the methane gas as part of the treatment. I wonder if either of you or anybody else who’s on the call has experimented with using something like [inaudible 00:30:03] for methane SIBO?

Dr. Gurevich:                     I thought that-

Dr. Rahbar:                        I don’t have any experience with it. I don’t think he’s strong enough to handle this.

Dr. Gurevich:                     I thought that he had some theories about it, but it didn’t come out in the phase three trials. But I don’t know, I’m not up-to-date.

Dr. Weitz:                          Yeah. As far as I know, so far it has not worked out. He is still talking about developing it. I think the problem with the trial was that they weren’t able to develop a form of Lovastatin that only stayed in the gut.

Dr. Gurevich:                     I’ve never tried it.

Dr. Weitz:                          Yeah. I’ve experimented with red yeast rice. I had a couple of patients where I thought it worked and other patients where I thought I couldn’t tell if it worked or not.

Dr. Gurevich:                     Welcome to SIBO.

Dr. Weitz:                          Well, that’s the thing. The thing about SIBO is it seems like we’ve got this easy disease process, we’ve just got too many bacteria and it should be easy to eradicate except that it’s not, and why is it so hard to eradicate? Is it because we’re not killing the bacteria? We’re not getting to them, they’re difficult to kill. Is it because maybe there’s multiple layers of problems? Maybe the patient who has SIBO, as you guys have both talked about, also has fungal overgrowth.  Maybe there’s other issues with their gut, maybe they have gut hypersensitivity, maybe they have food sensitivities, maybe there’s other issues besides  SIBO.

Dr. Gurevich:                     There is always other issues besides a SIBO, because there is that, there’s like what? A quarter of patients, maybe a fifth of patients, that you give them a round of Rifaximin and it’s like magic and they don’t see you again for a couple of years. There is a subset of people that are very easy to treat. I don’t think they’re coming into our office anymore because they’re getting caught by the regular primary care doc or the regular gastro. I think, unfortunately, I think that our population is just centralized on they have a lot of other things going on. Toxicity is one of them, fungus is one of them, hypersensitivity is one of them. They’re complicated.

Dr. Weitz:                          Right. Now, Ilana, when you do the, I’m assuming you’re using the Trio breath test. I heard Alison Siebecker say that she has her patients do it over a 3-hour period of time, whereas it’s recommended to do it for two hours. What do you do?

Dr. Gurevich:                     I’m having them collect breath every 17 minutes.

Dr. Weitz:                          That makes three hours, right? Because the recommendation is every 15 minutes, right?

Dr. Gurevich:                     Yep.

Dr. Weitz:                          Now, can you explain why?

Dr. Gurevich:                     Because I feel like it’s important to see when they get into the large intestine. I feel like it’s important, that gives us a whole different set of information.

Dr. Weitz:                          Well, explain what that gives us because once it’s past 90 minutes, it’s no longer the small intestine or we assume that’s the case, so then, why do we need to know past 90 minutes? Certainly, why do we need to know past 120?

Dr. Gurevich:                     I think that with intestinal methanogen overgrowth, we can assume that their transit time is greatly delayed. Then, if we’re going through that test too quickly and they’re highly constipated, I feel like we might be missing it, especially if it’s affecting the bottom of the small bowel. That’s why I like to go longer especially with IMO patients. I do like to see that drop and come up again to make sure that I can locate where I am in the bowel. I don’t know if that ever held water, but I think I’ve been doing this too long of a time to not feel comfort with [inaudible 00:33:58].

Dr. Weitz:                            I wonder if anybody has, I’m going to switch now to hydrogen sulfide SIBO. For years, we didn’t have a hydrogen sulfide breath test, so we used to use a flat line for three hours as indication of hydrogen sulfide. Do we know, at this point, has anybody really done a serious look at patients who had a flat line as compared to patients who test positive for hydrogen sulfide on the new test?

Dr. Gurevich:                     I don’t know.

Dr. Weitz:                          What do you think, Sam?

Dr. Rahbar:                        I’m not sure.

Dr. Weitz:                          Okay. Now, let’s talk about strategies for treating hydrogen sulfide SIBO.

Dr. Gurevich:                     For me, bismuth is king. I think bismuth has to be in that treatment plan no matter what you do. I think bismuth has to be in that treatment plan.

Dr. Weitz:                          Okay. Bismuth plus, I’m using Rifaximin.

Dr. Gurevich:                     I’ll use bismuth and Rifaximin. Well, I’ll use bismuth and herbs depending on cost and patient preference.

Dr. Weitz:                          Okay. What are your favorite herbs for hydrogen sulfide SIBO?

Dr. Gurevich:                     I find that oregano probably works better than anything else. I really, really like Alimed in there too. It’s always a cost thing, but I really love strong, strong Alicin. Then, I’ll play around there some Chinese herbs that I like to play around with that sometime have efficacy. In Chinese medicine, it’s Huang by Huang Leon and Huang Chin. I think Philodendron, Coptis and Scutellaria. Coptis will sometimes flare them a little bit too much, I think it’s high sulfur, but Scutellaria and Philodendron are actually well-tolerated by some.

Dr. Weitz:                          Interesting. Can you give us an oregano product that you like? Do you like the oregano oil? Do you like the dried oregano powder like the ADP?

Dr. Gurevich:                     I’ll use either ADP or I’ll use the oil of oregano by Gaia.

Dr. Weitz:                          Okay.

Dr. Gurevich:                     I’m getting my stuff from fullscript, and something’s on back order every other week.

Dr. Weitz:                          Oh, I know. I know.

Dr. Gurevich:                     Whatever I can get. Yeah.

Dr. Weitz:                          How about you, Sam? What have you found for the most effective strategies for treating hydrogen sulfide SIBO?

Dr. Rahbar:                        I use the combination of Xifaxan and also the Bismuth, but the Bismuth has to be compounded without the Salicylate to avoid any Salicylate issues. Either you can use Bismuth citrate or sub-nitrate. But I also have had some good luck with Mesalamine. Indeed, I know of cases we have had where this was a problem and there was a lot of abdominal symptoms. Even though the patient did not have inflammatory bowel disease, but the Mesalamine was a game changer in that setting. Now, whether it was because of controlling the hydrogen sulfide or something else, it is hard to know, but I know that’s one of the mechanism that it actually works.

Dr. Gurevich:                     Hey, Sam, are you ruling out microscopic colitis with these people first or not necessarily?

Dr. Rahbar:                        Well, I don’t use Mesalamine for microscopic colitis and care.

Dr. Gurevich:                     There’s data. I feel like Mesalamine actually for really complicated microscopic colitis patients, there is data that it has efficacy and I’ve been using it with those patients and I’m wondering if it’s treated, what it’s treating, you know what I mean? There’s a couple of papers, I can send them over to you if you want to see them.

Dr. Rahbar:                         Yeah. Mesalamine has been used for microscopic colitis. It has been used for irritable bowel syndrome. All of these, they have literature out there. But the question, how does it work? I think it may be tweaking the hydrogen sulfide and that’s why I’ve used it. In the few cases we have had, we have had good success with it.

Dr. Gurevich:                     Interesting.

Dr. Weitz:                          Somebody asked Sam for the dosing and the timeline for the use of Mesalamine.

Dr. Rahbar:                        Use equivalent to Pentasa, not other types of Mesalamine. Only Pentasa because it opens up in the small bowel. It also comes in a granule, so you can have the patient to open the capsule. If you buy it from Canada, it comes in a sachet, so it’s actually in a powder format. Because the concern many times with the small bowel, the majority of the Mesalamine products in the market, they deliver to the colon, but you need this thing to open up in the small bowel. If you have patients with unexplained abdominal pain, components of, we can call, bad IBS and some suspicion of inflammation going on that is hard to define, Mesalamine might be an option. If you search, you will actually see it has been used for the setting of “irritable bowel syndrome” with some success there.

Dr. Gurevich:                     How many grams? Four doses a day?

Dr. Rahbar:                        Four. You need to get up to about four grams a day if the patient can tolerate it and they don’t have side effects.

Dr. Weitz:                          Bernie said that he used oregano oil and ended up in the hospital with gut inflammation.

Dr. Rahbar:                        I’m sorry, what is it again?

Dr. Weitz:                           Bernie Bobman mentioned that he used the oregano oil and ended up in the hospital with gut inflammation.

Dr. Rahbar:                        I don’t think we have enough data to understand what the problem was there.

Dr. Gurevich:                     I do think it’s a strong anti-microbial. I think it’s a very strong antibiotic though, oregano, at least in my formulary.

Dr. Weitz:                          Yeah, it depends on the person. I’ve used oregano oil for myself and, for me, it’s a great product. It can be very inflammatory, especially using the oils. That’s why Alana mentioned that she uses ADP, which is a dried form of oregano and it doesn’t have the volatile oils. Some people find that that’s more tolerable, correct?

Dr. Gurevich:                     Yep, and you can go higher doses.

Dr. Rahbar:                        Yeah. I want to make a comment about the use of herbs. Obviously, we all use them. We have had instances where you have a case of evidence of fungal overgrowth and evidence of SIBO and said, “Okay, which one do you think might be the player?” We have used herbal combinations including Allicin, [inaudible 00:41:01], FC-Cidal, Dysbiocide, ADP, and in a few instances, and again this is a small percentage that when you attack the microbiome like this, there may be a predominance as which one of these kingdom they get more affected. In other words, if the bacteria got more affected, you can actually create a fungal predominance. I’ve had cases where people within a few days of taking five herbs, that’s a lot of, they actually felt a lot more bloated, which means that there was a lot more fermentation going on.  In those cases, we switched to a pure antifungal with some success. Now, this is a limited observation, but those cases are so prominent in their presentation that you would never forget how would somebody become more bloated while they’re taking five herbs at the same time? The same thing happened in one instance. I think I discussed it the last time, that the patient was an elemental diet and Rifaximin together for SIBO and Fluconazole and Nystatin, all of those and within three days of the elemental diet, the patient became more bloated on elemental diet, so we stopped everything and we switched to Itraconazole, and within few days, the bloating, everything went down again. It was obvious there was resistance of the fungi to those elements and even though there was no more SIBO, but the fungus took over in that setting there.

Dr. Weitz:                          Now, as a chiropractor, I can’t prescribe medications, but when I use herbal products for patients with SIBO, I’m aware of the fact that most of the herbal products that are anti-microbial are also antifungal, so I always feel good about that fact that we’re fighting against the fungal overgrowth as well.

Dr. Gurevich:                     A case like that, I often wonder if there’s a histamine component and especially if the fungus is overgrowing. The way I see it in my practice is, fungal overgrowth will usually lead to a histamine overproduction. If I see something like that, I’ll try to see if I can get some mast cell stabilizers on board to see if that would address some of the side effects. I also wonder, that’s like a big protocol, I’m often wondering, what’s left in there? If we’re getting rid of the bacteria, we’re getting rid of the fungus, then we’ve got viruses left and we’ve got the most resistible species, so I’m like, I wonder what’s left in there.

Dr. Weitz:                          That brings up another question, which is, when is it beneficial to use probiotics? Because as we all know, even using herbal antibiotics or herbal anti-microbials, they could possibly have a negative effect on the microbiome. I haven’t really seen it, but it’s possible. Certainly, we know that using antibiotics can have a negative effect on the microbiome. Is it appropriate to use a probiotic at the same time? A lot of people like to use the analogy that we have a parking lot, we have X amount of parking spaces, and if you leave some of those spaces open, they’ll get filled up by potentially pathogenic bacteria or fungus, so let’s put a car in there, let’s put some probiotics in there. Typically, when I have a patient on a SIBO protocol, I’ll use a spore-based probiotic with the idea that it’s not going to open up in the small intestine supposedly.

Dr. Gurevich:                     I usually hold on probiotics until what I lovingly call phase three. When we’ve done a lot of the treatment, I’ll try to introduce probiotics then. How about you, Sam? When are you using them?

Dr. Rahbar:                        I don’t use probiotics during the treatment and very cautiously after the SIBO is treated.

Dr. Gurevich:                     Because you’ve seen patients flare? Or do they but not strong enough?

Dr. Rahbar:                        Generally, I imply that, if you take probiotics, there’s always a chance you’re going to get more bloated again. It’s not completely predictable as how the body’s going to handle it. Bear in mind that when we give probiotics by mouth, we really mean the probiotic to land in the colon and see the benefits there. What about if it didn’t? What would happen if we put probiotics in our eyes? Sometimes it may behave like a bad thing. Again, I generally go slowly on probiotics, although patients ask us and they want to start early, but I go cautiously there.

Dr. Gurevich:                     Do you avoid fermented food as well? What’s your stance on fermented food?

Dr. Rahbar:                         I use fermented foods and also prebiotics, I liked it. I use the sun fiber, the PHGG [partially hydrolyzed guar gum] because that’s easy. It generally doesn’t cause gas, it’s interesting there. Then, if they tolerate it, I may add some psyllium slowly in a small amount to see if we can replenish the microbiome in that way after the treatment. During the attack phase, when you’re trying to correct the fermentation process, I think it’s unwise to put probiotics there. Indeed, one of the questions comes up that whether it is wise to use Saccharomyces boulardii. To me, it’s a double-edged sword and if I’m dealing with the fungal clinical picture, I usually do not use S. Boulardii. Okay. Now, I have had people who said it helped them, but that’s not always the case there.

Dr. Weitz:                          Do we think, somebody just asked about soil-based, same thing as spore-based bacillus, do we think that the claims that the spore-based probiotics don’t open up until they get into the large intestine? Do we think that that is the case or do we not know?

Dr. Gurevich:                     I don’t know.

Dr. Rahbar:                        I don’t know the answer to that question, but I can tell you one thing, that about half of the patients who have taken a spore-based probiotics, they will complain of bloating. This is not a magic bullet. I think it’s good to keep it in mind. I definitely will do it down the line after the attack phase, but in a small amounts and you really have to have them experiment with it to see how the body works with that.

Dr. Gurevich:                     I have seen more people flare from this soil-based probiotics or the spore-based than any other probiotic out there. I do think Dr. [inaudible 00:48:00], who’s just an amazing researcher, talks about how it does upregulate the TH17 pathway, and so you are getting upregulation of the immune response or the autoimmune response. If I use it, I’m going to go very, very slow. I’ll start with a quarter cap every other day because I do see people get angry with it. I will also say, from my perspective, I am definitely having a fermented food moment. I feel like when you look back at virtually every culture in history, fermented food has been one of the staples of their diet that is not on accident.

Dr. Weitz:                          What’s your favorite fermented food that you like to recommend?

Dr. Gurevich:                     This week, it’s definitely kimchi.

Dr. Weitz:                          This week?

Dr. Gurevich:                     [inaudible 00:48:42] to the Asian market, next week it might be sauerkraut, maybe yogurt, I don’t know.

Dr. Weitz:                          How about yourself, Sam? Do you ever-?

Dr. Rahbar:                        Kimchi, again, a question that are you aiming for bacterial fermented material or for fungi? I think kimchi has a little bit of both. I don’t think it’s all bacterial. I think it may have some fungal components there. It’s probably safer to use those than to use the pharmaceutical versions. But again, the key is the amount and how one would experiment with it.

Dr. Gurevich:                     And the patient. I also think the key is the patient. If you’re having somebody who’s very, very sick and very, very sensitive, I don’t know if I would jump on the fermented food train. But if you have [inaudible 00:49:35] that’s a little bit more resilient and you feel like the treatment trajectory is going how you expect, that is absolutely going to be in my phase three. I think it’s also, everything that we’re talking about is obviously exceptionally patient-dependent.

Dr. Weitz:                          Right. I would like to point out to everybody who’s listening to this discussion that if we had several other SIBO experts, we would hear several different opinions. A lot of the stuff we’re talking about, people have many different opinions about this. There’s one prominent practitioner out there who treats a lot of SIBO and he feels like probiotics, the first line, that’s what you should give. He feels that there’s enough evidence that probiotics have anti-microbial properties.

Dr. Rahbar:                       I also like the polyphenols. I think those have gotten more attention and we need to think about those more as supporting the local immunity of the gut and the recovery process.

Dr. Gurevich:                     I agree.

Dr. Weitz:                          This is not in the acute phase of SIBO, but have either of you utilized any of the probiotics that are the Akkermansia muciniphila and those other products that are the anaerobic bacteria that are being produced for the first time from, I forgot what the name of the company is.

Dr. Gurevich:                     Pendulum.

Dr. Weitz:                          Pendulum, right.

Dr. Gurevich:                     I’ve never used them.

Dr. Weitz:                          Okay.

Dr. Rahbar:                        What do you mean by anaerobic herb? Talking about the Akkermansia?

Dr. Weitz:                          Yeah, Akkermansia . They have an Akkermansia product and they have a product with Akkermansia and a couple of other similar probiotics that they have a study shows it reduces blood sugar.

Dr. Rahbar:                       Yeah. I actually use Akkermansia when I see it is low. The key is that Akkermansia tends to eat up the mucus layer. There might be a good theory that when there is fungus and the mucus layer becomes quite thick and the fungus gets embedded there, Akkermansia may actually come to the rescue and be able to loosen up that mucus layer and makes it easier to remove the fungus. Having a low Akkermansia and a fungal clinical picture is probably the worst combination.

Dr. Weitz:                           Oh, interesting.

Dr. Rahbar:                         I’m thinking sometimes to see if I can replenish what’s missing here.

Dr. Weitz:                           Yeah, and there’s some data showing, you mentioned polyphenols, certain polyphenols. I know flax seeds, one of them, but berries, the bunch of polyphenols can help to feed Akkermansia. But it might be interesting to try adding Akkermansia probiotic as well.

Dr. Rahbar:                         Do it gently and within in a small amount and be careful because Akkermansia in some literature actually has shown to promote inflammation. It’s not completely clear why that would happen and how you can separate those. One of the things that would actually help to support the growth of Akkermansia is omega 3s. That might be something to keep in mind if a person is on a low omega 3, we can incorporate that as part of the recovery.

Dr. Weitz:                            Okay. I don’t know if either one of you have heard of any practitioners experimenting with removing the anti-Vinculin and the anti-CBT toxins, the antibodies by filtering out the blood. No? I think-

Dr. Rahbar:                         Plasmapheresis?

Dr. Weitz:                            Plasmapheresis, yeah. I believe that Dr. Pimentel is working on doing that.

Dr. Rahbar:                         Risky and very expensive and probably not going to get covered by any insurance company for death. Now that you said those antibodies, we have been looking at antibodies on patients who have had SIBO, especially the persistent ones. How do you explain when these antibodies are not there, they’re negative and somebody has recurrent SIBO. There must be some other sort of either immune dysregulation or physiological alteration that allows the gut for these bugs to grow. As I mentioned earlier, I think the fungi, and I think Ilana pointed out that the fungi are major players and I think they contribute by mechanical disruption means that it’s not only that you have a distorted microbiome, you now have a surface area that is disturbed, is mechanically disturbed. It has cracks, it doesn’t have the smooth, used to be like an ice skating and the bugs can float on it, and now it has cracks in the wall.

Dr. Weitz:                            For anybody who’s not sure what we’re talking about, there is a blood test for SIBO that measures the anti-Vinculin and anti-cytolethal distending toxin antibodies. This comes from Dr. Pimentel’s theory that a significant percentage of patients who have SIBO that it starts with about a food poisoning. Then, the bacteria like Campylobacter that cause the food poisoning, those bacteria secrete an endotoxin, cytolethal distending toxin, the immune system creates antibodies, the cytolethal distending toxin, and then those antibodies cross-react with a protein called Vinculin, which is part of the nervous system of the gut. Then those antibodies attack the nervous system of the gut and that damages the motility of the small intestine and that’s what leads to the SIBO. That brings up the question, how do we best address the motility?

Dr. Gurevich:                     My favorite is always Prucalopride. I think Prucalopride is still magical. I think that there’s definitely a subset of people that it’s not magical for, but a lot of people it’s magical. That’s my pharmaceutical go-to, especially with IMO patients who are just severely constipated. Natural agents, I think artichoke and ginger, there is data on it and it seems to work for a lot of people. That’s my experience.

Dr. Weitz:                          Now, do you use prokinetics for patients with hydrogen and hydrogen sulfide SIBO as well?

Dr. Gurevich:                     Not religiously, and if I do, I really will stay in the ginger area because they’re already moving a lot, so I want to make sure I’m not giving them pharmaceuticals.

Dr. Weitz:                          Right. Now, I know in the past I’ve talked to Dr. Pimentel about this and he distinguishes between the motility of the gut and the MMC, the cleansing waves that happen when you haven’t eaten and that those are controlled by different mechanisms. Therefore, a patient who has hydrogen SIBO, who has increased motility might still lack the migrating motor complex, the cleansing waves that keep the bacteria from building up, so we still might want to use a prokinetic in those cases to make sure that we help clear the SIBO.

Dr. Gurevich:                     I’m very, very cautious about using anything too strong. I think the herbal agents are effective and generally well-tolerated, and I think the pharmaceutical agents are too strong for that population in my experience.

Dr. Weitz:                          What do you think, Sam?

Dr. Rahbar:                        We may have a little bit of a difference of opinion. I use antifungals and pharmaceutical approach at first. Most of the reason is that I like targeted attacks so I understand what am I dealing with. Herbs are good, but they’re broad. They’re too, I understand I’m capturing more bacterial, more fungi is a tradeoff. But as far as a die off, yes, the die off could be stronger, but that we can adjust it by taking less of the medication and less frequently. One patient I had to work with recently, I felt that the chance of [inaudible 00:59:01] was high, I just asked them to maybe use half a tablet of Fluconazole once a week, and if they tolerated that to go to twice a week. You can go slowly and also see what the patient’s comfortable with. If they’re more comfortable with herbal approaches, you can go that way.

Dr. Weitz:                            Do you use prokinetics either during the active treatment or afterwards to reduce recurrence, which is when Dr. Pimentel tends to use them?

Dr. Rahbar:                         I don’t use prokinetics during the treatment. I don’t want to push the drugs out. I want them to hang out in the small bowel, so I would use them afterwards, but not during.

Dr. Weitz:                            Okay, and you? Do you use? I’m sorry.

Dr. Gurevich:                       One of my selling points on the herbs is that they are broad spectrum, that’s one of the things I like about them. They’re less targeted, they’re less specific. The way I think about it is, humans evolve with plant matter for 200,000 years and we’ve had pharmaceuticals that are targeted for about a hundred and our health has significantly declined in that small amount of time, so that’s one of the reasons why I prefer herbs over the pharmaceuticals, if the patient [inaudible 01:00:18].

Dr. Weitz:                            Oh, I’m sorry.

Dr. Rahbar:                         They’re both good.

Dr. Weitz:                            What do we think about why the patients ended up with SIBO? Do you both think that … ? What percentage of cases do you think are probably related to food poisoning and decreased motility? What do we think are the causes for the SIBO? Also, do we think that hydrogen, do we think that stomach acid reduces the risk for SIBO? Because that seems to be in question now that, at least Dr. Pimentel has talked about the fact that PPI use does not increase the risk for SIBO. Does that mean that stomach acid doesn’t help to reduce bacteria growth in the intestines?

Dr. Rahbar:                          In patients who have low acid and they have SIBO, there may be other mechanisms involved other than just the low acid that is contributing to the SIBO. I am not convinced that the PPIs increase the risk of SIBO, although conceptually that makes sense. It’s just something in practice we have not seen to be a strong association.

Dr. Weitz:                            Yeah. No, Dr. Pimentel has said the opposite. He said that he’s convinced that they don’t increase the risk of SIBO and he seemed to hint that they might be beneficial for use as part of the treatment for patients with methane SIBO.

Dr. Rahbar:                          Right. I don’t know if I’m going to incorporate the PPI in the treatment of SIBO despite that comment. But if I have to use it for somebody who has bad acid reflux and we need some temporary relief, it probably would be okay.

Dr. Gurevich:                       I agree.

Dr. Weitz:                            Let’s see. Anything else we haven’t covered? They did not answer as to, what do you think is the cause of SIBO?

Dr. Rahbar:                         How much time do we have?

Dr. Weitz:                            We can do a couple more.

Dr. Rahbar:                         You should bring Mark back again to discuss that one. Come on, this is going to go on for a long time. I think that, as I said, in our experience, the alterations of the microbiome that we see, I think it has a lot to do with how that individual and the universe were interacting. Obviously, stress, lack of a sleep, late eating, alcohol, use of antibiotics, all of these things are the common ones. We know history of food poisoning, Vinculin antibody being positive.  But then there’s a subset of patient that are just exposed to chemicals. We see SIBO and C4 combination is quite commonly people have been exposed to more toxins. This is our own experience looking at a lot of patients that a SIBO that is really high hydrogen or the methane is high. It may very well be associated with the mycotoxin exposure or high level of BPA or Glyphosate or Phthalates. We are seeing these associations and hopefully at one point we can publish this so we can further confirm that. But as an observation, I find that as a subset of patients, they are dealing with this type of problem.

Dr. Gurevich:                     I totally agree and it was beautifully said.

Dr. Rahbar:                        Thank you.

Dr. Weitz:                          Sam, you’ve also published on the fact that there are cases of patients with SIBO who also have Lyme disease and that seems to be a factor.

Dr. Rahbar:                        Right. Back in 2014, I presented the data that if you see somebody with high methane that suggests immune dysregulation and if the clinical picture fits, you must think of Lyme disease or other tickborne diseases. We published this in 2021 in our experience, and the prevalence of SIBO was quite high in the subset of patients who had tickborne disease. But when we compared it with the control group and the people who did not have the tickborne disease, they also had a similar prevalence. However, I want to emphasize in that study we use a cutoff of 80 minutes for SIBO, not 90, not 100, 80 minutes. The reason I did that just to make sure there was no question that if there was SIBO, it was SIBO and it was not the borderline case. Only people who were abnormal at the 80-minutes mark we included in that study.

Dr. Weitz:                          All right. Great. Well, thank you both so much for filling in at the last minute. For anybody who just came in later, Dr. Pimentel wasn’t able to join us, but we hope to have him in a future meeting. Thank you everybody for participating and we hope to see you next month.

Dr. Rahbar:                       I hope so too. Have a nice [inaudible 01:06:06].

Dr. Gurevich:                    Nice to meet you, Sam. It was lovely hearing you speak. Very nice to meet you.

Dr. Rahbar:                       Yeah. Thank you. All the best. Take care.

Dr. Gurevich:                    Bye, everybody.

Dr. Rahbar:                       Bye.



Dr. Weitz:                            Thank you for making it all the way through this episode of the Rational Wellness podcast. For those of you who enjoy listening to the Rational Wellness podcast, I would certainly appreciate it if you could go to Apple Podcast or Spotify and give us a five star ratings and review. That way, more people will be able to discover the Rational Wellness podcast. I wanted to say thank you to all the patients that we’ve been working with at our White Sports Chiropractic and Nutrition clinic who, many of whom, most of whom we’ve been able to help with a range of various health conditions from various types of gut disorders to thyroid and hormonal issues, autoimmune diseases and various other cardiometabolic conditions, and so I very much appreciate you and I’m excited about going forward, helping you to do improve your health on your journey towards optimal health.  I wanted to let everybody know that I do have a few openings now for new clients and you can take advantage of that by calling my White Sports Chiropractic and Nutrition, Santa Monica office at 310 395 3111, and we could set you up for a new consultation for functional medicine nutrition and we can get that going as early as the New Year, so give us a call and I’ll talk to you next week.


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