Archive for category: Functional Medicine Notes

Dear Functional Medicine Discussion Group Members:

Once again, we had another incredible Functional Medicine Discussion Group meeting on February 22, 2018 on SIBO and the Microbiome with Dr. Sam Rahbar.  We thank both Genova Diagnostics Lab and Metagenics for co-sponsoring the food and the venue.  Genova offers SIBO Breath Testing and Stool Testing that both Dr. Rahbar and I use in our practices. Thanks to all our members who participated in the meeting.  Our next meeting will be Thursday, March 29 at 6:30 at the Santa Monica Library at 601 Santa Monica Blvd. upstairs in the Multipurpose Room and the brilliant Dr. Aristo Vojdani will lead a discussion on Autoimmune Diseases.  This meeting will be co-sponsored by Metagenics and by Cyrex Labs.  In case you are not aware, Dr. Vojdani is the innovator behind all the Cyrex Labs tests and he has published hundreds of papers and he lectures all around the world at various medical conferences.  This is a rare event to get to interact with one of the giants in Functional Medicine and be able to ask him questions and learn from him about such an important topic–Autoimmune Diseases.  Please email me if you will be able to attend and place Vojdani RSVP in the subject line.    If you are not already a member, please join our closed Facebook page, Functional Medicine Discussion Group of Santa Monica.  Also, please check out my new weekly podcast, Rational Wellness, on Itunes https://itunes.apple.com/us/podcast/rational-wellness-podcast/id1191232372?mt=2 or Youtube https://youtu.be/SP02TXgCaec 

Dr. Sam Rahbar gave a presentation on SIBO and the Microbiome that he originally prepared for the American College of Advancement of Medicine (ACAM) meeting on September 2017 that was cancelled due to the hurricane, followed by a Q and A session.  Here is a link to the slides from his presentation:  http://www.drweitz.com/2018/03/functional-medicine-presentation-slides-2-22-2018/  Here is the link to the video of the meeting: https://youtu.be/fd3fR97ilUA

I started the discussion by thanking our sponsors, Metagenics and Genova Diagnostics Lab, who offer SIBO breath testing that both Dr. Rahbar and I use in our practices.  Dr. Rahbar began his discussion by explaining that the microbiome is not just the bacteria in the colon but we also have microbiota in the oral cavity, the sinuses, the lungs, the skin, and the urogenital canal. He highlighted the sinuses, which may be a source of dysbiosis that is frequently overlooked and he referred to this as the blind spot.  

Then Dr. Rahbar talked about how dysbiosis of the lower gut can create symptoms like reflux in the upper gut in the stomach and the esophagus. When you have patients complaining of reflux and indigestion and dyspepsia but they have “downsteam problems”, PPIs and other acid reducers won’t work till you clean out the lower gut. He said that when you scope such a patient you may see bile in the stomach and this may be because you have SIBO or fungal overgrowth or a parasite, which results in reverse peristalsis. Dr. Rahbar discussed a case where a patient had Rhodotorula and Dientamoeba fragilis in their stool sample, so they had a contaminated gut environment, and I know it was chronic because they had a low SigA. He explained that if you try to kill the yeast and the parasite without first strengthening the immune system, it will be very difficult.  He uses certain supplements to strengthen the gut immune system first before using antibiotics or antimicrobials.

Dr. Rahbar emphasized the link between the microbiome in the gut and between SIBO and the skin and the sinuses. If you culture their sinuses and you find MARCoNS multiple antibiotic resistant coagulase negative staphylococci bacteria, this can affect the rest of their gut. It tends to lower Melanocyte Stimulating Hormone, which reduces the ability of the gut for recovery and repair, and this is commonly found in cases in which there is mold.

Dr. Rahbar showed the following slide and explained that this helps you keep in mind what is contained in a healthy gut microbiome:

                                         

                                               

Dr. Rahbar talked about how Methanobrevibacter smithii is the major methane producer in cases of SIBO and that there is some association between methanogens and colon cancer, polyposis, ulcerative colitis, and diverticular disease. He also said that when there is high methane, patients tend to have immune dysregulation and may also have Tick Borne Illnesses, like Lyme Disease. Dr. Rahbar also said that this may result from excessive exercise.

Dr. Rahbar defined SIBO as a quantitative overgrowth of bacteria in the small intestine. He said that you should have less than 1000 bacteria in the duodenum, approximately 100,000 in the jejunum, and 13 trillion the colon. SIBO is diagnosed when there are greater than 1000 bacteria c.f.u/ml and newer pcr technology may lower this threshold. Dr. Rahbar also explained how to diagnose SIBO with the breath test and how this test measures hydrogen and methane gas that might be produced by bacteria growing in the small intestine. The concept is that the bacteria consume the lactulose and produce gas and also organic compounds, so this can be measured by organic acid testing or through hydrogen and methane breath testing.  And there may also be hydrogen sulfide gas, though this cannot be measured yet by current testing, though Dr. Pimentel is working on this.

Dr. Rahbar said that when the patient has high methane gas, he often also finds tick borne illness like Lyme Disease, Borrelia, and Bartonella. Dr. Rahbar said that when you look at patients with Tick Borne illnesses, there is an overlap in their symptoms with SIBO.

Dr. Rahbar also mentioned the role of the intestines in the conversion of thyroid hormone T4 to T3 and that patients with SIBO or other gut dysbiosis may have low T3.  But rather than giving these patients thyroid, you need to fix their gut.

Dr. Rahbar showed some slides of normal and abnormal breath test results. Here’s a normal result:

Here’s a positive hydrogen test:

Here’s a positive breath test for methane:

Dr. Rahbar explained that a positive test for methane technically is when methane is above 10, but if you have a patient with symptoms of bloating and constipation and a methane of 8 or 9, you should probably treat anyway.  Here’s a positive test for hydrogen and methane:

 

When it comes to treatment for SIBO, Dr. Rahbar explained that the elemental diet has been shown by Dr. Pimentel to be highly effective for SIBO, though it does not work as well for methane. And if you use it, the elemental diet product has a lot of dextrose, so you have to be careful about yeast overgrowth.

Dr. Rahbar will often use Rifaximin at a dosage of 550 mg three times per day for two weeks, though some of the papers used only 400 mg, which is not as effective.  For methane producers, if you use Rifaximin, it is only 30% effective, while Neomycin will be 30% effective but using both in combination is almost 80% effective.  Dr. Rahbar also mentioned the study by Gerard Mullin that compared herbal therapy to Rifaximin and found that a combination of either Candibactin AR and Candibactin BR from Metagenics or Dysbiocide and FC Cidal from Biotics https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030608/ were as effective as Rifaximin.

Dr. Rahbar explained some of the factors that protect the small intestine from the buildup of bacteria, which includes gastric acids, pancreatic enzymes, bile acids, motility, migratory motor complex, biofilm, and Secretory immunoglobulin A.  Also, patients who have had a cholecystectomy have less chance of having SIBO and patients with SIBO are more likely to need a cholecystectomy eventually. He explained that the gall bladder may become contaminated and the microbiome of the gall bladder may feed the microbiome of the gut and make it contaminated.  I asked, if you have a patient without a gall bladder, don’t you get a more frequent release of bile and wouldn’t that keep the small intestine clear? Dr. Rahbar answered that once you remove the gall bladder, then the hepatoenteric circulation of bile continues and the actual bile pool may not increase. It may actually slightly decrease, so it may not create more bile.

Here is a slide presented by Dr. Rahbar with proposed treatment modalities for clinicians to use with patients with SIBO:

Dr. Rahbar said that those of us who treat SIBO will tend to use pro-motility agents at bedtime once treatment is completed to prevent recurrence, such as low-dose erythromycin or ginger, though there is less research on ginger. I asked about using 5-HTP and Dr. Rahbar asked how that works. I explained that you have a lot of serotonin receptors in the small intestine and the 5-HTP stimulates them, increasing motility.

Dr. Rahbar explained that he recommends that the patient go on a diet that is low in fermentable fiber, such as the low FODMAP diet or the SCD diet and he referenced Dr. Allison Siebecker, who’s website is a wealth of information about SIBO and recommended SIBO diets  https://www.siboinfo.com/

Dr. Rahbar finds SIBO to be a common finding in a variety of patients with chronic inflammatory conditions and it may be a primary cause or it may be a biological marker for underlying immune dysregulation, such as Tick related illnesses, esp. with high methane. Patients with chronic inflammatory conditions like Lyme Disease and who also have abdominal pain, bloating, constipation, and food sensitivities, should have the breath test to look for SIBO.

A negative breath test in a patient who has a negative SIBO test but has IBS type symptoms should be suspected of having SIFO, which is small intestinal fungal overgrowth. Dr. Rahbar mentioned some of the treatments for yeast overgrowth that include prebiotic supplements and foods, fecal microbial transplant, probiotics, and exercise and chiropractic treatment that can create increase vagal tone.

Dr. Rahbar then went through a case study of a 35 year old male with multiple GI symptoms, as well as postnasal discharge, brain fog, and peripheral neuropathy

  

Dr. Rahbar gave this patient a nasal culture and it was found that he had MARCONS and Penicillum upon

a nasal swab.  Dr. Rahbar gave this patient a Heidelberg acid test and found evidence of bile reflux and pyloric insufficiency

This patient also had a positive SIBO breath test.

This patient also had multiple food sensitivities, suggesting leaky gut/increased intestinal permeability.

But no gluten sensitivity.

His stool test also had evidence of dysbiosis.

This patient had too much bacteria, fungi, his nose was producing fungi, and immune dysregulation. He also had evidence of mycotoxins upon urine test:

Dr. Rahbar said that as part of the treatment he washed his nose out and asked him to check his home for evidence of mold and water damaged buildings. They also measured inflammatory markers for chronic inflammatory response syndrome (CIRS) as well as for some stealth infections.

 

This patient also tested positive for Lyme Disease:

When it comes to treatment, besides continuing to take the two herbal products he was already taking, Dr. Rahbar gave him immune support through nutrients via a nutrient analysis and also pregnenolone and DHEA and a bovine derived oral immunoglobulin product.

 

Dr. Rahbar also went through a second case of a female patient who was referred by another GI doctor who presented with dyspepsia and was taking 12 betaine HCL tablets per meal in order to digest his food. His stool test showed fat malabsorption and low butyrate other short chain fatty acids and also ow diversity. She also had dysbiosis. Her breath test was negative.  

 

Her Heidelberg test showed hypochlorhydria since it took 50 minutes to re-acidify:

This patient has Bartonella IgM at 20, which is borderline, but there is also a rash that is consistent with Bartonella.

Also, the HME , Human Monocytic Ehrlichiosis was positive

This patient was treated with Intravenous ozone and Ultraviolet and she did well and she was able to reduce her betaine HCL to one to two pills as needed.

I asked Dr. Rahbar how often he thinks motility is a factor in SIBO and how does he address it? Dr. Rahbar said that he has not done formal motility testing but he feels that the autonomic nervous system with the vagus nerve may be problematic. We discussed Dr. Pimentel’s concept of the migrating motor complex which stimulates the cleansing waves when you have eaten for more than a certain number of hours that help keep the small intestine free of bacteria. Dr. Rahbar said that when he has a hydrogen producer he may run Dr. Pimentel’s anti-vinculin antibodies and anti-cytolethal distending toxin antibodies serum test, aka, the IBS Check test. The MMC is controlled by the Interstitial cells of Cajal. Cajal was a neuropathologist form Spain 100 years ago. Dr. Rahbar said that this model of IBS being caused by damage to the MMC that can be measured with this IBS check test antibodies does not really fit with methane producers and his experience is that a lot of these patients have tick borne illnesses. Some of these patients have neurological conditions like Guillain-Barre syndrome and may benefit from taking lithium, which can help with axonal nerve regeneration. Sometimes he uses low-dose naltrexone to calm down the inflammation around the nerves. He has also used curcumin as an anti-inflammatory. Dr. Rahbar has also used BCP 157, a peptide to help with gut repair.

I asked about the role of abdominal adhesions affecting intestinal motility leading to SIBO and the benefits of visceral massage?  Dr. Rahbar said that he has referred patients for Wurm therapy using the Clear Passages physical therapy clinics. He has had a few patients who did not respond to SIBO treatment and after this treatment, their SIBO cleared up.

Dr. Rahbar explained that of his patients with SIBO he treats 2/3 of them with Rifaximin and the other 1/3 he treats with herbal approaches. But his protocol includes an initial gut preparatory phase that readies the body for the killing phase and then he has the maintenance phase.  The preparatory phase involves lifestyle modification, not eating later before bed, avoiding alcohol, avoiding sugar, oral immunoglobulins, zinc, high quality multivitamins, etc.   After the antibiotics or antimicrobials, Dr. Rahbar recommends slowly phasing in prebiotics but he is cautious about using probiotics until a period of time. He will recommend omega 3s, glutamine, amino acids, antioxidants, enzymes, betaine HCL, glutathione, he will slowly use probiotics.