Dr Nirala Jacobi

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Common SIBO Treatment Mistakes with Dr Nirala Jacobi


Dr Nirala Jacobi - Common SIBO Treatment Mistakes

In this episode I will be talking to you about common SIBO treatment mistakes that I encounter in my practice for the past 10 years.

I've been a SIBO specialist and functional digestive disorders specialist and have been in practice for much longer than that, but have really focused on the gut. And I have also created a website, The SIBO Doctor website that is an educational platform for practitioners as well as for patients. And there's a lot of good resources on that website. And I also own a breath testing company here in Australia called SIBO tests. So, I kind of live and breathe SIBO. And from all of those different perspectives I'm able to comment on common SIBO treatment mistakes, whether that's through the lab interpretation or through patients that come to see me in my practice or practitioners that I speak to and coach. And just a quick word on practitioners. There are amazing practitioners out there that really understand the gut and really put it all together.

But there are also people that are maybe not as savvy with SIBO as they would like to be. And so I thought it will be good to point out some of the more common issues that I see when, for example, I see a patient that has seen multiple practitioners and still has a lot of digestive symptoms. So, let's start with my most common pet peeve, which is when I see a patient that's been treated for SIBO that actually does not have SIBO. So, how do I know this? Is I test. So, I order a breath test or I evaluate previous breath tests and often find that this patient is not really in the diagnostic criteria for SIBO or has not been retested after they have been treated for SIBO. So, that's a really pretty common scenario where, an example is, I had a patient the other day that's been on multiple rounds of herbal anti-microbials that were very well, well, not just intention, but those were the right anti-microbials.

This patient had the hydrogen dominance previously, and a little bit of methane, but not much methane. And she had a sort of mixed stool pattern and was given these anti-microbials for about six, I think it was six weeks and her symptoms sort of got a little bit better, but not tremendously. And so after that six week course of that, she had been given by a previous practitioner. She had been given a whole nother round of different kinds of anti-microbials to see if her digestive symptoms would resolve and they did not. And when she then had come to see me, this is I think, a year after the fact. She had been on pretty much, I think it was five months of herbal anti-microbials and I retested her. I did a breath test and she did not have SIBO anymore. Her hydrogen was normal. Her methane was with also less than 10 and her digestive symptoms had not really improved at all over that last year, any further from the original improvement of the anti-microbial.

So, this is a really common scenario where people are just told they just have stubborn SIBO or very resistant to treatment SIBO, when in fact it had been treated, but the underlying issue for this patient were other issues that we're investigating. And I have a high degree of suspicion that there are other issues more in the poor digestion area. So, for example, I often, in those cases, do further testing, whether that's a stool test to assess microbial contributions or microbiome deficits or digestive deficits. And I also do a lot of other types of testing that looks for food reactions or fungal overgrowth or a multitude of functional testing that we have available now. And it can really help to pinpoint what's going on with a patient like that. So, my recommendation when you're treating SIBO is number one, you want to be really well-educated on all the different issues that can cause SIBO like symptoms or all the underlying conditions that can treat that can present like SIBO.

And I have created a SIBO mastery program that is specifically aimed at practitioners that need a little more well-rounded education on functional digestive disorders. So, I do think it is a great course to take, if you are still uncertain of how to treat SIBO. I will say that there are a lot of people that just self-treat and they're lay people. They don't know how to properly do it. So, this is often also the case when I see patients. So, treating SIBO when it's not SIBO is a common SIBO treatment mistake. So, take home from that is, do test for SIBO if you assume it's SIBO. Don't just treat it based on the symptoms. That's the other, the other often scenario is where a patient never actually got a breath test and was treated based on symptoms. This is actually really common.

One of my other pet peeves is not just not retesting after SIBO treatment, but no testing at all, where it's assumed this person has SIBO based on bloating after meals and et cetera. So, I often tell people, unless you test, you don't know if its hydrogen, you don't know if it's methane, how high those levels are. It really helps to guide treatment. So, those two scenarios of treating SIBO when it's not SIBO are very common. So, please test before you launch into SIBO treatment. Next category is Intestinal Methanogen Overgrowth or E-Mo, which actually is now considered, we're considering this as the official name that was previously called SIBO-C or constipation dominant SIBO. And the reason why E-Mo is a much better name than SIBO-C  is a much better name than SIBO-C, is because the B and SIBO stands for bacteria and the methanogens are typically not bacteria, they're typically in a different type of category called archaea, so it stands to reason that it was never a good fitting name anyways. And IMO or intestinal methanogen overgrowth is really the condition where methane is high and stays high throughout the breath test and a patient typically is constipated. There are sometimes cases where a patient has more of a mixed pattern, but these are not the diarrhea dominant patient, typically.

So it's the constipation and this has a lot of confusion, I find. This whole category of previously SIBO has a lot of confusion, where people really are uncertain of how to treat IMO, and what it really means. So in that category of common SIBO mistakes under IMO would be starting, I think one of the biggest ones for me is when I see a patient that has IMO and has been given anti-microbials right off the bat without actually being given anything to loosen the bowel. So nothing that actually opens the bowels, and that can really backfire in somebody who has a lot of overgrowth of Methanobrevibacter. And well, anytime somebody is constipated and you give them anti-microbials, that tends to backfire.

So in a naturopathic approach, what we often do is we open up not just the bowels, but the detoxification routes and ensure that the river is flowing, so to speak, before we really start giving a lot of anti-microbials. Because it's already a stagnant, toxic environment and then adding to that the die-off of organisms, can pretty much overwhelm a patient. That's often a recipe for higher reactivity, so what I often do when somebody has very recalcitrant constipation is just to use something like magnesium oxide, or even recommend enemas prior to starting an anti-microbial so that the river is flowing, everything is being able to be detoxified or to be eliminated prior to using anti-microbials. That's one more recommendation, is just make sure you open their bowels before you start anti-microbials.

The other common treatment mistake around IMO is treating it like regular SIBO, and it really isn't at all regular SIBO, so we won't need to necessarily use a lot of hydrogen herbs. Although that being said, when you see IMO or methane be high on a breath test, this often means that hydrogen bacteria are present as well, even though hydrogen may actually be quite low. That is because methane, or Methanobrevibacter, the organism that produces methane, actually requires hydrogen to produce methane, so it's not too far fetched. But oftentimes people are given the same exact treatment as for hydrogen and that is just not going to work very well.

We have very specific treatments for IMO that work pretty well, but it's a much slower process because yeah, it just is. For those of you listening that are SIBO practitioners, it seems to be a much slower process all around when we're dealing with IMO. However, Allimax or garlic medicines that are very high in allicin or Allisure, or any kind of garlic subs are medicine that has a high allicin content, will work. I will say that there are a lot of garlic substances out there that are just not going to work very well, aged garlic is one of them. And a lot of them that use the whole garlic bulb can actually be quite reactive for some patients, because garlic as a food contains a subset of FODMAPs called fructans that can be quite reactive to people.

But any kind of good garlic medicine can reduce, so we're expecting that medicine to reduce methane by about 30 parts per million in about four to six weeks. So that can help you, if you're looking at a breath test, to determine how long this patient may need this, and then periodically checking in to see if their methane is coming down. I often tell my patients, "Look, we're going to give you something so that you're not constipated, but we can't expect you to have spontaneous bowel movements until methane is below 10 parts per million, and in some cases lower than that, more around the three parts per million level." Although at that point, I might not use Allimax or any sort of garlic substance, but may switch to PHGG or other substances.

We also use oregano oil for methane, so this is another good treatment for that, but I don't like to use it as long as I would garlic products, because oregano oil, I find, is a little bit stronger for more broad spectrum results in terms of we can see it affect healthy microbiome if we use it for months at a time. I do use it, don't get me wrong, I use oregano oil a lot, for different reasons. And sometimes I do rotate, but common SIBO treatment mistake in terms of IMO is just making sure that you do use the right anti-microbial for the right diagnosis.

And thirdly for IMO treatment, a pet peeve is treating methane in a non-constipated patient. So methane on a breath test is actually quite common and sometimes when a breath test comes back, they're negative for SIBOs, or no real rise in hydrogen and methane is sort of low, maybe in the teens. And this patient is non constipated, that the patient is actually being treated as if they're a SIBO patient. This might be completely normal for that particular patient to have some methane on their breath test because methane or Methanobrevibacter is actually not a pathogen. This is something I've said before many times, I think, on podcasts and in my webinars, is that methane is actually pretty normal to find on a breast test. There are many people that are not constipated that have methane, and it's not pathological for them. As we get older, we also see more of a rise in methane.

And also just, I've said this before many times in other places, but methane was an evolutionary advantage for us because methane, when we think about gut motility, slows the gut down, and from an evolutionary standpoint, this was very advantageous because we're able to extract more calories from fibrous foods if transit time was slowed. So it's not a pathogen, and in some people it's perfectly normal to have a little bit of methane onboard. And yeah, don't need...to treat it unless somebody is complaining of chronic constipation. So just be aware of that. And I think this kind of falls also in the category of that... This is a practitioner kind of thinking, "Okay, I've tested. Maybe I found something and I better treat it," but sometimes tests are negative. Believe it or not, there are a lot of times when I look at a breath test, I'm like, "This is not SIBO. This is something else." So sometimes, just accept the fact that this is a negative test result, and look for other issues in that patient. This is definitely very prevalent when we talk about hydrogen sulfide and the infamous flatlining lactulose breath test. So hydrogen sulfide is sort of a very confusing topic for a lot of people. This is the third gas that is not yet commercially available to be tested.

Only one lab in the world is testing for hydrogen sulfide on the breath, and that is in America, so we're not able to actually access this. So what we've done for many years now is base our diagnosis of hydrogen sulfide on the infamous flatlining lactulose breath test, as well as hydrogen sulfide symptoms. And what I mean by flatlining lactulose breath test is where hydrogen is in the zeros, or one or two, and never gets above a one or a two, and is zeros, and methane as well. Very important, both of those are very low. So if you see a test result that has zeros for hydrogen but methane is all over the shop, that is not a flatlining lactulose breath test. Same with zeros on methane and very high hydrogen. That's not a flatlining lactulose breath test.

You need both to be low, and that is because when you look at hydrogen sulfide, which is also a gas that requires hydrogen for production, what we're saying there is that all of the hydrogen is being funneled towards hydrogen sulfide. And that's the only way we can assume that there is hydrogen sulfide present if that patient also fits other criteria, such as having very foul-smelling gas, potentially burning symptoms, bladder symptoms, those types of very sort of classic hydrogen sulfide symptoms, and often diarrhea-based if they have a true flatlining lactulose breath test. So this probably is one of the most common SIBO mistakes that I see, or SIBO treatment mistakes, is that people are told that they have hydrogen sulfide, and they don't. They have very low levels of hydrogen and methane, maybe in the five, six...

When you look at the graph, it looks flatlining, but when you look at the numbers, it's not flatlining. So be aware. I actually did a whole... I think it was a Facebook video. So if you go to the SIBO Doctor Facebook page, in the video archives, I did a whole presentation on how to spot hydrogen sulfide, and how to interpret your labs. So I'm really leaning away from just using flatlining at all, because it's just very inaccurate in many ways, unless that person has very classic hydrogen sulfide symptoms. The other thing about hydrogen sulfide, what we now know... And this is the wonderful thing about learning, is we've sort of learned from all these different experts that I've had on the podcast, and I've had the great privilege to interview many people that are amazing at what they do, and highlighting and different aspects of treatment. And one of them is about... How do we actually identify hydrogen sulfide?

I had a conversation, I think it was Dr. Hawrelak, about microbiome contributions to hydrogen sulfide, and we know that there are two bacteria that are very classic, so desulfovibrio as well as Bilophila wadsworthia, that are great hydrogen sulfide producers. So this is more when you do a stool test. Again, a stool test is not diagnostic at all for what's happening in the upper gut, but sometimes there are symptoms that would suggest that this patient has hydrogen sulfide overgrowth based on a stool test. But what I learned is it's not just Bilophila and desulfovibrio. There are other bacterial species that, under the right circumstances, can actually produce hydrogen sulfide. So even if those two bacteria are negative, you can have hydrogen sulfide production through other pathways. So we need to be aware of that, because oftentimes I see a stool test and a person was treated for hydrogen sulfide, and nothing on that stool test or breath test signified that.

So just aware that you can't just go by the presence or absence of Bilophila and desulfovibrio to make that decision, because there are other bacterial pathways that can be utilized. And actually, in that category of stool testing, I will loop back to [EMO 00:24:14], in that actually just two days ago, I looked at a stool test result from a patient from Germany, and that lab had actually suggested that this person may have SIBO based on a stool test level of high methanogens. And I just want to point this out. This is just so... I don't even have the right word. I think it's so irresponsible from labs, because there's absolutely no scientific validation to that.

You cannot look at a stool test and conclude anything at all about the upper gut or the small intestine. It just doesn't work that way. So whatever you find on a stool test, you can at best look at what's happening in the colon, but not at what's happening in the small intestine. So for some lab to say, "This person may have SIBO," when all they had were methanogens in the stool is just absolutely wrong. So always kind of question also the test results that you do get. Make sure it's from reputable labs.

Okay, the next common SIBO treatment mistake would be that using pre- and probiotics too early in the treatment. And so this comes with a huge caveat, of course, because there are many circumstances where I would use pre- and probiotics, but some people are given prebiotics like fructooligosaccharides or inulin, and very often I see big reactions with that. So just be aware that I think the only really safe prebiotic that I routinely use would be PHGG, or partially hydrolyzed guar gum, in the context of [EMO 00:26:20], because it's such a gentle SIBO-friendly prebiotic. But even there, I'm very, very cautious and start extremely small doses, like quarter-teaspoon or so, or even less sometimes. So be aware that I usually wait with pre- and probiotics until the patient is out of phase two treatment. And what I mean by that is for those of you who are not familiar with my biphasic diet, I created the biphasic diet about six years ago now, and it's just a really helpful tool to organize your thinking around treatment of SIBO and to give the patient very specific dietary guidelines. It's a free resource that is available on theSIBOdoctor.com. And good news, it's getting a major overhaul. We're finally combining the vegetarian and regular bi-phasic diets and we're looking at a re-launch of the combined diet very soon. So stay tuned. This is very exciting for us because it needed a major update. And yeah, so that's coming very soon. It'll still be free. And yeah, lots of new recipes. I think we are going to create a cookbook as well. So some fun things are coming up ahead.

Next on my list of common SIBO treatment mistakes is basically assuming that all bloating is SIBO. And this is a little much or a little bit similar to treating SIBO even when it's not SIBO. So if you're bloated, you have SIBO, it's like you have a hammer and everything looks like a nail. I would caution against that because it isn't, a lot of bloating is not SIBO. Consider other causes of bloating. SIFO, for example, or small intestine fungal overgrowth, or enzyme deficiency, or histamine intolerance, or constipation. Most people that are chronically constipated actually will be bloated. It's very, very common.

Consider this patient's stress level or anxiety level. And are they a fast eater? Do they need digestive support in any way? Do they have any issues with shallow breathing? So there are so many different reasons why people get bloated and just treating them based on bloating is too premature, I believe. So this comes back to test for SIBO if you suspect SIBO so that you understand what gas is dominant and also if they are a methane producer. Because treatment will be different if you have both hydrogen and methane versus just hydrogen.

So those I think are my top four or five pet peeves when I see patients or they may have treated themselves. So this is not against any particular practitioner at all. I think there are some amazing people out there that are doing amazing work. Just a reminder to not generalize, to keep being curious, to keep learning, to keep reading, to, yeah, keep learning. I'm still learning all the time. There's so much that's coming out all the time about gut health and the microbiome and it's really exciting to be in this field because it never really gets dull. But we all are subject to getting stuck in routines and sometimes it works and sometimes it doesn't.

So just remember to make sure that it actually is SIBO before you are treating SIBO. And with that, I'm going to sign off. I just want to remind you that there are some great resources out there for you on theSIBOdoctor.com as well as the Facebook page. Like I said, there are some videos there. And oh, the other thing I wanted to actually ask all of you is for podcast topics that you'd like to hear. I've interviewed some amazing people. Like I said, I'm just so privileged to be able to talk to these amazing experts. But if you have somebody specifically in mind that you think would be great, also looking at other chronic conditions that might contribute to the SIBO spectrum, I'm always very curious. I know that I still have a few experts up my sleeve in terms of what we want to look at.

For example, I know I'm looking for someone who I can interview about the oral microbiome and its contribution to SIBO. So this is a really highly specialized area that I would like to get more of an expert input. But if you have anybody that comes to mind or any topic, rather, that comes to mind that you'd like to hear me interview an expert, please send us an email to [email protected]. So that's always gratefully accepted, any suggestions. Hopefully you are getting some amazing results with treating your patients and wishing you all the best with your SIBO education and ongoing practice. And if you're listening as a patient, wishing you a speedy recovery from this very pesky and annoying condition that we call SIBO. So all the best.

Thank you for listening to The SIBO Doctor Podcast. We hope you find the information in this episode useful in the treatment of your SIBO patients. Thanks to our sponsors, sibotest.com, a breath-testing service with easy online ordering, and QuinTron, the maker of outstanding breath-testing equipment. Thanks again for listening.


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