Deeper Understanding of SIBO and IBS with Dr. Mark Pimentel: Rational Wellness Podcast 397

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Dr. Mark Pimentel discusses a Deeper Understanding of SIBO and IBS with moderator Dr. Ben Weitz at the Functional Medicine Discussion Group meeting on January 23, 2025.  

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page.] 

 

Podcast Highlights

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Dr. Mark Pimentel has  

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

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

Dr. Pimentel:  It’s great to be here, and thanks for the introduction, you remembered everything.

Dr. Weitz:  So, maybe we could talk about how you first figured out what’s, what was the cause of IBS, and if you could include my favorite Dr. Pimentel story, it’s a story about ordering that toxin book. 

Dr. Pimentel:  Oh, yeah, I can tell you both those stories. I’ll tell you that was the second one second because it’s, it’s funny and entertaining. Maybe not today, but it’s funny and entertaining. I’ll still tell it. No, I, you know, I finished my fellowship in 1999 and during my fellowship, we were seeing these patients with bloating.  Breath testing has been around since the 80s.  So we were doing breath testing at Cedars and we saw a lot of patients with bloating and then we’d do the breath test and the breath test is positive and we give antibiotics and they get better. And so, and the question kept coming up, well, this, this is an IBS patient. This isn’t At that time, SIBO was thought of separately.  It’s a separate thing. And then we started to put the two and two together that these are IBS patients. I remember distinctly a story of a 65 year old woman who came to the office and we did the breath test. We treated her with neomycin back in the old days when we didn’t have her vaccinated.  And she came back and she says, I’ve had this for 30 years. And in two weeks, you made me 90 percent better and she opened her bag and she brought a paper bag full of antidepressants and she literally dumped them on the table and she says, I’ve been taking all this crap for years and this fixed me.  Neomycin fixed me in two weeks. And so, you know, it’s, and I’ve had countless stories like that, but it’s just, that was sort of the thing that said, you know, we got to, we got to work this out. We got to figure this out. And you know, over, over time, we started to understand that. The, the bacteria are changing because of food poisoning and we did a study where we gave food poisoning to animals and they got overgrowth.

So food poisoning causes IBS and it causes IBS by causing overgrowth. But I was like, well, but Salmonella can do it, E. coli can do it, Campylobacter can do it, Shigella can do it, but they’re all so different. Maybe they have something in common.  So this is after 9/11.  And about, and the anthrax thing was going on, if you remember that and so I ordered a toxin book, which is like this big book, and it comes in the mail.  It took a long time to come. It finally came in the mail. By the way, the book helped me figure out the toxin, but that’s not the important part of the story. I get the book, and in the book, From the national security association that says we have registered your name having bought a toxin book on bacteria. We know you’re from Canada and we are keeping an eye on you and I’m like, wow So they knew who I was where I’m from all that kind of stuff and that toxin book.  I still have it but It’s a wild wild wild time and that toxin is cytolethal distending toxin toxins cytolethal distending toxin, which It is the cause of IBS, and then it actually creates or triggers your immune system to form an antibody to you, which is the vinculin, and that became the anti vinculin antibody.

Dr. Weitz: So maybe you can explain more, and it’s the cause of the hydrogen form of SIBO.

Dr. Pimentel: Almost. Yes, it’s true. So the food poisoning causes the diarrhea form of IBS, but when you get the toxin, Your microbiome gets screwed up in one of two ways, hydrogen form, which is too much E. coli in the small [00:04:00] bowel or the hydrogen sulfide form, which is too much desulfovibrio.  So we started to see that there are literally two bad SIBOs or overgrowths. One is the hydrogen and one is hydrogen sulfide. And that’s where sort of it started. And then EMO is the other form of SIBO. Right. It’s intestinal methanogen overgrowth. So. Not from food poisoning, but if you have too many methanogens or methane producers in the gut, the methane actually constipates you.

And we learned a lot about methane in those days. We, we started to put methane into into the guts of, sorry, live animals and watched what the transit looked like. Some of those studies aren’t easy to do or fun to do, but But methane slowed the gut down. And then we were able to show that methane actually doesn’t paralyze the gut.

It causes the gut to stop contracting forward and start contracting. Like this, it doesn’t move, so it keeps it stiff and, and prevents [00:05:00] movement. So methane was, became, became really important. And then the goal was to figure out, well, what are all the characters of SIBO? What are all the characters of this sulfur overgrowth?  And what are all the characters of methane to allow us to develop new drugs? Even all the while we had developed rifaximin, at least as a starting point. Now we’re way ahead of that. 

Dr. Weitz: So does everybody understand what he said so far about the autoimmune concept?

Dr. Pimentel: Speak louder. Yeah. I gave a two and a half hour lecture yesterday and my voice is, it’s, it’s me and my voice is weak. So, yeah. So, sorry. You wanted me to speak about,

Dr. Weitz: Well, so you got a question, Bernie,

something maybe I’ll ask again.

Dr. Weitz: Go ahead. What do you wanna ask?

Dr. Pimentel: Yeah, so that’s a extremely good question and we’ve tried to unravel that question. In many ways. So let me maybe you just repeat the question. So the question is, is there a predisposition or a genetic predisposition to developing SIBO? So we knew food poisoning caused SIBO. In our rats, if we give them Campylobacter jejuni, which is the number one bacterial food poisoning for humans in the United States.  27%, 26 percent of the rats get SIBO, they get IBS SIBO. In humans, it’s 20%, so it’s about the same. And what we see is that, for example, in Iraq and Afghanistan, when they deployed to Iraq and Afghanistan, Tons of IBS came back. These patients, people came back with IBS and it was all due to the food poisoning that got there, not the stress, not the, the, the trauma that they experienced or witnessed and, and so we understood that, that [00:07:00] stress is not the cause of IBS from that study, but it’s food poisoning, but why only, 10 or 20%.

Why that number? What’s, what, why are 80 percent getting food poisoning and not getting IBS? We don’t know. It’s got to be a genetic component to it. There’s one study that was done talking about some of the cytokines that might be altered like IL 6 genetically. But we, we just don’t know. And we can’t find a mutation in vinculin.

which is where the antibody gloms on to to say, well, the antibody forms in you and that’s why this happens. But what we do know is that if you get food poisoning and you develop IBS, it’s because of this antibody that develops that you get. And that antibody causes your cleaning waves of the gut starting at the top, not to work.  And when those cleaning waves don’t work, the bacteria build up.

Dr. Weitz: Is there something about some antibodies that are more likely to cross-react than others? Can that be one of the factors? So Well ’cause it’s a cross [00:08:00] reactivity. Yeah.

Dr. Pimentel: From CDTB to bin CDTB. And we figured this part out, which I don’t talk about yet because exactly the sequence, but we figured out the sequence in CDTB where the antibody then looks or the sequence looks like vinculin three dimensionally, and that’s where the antibody learns to go after you. And, and that’s, that’s really how it happens. It just goes after your vinculin, and then you’re stuck with this thing. The, the nerves are impaired.

Dr. Weitz: Wait, by the way, is the same concept why most autoimmunity happens through this cross reactivity.

Dr. Pimentel:  Exactly. It’s called molecular mimicry is the technical term. This molecule is mimicking or tricking you into thinking Vinculin is the same molecule. So you’re attacking yourself because of that. The way that tricked your immune system. So food poisoning multiple definitions, because you could have it from parasitic infections.  You could have viral infections, but generally food [00:09:00] poisoning, we think of as from food like E. coli, Campylobacter, Shigella, Salmonella. Those are the four primary food poisoning organisms.

Poison.

Dr. Pimentel: Right.

And, and, and that’s been shown in multiple studies. There’s now 49 studies of food poisoning, developing IBS, and that’s in a big meta-analysis that I presented yesterday in, in, in the talk I gave. Campylobacter is the worst. It’s the worst. It’s more likely to make you have IBS than anything else that you could get but they all can do it.

And that’s, that’s, but, but food poisoning, when I mean food poisoning, I’m using more lay terminology, but it’s really what we call acute gastroenteritis.  So it’s the antibody reaction more than the toxicity.

Dr. Pimentel: Right. So what happens over time is sort of like [00:10:00] the COVID vaccine, right? You get the COVID vaccine, your antibodies go up, you get the booster, they go up and then you don’t get the vaccine anymore.  And the, it goes down, down, down, down, down. When you get the food poisoning, the CDTB antibody goes up immediately. Because you got exposed to CDTB, not Vinculin yet. This antibody starts to drift down and about three months later, you start to get the autoimmunity buildup. And then CDTB goes away. Because you haven’t gotten CDP, you haven’t seen it in a while.

Let’s say it’s three years later, CDTB is gone. I use an example of of somebody, a case example. There was a guy I had who, you don’t get both antibodies all the time. This is, this is kind of an anecdote. He swam in his neighbor’s pool when they were on vacation, but the neighbors turned the pool off.

So the pool was kind of gross, but he thought, okay, it’s fine. It’s cold. But he went in it, he got really, really sick. And then ever since then, he had IBS. And he only had anti CDTB. He never developed the antivinculin. And over three years, he was on lots of medications, Rifaximin, [00:11:00] Prokinetics, everything. And then over three years, the antibody drifted to below detection or below thresholds for IBS.  And he stopped all drugs. But he’s susceptible. So if he goes on vacation, he’s got to be more careful than the other people because he can form antibodies and he can get the IBS again. And maybe next time it won’t be so friendly.

Dr. Weitz: Now, these bacteria secrete other endotoxins like lipopolysaccharides, do we form antibodies to LPS?

Dr. Pimentel: Well, I think you do, especially if the bacteria goes systemic but what, what we were trying to identify here is, and you form antibodies to a lot of different things that are, that your body doesn’t want But you’re, but most of the bacteria of your gut, and there’s a lot of E. coli in there that are friendly E. coli. So the E. coli I’m talking about for food poisoning is pathogenic E. coli, but friendly E. coli, they’re there. You don’t, and they have a lot of polysaccharide, but you’ve acclimatized to your [00:12:00] normal microbiome, and so you don’t really attack it. But what I wanted to say about the antibodies is that the, these antibodies, like you, you’ve seen probably antibodies for celiac or antibodies for Crohn’s disease, right?

They’re markers. They’re not causative. Vinculin is causative. We’ve, we’ve proven that. So the higher that antibody is, the sicker you are, the more neuropathy you have. That antibody is causative. So, why is that so important? First of all, it’s important because the test make, becomes more accurate. The second thing is, if we get rid of that antibody, we cure IBS.

We cure SIBO, and we sure as hell are working on that right now. So, So isn’t emo also a cause of IBS? It’s a cause of constipation IBS. And emo does not come from food poisoning. We don’t know why people get a buildup of methanogens. We just don’t know. You know, we think that it’s from your family.

So we see methane run in families, for example. You, your, [00:13:00] your mother had it, your father had it, you’re sharing the same bathrooms, you’re sharing a lot of different things, and then you end up being colonized early, and then it blooms at some point, and then you get constipated.

Dr. Weitz: Is everybody familiar with the term IMO?  Yeah, it stands for intestinal methanogen overgrowth. So the three forms of SIBO that Dr. Pimentel has deciphered is SIBO, which is hydrogen and it includes hydrogen sulfide. And then ISO is hydrogen sulfide. ISO is hydrogen sulfide. And then IMO is intestinal methanogen overgrowth. And so if you have IBS with diarrhea, it’s probably from hydrogen sulfide or hydrogen.  Whereas if you have IBS with constipation, it’s probably from methanogen overgrowth. Yeah.

Dr. Pimentel: And we don’t know why methanogens bloom or overgrow like that but when they do, they cause a lot of constipation. They also cause weight gain. They cause other consequences as well. [00:14:00] Is

the bacteria that cause the methane gas or methamphetanes different than the bacteria that cause the hydrogen?

Dr. Pimentel: So, so methanogens are not even bacteria. They’re archaea. So they’re, they’re a totally different kingdom of life, separate from bacteria. And, and they have different DNA, different this, it’s very different organism. More ancient from the primordial soup or, or so they suspect. So they’ve been around a long time and they produce methane.  That’s one of the things they produce. And and there’s a lot of methanogens, but we, we know one organism is the culprit in IBSC and it’s methanobrevibacter smithii. So. Don’t memorize that. He will, but you don’t have to. It shows up on a stool test we do all the time. Methanogrebiacter smithii.  Smithii. Yeah, it was discovered by a guy, my last name’s Smith. Everybody’s naming bugs, so. Yes, sir.

A lot of things that people are [00:15:00] worried about. solution, then the cows produce a lot of methane gas,

Dr. Weitz: right?

Does this mean that they have more of that part of, we don’t call it material, do they have more of that, which produce more metal gas?

Does this mean cows have Yes,

Dr. Pimentel: so it’s a very complicated question to answer, but I will try because, because the cow stomach, of course, it has multiple stomachs, ruminating animals have these, there’s a lot of methane produced by ruminant animals, cows being the largest. Population and they’re contributing to global warming because of the methane they produce.  And yes, it is these methanogens like methanobrevibacter smithii that are colonizing cows. The question is, does the cow need that preserve for proper digestion? Is that the way it’s supposed to be? Or are they being colonized in [00:16:00] overabundance and maybe that’s not normal? We don’t know the answer to that, but there is a a disease in, in cows.

So if you give a cow. antibiotics and wipe out its entire microbiome, a cow will die in three days. Because the cow cannot survive without bacteria. The cow can’t digest grass. The cow is not digesting grass at all. It’s chewing the grass, putting it in its stomach, the bacteria and archaea in the stomach are breaking the grass down, it then brings up the bacteria, chews the bacteria, and gets the calories from that.  So cows are very, you know, ruminants are very different. So if you get rid of the methanogens in cows, is that going to hurt the cow? We don’t know the answer to that. But we could turn down the methane in a cow and maybe help the environment. So that’s something that, you know, we’re looking at and others are looking at.

Dr. Weitz: And you were researching a form of seaweed that was used with cows to reduce

Dr. Pimentel: methane. Right. [00:17:00] There’s a Hawaiian seaweed that really blocks methane synthesis. And people started to find out about it, especially the cattle industry, because they want to reduce methane because they got a bad rap for the environment for cattle.  And the problem is that Seaweed is quite rare and Hawaii does not want all of it harvested because that would be bad for their environment. So there’s a group in Oregon that’s cultivating it in small quantities and selling it to the cattle industry. And so that’s all I know at this point, but there are some patients who tried it and did okay.  But it’s hard to get hard to get.

Dr. Weitz: So you’ve identified methanobrevibacter as the cause of IMO and what are the organisms that are the cause of hydrogen and hydrogen sulfide?

Dr. Pimentel: So what’s interesting in, in the hydrogen side is which is the most common form of these overgrowth scenarios SIBO as we call it, is that it’s not colon, which is why it’s SIBO, small intestine, because everything’s happening in the small intestine and it’s an overabundance of E. coli and Klebsiella. [00:18:00] Now, I don’t know how much any of you know about traditional SIBO, but it used to be thought that SIBO was the bacteria of the colon are moving into the small bowel because you don’t have an ileocecal valve or this or that, or the other people still say that is not what this is.  It’s actually just two bugs. That are overgrowing and they’re overgrowing because the small bowel slow on the small bowel slow E. coli can outperform outcompete and destroy everything around it. So they’re like a wrecking ball to the rest of the microbiome. When we look at, we call them networks, but you couldn’t think of it as a city.

And if you look at the city, you’ve got doctors, plumbers, lawyers, all these different components of the city that make a city healthy. When the E. coli and Klebsiella there. The whole thing craters. And so E. coli and Klebsiella have taken over everything and everything’s wiped out. So when we actually give Rifaximin, for example, to a SIBO patient, we get rid of the weeds and the garden comes right back to normal.  So it’s counterintuitive with [00:19:00] Rifaximin because it’s an antibiotic, you think, Oh, it’s going to wipe out the microbiome. It actually regenerates the microbiome by getting rid of the bullies. So that’s SIBO. Those are the characters.  These two bugs, they are in the small bowel, also in the ovary, and they have overgrown in both of these places.

Dr. Pimentel: So for SIBO, it’s primarily that they are overgrown in the small bowel. That’s why the terminology is small intestinal bacterial overgrowth. For EMO, they’re methane, they’re overgrowing everywhere.  That’s why the small intestine is not part of the acronym. And same with ESO, they’re overgrowing everywhere.  That’s

These two, they are present in colon.

Dr. Pimentel: They’re present in small bowel in overabundance.

In overabundance.

Dr. Pimentel: Yeah. And they’re from the small bowel. They’re just now, they, they have taken advantage of the slow transit and they’re wiping everything else out. They’re winning. In the back. So they [00:20:00] have

a slow genetic.

And then what was the

Dr. Pimentel: last part?

So if you have, so there are some genetic motility disorders for example, visceral myopathy is a genetic disorder or scleroderma, maybe not genetic, but a very slow, small bowel, very difficult to treat a lot of overgrowth. It’s so slow, the transit that it’s hard to keep it away. So those patients, some of those patients, I keep them on chronic rifaximin because as soon as I stop the rifaximin.

They’re back in the hospital, very expensive. So we have to come up with better ways, but we try to put diet on board and, and pro kinetics and other things to try the best we can so that we can use as little antibiotics as possible.

So loaf, let me say it in an extreme form. [00:21:00] Okay. If you eat nothing, your bloating will go down because you’re not feeding the bacteria and they’re not producing gas or bloating and you’ll starve them to death. We also starve yourself to death. The low FODMAP diet. On that side of the equation where you’ve restricted so much that you actually can cause nutritional deficiencies.

It works, but you want to use it for a short period of time and you don’t want patients, you don’t want to say, Hey, go on low five map diet and see the patient two years from now. And they’re still on it. That’s, that’s not healthy for the patient. We we’ve sort of devised a softer version of that. That actually predates the low FODMAP, so it’s not like we got it from them.

I would call it a low fermentation diet, where you don’t, you’re not as restrictive. You can go to any restaurant in the country and you’d find something. You know, one of the things that, that sort of bothered me about IBS all this time is number one, it’s called a syndrome and it’s dismissive to patients and patients feel like IBS is in your head and that’s what they were told.

I hate that. Second [00:22:00] is that it’s a woman’s disease. It’s not true and it’s not, you don’t blame a gender for a disease and that’s what people were doing. And, and, and, and so these are the things that, and third is that these pages, 

Dr. Weitz: I’m sorry, Dr. Pimentel, that’s a DEI version of IBS. It’s not allowed.

Dr. Pimentel: You went there. It’s scary times. But but. Anyways, and then the other part is lifestyle, right? These patients are miserable. They can’t go out. They go to, they go on a date and they’re at the restaurant, they eat food, there’s something to have diarrhea, they disappear for half an hour cause they can’t stop having diarrhea for half an hour.

Then they come back. How does that date go? You know, stuff like that happens, or they go to the restaurant and they’re the person asking the waiter, does it have this? Does it have that? I can’t have gluten because I’m on low fodmap. I can’t have butter. Does it have butter? And then the rest of the table is like, Oh my God, we’re not bringing that person again.

[00:23:00] You know, I want people to be able to live their life. And not be embarrassed and not to be sort of discriminated against as a patient because it’s in your head or other reasons. So, that’s why we devised the diet.

Sam?

Dr. Pimentel: Oh, for sure. I can send it to Dr. Weitz. Sam. Hey, Sam.  So nice to see you again.

Dr. Rahbar:  Likewise. Mark, do you ever check the MAO in your patient? Try and check it on the side. Yeah. So, that’s usually the time with Exocan.

No more patients of you that we can exist and doesn’t anything to make a drop in. Oh, and the kid is in the U. S. Really?

It’s in production.

Dr. Pimentel: Yeah. So, we are studying TMAO. [00:24:00] We have some data that just, just got produced because TMA and TMAO are also risk factors for cardiovascular disease when they’re produced in the gut, maybe, maybe, you know,

Dr. Weitz: right. Cleveland clinic. But by the way, fish is the leading source of TMAO.

Dr. Pimentel: Yeah. So, but we’re looking at it and there is a, if you think there’s some in the blood, Wait till you see what’s in the gut.  There’s a ton being produced in the gut. And it’s being decontaminated or, or, or converted. So, we’re looking at that. But, one of the things with methanogens, to your point, that I think is really important, we can create an animal with methane. You know how we do that? High fat diet. We put them on wheat or egg yolks or whatever has high fat.

High fat makes methanogens grow. We don’t know why, but it makes them grow like crazy. And then the rat gets constipated as the methane goes up. And we use that rat to study drugs. So [00:25:00] what you’re saying, if you go on a low fat diet, you could actually make possibly the methane go down just by doing that as well.  Oh, that’s what I mean. And methane will go down and then there they’ll be less constipated. Yes, sir.  You mentioned good question, but you mentioned seaweed.

Dr. Pimentel: Yeah.  So if we go to an restaurant, Japanese, on the menu, there’s a seaweed salad.

Dr. Pimentel: Yeah.

So with somebody with sibo.

Dr. Pimentel: So it’s only, first of all, IMO is the only one that would respond to seaweed, and it’s not that seaweed.  So it’s a special one, special seaweed that’s from Hawaii. So another question is mentioned cost of random is, yeah. And the generic is AXA or rif. Correct. So from personal experience. I was in Columbia, five 50 milligram made by Abbot, which is the company [00:26:00] was 42 tablets, was $72, and in Mexico that’s a great deal.  It was $56 for the same two tablets, while with not insurance in the SA is 2,800 and this insurance is nine.

Dr. Pimentel: And I was in, and I was in India in November and I got a hundred tablets for 14 that paid for my plane ticket.

So why is it because the company that makes it here don’t allow generic to be made or why is this?

First of all, is it okay to take something which is Made in by Abbott, let’s say, and distributed in Colombia.

Dr. Pimentel: So, my understanding is the Abbott product is identical to the one here. That’s my understanding. The, the, most of the Rifaximin in India is made by a company called Lupin, which also sources some of the Rifaximin [00:27:00] for here.

So, It’s my understanding. It’s the same. I can’t answer your question as to why it’s expensive, except that there is no generic here currently. And that’s maybe the only explanation.

Dr. Weitz: Unfortunately, in this country, it’s written into the drug laws that they will not negotiate for lower drug prices. So, other countries negotiate for a lower price. Yeah.

I mean, that’s an aerobic bug, isn’t it? Right. There’s always a little air up there. You must have created some sort of aerobic environment for that, because if you follow oxygen, you probably can kill the bugs.

I mean, is there any theory as to how you remove oxygen from the upper

Dr. Pimentel: gut? You know, I don’t want to digress, but when we, when we started to put [00:28:00] Campylobacter in rats to see that it developed IBS, I asked around with some people who had animal models. They say, don’t do that. Rats are dirty.

Campylobacter will never infect them. It will never work. It will never do anything. They’re dirty animals. First of all, they didn’t have the antibody at all, so they never saw Campylobacter before. Second of all, we created beautiful IBS from that model. We were told that, well, overgrowth is colon bacteria getting in the small bowel.

That’s not what it is. It’s E. coli and Klebsiella. We were told that, oh, we checked for methanogens. They’re only in the left colon. They’re only in that anaerobic environment. And we just presented a DEW. We found M. smithii in the small bowel, and it correlated with the breath methane. So this one is producing this breath, or at least part of it.

But. So the question is Ms. M. Smithii is very oxygen sensitive, so it will die in oxygen, but it can be buried in that [00:29:00] mucus and create micro environments where the bugs around it are sucking up all the oxygen, making a micro anaerobic environment for them to survive. And, and there are things like that, that happen in the microbiome.

Yeah, you have another theory?

Because I have my own theories on this. Well, tell me. I want to know. But

Dr. Pimentel: if it’s top secret, you can keep it. Top secret. Top secret.

So, when you did your study of the economics of the small valve, how did you get the samples for the proportion of the fungi that you detected in the valve tube?

Population was low. That is not consistent with our clinical impression. We’re observant also. Right. And our observation is the number of times is a clinical response. I can’t ignore it. Just see [00:30:00] it by having clinical experience. Right. And we also aspirate the samples, not as we thought it gets it, but you know, some of the samples, the microbiology.

Now that is some sample of the action group on guy and sometimes they show, you know, the DNA testing. Yes, may show it. Yeah, but the proportion is not small, but more, especially when you look at the new genome and interesting. If you see a white coating like slow white appearance, very, very likely that is I believe My question is, how did you get the sample?

All the way down to the genome, was it biopsy, aspirate?

Dr. Pimentel: So, we now have the largest collection of duodenal aspirates and the microbiome of the small bowel in the world because of this reimagined study we’ve been doing for the last five years. But the first two years were all about validation. So we, we developed a double lumen catheter with a cap on it [00:31:00] because the catheter has to come out sterile.  We can’t pass this aspiration catheter, a single lumen. Open through the scope, you’ve sucked mucus, you’ve sucked saliva, you’ve sucked esophageal gastric juices, acid from the stomach, how are you going to culture once the bugs are exposed to acid? So we’ve got a double lumen catheter when we get, we, we, when we do the re imagine.

We don’t look at anything. We just go boom, boom, boom, boom, into the duodenum second portion, and then we put the catheter in, displace the cap, put the inner catheter out, and then suck juice. And then we, then we take biopsies of that location. We’ve got blood cytokines, we’ve got like a whole bunch of things that we do in addition to that genetics.

And in doing, in doing that. We have very, very, very little contamination. We can tell.

And we get saliva,

Dr. Pimentel: too, just to be sure we’re not contaminated.

Let’s take a look at one thing. You sampled the jejunum.

Dr. Pimentel: Yes. Not the jejunum. About 10 feet of a small bowel.

Dr. Pimentel: Yep.

Dr. Rahbar:  That sample. My question, what’s your diagnosis for [00:32:00] fungal overgrowth?

Can it just be I’ll

Dr. Pimentel: get to that. I’ll get to that. So, and then if the patient’s going for double balloon endoscopy, we get duodenum, jejunum, and ileum in that patient for the study. And what we find is that the duodenum, are almost identical, almost identical. And that includes fungi. And so we recently, and 16S doesn’t identify fungi well at all.

It’s very inaccurate. So we’ve actually gone to shotgun sequencing, which sequences all the DNA that’s there, including human. And then you’ve got to remove the human DNA, purify it to the bacterial DNA, which it takes a number of steps. And then we find fungus. We actually find fungus there. And when it’s high, and usually when it’s over a thousand, it is associated with symptoms, and it’s almost always, but not always, candida associated with symptoms.

So, [00:33:00] and what are those symptoms? The symptoms are bloating, pain, sometimes diarrhea, but mostly bloating and pain.

And muscle activation.

Dr. Pimentel: Can be. Yep.

Dr. Rahbar:  Now Ali made a comment which I wasn’t quite convinced is the case, that there’s no hyphy format. I have literature publication from the European source, obviously not from the U.

S., that they have actually described the pictures with the hyphy. I mean. I have two different opinions here, because I think hyphae

Dr. Pimentel: All I can say is that if you do a double lumen catheter, you get no contamination. Yeah, you can have hyphae in the upper gut. The esophagus can have hyphae, and we see that all the time.

Or not in the small bowel. Maybe it’s the acid, maybe it’s the bile, maybe they grow better without hyphae, I don’t know why. But we don’t see hyphenated, we don’t see hyphae in the small bowel much.

That level to be able to see it at the microscopic level.

Dr. Pimentel: Yeah, but we haven’t seen it. [00:34:00] What we have seen, which is extremely interesting, is we actually can see that because we sequence the entire microbiome DNA, we find penicillin, penicillium fungus in the small bowel.

And when they’re there, There is more antimicrobial resistant genes in the bacteria because penicillium is there. So now the question is, is antimicrobial resistance to antibiotics due to the fungi that are there? Are the fungi there to help control the microbiome properly so that you don’t get an overgrowth?

Oh my God, this opens up an immense number of questions that we don’t have answers to, but when we saw penicillium in the small bowel, which was not uncommon, uh, that opens up a whole window of ideas. What’s going on?

Mark, two questions. I’m so sorry.

Dr. Pimentel: Yeah.

When you did your study, did you make the biofilm using Always.

We have to. the centrifuge in it? [00:35:00]

Dr. Pimentel: No, we use diphthyl 3 etol. It’s a a mucolytic. And so we, we learned that if you don’t do that, you don’t see the entire microbiome. And other centers that publish on the microbiome don’t do that. We published an entire study validating that you have to break the mucus.

You have to do all these steps. Otherwise, you, you miss half of what’s going on

there. Wide angle brush. Brushing of the small bowel as opposed to biopsy.

Dr. Pimentel: No, we haven’t done brushing. But we do take the biopsy and immediately take it to the lab in anaerobic conditions and then we vortex the surface off with a mucolytic so that we get the surface bacteria in a separate container for further analysis.

So

White angular crush cytology similar to what they do for parrots. It could be done.

Dr. Pimentel: Oh, so we got to be careful because the microbiome world thinks [00:36:00] of luminal bacteria. And there’s mucus containing bacteria, and then there’s the bacteria along the lining. And you’re, you’re going to get a little bit of everything, I think, if you do it with a brush.

But that’s, that’s okay. You can do it.

You can do it. A practical question. I assume the first line of defense, if there’s a placebo, would be antibiotic treatment, would be taxidermy or whatever. If either they don’t have insurance, it’s going to be cost for, you know, tablets They had some side effects, the cookie didn’t have doxazycline in combination with neomycin and maybe a third medication, or flagyl or whatever would be a second, third choice.

Dr. Pimentel: So we used to give neomycin, we used to give doxycycline just by itself, used to work fairly well. Metronidazole is useless, absolutely useless. Cipro is useful, can do it. [00:37:00] The problem we encountered, and we published this paper, where if you took any of those antibiotics and it worked once, If they relapsed, it would not work again in about two thirds, because they would develop resistance to it.

So you’d have to be going to another antibiotic, a different one, and a different one, and eventually they’d be resistant to many of them. And so then you end up in a cycle of, now what do I do? Rifaximin doesn’t create resistance. We’ve given it again and again and again. And I’m, I’m, I can’t argue with the cost.

I understand that that that’s a really big problem, but rifaximin doesn’t have that problem. And that’s why it’s kind of special in that way. Bloating is one

Dr. Weitz: of the most common symptoms. Right. of SIBO. Have you had patients who had Bloating just from the time they wake up all day, not around meals.

Dr. Pimentel: Yes.

And those patients I do barium studies on because I’ve had patients and I had one recently, another one [00:38:00] where they have never had surgery, but they remember when they were 18 years old, they had this really bad pain ended up in the emergency room. It turns out they had an appendicitis that healed spontaneously, which can happen just like diverticulitis.

And it scarred the ileum. And they have a narrow ileum from an adhesion and the surgery, they went in, cut one adhesion took like two minutes and now they have no bloating. So anybody who’s bloating all day, all night will get overgrowth. But it’s not because of the usual stuff with the antibodies and the IBS.

It’s you got to look for other things. We’re not saying they’re all like that, but you have to start to look for other things is what I mean. Have you had patients get the like clear passage soft tissue, myofascial work on the adhesions? Yes. And I’ve done that for some patients, especially patients where they have more of a locked in bowel where they have so many adhesions that the surgeon’s like, I don’t want to go in there because I’m, it’s so bad.

I have one patient right now who just got out of the [00:39:00] hospital who had this situation. And she had done clear passage, but you know, where do you start in that patient? It’s, it’s so hard, you know, but doing surgery to remove adhesions is tricky. Cause this, this lady had just one little strand. Okay. It was so simple.

And even the surgeon was like, wow, this was the easiest thing. And then the patient just felt so good.

Uh,

Dr. Pimentel: you mean in the lumen or outside the loop inside the peritoneal cavity, but wrapped around the bowel on the outside. Appendicitis, but it could be trauma. It could be a prior surgery. I’ve had patients where they had a blunt trauma from football and then they got one adhesion and they didn’t even know it just somebody hit them in the abdomen and they were in the ER and then three years later now they’re bloated.

It’s it’s just a slightly perforated bowel. I think you got a question first. So before we[00:40:00]

A lot to be honest, it’s quite a bit, it’s about 10 percent have intestinal sulfide overproduction. And those, those, for example, I had a patient, it was hydrogen, it was hydrogen, and they’d seen a gastroenterologist and they’d had Rifaximin three times, got a little better, a little better, but not much.

And they did a full workup trying to figure it out. And then they came to us, we did the three gas, it was hydrogen sulfide. I treated her one treatment with Rifaximin with Pepto. A year later, she’s still normal. Still normal. Abysmal? Yep, still abysmal. Yeah. Which gets rid of H2S. And she’s still normal.

Which, and, and it’s frustrating because if we, if we knew, we didn’t know this five years ago either. But that, that helped a

Dr. Weitz: lot. A lot of patients are just getting two gas tests because a lot of the gastroenterologists have a two gas test in their office. [00:41:00] The three gas is TrioSmart. Right. Now, are there plans to make that machine available for purchase by

Dr. Pimentel: gastroenterologists?

So it’s, it’s not currently in, in the works that way. It’s at a CLIA certified laboratory currently. So that’s how they do it. But, but the TrioSmart test is very helpful because the other thing about hydrogen sulfide, hydrogen sulfide, even if you have the other gases, predicts a greater severity of everything.

So if you’re, if you have pain and you have H2S, the pain is worse. If you have diarrhea and you have H2S, the diarrhea is worse. So it’s a predictor of severity as well. Rifaximin. So I use 550 three times a day of Rifaximin, the typical dose for 14 days. And at the same time you take the Rifaximin, you get a cap full of Pepto Bismol, which is about 520 milligrams ish, something like that.

Two weeks. Sort of like H. pylori actually, [00:42:00] the old H. pylori. Oh, sorry. This gentleman was

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Dr. Pimentel: to our discussion. Oh, I see what you’re saying. So, the GI infection that you had, the food poisoning or gastroenteritis that you and I were dialoguing about earlier, so, that causes the antibodies to go up and causes you to be dysfunctional. That puts you at risk for recurrence and relapse, so that, now if you get another food poisoning, the antibodies go even higher, and you’re more likely to relapse.

[00:44:00] But I think your question is, if you take the antibiotic, most people do really well for many, many months. I have patients who, Take it once and two years later, I see them at the mall and they’re still doing well. But I would say the majority of patients have some degree of relapse over time and need to take another course without food poisoning, but Yeah, but I counsel all my patients on travel and just to be careful.

This lady first.

My lens for me is like fungus and mold exposure and that’s what I’m like focused on, love treating, but I see a lot of SIBO. Yeah. So the fungus component is interesting to me, just to speak about it, treating the fungus and the fungal burden, and that kind of then brings down the nasty pathogens, we find that the cereals seem to kind of withdraw a little bit.

And I’ve had a lot of banter, I don’t know if you know

Dr. Pimentel: Nicole Bisnick. I know the name.

She’s a nutritionist, but loves it too. [00:45:00] We’re trying to banter about the fungal side of it often.

Dr. Pimentel: So have you done breath tests like the TrioSmart breath test or one of those kinds of breath tests before and after your antifungals to see if it works?  

Because antifungals, going back to Dr. O’Barra’s

question. Yeah, going back to your reason why, it doesn’t make sense that fungals

Dr. Pimentel: become a two different thing. But remember and this way may be why more women have IBS than men, because women tend to get autoimmune diseases more than men, for whatever reason we don’t understand.

Maybe the immunity of the person who might be sensitive to some of these other toxins also puts them or at risk for these events that we’re seeing with SIBO. We don’t know, but there’s something wrong with the immune system that some people react to mold and some people don’t because mold is pretty ubiquitous around.

Neighborhoods and houses and just some people are really sensitive to it and others maybe not you can correct me if you see the same thing.

Dr. Weitz: Yeah, isn’t one of the reasons why women tend to get more autoimmune [00:46:00] diseases is because generally prior to menopause they have a more robust immune system and then we see autoimmune disease frequency decrease after menopause.

Dr. Pimentel: Yeah, some, most of them do decrease. Rheumatoid arthritis goes up, but okay. Yeah,

the autoimmunity part, or bone exposure, I think makes you more susceptible to food poisoning and things along those lines. That’s what

Dr. Pimentel: I’m wondering, and I don’t know the answer to this because I don’t see enough of the cases like you see, but If the people who you know that are sensitive to mold, are they more susceptible to food poisoning?

Do they get it more often?

Well, you talk about their history, it’s hard to tell. Yeah. Everybody remembers. Everybody

Dr. Pimentel: remembers food poisoning.

We haven’t been testing the trio after very often because they don’t have

Dr. Pimentel: symptoms. No, I was more thinking for academic reasons. For scientific reasons.

Dr. Weitz: Yeah. Given the fact that there’s a fairly substantial percentage of the population whose [00:47:00] immune system is, Less than optimal.

And just looking at U. S. response to COVID, for example can a Less than optimal dysfunctional immune system be one reason why patients fail treatment for SIBO. Should we be analyzing the immune system in some way, such as looking at secretory IgA levels on stool testing or something like that, and then addressing the immune system component as part of the treatment for SIBO?

Dr. Pimentel: All possible, but we haven’t done it.

Margarita asked the question what is the relationship?

I thought that your study showed that that were not correlated.

Dr. Pimentel: I don’t, I don’t generally order the antibody if they’re methane or constipated. I think you study, I think

how easy

Dr. Pimentel: it is. Yeah. So if you look at the original studies we did with the first [00:48:00] generation, the less, less accurate test, but we do see that diarrhea and mixed IBS, they’re the ones that have the majority of it.

So about 58 percent is the exact number, because I did the talk last night, of IBSD will have the antibody, which is about the percentage of IBS that’s post infectious. In the constipation it’s about 27%. In healthy it’s about 15%. So it’s still higher. in the methane group, and it’s still statistically higher, but it doesn’t feel like it’s as important to the mechanism, and not as often important.

So, yes, you’re right, I don’t measure it generally.

What’s the significance of excessive mucus in the stool? Do you correlate that with the biofilm in the gut?

Dr. Pimentel: So, you know, there’s a lot of work, you probably are aware of this, of stripping the biofilm from the colon to help patients with certain symptoms, including bloating, and they go in and they power wash, basically, and peel the biofilm off the colon when they see a very thick [00:49:00] biofilm, and some people get better from that, but it, it’s, I don’t see it that often, but I do see it sometimes when I do colonoscopy, I don’t know your experience.

In

our experience, amazingly, that’s correlated It’s almost like the body creates that

Dr. Pimentel: defensive

to keep it out

Dr. Pimentel: in the colon or in the small bowel you’re talking about.

I even have one patient from the local community. He did a colonoscopy. The amount of mucus after the colonoscopy was it was so excessive.

I could not colonoscopy. Wow. Interesting. I know. That particular patient, the one that was moving. And mold toxins are commonly associated with immunosuppression, which promotes the fungal overgrowth. But that’s what our patients are admitting.

Dr. Weitz: Interesting. Very interesting. You said before, last time we talked, that [00:50:00] emo can be only in the colon, and yet the breath test can

Dr. Pimentel: pick that up.

Yeah, no, what I was saying is that, that We were told it was only in the colon, but it wasn’t true. When we actually did the sequencing of the small bowel, we found methanogens everywhere. Right. But a patient who has emo Yeah, right. Might just have it in the colon, right? Correct. Yeah. That can happen. And they could still have a positive breath test.

That’s correct. Because EMO is by definition that that excessive methane is causing constipation. Doesn’t matter where it’s coming from, it’s constipating. That patient,

Dr. Weitz: if

Dr. Pimentel: that’s the

Dr. Weitz: case. We think of the breath test as just measuring the small bowel, but if it’s measuring methane from the large bowel Couldn’t it be measuring hydrogen from a large bowel as well?

Dr. Pimentel: So I can tell you the answer is no because when we do the hydrogen If you don’t put fuel The bacteria that are producing hydrogen run out of fuel very quickly. The [00:51:00] types E. coli, Klebsiella.

Dr. Weitz: Okay.

Dr. Pimentel: They are, it’s when we did the, what we call metabolomics, metabolomics means, we’re able to see what the bugs can do metabolically.  Like what is their function? E. coli. SIBO in the small bowel, your ability to make gas from sugar, is 63 times faster than a person without SIBO. So when a patient comes to your office and they say, I get gas and bloating 10 minutes after I eat, and you say, yeah sure, 10 minutes, they’re, they’ve got a, they’ve got a Ferrari engine for making hydrogen in there.

But when we check it in the morning, after a fast, It’s turned off. There’s no fuel. They’ve burned through all that fuel overnight so fast. And so I think when they run out of fuel, they’ve run out of fuel because we, that’s why the breath test in the morning for hydrogen, we can see methane because methane is just going and doing its thing.

So you can see methane first thing in the morning. You can [00:52:00] see it even on a breath test. The first sample could tell you they’re already emo before you, but you have to give the lactulose or the glucose to get the energy. You ever

Dr. Weitz: see methane without the lactulose?

Dr. Pimentel: Oh yeah, for sure. First, first breath sample, you might see 20 and that’s an emo patient right there.

You don’t have to continue. So, so they could be having gas before they even eat. Because methane is different. So what methane does is, and this is why you can’t, it’s nothing isn’t about a two hour test. The methanogens, they basically, how it works, you take the lactulose, the lactulose gets to wherever the methanogens are.

The hydrogen producers produce hydrogen. That takes about, you know, 20 minutes, an hour, whatever it is, and then that hydrogen then has to go to the methanogens. And then the methanogens slowly convert it to methane like a very slow engine, an old engine, because they’re archaea, right? They’re ancient, and they’re generating methane slowly to generate energy.

And [00:53:00] they keep doing that all night. And so you wake up in the morning, you’re fasted, you still see the methane. That’s, that’s how it works.

Dr. Weitz: There seems to be an interaction between a percentage of patients that I’ve seen who have methane, especially the ones who are resistant to treatment. And we sometimes find out that they had mycotoxin mold exposure.

And when we reduce the mycotoxin level, then their treatment for the emo ends up being more effective.

Dr. Pimentel: Yeah, I mean, it’s possible that could happen. So I, I can’t, can’t argue with that. Yes.

Question about the sugar. From my understanding that if you drink something with pure, or eat pure sugar, the basic sugar.

Dr. Pimentel: Like the white stuff. Yeah. The

white stuff. Then this is being absorbed by the stomach. It is the esaccharide or polysaccharide, like fructose and lactolose, that gets absorbed in the small intestine. It doesn’t

Dr. Pimentel: get absorbed. Lactolose goes all the [00:54:00] way through. No absorption at all. Yeah.

So pure sugar. Is it okay, let’s say, tea with one spoon of sugar, as compared Having a fruit which has fructose or a glass of milk with lactose for people with SIBO.

Dr. Pimentel: You just invented my low fermentation. That is exactly the principle. Because sugar, table sugar, or glucose, it’s not glucose. It’s glucose fructose combination, but there’s a glucose fructose or sucrose transporter for it. Pure fructose is hard to absorb, so that’s why fructose, you want to limit it.

Lactose is hard to absorb, you want to limit that on your diet. But pure white sugar, no problem. You get most of it. The bacteria don’t even have a chance. You’re way better than E. coli and Klebsiella to get sugar. And, and so sugar is an acceptable food. thing that these patients, these patients can eat.

Dr. Weitz: But this is exactly why so many of us in the nutrition, functional [00:55:00] medicine world just have a tough time with the low fermentation diet because they eat sugar and white bread and white rice.

Dr. Pimentel: Well, so I’m not, okay. So let me be clear. The low fermentation diet isn’t. You sitting at home spooning sugar as your meal.

Okay. It’s a, an allowed item, but it, I don’t intend for people to be Right. Sugaraholic. No, I understand. So that would be bad for sibo probably. ’cause you’d overwhelm your system and give it to them. And, and I wouldn’t, I wouldn’t want that. But, but there’s one aspect of this that I wanna draw attention to because a lot of people do glucose breath tests.

So if a diabetic gets a low blood sugar, what do they do?

Where do they put it? Why? Because you can absorb glucose from right under your tongue. So if you do a glucose breath test, and you take that little cup of glucose, and let’s say I’ve got a, [00:56:00] a 4 foot 10, 16 year old, getting a breath test, or me, I’m going to drink the same amount of glucose, I’m going to absorb it in this big mouth, this big esophagus, this big stomach, how much is going to get to the small bowel?

My breath test, sure as heck, is going to look a lot different than that because very little of that glucose is going to get to the bacteria. I’m going to be negative. And that person might see more glucose in their small bowel. Lactulose, you don’t have that problem. It doesn’t get absorbed. It’s going through for both of us.

So glucose has a problem and we see it and we know it and that’s why we don’t like glucose. Even though some of the scientists continue to argue we should do glucose, it’s more specific even if it’s less accurate.

We talk about the heterogenic SIBO. And there’s the area type and constipation type.

Assume the constipation is also the bloating and so is the enemy of SIBO as well. So, what would [00:57:00] be the best treatment would be Miralax. Integrity would be . Would you wanna take it from diet and control the constipation?

Dr. Pimentel: Right. Well, I mean, so I, I’ve had, I’ve had this argument last night in my, in my talk, one of the biggest problems we have in irritable bowel syndrome is the Rome criteria, the criteria that tell us they have IBS, the old criteria that would develop in the late, in the early nineties.

The Rome criteria says you have IBS, if you have pain. and diarrhea, that’s D IBS. If you have pain and constipation, that’s C IBS, assuming you have no other disease. Okay, so you gotta do all these tests, everything’s negative, you put these criteria. So IBS, by definition, is defined as a symptom disorder.

What happens when you go to the FDA with drugs? You want a drug that treats symptoms. Where’s the drug that treats causes? Crohn’s disease, there are 40 [00:58:00] drugs out there that are FDA approved that treat all the inflammatory cells that are causing Crohn’s disease because they know what’s going on. And IBS, in our IBS guidelines, I wrote part of the guidelines, I’m on that guideline paper.

We have Imodium there, Imodium in the guideline for, Imodium wouldn’t be in a Crohn’s disease guideline because Crohn’s disease, Imodium, yeah, it would make the diarrhea better, but nobody’s, who would think to use Imodium for Crohn’s? It treats the symptom. It doesn’t treat the cause. And so my argument. In all my career is stop treating symptoms, start treating causes.

And I think you guys know this because this is what you do every day. Isn’t that the

Dr. Weitz: story of conventional medicine?

Dr. Pimentel: Well, you trapped me now. But, but, but yes, stop treating this. I mean, of course you want to relieve symptoms. Linzess will relieve symptoms. It’s not treating the cause. You know, the GC guanylate [00:59:00] cyclase agonist is using a mechanism from bacteria to cause diarrhea.

But GC has nothing to do with the cause of IBS. It’s just relieving constipation. It’s a good drug. I’m not saying it’s a bad drug. I’m just saying, I’m kind of tired of drugs that are out competing each other to cause diarrhea. And the other thing that I say, and I go, now I’m on a rant, now I’m on a rant, you see?

Diarrhea is not the treatment for constipation. And constipation is not the treatment for diarrhea. I want to make my patients normal. But all these drugs do what I just said. They treat constipation by causing diarrhea. So we need to start to think differently. That’s my Should we, should we be, go ahead, sorry.

So if you can’t afford Zyfaxan, there are other antibiotics that you can try. And I, and I hate to say it, but yes, those were the ones I listed earlier, Doxy, Augmentin, and those. But You don’t want to

take your boy from Canada?

Dr. Pimentel: We [01:00:00] talked about buying it from India. We went further. So yes, Canada, Mexico, and

Yeah, so, stress is not the cause of IBS, but it is a trigger. It is a, it worsens the symptoms. So when you’re in a stressful patch, your IBS will be worse. Your cleaning lines will be less. Your overgrowth might go up. So yes, these, this is, this is a true statement. But to tell a young woman you have IBS.

Everything’s going to be better here. Take this video. And, and, you know, this kind of stuff to try and relieve stress. No, I mean, yes, do it. But that’s not the full answer.

Dr. Weitz: Now, one of the mechanisms by which stress could play a role is if the person is stressed a lot, [01:01:00] they’re in sympathetic mode, and that’s going to affect the vagal nerve.

And so aren’t strategies to have the person. Spend more time in parasympathetic mode, potentially beneficial because it’s not, not because of psychological, but because they might stimulate the vagal nerve and yeah,

Dr. Pimentel: well, I mean,

Dr. Weitz: I definitely address

Dr. Pimentel: stress, psychological trauma and other things very regularly with my patients because it is a very big problem among all our patients.

And when we identify it, they have to be treated by professionals. And it’s a serious thing. But what I’m trying to get away from is the notion that it’s in your head, your IBS is in your head. Yes, stress affects it, and stress modification can make it better, but it’s not going to cure it. And so we have to focus on both aspects.

So I agree. What about strategies

Dr. Weitz: to promote vagal nerve stimulation [01:02:00] and parasympathetic

Dr. Pimentel: tone? There’s nothing that we know of, like even stimulators, auricular stimulators and various other vagal stimulators, right? None, none of that have triggered cleaning waves that we could see. They, they’ve tried pacing the cleaning waves with pacemakers in the stomach.

Electrophysiologists have done this. Can’t get it. Can’t turn it on. It’s stubborn. It’s stubborn like Moeity makes it go. Erythromycin makes it go, low dose naltrexone might make it go, but electrically, you can’t turn that thing on, you can’t jumpstart it. But you had a second question.

I’m wondering if there’s a hide from this, there’s one drop in there.

No,

Dr. Pimentel: I’m happy to discuss lots of different things. For example, for methane, Alimed or Allicin, which is a garlic extract, works quite well for that. Temporarily, it can reduce methane. Peppermint has some effects, antimicrobial effects, but I see it very short [01:03:00] lived, so that doesn’t work as well. Elemental diets work terrific to get rid of bacterial overgrowth, better than antibiotics.  Way better than antibiotics. Also very expensive, though. That’s the shame. M Biota, we just published, we just presented it, M Biota gets rid of methane by 70, 75 percent of patients who took M Biota, methane’s gone. It’s a new elemental diet, but that’s palatable 14 days. It’s palatable, tastes great. It really tastes good, not like the Vivenex.  M, like M, like Mark, Biota, but not after me, not my name.

Dr. Pimentel: If you use neomycin for SIBO, you’ve got about a 30 to 40 percent chance of it working versus 60 to 70 percent with rifaximin. That’s the difference. And then if you want to use neomycin again, [01:04:00] it’s 10 percent chance of working the second time. It’s a third, it’s two thirds less. So 30 percent goes down to, to one in three or 10 percent.  That’s it. There’s no issue of cost. How often So you treat somebody who’s been off for 40 days, Right. And then, they get better.

Dr. Pimentel: Yes.

Then they come to you, they have another symptom, you repeat the test, and again, the methamphetamine gas is way up, and so on. You treat them again.

Dr. Pimentel: Yes.

Now, obviously, antibiotics have some side effects as well.

No. But how often You can give Rifaximin every 3 months, every 6 months, 10 times over 5 years, if there’s any. So what’s your longest status with patients?

Dr. Pimentel: So we’ve given it up to a dozen times and it works just as well the 12th time as it did the first time. Rifaximin, we looked at a, we published a paper in the American Journal of Medicine, very high profile [01:05:00] journal, looking at.

number needed to harm for all IBS drugs. Tricyclic antidepressants are used for IBS. In the old days, still some doctors do it. For every 2. 3 people that get better from a tricyclic, one is harmed. For every 846 people who took Rifaximin and it made them better, one person stopped the drug from a side effect.

Out of 8, 800 people, one person dropped out of trials for Rifaximin. It has no side effects. And we now repeated the analysis. We’re doing it at DDW, and I’ll tell you only one thing about Rifaximin. Placebo was worse than Rifaximin, so we can’t even calculate the, this, the, the danger of Rifaximin because placebo was worse.

So Rifaximin is extremely safe.

Can you give it in conjunction with another antibiotic? [01:06:00] No.

Dr. Pimentel: Well, yes, for methane. For methane, it’s rifaximin plus neomycin. For hydrogen sulfide, it’s rifaximin plus hydrogen, plus pepto. And for a SIBO, regular SIBO, it’s only rifaximin. Now, I agree with you, I keep talking about the same drug, but that’s because the questions are directing that way.

But there are other therapies, but this is the one that really works the best. That’s unfortunately the way it is. And we have a drug for methane that’s coming. It’s already working. I can’t talk about it, but it’ll be next year. We have another drug that advances Rifaximin to much better effectiveness.

That’s going into clinical trials in April. It’s a phase 2b trial with the FDA. That’s Rifaximin with specialized NAC? Right, right. And then we have we’re working on a biologic agent for vinculin. So we’ve got lots in the hopper that are coming down the pipeline that will be better than anything we’ve ever had.

Is,

Dr. Weitz: is the methane drug, [01:07:00] I know one time you were working on some form of lovastatin? Not lovastatin,

Dr. Pimentel: something new. Okay. Sorry you go, you go first. Yeah, you’re on the outside.

I’m not an expert in SIBO. I’m not a prescriber, so. I don’t have access to her food. But what I’m getting is this biopsies always SIBO, or it can be a dysbiosis without SIBO?

Because what I’m, what I’m getting is like everything is some sort of a expression of SIBO.

Dr. Pimentel: So, so when we looked at the, we have over a thousand patients in this reimagined study that I mentioned earlier. In that study, the most apocalyptic microbiome we see is SIBO. But there are other dysbiosis. So, and we haven’t talked a lot about that today, and it would open up another hour of conversation, and I think maybe, maybe not.

But but one of them is SIFO, the fungal overgrowth that was brought [01:08:00] up. There are other things. So there are other dysbiosis is what I’m getting at. So you are right. It’s not all, but the conversation was meant to be about SIBO today, so that’s why we focused a lot on this.

Dr. Weitz: You’ve said that methane tends not to be present in patients with IBD.  If it were available, should we be giving probiotics of methanogens to patients with Crohn’s?

Dr. Pimentel: You’re thinking like a scientist. So, so, look, when I think about the microbiome, it sort of dovetails with your question. First of all, your microbiome is different than your microbiome is different than your microbiome, which is why we’ve had such a, there is no publication that says, this is the normal microbiome folks, everybody should have this.

There’s no such thing. Because, and the other thing is, Sweden, Italy, they’re eating different food, different microbiome, everything’s different. Okay. We’re versatile. So if we move to different countries, our microbiome will shift a little [01:09:00] bit, but, but there’s no one magic microbiome. But is diversity still important?

So if I put you on Linzess, your diversity is going to go down. Crohn’s patients have diarrhea. Their diversity is going to go down. So the question is, is the low diversity causing the illness? Or because you’re having diarrhea, you have low diversity? I think it’s the diarrhea. I’m not sure that that’s the culprit.

So, you know, we put a lot of stock in diversity, but

Yeah, when I dealt in the low carb submarine, I talked a lot about carnivores and all that. And the balanced diet, you need the microbiome, but those things are, those people are, seem to be

Dr. Pimentel: thriving, so.

Microbiome is different for everybody.

Dr. Pimentel: Your question sparks a lot of things that I’ve answered questions on in the past, and one of the things that I tell my patients, you know, because patients will say to me, you know, I have this IBS SIBO, and yeah, I [01:10:00] took Rifaximin, still having symptoms, but I went to Italy.

And I felt great the whole time I was there. Well, everybody feels great in Italy, but it’s the food, right? So you can look at it in different ways. Maybe it’s GMOs, maybe it’s the preservatives. Obviously, that’s part of it, right? There’s a lot of crap we put in food here. But there’s also in Italy, what do you eat for lunch?

Italian food. What do you eat for dinner? Italian food. What do you eat for breakfast the next morning? Italian food. Yeah, and it’s brilliant. It’s wonderful. And I could live like that forever. What do you eat in L. A.? Sushi one night, Mexican the next night, Indian the next night, and then you’re going off to another part of town to have Greek food.

So, your gut’s like, what’s going on? You know, because it’s all this different variety, and is that healthy? Why does your mom say, eat chicken and rice, eat chicken and rice, your stomach’s not good, eat chicken and rice, just everyday chicken and rice. But it’s consistent, right? And the microbiome kind of goes, okay, we know what’s going on, this is what we are today.

And stay that way. And [01:11:00] sometimes that’s good for the gut to get that stability. So,

part of the low

Dr. Pimentel: fermentation diet is not just the food composition. It’s that fasting business because the more you fast, the more likely you’re going to have a cleaning wave and clean up. There’s a reason why cleaning waves, okay, so people say, oh, you should have five meals a day.

That’s a healthy diet because that gets your metabolism up or whatever, right? Weightlifters do this. You eat five meals a day, you never have a cleaning wave. You never have a cleaning wave because you’re always in fed state. So why do you need cleaning waves if you’re never going to use them? We grew up or evolved, you killed a buffalo, nobody had a refrigerator.

You ate that buffalo. The whole tribe ate that buffalo until they were full. And then they didn’t eat for a few days. And then the cleaning waves cleaned up and stuff. And then you killed another buffalo and, and that’s, that’s, it’s feast or famine. That’s what our bodies are designed for. [01:12:00] Clean up between.

Yes. Oh, you’re, are you paleo?

I work in that environment. That’s what I teach people. I tell them exactly that. You need to imagine yourself 20, 000 years ago in a cave. Exactly.

Dr. Pimentel: Yes, exactly. You didn’t have

a closet full of cereals and oatmeal and blah, blah, blah. No. So we need to mimic that. That’s what I tell

Dr. Pimentel: my wife.

I’m changing in the closet. She says, what are you doing? I said, I’m changing in the closet. They didn’t have closets back then. You know.

Anyways, that was meant to be a joke. I didn’t pull it off very well. So,

anyway. Is there any, like, do you have any thoughts on any, any,

Dr. Pimentel: any link? So. I was a disbeliever in, and this happens, I’m a disbeliever in something and I prove myself wrong and that’s [01:13:00] always fun. So gluten, so we looked at people in the reimagined study who self identified gluten intolerant and self eliminated gluten.

And they felt better as a result of it. And we looked at their cytokines, and their cytokines are much lower than people who are on gluten. So there’s something about gluten that fuels cytokine production, and we haven’t gone back to it because we want to look at the microbiome in all those different states, and why gluten is triggering that.

But there’s something pro inflammatory about gluten, and we know, of course, the ultimate pro inflammatory is celiac, but maybe there is some true gluten sensitivity that’s out there. And, and needs to be explored further.

Dr. Weitz: We have Alessio Fasano talking about how gluten is often a contributor to LeakyGuide.

Yeah.

So we have wild, that’s full of molecules of water and gluten, I think. Well, it’s just like I think I don’t want people to go to

Dr. Pimentel: Italy.[01:14:00]

And Bruce Lee all we need is cow milk. It’s there’s an original variety of cow milk.

A2.

Dr. Pimentel: A2, that’s it. A2. We don’t have A2 here. And so it’s more allergenic cow milk here than A2 milk and more intolerant. Now we do. Now we do. Yeah, I know.

Dr. Weitz: And pretty much all wheat is sprayed with glyphosate. Maybe glyphosate is one of the problems creating inflammation.

I think Dr. Bahr is working on the role of toxins and

It’s a very comprehensive protocol we wrote to look at symptom presentation and ICD diagnosis on the second visit and the number of chemicals and toxins that we show in the urine. We’re checking 120 [01:15:00] different metals, chemicals, and both toxins and the PFAS and the POAs. Wow. The study has been approved.

I get toxins that you show. Eventually, I’d like to have something like yourself on here. Part of the editorial review the volumetric work, but

Dr. Pimentel: Send me an email.

Alright, have we gone over time? No. Okay. Yeah.

Dr. Weitz: So I, thank you so much. I’m not trying to cut it. But I don’t. So generous with these time.

Dr. Pimentel: These people have, you know, been amazing. You guys, your questions are really quite amazing. So, did you have a question? One last one?

Who is it? Methanogens may be beneficial, but we’re not there.

We didn’t get

Dr. Pimentel: there. Because I sort of didn’t. Well, yes. It’s possible. Methanogens are anti inflammatory. So what I was going to say is that. I don’t think of, I don’t use the word good or bad bacteria ever. Because good [01:16:00] bacteria are good if they’re supposed to be here. They evolve if they’re in the right place where they belong and they’re not hurting you.  It’s as soon as they hurt you that they’re no longer doing the right thing. There’s too many of them. There’s too, they’re in your bloodstream. You can’t have lactobacillus in your blood. It may be a good bacteria in the gut, but it’s not a good bacteria in your blood. So there’s no such thing as good. And methanogens should be here, not here.  Or here, but they should be here. So my goal is not to wipe them out, not to exterminate them. My goal is to rebalance them. And I think that’s sort of the philosophy in this room. You want to rebalance. You don’t want to just catastrophically destroy things.

Dr. Weitz: One more thought about what have you looked into using phages?

These are viruses that

Dr. Pimentel: kill bacteria. So there are people, we aren’t, but there are people in France, for example, looking at phages for methanogens. that are specific for methanogens. Again, the question is, is that the apocalypse for the methanogens? Or is it just going to tone them down? I don’t know the answer to that.

Phages scare me a little because [01:17:00] they’re a little, it’s like a wild card.

Are they working for that, for the

Dr. Pimentel: environment or

something? What’s that? On that kind of intervention for the environment, the methane environment.

Dr. Pimentel: Oh, for trying to reduce it using phages. Yes, they are. Yes, they are. That is correct.

So, but pages are, to me, are scary. They’re, they’re very I don’t know, I don’t know if you can titrate them just to get things down, or are you going to wipe everything else out? I’m not sure. So that’s sort of, I’m timid about that, but I could be wrong. Final questions?

So I do use sometimes Atrantil, which does reduce bloating and, and it does for methane particularly, you know, sometimes it’s beneficial, so that one I do use. What

is it?

Dr. Pimentel: Atrantil. It’s a natural product. A T R A N T I L. Are you familiar with it?

On a practical level, let’s say, what are your recommendations for someone with a high blood pressure?[01:18:00]

Oh yeah. For you. Can’t do that breath test. I’m not doing that Breath test. There’s no, they’re in pain.

Dr. Pimentel: I have 95 year olds doing breath test. I don’t understand why somebody would not do a breath test. It’s so super simple. But I, I get it. I, I, if they don’t wanna do it, I’m not gonna shove it down their throat, obviously. You know, you could technically do, if you’re looking for methane. Or if you’re looking for sulfur, you could order the kit, not give them the sugar, just blow in one bag, and it should show up in that one bag.  But, if you can get them to do that much, you might get something out of it. I don’t know if that’s helpful.

Dr. Weitz: Is there any benefit to doing the test for three hours? There’s still a percentage of practitioners that insist on doing three hours and even use a Tredo smart test for three hours. They just do like every 20 minutes instead of every 15.

Yeah, cheating the

Dr. Pimentel: [01:19:00] system. But it’s, you know, maybe there is, but it hasn’t been properly validated. So I can’t say no, but what we’ve seen is two hours seems to be the magic amount. You had a question and you never asked a question yet, so I’ve got to get to that one.

The correct spelling of the expensive medication, is that

Dr. Pimentel: Rifaximin?

Rifaximin. R I F A X I M I N. Rifaximin.

Dr. Weitz: All right. Great. So thank you everybody. Thank you.

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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 podcasts 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.