Beyond Bloating: Navigating SIBO with Dr. Mark Pimentel: Rational Wellness Podcast 394

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Dr. Mark Pimentel discusses Beyond Bloating: Navigating SIBO with Dr. Ben Weitz.

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Podcast Highlights

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Dr. Mark Pimentel is a distinguished gastroenterologist, researcher, and innovator in the field of gut health and microbiome science.  He is the Executive Director of the Medically Associated Science and Technology program at Cedars-Sinai Medical Center, where he leads a multidisciplinary team focused on understanding and treating diseases linked to the gut microbiome.  Dr. Pimentel is internationally recognized for his pioneering research in Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome.  His landmark work established SIBO as a leading cause of IBS, fundamentally altering the way such patients are diagnosed and treated. He also developed the first non-invasive breath test to identify SIBO, which has become a standard diagnostic tool globally, including the Triosmart SIBO breath test that measures three gases—hydrogen, methane, and hydrogen sulfide.  He has developed a blood test for measuring antibodies that documents the autoimmune origin of SIBO, the IBS Smart test.  He has mapped out the microbiome of the small intestine for the first time and he now has documented the specific microbes that cause the three forms of SIBO.  He pioneered the use of Rifaximin, a minimally absorbed antibiotic that has become a cornerstone treatment for SIBO and he is actively developing additional and better therapies for treating the root causes of SIBO, which is one of the reasons that Dr. Pimentel’s work has been so embraced by the Functional Medicine community, sharing our focus on root cause medicine.

Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure.  Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.

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Podcast Transcript

Beyond Bloating with Dr. Mark Pimentel

Dr. Weitz: [00:00:00] Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. And to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.

Our topic for today. is small intestinal bacterial overgrowth and irritable bowel syndrome with Dr. Mark Pimentel. For listeners who are not familiar with SIBO or SIBO, which is the correct pronunciation? I call it SIBO. Okay. This will be an advanced level discussion.  So if you want to learn some of the basics, I encourage you to listen to one of the prior discussions that I have had on the podcast with Dr. Pimentel or with Alison Seibecker. And for this discussion, I’ve solicited some questions both from Allison and from Dr. Rhabar, both who are friends of mine and I’ll read a little intro.

Dr. Mark Pimentel is a distinguished gastroenterologist, researcher, innovator in the field of gut health and microbiome science. He’s the Executive Director of the Medically Associated Science and Technology Program at Cedars Sinai. where he leads a multidisciplinary team focusing on the understanding and treating diseases linked to the gut microbiome.  Dr. Pimentel is internationally recognized for his pioneering research in small intestinal bacterial overgrowth and irritable bowel syndrome. His landmark work established SIBO as the leading cause of IBS. Fundamentally altering, altering the way such patients are diagnosed and treated. He also developed the first non invasive breath test to identify SIBO, which has become a standard diagnostic, including the TrioSmart SIBO breath test that measures all three gases for the first time.

He’s developed a blood test for measuring antibodies that documents the autoimmune origin of SIBO. The IBS smart test. He’s mapped out the microbiome of the small intestine for the first time as now and now has documented the specific microbes that caused the three forms of sibo, and he’s bi pioneered the use of rifaximin, a minimally absorbed antibiotic that has become the cornerstone treatment for SIBO. And he’s actively developing additional and better therapies for treating the root causes of SIBO, which is one of the reasons that Dr. Pimentel’s work has been so embraced by the functional medicine community, sharing our focus on root cause medicine. So Dr. Pimentel, thank you so much for joining me today.

Dr. Pimentel: Well, thank you for the nice introduction. I really appreciate it. Good to be with you, and I’m happy to take those questions that you’ve got.

Dr. Weitz: That’s great. So, we now understand that instead of hydrogen, methane, and hydrogen sulfide SIBO, we now have hydrogen SIBO, EMO, and ISO, or Intestinal Sulfur Overproduction.  So, with IMO and ISO, we now have are in the colon as well as in the small bowel. Does this mean that we’re no longer dealing with SIBO? Is SIBO even an appropriate name? Should we just use intestinal bacterial overgrowth?

Dr. Pimentel: Well, as with everything in medicine, the more you learn, the more complicated it actually gets.  It’s never quite, you know, one equals one. It’s always some large formula. And I think that’s what we’re seeing here. So what we see is that the breath test is very quantitative. So let me start with that.  So the amount of methane you see on a breath test is proportional to the amount of methanogens we see in the colon and in the small intestine.

So, that’s great because you don’t actually, you can do something simple, do a breath, and then you know how many methanogens you have and particularly M. smithii, which we may get to in some of your questions. That’s the, the, the big character. The funny thing about that. Not to be too long winded, but, but I just want to get some information out, because it’s really important, is that M. smithii is the character, both in the colon and the small bowel. And people said to me, oh, you’re not going to find M. smithii in the small bowel, there’s too much oxygen there. Well, you can’t say no. You got to check. And so we checked, and it was M. smithii, and why it grows in that oxygen richer environment is unclear.

Hydrogen sulfide, the problem here is that we do see a really beautiful correlation between hydrogen sulfide on the breath and the small bowel, more so than the colon, but also correlating with the colon. So, the, for example, the p values are stronger for the small bowel. The, the challenge with hydrogen sulfide is, and we knew this all along, there’s a whole bunch of hydrogen sulfide producers out there.  And in the colon, it’s really Fusobacterium and Desulfovibrio. In the small bowel, it’s Proteus and Desulfosarcina and others. So It’s a different cast of characters in the different locations for that. When you talk about post infection IBS, which is where the blood test comes in, you get SIBO first, you get the hydrogen producers, E. coli, Klebsiella, and that’s driving the hydrogen sulfide producers to have a more favorable environment, we think. Again, things could change as, you know, we learn, we get, things get more complicated. But the SIBO is really the source of hydrogen for us. [00:06:00] ESO. It’s a little unclear for EMO, whether it’s the source of hydrogen for the methanogens in the small bowel versus the colon, because the colon is different.  And then I really get into the weeds after that, and I don’t want to bore your, your viewers, but.

Dr. Weitz: So if these organisms, if the methane is just in the colon, would it still come up positive on a breath test?

Dr. Pimentel: So the answer is yes. So it does. So when you do a breath test for methane, because methane is so downstream, you got to get food or sugar, then the hydrogen producers have to ferment it.  And that takes an hour or two, you know, it’s like making bread, right? It takes an hour or two for things to rise. And then the hydrogen has to go to the methanogens and then the methanogens got to slowly convert it to methane. So, really, it’s hours later. Whether it’s in the small bowel or the colon, it’s hours later.  It doesn’t really show up. [00:07:00] Methane is not a time dependent number on the breath test. So, if you see it high at fasting, more than likely it’s going to be about the same all the way through the test. And so, that’s the funny thing about methane. So, I don’t care if it’s small bowel or colon, in the sense that it’s still doing the constipation part of things.  But there was a study that just came out from Stanford, and you may or may not be aware of this, where they did SmartPill in people with methane. And what they see is, wherever methane gas is, it slows the gut down. And they see that the small bowel is slow, and the colon is slow. So I think for the majority of patients, the methane is everywhere, or the methanogens are everywhere.  And they’re slowing everything down.

Dr. Weitz: But if Rifaximin acts mainly in the small intestine, and the methane is in the large intestine, is that one of the reasons why it’s not always effective?

Dr. Pimentel: Right, or it could be the reason why we have to add neomycin or a surrogate, because we’re getting some effect in the small bowel with rifaximin, but maybe the neomycin is a carryover effect to the colon.  That’s one possibility. Hard to know.

Dr. Weitz: Or could another possibility be that you, you take the neomycin and the rifaximin, it reduces the methane in a small intestine, but now you still have it in a large intestine that can repopulate.

Dr. Pimentel: Well, there’s a possibility that it repopulates from the colon, so therefore you get the relapse rate.  I think that’s what you’re sort of alluding to, but there’s, there’s something we sort of haven’t touched on is, I like methane. I think methane is, and methanogens are beneficial when they’re this high. But when they’re this high, that’s not a good thing. So, it’s not about wiping them out, because I think if you wipe them, we have papers already where we show in Crohn’s and ulcerative colitis, we can’t find them.  We can’t find methane in Crohn’s and ulcerative colitis, and [00:09:00] we think methanogens do have a little bit of anti inflammatory effects, those organisms do. And so, they are good. They are not good here and so, we’re not looking for something to wipe them out, but maybe if you just, as you said, get them down, maybe just in the colon, they’re still there, maybe that’s okay.  And that’s enough to feel good enough, or to feel normal, because you should have some methanogens. I don’t know, so we’re, we’re dissecting all those details, but that’s sort of where things are heading.

Dr. Weitz: You, you mentioned that methane is always associated with constipation, but why is it that some patients with IMO have diarrhea?

Dr. Pimentel: So when we did this a study that we published about a year and a half, two years ago, we at D IBS, diarrhea IBS patients, and literally none of them were methane positive. And then on C IBS, of course, not all of [00:10:00] them have methane, but a good 60 percent had methane. But we do see, and, and this is the funny part, and we have a couple of abstracts at DDW I can’t talk about, but, but the funny part about symptom presentation varies by gender.  So, people say, oh, there’s more IBS. In women than men. Yes, as a pool, this is true, but if you look at the extreme diarrhea side, men are 2 to 1 higher than women. If you look at the extreme, so men are more than women. If you look at the extreme constipated side, women are 8 to 1 higher. So when men have methane, they tend to be mixed.  They don’t tend to be as far right constipators. But when the women are methane, they tend to be more constipated. Again, it’s a gender difference in how they react to methane that we still don’t understand. So there are, if you’re going to find a little diarrhea in a methane producer, usually it’s a male.  [00:11:00] usually, because they tend to stay more towards the middle.

Dr. Weitz: Boy, I have some male patients who, their constipation is so bad, they end up in the restroom for so long it messes up their appointment time.

Dr. Pimentel: It’s true, but I can tell you, and I can’t talk about the abstract at DDW, but historically, I can tell you, We, in 27 years at Cedars, have taken colons out of people for bad constipation, and not one of them is a man.  So, it’s all and only women for that severe group. Yes, I think there’s a group of men that get constipated, I’m not arguing that point. 

Dr. Weitz: But how does a methane patient get diarrhea though?

Dr. Pimentel: Well, I, I think it’s probably they, first of all, we see on the 3 gas breath test a combination of people where they have hydrogen sulfide and methane, and they can have all sorts of diarrhea because of that.  So we can, and again, I’m touching on some things that are going to be at DDW, because we can break SIBO [00:12:00] down into SIBO, ISO, IMO, SIBO and IMO, SIBO and ESO, IMO and ISO, because now there’s multiple combinations you can have, and they present I have different symptoms depending upon which profile of gases they have and how high the methane is and so I’m making breath testing more complicated by adding ISO But you’re gonna see some of those interesting facts come out at DDW

Dr. Weitz: So, if we have this hydrogen producers, and hydrogen goes to methane producers and hydrogen sulfide producers, it’s like a two level thing, and so, if we then reduce methane, might mean, Might we then all of a sudden find out an increase in hydrogen because now we’ve taken away the, the the eaters of the hydrogen and all of a sudden now the hydrogen goes up?

Dr. Pimentel: Yeah, [00:13:00] so that’s also a very complicated answer microbiologically. If you take, so, and this has been shown by some of the early microbiome people from about 15 years ago, If you take hydrogen producers They can produce hydrogen only to a certain capacity because once they reach an amount of hydrogen it starts, they start to auto regulate and then stop fermenting because the hydrogen intoxicates them.  But if you put a methanogen with that hydrogen producer, they produce double, triple the amount of hydrogen because the hydrogen doesn’t accumulate. but the methanogens are feeding off of it. So, if you get rid of methanogens, you will transiently see on the breath test a rise in hydrogen, and then it will come down.

So, I guess what you’re getting at, and these are things we think about every day on how to treat this. So, do you want to treat the methanogen, or do you want to get rid of the hydrogen so the methanogens don’t have [00:14:00] hydrogen, therefore don’t produce methane? You can do either. So, both are ways to tackle it, but the problem is, when we do our treatments, we don’t have enough knowledge, you know, Before treatment, after treatment, small bowel aspirates, what’s happening to the, the mix of bacteria?

Are they going away? Or are they changing their function? What’s happening in that, that, you know, what’s ideal? Getting rid of hydrogen or getting rid of methane? And, and can you just get rid of hydrogen and get rid of methane that way? So, so those are things we’re contemplating with new therapies that we’ve already developed.

Dr. Weitz: And corollarily why do some hydrogen sulfide patients get constipation?

Dr. Pimentel: Yeah, so it’s hard to understand that one because we do see that occasionally. But I gotta tell you that, again, from a 6, 000 patient study we just finished, [00:15:00] Can’t talk about the results. I think you’ll be impressed that, that does not happen often.  But yes, it does happen and it’s hard to understand those rare events. You know, because you can get SIBO from just being, if I put you on morphine, you’ll get SIBO. You might even get ESOP because the hydrogen builds up and the sulfate reducers start to go up and then you’ll do a breath test and you’ll have SIBO and ESOP, but you’re constipated because you’re on morphine and the morphine caused the SIBO to begin with, so there are reasons to get SIBO that aren’t necessarily the consequence of the bacteria, but the consequence of some motility disorder, and you got to try to untangle that in clinic.

Dr. Weitz: So, for those who didn’t follow that, the opioids slow down the motility, and that’s what leads to SIBO.

Dr. Pimentel: Right. It’s a different cause of SIBO than the IBS SIBO that we generally, when we’re talking, we talk about.

Dr. Weitz: When it comes to breath testing, [00:16:00] I know you prefer lactulose. You don’t like the idea of using glucose because it’s so readily absorbed, even in the mouth.  Some practitioners like to use fructose, including Jason Hawrelak from Australia. What do you think about using fructose?

Dr. Pimentel: So I think fructose is going to be halfway between glucose and lactulose. In the 6,000 breath test study that I’m talking about, we’re going to be able to settle the argument at DDW.  I already sent the abstract in. I know I hate doing this to people because you’re all, Ben, you’re always on the cutting edge, right? So when you’re on the cutting edge, you’re asking questions we’re asking, and we’re answering them with our data, But it’s always 3-4 months from now that you’re going to hear the result.  We’re going to settle the argument between glucose and lactulose. But glucose and lactulose really are on the extreme left and the extreme right. Meaning glucose is easily absorbed, [00:17:00] so you’re going to under call overgrowth in general. We know that from other papers. Lactulose is on the opposite end of the spectrum, because it always gets to the colon.  And so the argument is, oh, maybe it’s measuring transit, which is not true, but you’ll hear more about that in a couple of months. So then, maybe we should find something in the middle. And that’s Harlech’s principle, is fructose is relatively not absorbed, so it’s going to be somewhere closer to lactulose, but not quite lactulose because it gets, so maybe, but we don’t have enough breath tests in the 6, 000 patient breath test study of fructose to be able to settle that argument, but he could be right, he could be right that fructose might be a better substrate but you know, the problem with fructose, the other problem with fructose is even humans don’t metabolize fructose as readily as glucose. It’s a different system. The absorption of fructose is very different because we [00:18:00] don’t like it. It’s not our, it’s not our favorite. 

Dr. Weitz:  Roundabout through the liver, similar to the way alcohol gets metabolized.

Dr. Pimentel: Exactly. So bacteria, same thing. Fructose is a little funky for them. Not all of them use it as a substrate.  So we don’t know what the dynamics will look like in terms of fermentation. We do not have an abstract on fructose, so I don’t have a clear answer coming, at least for the time being.

Dr. Weitz: So here’s another idea maybe you can put to bed. if you know for sure. The old theory about trying to measure hydrogen sulfide was with a flat line on a breath test, with a two gas breath test.  Do we know, is there any correspondence between that and the new hydrogen sulfide testing? 

Dr. Pimentel: So, a portion of the flatliners, which I can’t tell you exactly what portion yet because it’s a 6,000 patient study, because that’s, that’s the ultimate, the big huge study tells us all [00:19:00] the answers exactly as they are but a portion of flatliners We already knew from some previous data are H2S.  The problem is H2S is present in a lot of people who aren’t flatline also. Same thing with methane. We saw, we see a lot of flatliners with methane for hydrogen, but not all of them are flatline for hydrogen. Some of them are mixed. In fact, most of them are mixed. And we’re seeing that with hydrogen sulfide too.  Most have both hydrogen and hydrogen sulfide or a mixture of gases. So. But we are capturing more patients because of that. And, look, now, you know how many flatliners we’re seeing now? A lot. Because of GLP 1s. Oh, okay. The lactulose, the glucose, whatever, doesn’t get out of the stomach, we see flatline.  Not because there’s no SIBO there, it’s just The sugar never gets out of the stomach. So we’re seeing more flatliners now, which is going to confound everything, because we don’t know if the flatliner, if they’re on GLP 1s or not. And you got to ask that [00:20:00] question when we do breath tests now, and, and things are really getting

Dr. Weitz: But, but you understand, like, three quarters of the population is overweight.  We’re going to have a huge number of people on these drugs, if it doesn’t bankrupt our healthcare system first. Yeah, both of those. Maybe we should just stop eating junk food before we get fat.

Dr. Pimentel: Yeah, well, it’s a, it’s a huge problem. And, and you know, these drugs are effective, but like everything else, there’s always a give and take.  And now we’re seeing muscle loss from these drugs. And now the drug companies are trying to solve the muscle loss because you lose fat and muscle, and then things start to. And now osteoporosis. There was a study that just came out saying these GLP 1s are causing osteoporosis to some extent. So, you can’t get things for free, unfortunately.  Right. And, and as we learn more about them, great drug, but in context, it’s got to be more. [00:21:00] 

Dr. Weitz: And we’re liable to see a tsunami of SIBO, right?

Dr. Pimentel:  We could. I mean, this could be causing SIBO. We just have to wait for the signals to start to kick in.

Dr. Weitz:  So SIBO often starts with food poisoning. Do patients after treatment ever get antibody negative?

Dr. Pimentel: So we did a study with the old Rifaximin trial, the Target 3 trial, where we did the blood testing before Rifaximin. And after Rifaximin, and tracked whether they responded to Rifaximin or not by breath test, as well as by symptoms. And basically, the bottom line is the antibodies don’t change. So, you can take antibiotics until you get rid of every bacteria in your gut, it’s not going to change the antibodies in your blood.  That’s from the food poisoning that happened. six months ago, two years ago, five years ago, whatever. But what we do see, and this was something we presented [00:22:00] at DDW, is that if we can push the antibodies down with immunosuppressives, I’m not recommending this for anybody, because this is just experimental stuff, the IBS goes away, or goes down.

So, the root cause of the SIBO IBS are these antibodies, we believe. And so, we’re doing a lot of active work in this area to try to develop therapies that could push the antibodies to normal. And then maybe we don’t need antibiotics. Maybe we don’t need all this breath testing. Who knows? 

Dr. Weitz: Can you give us any idea of what this treatment might consist of?  Does it consist of plasmapheresis? 

Dr. Pimentel: So in the study that we presented, some of those patients were plasmapheresis. And when we got the antibodies to zero, those patients, their IBS went away for a month. The problem is the antibodies come back because the B cells are still there. So, plasmaphoresis is not the answer.  Please do not do this at home or with your patients, because it’s a, it’s a chronic, it’s like dialysis. It’s, and then you’re immunosuppressed, because you’re getting rid of all your antibodies with plasmaphoresis. So, you can get the flu, you can get COVID, the vaccines from COVID are worn off, and you, you know, you’re gonna be taking those antibodies out of your blood.  It puts you at risk. So, that’s not a treatment for IBS. But it is something we’ve tried for some of the extreme cases we see that some of them are so bloated they’re in the hospital.

Dr. Weitz: Okay. Have you ever used Alinia, which is an antiparasitic that some functional medicine doctors have been using with some success?

Dr. Pimentel: Yeah, Alinia is sort of like metronidazole. It’s nidazoxonide, and it it has a similar property as the metronidazole category. So, we use metronidazole for SIBO. Alinia can be used for SIBO. Metronidazole, on its own, is about 20-25 percent effective for SIBO. It’s about the [00:24:00] range of neomycin by itself. So it’s not as effective as other drugs, but there are patients who benefit.  Or, you do it in combination with Rifaximin for methane, it probably will have a pretty good effect. I don’t use it often, not because I don’t like the drug, it’s because if I give Rifaximin and Alinia, somebody’s gonna have to take a loan out to pay for it because they’re both extremely expensive.

Dr. Weitz: To, to follow up on what you were, we were just saying about how methane and hydrogen sulfide can be in the large bowel.  How else can we analyze the large bowel except with the stool test? I know you’ve said that the stool tests that we have currently available are, are, can’t really be used for that purpose. You just need to develop a new stool test for that, but it seems like there should be some way to analyze that.

Dr. Pimentel: Well, you know, there, there are people struggling with capsules to see if they can diagnose the, the bacteria in the small bowel, not just the colon, because, you know, you gotta see [00:25:00] both, and the colon and small bowel are so dramatically different, you really can’t see everything in the stool, and, and so, I’m not saying you shouldn’t do stool studies, I’m not saying the technology’s not improving, and maybe methanogens are starting to be quantifiable, and maybe clinically relevant from stool, I’m saying that it’s way, it’s a little more complicated than just measuring stool because of the small bowel factor. So again, the capsules are something that are starting to emerge. Probably capsules are, you know, some of the stuff I’m seeing on the, in the meetings are they open the capsule and it’s brown in there.

I can tell you, I’ve never had a brown sample from the juice of the duodenum or the small bowel. It’s always greenish yellow. So if it’s brown, You’re not getting the sample from the small bowel, or it’s growing in that capsule for a day or two till you retrieve it, and then you’re trying to figure out if it, if it’s still representing the original sample.  So there’s a lot of [00:26:00] technical challenges with capsule, and I’m not 100 percent sure where, where we’ll be a year or five years from now with capsules, but let’s see. But it’s ideally you want to see the whole spectrum. The reason why we keep pushing forward is that we’re seeing that the gases on the breath test truly represent at least those classification of organisms that are producing those gases.

They’re not telling you everything that’s there, but they’re telling you if hydrogen sulfide is elevated, those characters are elevated in the gut. If methane is elevated, those characters are elevated in the gut. The methane is causing constipation, so, bingo, you know, you don’t have to do a stool study to tell you, just do a breath test, and we think the same for hydrogen sulfide.  Over time, maybe there’s other characters cast, in the cast of characters that are causing problems that you can’t measure on breath but for now, I think, We’re doing okay. We continue to get good signal. There’s more to come.

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Dr. Weitz:  I read your paper on NAC that you use as a mucolytic along with Rifaximin in the RAD SIBO study, and I know you’re going to be publishing a study soon with… Functional medicine practitioners have been using NAC in their protocols, and we’ve thought of it as a biofilm busting agent. So a couple of questions. One, if we wanted to use NAC now as part of our protocol I’ve heard you say in another podcast that you need a special formulation of NAC.  If we wanted to use NAC now, how much would we use? When would we use it? I, one of the patients I talked to had seen a naturopath who recommended taking NAC 30 minutes before the meal, that somehow it would get in there, and I understand that you’re You’re using NAC to thin the mucous lining where some of these bugs grow.  And then so why don’t we start there?

Dr. Pimentel: Yeah. So yes, published the NAC data works better than rifaximin alone in animals, in animals with IBS, post infection IBS who have SIBO and the E. coli and desulfovibrio, those H2S and H producers, they go down. Only with the NIC, with Rifaximin, [00:30:00] not Rifaximin alone.  So, and clearly, and their water content goes back to normal. So, this works, and it works better than Rifaximin, which is fantastic. The question you’re asking is, how can we jack the system now with what we have? And, and the answer is, maybe you can, maybe if you use enough NAC, but gotta be careful, you can’t just pound the people with NAC.  The problem with NAC is. It’s not like a drug where the drug stays intact as it goes through and once it does its thing, it continues to march, like Rifaximin continues to march down the gut, kills bacteria and it’s still there. The chemical doesn’t get decomposed. That gets consumed. And so when it’s consumed, it’s done.

And there’s so much mucus, you know, when you vomit and you get that thick stringy Goopy stuff when, when you vomit that’s stomach mucus, which is thick, dense, and a lot. And you can consume most of your NAC in the stomach without ever it getting into the small intestine or [00:31:00] releasing along the length of small intestine.

So NAC gets consumed quite easily. That’s the problem with NAC. So we’re starting a phase two study, everybody, in February, March. The FDA documents are going in. It’s an FDA trial. With a formulation that’s specially released for Faxman, with specially released NAC. You know, based on all of this work, and the humans trial that you talk about that we’re going to be presenting at DDW again.  But but yeah, so this is, You know, you don’t go to Phase 2B unless you have some good data, and that’s all I can say. So we’ll be starting that trial soon.

Dr. Weitz: You know, I wonder if a special formulation of NAC is really needed. We use NAC a lot in the functional medicine world. It’s one of the most amazing compounds.  It has all these benefits. It’s a precursor for glutathione. It helps the immune system. And that may be another reason why it might help with SIBO. So, I wonder if, if it’s got to be a fair amount of it [00:32:00] gets absorbed into circulation if it has these other effects.

Dr. Pimentel: Yeah, I mean, if you slow release it then it’s going to mostly be consumed by the mucus right at the layer, at the level of the, of the lining.  If you give it on a big, big, Bolus that just gets plopped in your stomach. Some of it’s going to get in your blood, some of it’s going to be consumed by the mucus of the stomach. How much is going to get into the mid small bowel? I don’t know. So that’s, that’s the challenge which we were trying to address when you talk about SIBO being distributed across 15 feet of small bowel.  And, and so I’m not, You know, this, the merits of NAC have been recognized by the naturopathic community for a long time, for good reason, and, you know, we’re charting a slightly different path. way to release it, hoping that we get an even greater benefit than what would be realized by simply pounding a capsule with NAC in it.  But, you know, we have to see what the data shows, and then we’ll be able to give you better. 

Dr. Weitz: Yeah, I started adding [00:33:00] 600 milligrams of NAC each time they take their antimicrobials.

Dr. Pimentel:  You find it works better for your patient?

Dr. Weitz:  I think it’s helping, yes.

Dr. Pimentel: Yeah, no, I think, I think there’s, it’s fair to say that the question is, the question is if you distribute it more evenly across the entire small bowel, will you get an even better effect?  That’s what we’re trying to distinguish. So the

Dr. Weitz: So the mucus layer is this lining of the intestinal tract and, It’s sort of a biofilm, but in the functional medicine world, we’ve often talked about biofilms. And I’m assuming that there’s been some discussion in the conventional GI world as well. And the normal thought of a biofilm is this is this layer that bacteria and or fungi surround themselves with to protect themselves.  So apart from the mucus layer, are there often biofilms that these [00:34:00] bacteria use to protect themselves?

Dr. Pimentel: Well, they certainly protect themselves from Rifaximin. ’cause rifaximin is not water soluble. It can’t get through the biofilm to the bugs that live in there.

Dr. Weitz: So are we just talking about the mucus or are we talking about is there a biofilm that surrounds the bugs in the intestine or is the mucus a biofilm?  Or is, are we talking about the same thing? Are

Dr. Pimentel: there it, it, it’s, it’s both. So, you know. As I understand how things work in the, in the intestine is there are many ways to protect the human. The, the mucus can be produced by the colon or the small bowel in order to create another layer of defense against microbes that you don’t want getting in.  So, people talk about my biofilms being protective in one instance or bad in another instance. And so, That, that’s sort of the challenge, but when you have bad bacteria in there, your, your mucosa [00:35:00] wants to produce more biofilm to keep them there so they don’t get in and I think in the case of E. coli and Klebsiella, which are the SIBO, you know, characters, when we do the microbiome analysis and we look for E. coli and Kleb, we find this much, but when we then do the microbiome analysis, but first dissolve the mucus, we see this much E. coli. They’re swimmers. They live in the mucus. They swim through that mucus layer, and half of them are in the mucus. So, it could explain why Rifaximin relapses, you know, you get relapses because you’re receding from that mucus layer, all that E. coli and Klebsiella. So, the hope is We get them all, the gut repopulates like nice and normal again, like we saw in a paper that just came out from the Cork group, and E. coli doesn’t have an opportunity to grab hold as prominently as it did before. That’s the hope, but [00:36:00] let’s, let’s see what happens with the data.

Dr. Weitz: Not to keep beating the same horse, but this mucus layer is a biofilm?

Dr. Pimentel: So, okay, so there’s mucus that’s produced by the gut by muck cells, right? Okay. So the mucus producing genes. So there’s that mucus. A biofilm is something like, for example, the plaque on your teeth is created by bacteria. That’s stuff that they scrape off at the dentist.  The bacteria create that so they can live in there so that they don’t get infected. Dissolved or swallowed or whatever. So that’s a biofilm, but there’s different kinds of biofilms. So bacteria can produce a mucous like substance that then surrounds that bacteria like a, we call it a glycocalyx in other Example of a film around a bacteria that is a biofilm, but there’s so many different biofilms.

The one in your teeth is this hard, like a rock biofilm. The one in your gut is more liquidy and then mucus is mixed in [00:37:00] with that and the bacteria then live in their own little egg shell of biofilm plus in the mucus plus. So that’s what makes, when I get these. Questions, not from you, because I know you, you understand things in a greater depth, but sometimes this commentary about biofilms, it, it’s not as simple as biofilm equals biofilm equals biofilm, because there’s so many different biofilms, because the mucus that you produce, is a reservoir for the swimming bacteria.  And so in essence, it becomes a biofilm because it’s a bio harborer of it’s a harborer of bacteria, but then bacteria produce their own little shells and things to protect themselves in their niches as well. And those are also biofilms, but NAC’s not going to dissolve your teeth stuff at biofilm, but they might, it might dissolve some of the more liquidy things.

Yeah.

Dr. Weitz: I’m so excited that you just used the word glycocalyx because that sets up my next question, which is asking about the, I understand [00:38:00] there’s a seaweed extract that you’re testing for methane that works similar to lovastatin, and there is a seaweed extract that we use a lot for cardiovascular disease called Raman Sulfate, which helps with the health of the glycocalyx in the arteries. Is that the same seaweed? Are you allowed to say that you are using?

Dr. Pimentel: So to be honest, I was super excited about this seaweed about a year and a half ago, two years ago, and we were getting some of it, bits and pieces of it, but it’s extremely hard to get.  So it’s only, the one that really works, is only available in Hawaii. And it’s a protected species that they’re worried about, because they were harvesting it for giving to cows to reduce methane. They were putting it in their feed. And so as this was beginning to take off, the Hawaiian government The Hawaiian government said, Hey, people, you can’t be harvesting every bit of this [00:39:00] protected seaweed for cows, which are billions of cows on earth.  That’s not going to happen. We will lose the seaweed. So then Oregon state, they’ve started to build farms for a seaweed like this Hawaiian one. And then they dry it, and it has some properties of anti methanogen, but not as good as the original Hawaiian seaweed. So you can’t get the Hawaiian seaweed anymore.  So I’m basically hitting a wall, is what I’m telling you, and I’m sort of keeping it aside for now. Because it’s so hard to get, and it’s become a protected species. And I’m not sure the farmed version is as good as the original version, and so we’re sort of in this limbo, and that’s, that’s where that’s at.

Dr. Weitz: When it comes to Rifaximin, it’s typically recommended for two weeks, but so many other antibiotics are used for longer than two weeks. Do we know that two weeks is really the proper course? Could it be used longer? Should it be used longer, at least in some cases? [00:40:00]

Dr. Pimentel: So, in clinical trials, double blind randomized trials, they’ve looked at 1, 200 milligrams of rifaximin all the way up to 2, 400, and the sweet spot was 1, 600.  So that’s one aspect of rifaximin for two weeks. And then they looked at 10 days, 2 weeks, 1 month, and the sweet spot was 14 days or 2 weeks, that was the sweet spot for, for that. But, there are patients, for example, where their antivinculin is 3, and they go on Rifaximin, they feel great, they come off Rifaximin, 2 weeks later they’re back to being bad again.  And I have a handful of patients where they’re on chronic Rifaximin, because, We can’t find any other reason for their SIBO, the vinculin is very high, and they have this almost pseudo obstruction pattern. And as long as they’re on Rifaximin, they feel fine. Sometimes it’s one a day, sometimes it’s three a day.  But, yeah, we do use chronic Rifaximin in some patients. But, [00:41:00] if the question was, do I ever give one month of Rifaximin instead of two weeks as a first treatment? No, I don’t.

Dr. Weitz: I, I read an article from 2015 from Herbert DuPont who is explaining how Rifaximin not only reduces the bacteria but has an anti inflammatory effect in the gut.  Is that one of the goals of treatment?

Dr. Pimentel: Yeah, so, I mean, E. coli is lipopolysaccharide producing, so that’s a pro inflammatory chemical. When we, if you looked at the paper, and I know Herb Dupont very well, he’s a traveler diarrhea guy, I’ve known him for years, he’s, I think he’s retired now, but his son is now a gastroenterologist.  But the, yeah, so, when we did cytokine analysis using the rifaximin and NAC, we were able to reverse the bad cytokines using rifaximin and NAC. by getting those E. coli and Klebsiella down far enough. And then the cytokines revert to a normal [00:42:00] state and not a pro inflammatory, pro diarrhea state of the mucosa.

Dr. Weitz: Is is that inflammation related to the visceral hypersensitivity that often occurs?

Dr. Pimentel: Yes, yes, all of that. So hypersensitivity goes down. We’ve actually shown in this, in this animal model, which we tested this in, that even though we put the CDTB toxin, which is the food poisoning toxin that causes this whole cascade in the back of the animals, their lining of their intestine has barrier function problems, serotonin problems, Visceral Hyperalgesia, Signaling Problems, and Circadian Rhythm Problems, which you guys know a lot about.  And so that’s also messed up in this population. And most of those things reverse with the, the, the new formulation is what we’re seeing.

Dr. Weitz: Have you ever used curcumin because there’s some data showing it helps with visceral hypersensitivity and certainly it’s a, can be a very effective anti inflammatory.

Dr. Pimentel: I do. I do use curcumin in some patients. Usually if rifaximin doesn’t work or we’re having some modest success and I try to do something more natural. It has antimicrobial properties. You probably know that well too. And anti inflammatory properties, so I think there is some benefit there. I haven’t formally tested the cytokines before and after curcumin or the microbiome before and after curcumin, so I don’t have a lot of you know, randomized control data, but absolutely I do use it.

Dr. Weitz: Now, if you have some extra research money one of these days, can you do a study on berberine and allicin or oregano or some of these natural compounds so we can have a double blind study to prove what we’re doing?

Dr. Pimentel: I’d [00:44:00] love to do a double blind study on allicin. I think my experience with allicin, and of all the things that you might mention, allicin is the one thing that I use most in these methane patients, the Alimed and the Alimax products, and they do reduce methane.  But temporarily, so they’re staying on it, methane goes down, and then about a month or two later, the methane starts to creep back, even though they’re still on it. So there’s something perplexing about that to me, that the bacteria get a workaround you know, the methanogens find a workaround. And I think Alice Seibecker also says the same thing, that she does see some breakthrough with these methanogens, if they’re on it for a while.  So, that worries me for doing a double blind study, because it’s a lot of work. And then only to find what I’m already seeing in the clinic, I kind of get a little bit discouraged to do a, you know, 1, 000, 000 randomized control trial on Allison. only to [00:45:00] find what I’ve been seeing in clinic. You know what I’m saying?

Dr. Weitz: That’s, that’s my Yeah, no, I, I understand. And like some of the protocols that we use, like we typically will use something like allicin along with another antimicrobial and then we’ll typically do it for four weeks and then rotate to two other antimicrobials and that makes it a lot more non double blind placebo testable.  

Dr. Pimentel: And, and I’m doing similar things. to what you’re saying in some of the refractory patients and it does work but it’s not amenable to a randomized controlled trial for the reasons you just mentioned.

Dr. Weitz: I know you found seabone a percentage of patients and so I spoke recently with Dr. Abar who’s an integrative gastroenterologist in LA and he often finds that his methane patients respond to Nystatin and he He has found some evidence that that CFO may be present, that [00:46:00] Candida may be present in hyphae form, and he feels that the, one of the reasons that Candida is there in a small bowel is it helps to make it more anaerobic, and, and that allows the methanogens to flourish, and that there’s this relationship.

Dr. Pimentel: Yeah, so, that’s an amazing observation. I haven’t even looked at that. So we’ve looked at SIFO for sure, because we’ve done the first shotgun sequencing of the human small intestine on the planet. And we see SIFO. It is there in a small percentage of patients with bloating. We do see it, and it’s usually candida, usually albican, some glabrata.  And, and so we do treat those when we bind those, but it’s not ubiquitous, it’s not, it’s not epidemic in the group, it’s there, it’s, it, and it correlates with symptoms, so the higher the candida is in those individuals [00:47:00] where it’s abundant, the higher the symptoms are, so we believe it’s, it’s a player.  and it’s playing and it’s making symptoms but looking at it in connection with methanogens, that’s an interesting thought. I hadn’t thought about that, but we can see that in our data. We can look for it because we have the data.

Dr. Weitz: Dr. Rahbar also wanted me to mention to you that one of the reasons why Lovastatin may have some effectiveness is that it is also an antifungal agent.

Dr. Pimentel: Lovastatin can have some antifungal properties. It can also have anti inflammatory properties, as we know. So, Lovastatin is kind of one of these magic molecules for a lot of different reasons. So, it’s possible. It’s possible.

Dr. Weitz: One more comment from Dr. Rahbar. He has been using mesalamine for some patients with ISO.  That it influences hydrogen sulfide production in the gut. What do you think about this? 

Dr. Pimentel: Yeah, so there’s a very good paper on using bismuth for hydrogen sulfide, that it really reduces those H2S producers by a very reputable group from the 1990s and, and then mesalamine has antimicrobial properties.  We’ve known that for decades. So if you put mesalamine on a dish of E. coli, it’s going to inhibit E. coli growth a little bit. It’s not like an antibiotic. It’s not going to wipe it out, but it will prevent the growth. Aspirin is an anti microbial, so we don’t talk about, oh, we shouldn’t give aspirin to people because it’s an antibiotic and it’s causing resistance, but it is an anti microbial also with Mezalamine is in the family of Aspirin.  I see, interesting. It’s a 5 ASA vs. ASA right? Mezalamine is a 5 ASA. So

Dr. Weitz: Yeah, it’s, it’s interesting that hydrogen sulfide seems to also be linked with Crohn’s disease and ulcerative [00:49:00] colitis and certain other autoimmune diseases.

Dr. Pimentel:  Exactly. We’re finding hydrogen sulfide to be so important, more important than the other gases, because your reaction to hydrogen sulfide as a human in a bad way is way higher than methane and hydrogen in terms of the kind of signaling pathway problems we’re seeing in the gut because hydrogen sulfide is elevated.  So hydrogen sulfide is really devilish to you. It’s, it’s, it’s the biggest strongest effect on the, on the human that we’re seeing.

Dr. Weitz: When it comes to diet, I understand you don’t recommend changing the diet during the treatment phase because of the way antibiotics work. And I, after the treatment, usually recommend a low fermentation diet because a low FODMAP diet is too restrictive.  For ISO, have you used a low sulfur diet?

Dr. Pimentel: So we’ve [00:50:00] dabbled with low sulfur diet in ISO, but I can’t say we’ve done it systematically. So I don’t have a good answer for that. We don’t have good data on that yet. Have you tried?

Dr. Weitz: I’ve tried it. It’s, you know, it gets tricky if you’re trying to layer different types of diets.  So I hate being too restrictive. So I always try to be somewhat liberal with it.

Dr. Pimentel: Yeah. I mean, the problem is you get into a situation where you eat nothing. If you eat nothing, you will never be bloated because you have no fuel for bloating for gas.

Dr. Weitz: Yeah. And then you get kind of liberal and the patients come in, you, what have you been eating?  Oh my, you, you know, so we have to find a happy medium. It depends on the patient. 

Dr. Pimentel: My goal in life always with this research is to try to find a path for the patient to feel as normal and as human and as socially capable, that’s the word I use, socially capable as possible, go to a restaurant, you don’t have to ask 20 questions, [00:51:00] we should have a diet that you should be able to pick from the restaurant, something that’ll be pretty good for your SIBO or whatever.  And you don’t have to be that weird person at the table that’s awkward because it, that adds to anxiety and not wanting to go out, not wanting to be with friends, not want to socialize. And I want people to be as normal as possible.

Dr. Weitz: Yeah, I always try to emphasize to the patients Not to get obsessed that there’s a food you can never eat or and think of it just in terms of the amount of fermentable fiber.  And as long as we keep that from being too much, then we’re on the right track. What about if a SIBO patient wants to use a sweetener for a cup of tea? Is it better to use, and I know you have an article out there about artificial sweeteners, is it better to use honey, sugar, stevia? What is the best sweetener to use?  And I, I, I’ve heard you say that, or I [00:52:00] think I stevia is particularly bad.

Dr. Pimentel: So all the non absorbed carbohydrates change the microbiome in a not great way except for equal or aspartame. So aspartame is a, basically a protein and it has a mimic. It’s, it stimulates your sweet tooth or whatever your, your sweet receptors.

So you taste things as sugary, but it’s not sugar. You can use sugar table. Sugar is sucrose. Or honey. Honey contains the right combination of glucose and fructose, which you sometimes attribute as bad, but there’s a glucose fructose co transporter, and as long as they’re there in the correct proportion, it comes in faster than the bacteria can eat it.  So honey is a good one, but stevia, not so great.

Dr. Weitz: Okay, and you have a new version of the elemental diet.

Dr. Pimentel: Yeah, that, that new version is, the, the trials are done and, and we’ve [00:53:00] already presented a lot of that data. That’s, it’s, Nearly universally effective in SIBO and better than the old Vivonex for for IMO.  So, we’re very happy with this new 

Dr. Weitz:  Can this be used as an adjunct for treatment? Like, if the patients don’t want to have to just rely on that could they use it, say, for one meal a day?

Dr. Pimentel: So we have patients who do that. It’s not a treatment that way. It may be a way to maintain so that you have a little bit less feeding of the bacteria and then maybe they grow back more slowly, but we haven’t used it that way.  We don’t like put people on two weeks of the product and then one a day and start to wean them off of it. It’s but there are some select patients where They do use it as a supplement for a meal just to give themselves a break so they don’t get as much bloating.

Dr. Weitz: Okay, so if, if hydrogen SIBO is [00:54:00] caused by damage to the migrating motor complex, what is the mechanism that leads to IMO?

Dr. Pimentel: Okay, so hydrogen and hydrogen sulfide we think are the same mechanism, because in our animal study, or animal studies, there’s like ten of them now, when we give the toxin, they develop ESO and or SIBO, because we develop two microtypes in that. Food poisoning, we don’t think triggers methanogens growth, IMO.  We think that IMO is family related, so your parents had emo or methanogens, you get colonized, and then for some reason, over time, something happens, and they blossom or bloom, and then you get an excessive amount of methanogens relative to everything else, for reasons that are not clear, so we don’t know why that happens.

Dr. Weitz: Is it one of the other mechanisms? Because the [00:55:00] mechanisms that have been talked about that keep bacteria from building up, besides the migrating motor complex or the cleansing waves, are the production of HDL, the digestive enzymes, bile, the ileocecal valve, the gut immune system, is there some issue with this?

Dr. Pimentel: Yeah, all of that needs to be looked at, because the answer is we haven’t looked at everything there. What we do know, which is a subtle answer to your question, is when people are on PPIs, they have less acid. Those people with less acid have less methane, because acid is a hydrogen source, just like hydrogen is a hydrogen source.  So, and methanogens can use acid, the proton hydrogen to make methane. So you could say people with achlorhydria or low acid in their stomach, maybe they have less methane. You know, we don’t have enough patients to look at that [00:56:00] specifically, but that’s another interesting angle. So there are things we should look at more closely and your list is a good list.

Dr. Weitz: Yeah, I want to ask more about the enzymes since, since we know that pancreatic enzymes is one of the ways that gut keeps bacteria from building up. Does it make sense to use digestive enzymes? And also I have you looked into some of the new products on the market. There are specific enzymes that break down fermentable fiber.  There’s one called FODMATE, and then there’s one called FODZYME that you actually sprinkle on the food.

Dr. Pimentel: Right. So, I mean, look, this reminds me of the early days of Lactaid, right? Who goes to the store and buys Lactaid pills now? I don’t, none of my patients do. But back in the early days when Lactaid was first launched, people were buying that a lot.  And what we learned was if you sprinkle Lactaid [00:57:00] or you in, you know, swallow a Lactaid pill with your food, It’s gonna break down some of that milk, but not enough. And so, what the lactate people figured out is, let’s do this at the factory with the milk, so it’s, we has enough time to digest all the lactose, and it’s all gone.  And then you can drink that milk. The problem with these Fodzymes and things, I’m not against them, But they break it down modestly. It’s, it’s not like, you know, what, what people get into the zone of, Oh, I’ve got my Fodzyme, I’m going to pound those fermentables, it’s going to be fine. It’s not like that.

The enzyme can’t break it all down. It just doesn’t work that way. As soon as the enzyme gets in the stomach, the acid of your own stomach denatures the enzyme and it deactivates it anyway. So that was the other problem with lactate and other, other enzymes is they got denatured in the stomach. So. It helps a little.  I’m not saying it doesn’t work. I’m saying it probably helps a little bit, but not enough.

Dr. Weitz: When it comes to the use of [00:58:00] Prokinetics, and you typically recommend Prokinetics after the antibiotic treatment. Yes. I’ve also heard you say there’s a different reason to use Prokinetics with Emo as compared to with Hydrogen, that with Hydrogen you’re gonna recommend a Prokinetic in the evening to restore the MMC.

Dr. Pimentel: Yeah, so what we want to do is give the Prokinetic at a low dose at night, and I mean two to three hours after the last bite of food. of that day because you want to do it on a relatively empty stomach. The cleaning waves only occur on an empty stomach. And that’s all you want to create with the motility drug.  But for IMO, you may want to stimulate more colon movement, and so you might want to give that in the morning. You can still try the evening, but I tend to be a little bit more towards the morning for some of those patients. Or [00:59:00] would you want to use it with each meal? Well, the problem with prokinetics is tachyphylaxis.

All of them have tachyphylaxis. Erythromycin has tachyphylaxis if you give it more than once a day. Motegrity, which is my choice of this year, is a very good prokinetic. But after about six months, your body gets used to it and you have to take a drug holiday. If you divide it into multiple doses a day, you basically have to do a drug holiday sooner.  Because your receptors are just bathed in it all the time. And so I don’t like to go multiple times a day with these, unfortunately.

Dr. Weitz: We sometimes see patients with SIBO who also have excess histamine or mass cell activation syndrome. And I also heard you say that Klebsiella tend to be big producers of histamine.  Yes. Can that be one of the relationships?

Dr. Pimentel: Well, we, we see even in the papers that we published this year, that histamine is one of the signals that is published in those [01:00:00] papers as being elevated in various aspects or different types of SIBO. So histamine is part of the story. You know, the question is, you know, with these new therapies of antibiotics or whatever, if you slug the bug, then you’re not producing histamine, then everything goes away.  That’s one approach. Or is the other approach sort of an anti histamine type of approach? Well, that’s sort of covering up the symptoms, but that’s also doable, you know, taking, taking anti histamines. But histamine is part of the story, and we’re getting, just sinking our teeth into that a bit more lately.  So you’ll hear more, more about that in the coming year or two.

Dr. Weitz: I saw you publish a paper about exotoxins. So I just want to ask you about exotoxins and also endotoxins, because we know cytolethal descending toxin is the endotoxin that often leads to SIBO. And when we have patients on treatment, they often [01:01:00] feel bad and we think that That may be because, as the bacteria die, they’re giving off endotoxins,

Dr. Pimentel: and So, I mean, there are patients, for example, in ICU, who come in with a very bad pneumonia.  You put them on antibiotics, and they get worse before they get better. Their blood pressure bottoms out, because the bacteria are basically breaking apart, releasing all that crap. And your immune system is reacting to it, and sometimes that can put you over the edge when you’re already at the edge.  That’s the extreme example of that effect. In the gut, you’ve got a lot of bacteria there, and then you’re sort of lysing them, or they’re breaking open. And so there is an opportunity for you to feel a little bit fatigued, or feeling a little under the weather, is sort of how I see it. As you’re taking the antibiotics, sometimes that gives me the confidence that it’s working, and I, that’s how I convey that to the patient and then, you know, you know, we have to wait till the 14 days are concluded before we know.

Dr. Weitz: We, in the functional [01:02:00] medicine world, we sometimes use certain nutritional products that are known to bind those endotoxins, and one of them is, is serum bovine immunoglobulins, and then, And then there’s other binding agents. What do you think about using something like that specifically to bind some of those endotoxins?

Dr. Pimentel: Yeah, so the serum, bovine serum immunoglobulin, I met with a company that was selling a product in that area a number of years ago. The principle is the cows are exposed to fecal material and they’re walking around and so they get antibodies to all that. Coliform Stool Type Bacteria, and they have a lot of antibodies we don’t have, so if you purify those antibodies and you administer it by mouth, it will bind to some of those toxins or some of those chemicals, and that’s generally how they think it works.  The problem, what we saw when we tried giving it to these patients, and we were beginning to do a trial, but we had such [01:03:00] not two great results that we just basically said, look, we’re not seeing a signal here. As we sort of moved on, that doesn’t mean that every product is like that, or every company’s product is like that.  We just didn’t revisit it. So, in principle, it’s an interesting concept, but we haven’t developed anything more in that area.

Dr. Weitz: What about these exotoxins that you find are related to SIBO?

Dr. Pimentel:  Okay. Yeah, so is a, I, I’m going to have to go soon because it goes to one. Yeah. Yeah. I’m sorry. Yeah. Okay. I love the conversation.  DDW day today. Today I have an abstract.

Dr. Weitz:  Oh, okay. Okay.

Dr. Pimentel:  And, but I will answer it this way. So we see. A plethora of toxins in the SIBO small bowel but one thing I think your audience would find extremely fascinating, which we presented at this past DDW, is that you would be shocked to know that in the [01:04:00] small bowel is a fungus called Penicillium. And when it is present, you have more resistant bacteria to Penicillin in your gut. So, you have in your gut Penicillium controlling the population of your bacteria, and you’re getting resistant to it because that’s what happens in nature. And it isn’t due to the fact that you took an antibiotic two years ago for a tooth infect, toothache.

It’s there naturally. So there’s literally a battle of harmony going on in a human gastrointestinal tract between fungus producing chemicals that are toxic to bacteria, bacteria producing toxins against each other, phages that are in there like viruses for bacteria, which are wiping out populations of bacteria, yeah.  And then toxins of bacteria produced that affect you. And trying to understand all of those things happening at once is the great [01:05:00] mystery of the next 10 or 20 years of microbiome research, which I’m super excited to learn about because just finding penicillium in the small bowel is crazy because nobody would have imagined it.  You know, so it’s, we have a lot to learn. And I’m super excited about continuing this journey for a while longer and maybe doing more interviews with Ben Weitz who has some of the best questions out there. So great podcast.

Dr. Weitz: Thank you so much Dr. Pimentel for all the work you do and all the patients you’re helping.

Dr. Pimentel: No, my pleasure. And Ben, thanks for doing this and I’m sorry, I’m running, but it’s DDW day. This is,

Dr. Weitz: I understand. Okay. Have a good day.

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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 very much appreciate it.  If you could go to Apple podcast or Spotify and give us a five star ratings and review. As you may know, I continue to accept a limited number of new patients per month for functional medicine. If you would like help overcoming a gut or other chronic health condition and want to prevent chronic problems and want to promote longevity, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111 and we can set you up for a consultation for Functional Medicine and I will talk to everybody next week.