Hello, everyone. Okay, we're gonna give people a few more minutes to filter in. And I'd like to give a big welcome back to Alicia. She's been on maternity leave with her two sweet twins.
And we're very thankful to have you back. I'm happy to be back. I'm happy to use my brain again. And while everyone's filtering in too, if you want to drop in the chat where you're tuning in from, we always love to see where you're coming in.
from. I'm currently in California. I'm in Dallas, Texas. I'm in Colorado. Where in California are you?
I'm in Escondido. So like 30 minutes. east of Carlsbad. Ah, oh Puerto Rico. That's fun.
Kind of a lot of Tennessee, Arizona. Awesome. Well, welcome everybody.
We're happy to have you here and we're excited for this really wonderful webinar. I'm very excited that Dr. Jacoby is able to join us from way over, way, way over across the pond. It's early in the morning there for you, I think.
Just 8am. 8am, 8am. Okay, that's not too bad.
But yeah, she's off in Australia. So but we're very excited to have her. I've taken a glance at her slides.
And I think this will be a very informative, very practical webinar for everybody. So I'm hoping we have a really lovely Q&A at the end. So please stay on for the Q&A.
I'll be gathering questions throughout the webinar. Please put them in the Q&A just to help keep everything in one place. Any questions that are in the chat box, there's a chance that it will get lost. And so just to make sure that we can get to all your questions.
um you can gather them effectively please put them in the q a yes and i'm just making sure i'm doing the right link and i'm putting right now the link to the slides in the chat if you'd like to follow those along you can click that link it has access for everyone and before we get started i'd like to give a quick apology for everyone who may have gotten multiple confirmation emails today for their webinar. We are having a little technical difficulty on Zoom's end that they weren't sending the confirmations and we got notified of that this morning. So I pushed them out.
I sent emails from Salesforce and I know it was overloading, but I want to make sure everyone had access and could get in and we can get started. I will do an introduction for Dr. Jacoby. Dr. Jacoby is a naturopathic doctor and internationally recognized expert on small intestinal bacterial overgrowth.
She is the creator of the SIBO Bifastic Diet, a resource that has helped tens of thousands SIBO sufferers around the world. Dr. Jacoby is the host of the SIBO Doctor podcast and the founder of the SIBO Doctor, an online educational platform that includes a practitioner certification program. She is also the medical director of SIBO tests, providing innovative testing options for SIBO and IBS in Australia. Dr. Jacobi is known for her systematic and effective approach to diagnosing and treating SIBO and other functional digestive disorders.
Having received her naturopathic doctorate in 1998 from the esteemed Bastyr University in Seattle, she brings more than two decades of clinical experience and expertise to her clinic, The BioClinic. And then let's get started. Oh, no. We'll stream the recording and we'll watch the content.
And then we will go into. my presentation on clinical applications and then we'll have a Q&A at the end. So please go ahead and put your questions in throughout the presentation and then we'll answer them at the end.
Just hold tight for one second. I just got a little alert on my screen that it was the wrong bandwidth, which everything's working. So another little technical difficulty.
hold tight, please. I'll get this going right now. And while we're waiting, I'm just curious to hear from those of you who are joining us tonight.
How many of you are familiar with SIBO? Is this something that you see in your practice? I guess let's rate it on a scale of one to five, with one being this is really, you know, the series has been brand new information for you.
Five being close to an expert, maybe you see it a lot in your practice. Just put anything from a one to a five on what you feel like your experience level is. So we have some fives, threes, fives, threes, twos, a couple ones, some threes.
So a lot of you are kind of middle of the road. Oh, somebody says that they have it. So hopefully you're getting some good information for yourself. Okay. Yeah.
So we have quite a few people who are kind of in the middle. So they're not feeling like they're expert, but they're not a beginner either. And then we have a few who are experts and feeling that they're very comfortable with SIBO. And then, um, a few who this is really brand new information.
So, uh, so that's great. Um, Catherine went to order GM at first, and it's wonderful that you asked that question, because I'm actually going to be talking about when you would use stool testing versus when you would use SIBO breath testing and some of what the criteria would be. And it actually, uh, mirrors.
very nicely what Dr. Jacoby will be discussing and she'll be going through some case studies. So some practical application will be here. And so hopefully you get your question answered during our presentation tonight. And so how many of you are using stool testing, whether it be of any brand of any brand, how many of you are currently using any stool testing? So some of you are using in and how many of you?
you know, are maybe not using stool testing at all. A lot of you are using not at all, lots of GI maps, more breath testing than stool testing. Okay. That's great.
Wonderful. And if we needed, if we need to Dr. Jacoby, where are you prepared to present your presentation if we need if there's an issue technically are you prepared to prevent life Dr. Jacoby you did everything the right way recording it's just saying it's too big of a resolution size for some reason which I've never run into that issue before in my life so I'm so sorry that I'm keeping you on the spot to do this live. Okay. Let's see.
She's a thought leader. I'm sure she can. No worries. I can, I can do this.
Yes. Yeah. She could probably talk about it in her sleep.
So we'll just, we'll just run it live and it'll be, we'll still get the great information. My apologies, everyone. Thank you for staying with us.
And like I told Alicia earlier, something must be in retrograde because it's been a technical difficulty day with this too, but thank you so much for being with us. Dr. Chico, be taken away. Okay.
Hang on just one second. Okay, is that pretty visible? Everyone, everyone can hear me? Excellent, great. You can see and hear you.
Well, I had pre-recorded this talk because I'm actually down here in Tasmania, which is at the very, very southern tip of Australia and the next landmass is Antarctica. So I wasn't quite sure about the internet reception, but thanks to Starlink, we're all good, I think. So this is a presentation about tough SIBO cases that I've encountered.
And I've had, I've been a SIBO specialist now since 2011. So it's been about 13 years that I've exclusively concentrated on SIBO. And in that process have become quite. aware that it's not just about bacteria. If it was just about bacteria, I don't think we would be having big summits about it. There's a lot more at play.
And so hopefully these lessons that I call from the SIBO frontline will elucidate some of your experiences as well, perhaps. So I first heard of it, like I said, in 2011. And I kind of came back to Australia with this information and endeavored to research everything I could and started a breath testing lab in Australia and also a SIBO education platform where I do courses, etc. But really, what a lot of people know me for is this biphasic diet that I created that has...
been used all over the world. And it's a two-phase process that you use with your products or your medication to help people. And really it came out of this, you know, of this German background and it just, everything needs to be organized. And I didn't want my patients to leave, excuse me, with 20 supplements the first visit.
So it was a more organized approach, but anyways, moving on. I wanted to kind of talk about... what causes SIBO. That for me, when I present is really the sweet spot because a lot of people think it is just about treating the bacteria. But for me as a practitioner and my sort of approach to it is to understand what has caused the SIBO in any particular patient.
And it's really, hopefully this presentation will help you think through some of these tougher cases that you have. So. I think about it as three different categories of causes. So number one is something is not quite right with the bacteriostatic effects of the digestive juices, like hydrochloric acid, as we know, acts also as an antibacterial. Also bile and pancreatic enzymes all help to control bacterial overgrowth in the upper gut.
So if your patient has something going on with any of these organs, they may have an underlying cause of SIBO due to this. The biggest category is something impairing the motility of the small intestine. So something is not moving through or the movement is ineffective through the small intestine and therefore bacteria are allowed to remain in the small intestine. and multiply.
So this could be the migrating motor complex, but there are other contributing neurological tissues that is also involved, Magus nerve and other peristaltic actions. But yes, migrating motor complex, for those of you who've heard of this, I'm sure by now many of you know about the housekeeper wave that is in the small intestine that ensures that the small intestine is swept clean of content every 90 minutes on an empty stomach. And if anything damages that, then bacteria are allowed to remain.
And last category would be something that's impairing the outflow, meaning there's some anatomical changes to the bowel that also causes some sort of obstruction, not necessarily from the inside, but from the outside, like pelvic adhesion, et cetera. So something is impairing this outflow. So if we think about it in terms of these categories, medications also, but I kind of always think that's an easy one to address.
So if you're on medication that slows these peristaltic waves or if anything affects the PPIs, for example, that's something that you can address as a practitioner. But so we have motility category is the biggest of the underlying cause categories. And in this category, we see this autoimmune IBS, which is this damage to the migrating motor complex that comes as a consequence of food poisoning.
Okay, sometimes, not in all cases. We also see traumatic brain injury in this category, traumatic brain injury really can cause quite a bit of digestive mayhem because it affects the motility of the small intestine also. Hypothyroidism, we've always known that this affects motility of the gut. But then chronic infections, and in the last years, I've really seen this a lot in terms of EVV and other stealth infections. that can affect motility.
Diabetes, mold and chronic inflammatory response syndrome is a huge factor in this category and I've actually had to become... a mold expert in this process because there were just so many people and the area where I live in the northern rivers in Australia just recently had terrible floods and I know many of you also have experienced this quite recently so this is this I think is going to get become a bigger problem and then the the dysautonomias of Ehlers-Danlos syndrome, postural orthostatic tachycardia syndrome and mass cell activation syndrome all can affect motility in the small intestine as well. And then scleroderma, because as you see thickening of the connective tissue and of the digestive tract, whether that's EDS or scleroderma, you see this very impaired propagation of a motility wave. The impaired digestion category includes microbiome dysfunction. And as I think what we're What we're starting to understand more and more is also this idea that SIBO is not just bacterial overgrowth, mostly of gram-negative bacteria, but also this real dysbiosis of the small intestinal microbiome that's meant to be there.
And that's difficult to really correct in some ways. But I've seen people that have had such severe dysbiosis and really It's just really impossible for them almost to regain their normal microbiome. We've seen a lot of people in chronic stress and fight or flight. We know that this dramatically affects the digestive tract and also the digestive output, of course, as a consequence. So that can also impair digestion and cause SIBO and secretory IgA deficiency.
as mentioned, deficiency of pancreatic or brush border enzymes, and then poor bile flow and hypochlorhydria. In the outflow obstruction adhesion category, we see also ileocecal valve dysfunction. EDS is also in this category because of this very disturbed connective tissue, or it can result in very almost anatomical collapse of the digestive tract, a positional collapse. in later stages of EDS. And then of course, endometriosis, the big one for adhesions.
And then any abdominal surgery can cause adhesions. So think of people with cholecystectomies, hysterectomies, C-sections, etc. So these are fairly routine surgeries that can result also in this adhesive issue.
And then the medications that we know can affect motility, but also the stomach acid, obviously, PPIs, and then opiates and narcotics. And then there were interesting studies that showed that T4-only medication, so Synthroid, et cetera, actually was associated with a higher risk of developing SIBO. That was a German study that came out of about five years ago.
The proton pump inhibitor studies or the research on that is a bit like both sides. So some studies show there's no impact and some studies show that there is impact. But we know, I certainly have seen it be causing or really contributing to a difficulty of regaining a normal microbiome in the upper gut. All right, so let's talk about these cases. And each one of these...
really taught me a lot. The first one is a case of dysphagia, then we have constipation, more of an emo case, and then abdominal pain. So this patient, John, in his mid-30s, he had symptoms of bloating after meals, but this real intense burning of the soft palate, uvula, and throat since he had his wisdom teeth extracted 14 years prior.
to seeing me. So he had them extracted and then right away the symptoms began 14 years ago. So since 14 years, he's had this issue. He was very reactive to supplements and medications. And I find this a lot with people that have had longstanding SIBO.
They just have this MCAS, almost, not all cases, of course, but many can be super, super sensitive and you have to be very slow and meticulous with how you approach these patients. And I don't give poly, like I don't give a lot of supplements to these patients. I start slow.
He was diagnosed with laryngeal and vagal neuralgia and Hashimoto's thyroiditis. and he had had a fund application for GERD, which did nothing. And for the last eight years, he was just on every possible asset suppression that is imaginable.
So PPIs and Zantac and Gaviscon, and none of those did anything. But of course, if he tried to stop them, he would have this rebound hyper, like worsening of his symptoms. He had, this was a patient that was referred to me.
And to be honest, in the last seven, eight years, I've gotten a lot of referrals from practitioners and people that self-refer. So these are the people that have failed normal, like the treatment that we all know. Right.
So this has been my life for the last eight years. But this very astute practitioner had actually done. This is the this is the breath test that we did in Australia.
But this practitioner. had done a lactulose test on this patient, which was negative, but he had such a sense that this patient did indeed have SIBO that he followed this up with the glucose. And I really recommend this to consider other substrates and not just only think of lactulose as the be-all end-all, but glucose is a great substrate.
As you know, it's absorbed very rapidly in the proximal system. small intestine, so sometimes it can miss distal SIBO. But this patient was extremely positive on a glucose breath test. He'd been on multiple rounds of herbal antimicrobials before seeing me, so he had never been on Rifaximin. So I said, all right, let's just go for it.
Let's just do two rounds of Rifaximin, so two times two weeks. And these were just, let me see if I can put my laser pointer on. So you can see here, these numbers in the hundreds on a glucose are really, really significant of hydrogen.
And then I also told him to retest the day after the completion of the last round of the rifaximin. And I like to do that. I recommend testing the day after.
the treatment has been completed, just so you know that when you retest, this is really the effect of the medication. And for example, if it's still positive, you don't know if there was a relapse in between the completion of the products or the treatment and the recurrence of SIBO, if SIBO was really cleared. So we see here a reduction, but...
definitely still in the hundreds. This should have worked way better. So this was interesting.
And then I said, all right, you've not done the elemental diet. Let's do that. And let's see if you see any significant relief. He was still very, very symptomatic.
And at that point, I still thought, all right, this must be due to SIBO. He said he's never felt worse than on the elemental diet. He was still positive.
on a retest. You can see here at 40 minutes, a 60 parts per million rise in hydrogen from 20 minutes to 40 minutes, but significant reduction, but he felt like it was much, much worse. So I added a tincture for the upper gut.
So I use all different products and I have a dispensary. That uses also liquid tinctures. And because it was so proximal, I felt like, let's just try that.
It was a bit iffy because of the alcohol content. Five mils of water three times daily and retest in four weeks. And I didn't want to do anything else. You can see that I just did one thing at a time.
Finally, the test was negative as a result of this. But and with a dreaded. I know we've all had experiences like this where they say, I don't feel any better. And I've really learned to take this in stride with SIBO because there are so many underlying causes that contribute to the overall symptomatology.
So I ordered an organic acid test because he had this burning quality to his symptoms and also increasing fatigue and bloating on the elemental diet. And because of his PPI use and... I really thought of basically Sifo. And he definitely did have fungal overgrowth and mold.
He had three markers for Aspergillus that were elevated. And his arabinose was very elevated, which I find a useful marker for Candida. And on the microtoxin panel, his ocrotoxin A was quite elevated.
So I also ordered a nasal swab, which definitely showed he had mold exposure. So Marcon's positive, Aspergillus positive, Penicillium positive. So mold can actually affect GI motility. So mycotoxins are very toxic to the myenteric plexus and the vagus nerve.
So this is the sort of central intelligence of the gut. And if you have these mold toxins, they can certainly affect more than just motility. At the time, I wasn't yet adept at treating mold patients to the level that I wanted, so I referred this patient, and he was doing really well under the mold expert's care.
The lessons I learned from this case is, if symptoms strongly suggest SIBO and the lactulose breath test is negative, definitely consider a follow-up substrate that could be glucose or fructose. The elemental diet is effective in treating SIBO. I didn't know this before, but of course, I'm going to do it. of course.
It was nice to see. Herbal tinctures are excellent for proximal SIBO. And SIBO was not the underlying cause of his symptoms, but the underlying cause of his symptoms caused his SIBO and SIFO.
I hope that makes sense. So the mold was the underlying issue. And at that point, I wondered if, because the symptoms began with the teeth extraction, wisdom teeth extraction, if that somehow triggered a sinus biofilm. because he didn't really have significant flooding exposure in his house or anything.
So we didn't quite know where this came from. Okay, so John's underlying cause was chronic. He was quite stressed out, obviously, understandably so, with all he had gone through.
And also mold and chronic inflammatory response syndrome. And also proton pump inhibitors, I think, were sort of exacerbating and perpetuating his situation. Case number two, constipation. This was a woman. This was not necessarily a difficult case.
But I wanted to show a case where we see that it's part SIBO, part something else as well. She had suffered from constipation all her life. So.
when somebody says that, I know it's not just, it's unlikely to be just emo or SIBO. Emo, of course, being intestinal methanogen overgrowth. Symptoms included bloating, belching, constipation, and mild fatigue. And she had no bowel movements unless she took magnesium and partially hydrolyzed guar gum and a herbal laxative.
Like she would go. could go two, three weeks without a bowel movement. So she hadn't actually tried stopping anything for a while. She had gone about, this was a couple of years ago.
So she had gone to a trip to Sri Lanka in 2017 and had food poisoning, but didn't really have diarrhea or vomiting. She just had cramping in her abdomen and these symptoms resolved with metronidazole. also been diagnosed with Hashimoto's the year before she was on T4, T3 medication, and it looked controlled and she didn't really notice any difference other than mild improvement in her fatigue, but no changes in constipation.
Coincidentally, she had brought this to me. And also the practitioner before her had, I can't remember now the reason why, but he did a blood level of mercury. And lo and behold, it was high, just a resting blood mercury of nine with a normal of zero to five.
And this we attributed to, she had no amalgams to this daily tuna consumption. And whenever somebody has heavy metals and conjunction with constipation, I do consider that. But in this case, we'll see it was not necessarily due to that. But I thought it was interesting to include this here.
Of course, she stopped the tuna now. She had also been treated or tested before by another practitioner. And this was a lactulose breath test eight months prior that definitely showed.
So here's the yellow sort of diamond on the bottom. That's your hydrogen. And that is fairly normal.
There was no elevation. You can see the numbers here. Actually, totally negative.
And methane, however. at starting point of 60 and then rising to a high of 87 was really quite elevated. And not surprising, this was a case of intestinal methanogen overgrowth.
So she had... received herbal antimicrobials at the time of this test, but only had mild improvement and no one retested. And symptoms continued. So I said, all right, let's just do an emo treatment that I know will at least shift this and let's see what happens. And I gave her the high strength garlic, so very high allicin content, berberine, PHGG, and the biphasic diet with added flaxseeds because flaxseeds actually are quite helpful.
with reducing methane. And then I said, retest at the end of three months. So we repeated the lactulose breath test, which really was quite successful. It was still considered mildly positive for Evo, as we know, anything over 10 parts per million is throughout the test is considered positive. Although when it comes to methane, I always say you really need to...
to have the presence of constipation for methane to be positive at those levels, meaning that it's quite normal for non-symptomatic adults to have higher levels of methane. They're incidentally found and there's nothing and if they're not constipated I don't necessarily think that there is an issue oftentimes. So there's lots of different reasons which can raise methane.
But we saw a really good reduction, I thought. And she was feeling better after the three-month program, but bloating and constipation still persisted. Although she did notice, she basically reduced, she wasn't taking the laxative anymore, and she was just on the magnesium and the PHGG.
And magnesium, of course, is more of an osmotic laxative. And she was able to have... bowel movements every other day. So then I said, all right, let's do a stool test.
She'd done one years before, but let's just see what's going on as a residual. She had high products of protein breakdowns, strongly suspicious of low stomach acid or low HCL. She had high fecal fat and her microbiome had high bacteroidetes, phylum and normal butyrate producer.
To be honest, her microbiome looked pretty good. which was a bit of a surprise after this very long-standing constipation, in which case I often see very high levels of gram-negative bacteria like Klebsiella and E. coli.
It's just this stasis that happens. But that was all pretty good. So I said, all right, let's just give you digestive support, possible lack of bile as well. And she had...
had a quite a high fat diet though. And so I wasn't quite sure if this was due to bile issues or high fat consumption, this residual fat in the stool. But when somebody says I've had constipation all my life, I now often think there is some problem with bile in addition to so I think that that may have, or the low HCL would have preceded all of this, of course.
She also could have possibly had a high bacteroidy. bacteroidetes phylum due to the high fat diet. So I had recommended a vegetarian low fat diet.
So not the by, so not low FODMAP anymore, just a vegetarian low fat diet. And then I just, I often say, or I often recommend when somebody has had very long standing constipation, just to do some colonics and enemas. It's like, you know, we're naturopaths, so we do. We do recommend those kinds of self-care for people.
And I recommended also herbal bitters. I didn't want to start with HCL. I just wanted to see how she responded to bitters.
And then also herbal prokinetic with artichoke and ginger and a probiotic that's been a particular strain that's been very well researched in constipation. She was having... Last I saw her, she was having daily bowel movements, no bloating or belching, the fatigue resolved. She stuck to the vegetarian diet, occasional added in some fish or chicken.
She loves the bitters, but takes the HCL with higher protein meals and was able to discontinue the herbal prokinetics. So a complete resolution of her case. So what Ellen's underlying cause was probably elements of like, obviously, she did have hypothyroidism. but also poor bile flow and low stomach acid.
The lesson I learned with Alan is that methanogen overgrowth is not always the cause of chronic constipation, even if methane still is. in a positive range on a lactulose breath test. So if you get stuck with the numbers and nothing is moving, well, we did see the numbers move and her bowels did improve, but I could have just persisted on the SIBO. It's got to go below 10, but I felt like there was something else going on.
So always at this point, I usually do breath test and stool testing, but that's me. I'm a... functional digestive specialist.
So I like to know what's going on from the get-go. This potentially, this next case was potentially one of my most difficult cases because it was, it went on for, I think for three years before we figured out what was going on or two. She was, this is Joan in her sixties. She had anxiety and panic.
These were random, but more common. reactions with foods and supplements and medication. So again, a super sensitive patient.
She had bloating, constipation, and burning bladder. She had sharp abdominal and pelvic pain that varied in intensity, but was pretty much constant. She had very significant surgical history and appendectomy.
She had a total abdominal hysterectomy. She had transvaginal mesh placed for pelvic organ prolapse. And subsequently, substantial adhesions were noted.
This was her first lactulose breath test. So again, we see definitely a SIBO picture with elevated hydrogen. And so over the next year, I really threw pretty much everything at her, including herbal analgesics and antimicrobials and mucosal products, probiotics.
The anxiety overall did improve, but multiple lactulose breath tests never really showed a clearance of SIBO. And the pain intensified after I had recommended. I said, all right, let's just see what happens if you take a prokinetic.
And I wanted to just go with Procalopride, which is Rezolor in America, 0.5, so just the standard dose. And it really intensified with that. At that point, I referred her to a visceral manipulation therapist who reported back to me that there was pronounced restrictions pretty much around her entire digestive tract. She also had a rectocele, cystocele, and a urethrocele.
And the patient did multiple sessions with some improvements, but had minimal. improvement with pelvic pain, dyspareunia, urinary urgency, incontinence and obstructive defecation. So then she went down this whole mesh, like she somehow found out about this mesh injury Australia, which is this group of patients who all suffer from this chronic pain. This, you can read it in the notes, but it was a letter from a surgeon that I found very, very interesting about all the different symptoms that mesh, that was a very inappropriate mesh that was placed.
So they actually did a class action suit against Johnson and Johnson. And she was one of those women. So she then commenced to have this mesh removal. It was a very specific removal.
And if you can imagine. This mesh now ending up completely contracted and around her organs, her bladder, etc. And there's very, very few people, surgeons who do this surgery. And she said it feels like a weight has been lifted. And then we followed this up with a lactulose breath test.
And interestingly, now her methane showed up a little bit, but she really didn't have any constipation. So I really. didn't feel like we needed to do much about this because she was having regular bowel movements. So what I learned with Joan, this was Joan's underlying cause, very clearly abdominal adhesions. But what I learned is a really important clue is when you give a patient prokinetics and their abdominal pain worsens, that is, so I now think it's really contraindicated to give people.
prokinetics when they have adhesions because it's obviously not the problem, it's not motility, it's just the obstruction. Also learned that visceral manipulation is helpful but cannot overcome mechanical. implants and continued triggers for adhesion formation.
So very likely more effective now that the mesh has been removed. I wanted to quickly talk about managing expectations in chronic SIBO cases. So when there's a direct cause, like a patient has had food poisoning, has antivinculin and anti-CDTP antibodies causing damage to the migrating motor complex, so autoimmune IBS.
SIBO symptoms resolve really quickly when SIBO is cleared. So we know that's the cause. And then they're put on a prokinetic and it's all, you know, they're pretty happy. But when you have other issues and systemic causes, the symptoms don't. typically resolve.
So for example, mold. I stopped treating SIBO until mold was actually addressed and cleared. And then sometimes SIBO actually clears up by itself.
I've had many, many cases of patients with mold as an underlying issue that just even if you clear, if supposedly the test is clear or the lactulose breath test is negative, yet their symptoms persist. So systemic causes really has this other addition to the symptom picture. And then, of course, as we know, we have other contributing factors, all the environmental toxins and detox impairments. Turns out that a lot of the P450 system is actually lining the digestive tract.
So when you have a lot of damage. in the digestive tract due to these gases, you can actually have people that become really sensitive to toxins, etc. And then genomics, I had to really go into a lot of the genomic issues around some of these patients and learn a lot more about detox impairments and etc.
And of course, also immunological issues and inflammation. So these all affect how a patient will respond to treatment. And then the causes we've discussed, but also management can be affected by this. And of course, these are more lifestyle issues, et cetera, that affect how a person will respond to treatment. This is a questionnaire I developed a few years ago that you can download on thecebo.com that I find really helpful.
You give this to a patient, have them fill it out, at least it gives you a starting point. to see what category of underlying causes they might be falling into. So it's definitely not completely exhaustive of all the underlying causes, but it can give you a little bit of a clue. And thank you for your attention. These are my social media handles.
This was me at Cradle Mountain a few weeks ago, having a wonderful time in Tasmania. Thank you for your attention. Thank you so much, Dr. Jacoby. And I hope everyone really, I think cases are such a wonderful way to teach.
I think that's how we learn because, you know, we are as practitioners, we see these walking into our office every day. And so I think the case study presentation and integrating that with the root causes is just such a, it's just a wonderful way to teach. So well, we're going to transition into you. the sort of clinical application piece, although Dr. Jacob did a wonderful clinical application piece throughout her presentation.
But I'll be discussing just some of the microbiome lab specific options, but also discussing when, because there were some questions about when would you use stool testing? How do you choose a SIBO breath test over a stool test? And so We'll go into that and then we'll go through Q&A.
And for those of you who have been posting your questions, yes, I've been gathering them and we will go through that at the end of the presentation. So we should finish early today. All right. Can you guys see that?
Okay. Can you guys see my screen? Yes, we can.
Great. Okay. Well, my name is Alicia.
I'm a clinical science liaison with Microbiome Labs, and I'm a registered dietitian. And I've been with the company for a couple years now. And just really, this is actually a passion project of mine, SIBO. I just feel like it's something that we see walking into our offices.
probably almost every day. As Dr. Jacoby showed, there are many root causes and many of those root causes of SIBO are the same root causes that can also cause dysbiosis in the colon. And so when we think about just our modern day lifestyle, the various medications we're exposed to, you know, stress levels, dietary changes, you know, the things that can trigger digestive insufficiencies and dysbiotic.
or dysbiosis in the small intestine and the large intestine are very rampant. So this is SIBO, I think is something that it doesn't really matter what area you specialize in. You're going to be seeing this as part of your patient population.
So does this sound familiar? A client walks into your office and maybe they've seen multiple providers, whether it be conventional or functional. Maybe they were told to follow a low FODMAP diet, or maybe they're gastroenterologists with. and they maybe have had some mixed results, but they can't expand their food choices.
So every time they try to bring in garlic or onion, or, you know, artichoke, they can't, they can't tolerate it, it causes digestive issues. Maybe they've been on multiple rounds of rifaximin, or some other type of antibiotic, and they'll feel better during the course of the antibiotic, but then their symptoms will return once they go off. And they're looking for root cause answers.
And maybe they're coming to you with the cheek. chief complaints of bloating every day, or maybe worse bloating as the day goes on. Maybe they're struggling with some gas and having alternating bowel movements.
And then maybe they're having other systemic symptoms. So it's itchy skin or fatigue or headaches, or they can't lose weight. I bet that probably almost all of you have seen somebody that in some level fits this description, because these are the types of patients that come in.
to a functional setting looking for answers. And this is where being knowledgeable around SIBO and how to, you know, identify it and then know what to do about it and how to assess for it is really important. So I love that Dr. Jacoby has that questionnaire because I think that makes this, you know, figuring out what to do with a patient when they're coming to you with all of these complaints, it makes it much more clear cut on what do you then do as a next step. So what would you do?
And I'm curious, this is going to be a little interactive. and you can feel free to put it in the chat box, but, um, do you, in this case, do a SIBO test for this patient? Do you do a stool test? Do you do both? Or do you do neither?
If they're coming to you with all of the symptoms that I had just described, and maybe some of you were thinking that that was, you're like, yeah, that was my noon patient that I saw today. Um, and so please feel free to put into the chat. If you have any thoughts around what you would do.
for that patient. So some of you are saying a stool test first to check for pathogens, SIBO test first. Some of you are saying a stool test, SIBO test. Yeah. So let's, let's explore that.
All right. So the way I like to think about SIBO and stool testing is that you have a stool test that maybe you're using. And then we have this wonderful SIBO breath test that can be used as an at-home, more convenient way to assess for SIBO. And so think of it as more of a, a, you complete me type situation because these both have a really wonderful role to play when you're doing your assessments.
Now, obviously it's not going to be practical for everyone to do both. If you can do both, that's ideal because then you can really see what's going on across the entirety of the, uh, the intestines. But Um, they really compliment each other. They're not, they, they look at different things in different areas of the digestive tract. And so they can compliment and can complete each other versus compete.
So today we're going to quickly recap what biome effects is. Some of you might be familiar with the biome effects stool test, and some of you might not, this might be newer information. Um, we're going to look at patterns. I saw in the chat, there was someone asking about how do you know if someone has protein digestion that's insufficient. And so we'll look at what those patterns would indicate.
identify when to use which tests. I have a little algorithm that I'll walk you through that I sort of use when I'm thinking about what to do first. And then we'll talk about some solutions.
So how many of you are currently using BiomeFX? So testing, I know we have a lot of you on who are using GI maps, but are you, is there anyone here who's already using BiomeFX? And then also how many of you are using SIBO breath testing currently in some form or fashion?
Let's see. So some of you have a couple of times used BOM effects. So some, yeah, so some are using BOM effects and some different SIBO tests.
And then, oh, someone just ran their first BOM effect. So that's great. So some new and some, this might be new information.
So what I'll be presenting is showing you some patterns and also discussing kind of what the differences are between BOM effects and other stool testing options. So let's first recap that what's going on in the colon. So there, when we think about stool testing, there's really two different ways to look at it. We have our, what we call the functional microbiome analysis or an FMA. And then we have traditional testing.
So traditional stool testing is what you're mostly going to get from like a doctor's office, or just kind of your, they're really looking at a specific condition. And they're really just looking at what can we identify to kill. Um, you know, so looking at what do we need to eliminate versus a functional microbiome analysis is looking at more of the function of the microbiome.
So it might be looking at things like diversity because we know diversity plays a huge role in overall resiliency of the microbiome and overall health. We also want to look at the function. So not only who is there, but what are they doing?
And then a functional microbiome analysis is going to look at patterns and function and more of a microbial mapping. And So it's going to give you more just exactly that the function of your microbiome and how that's then going to relate to your overall health. And then from there, you can address and give certain specific diet, lifestyle and supplement protocols to then try to regain that strength and resiliency of the microbiome.
So basically, as traditional sources, who do we need to eliminate versus a functional microbiome analysis is looking at who do we need to support? by increasing or balancing. So they're really two different tests.
So a functional microbiome analysis is going to look at functions and byproducts of the microbes. So that can be things like ammonia production, which would indicate some liver challenges. It can look at hydrogen sulfide. It can look at short chain fatty acid and estroglone, just a few of the functions that can be looked at.
It can also look at how do we create a healthy ecosystem that's going to more naturally crowd out those pathogens. So more of a... rebuild versus a kill off.
And then what we, you know, and what Dr. Jacoby showed with her, her cases is, you know, you can use this with patients who have the GI symptoms and those who do not have GI symptoms, because obviously the gut organ access is a huge player. And we know our microbiome plays a big role in that gut organ access function. So this is just a sample first page report of the biome effects test.
So this is looking at who is in the gut. So we're looking at alpha and beta diversity. And I will say, I'm going to go through the biome effects very, very quickly.
We're just going to touch on it for a couple of slides. If you are interested in learning more about biome effects, or if you're new to biome effects, we have a whole series on biome effects that goes through patterns, pattern recognition, going through the reports and case studies. And so if you're interested in diving deeper, definitely reach out.
to your rep and they can get you some of those recordings. But basically we're looking at who's in the gut, how rich is that community? And are they evenly distributed?
Because one of the most important factors with the microbiome is that we have a really rich, diverse community, but they're also evenly distributed. So we're not having, you know, too much of one versus another. And then what are they doing there?
And this is unique to the technology that BiomeFX uses, which is full genome sequencing. With whole genome sequencing, we're able to actually look at the pathways of the functions. So hydrogen sulfide production, P-crestal production, sacrolytic and proteolytic fermentation. So whether someone's preferentially favoring carbohydrate digestion and fermentation versus protein, and we'll talk about some of that here in a little bit. So it looks at those different functions and how they're interacting with the environment.
And then is there balance? So are we're looking at the ratios of the main phyla in the microbiome to see if there's balance across those larger groupings of bacteria. And so then from here, we can look at how to restore balance and bring that strength and resiliency back. And so patterns are a big, you know, they're really important here when we're looking at a stool test because they can give insight into what's happening further up the digestive tract.
So things like SIBO, you can't, you can't diagnose SIBO via a stool test, but you can certainly find patterns that would indicate that SIBO could be an issue. So let's look at some of those. So Dr. Jacoby did a great job. I love her slides with her little animations.
I want to learn how to do that. But I, so she brought it to life. Mine is much more boring, but this is a table from the American College of Gastroenterology. from Dr. Pimentel that essentially reiterates what she was discussing in terms of those root causes.
Because if you're, because if you think about the digestive tract, it's set up to keep everything in check through these different checkpoints. We have these digestive checkpoints. So we have gastric acid, which is very acidic. So you're supposed to neutralize most of the bacteria that's coming in from the oral cavity or from the respiratory tract. Those are supposed to be neutralized as they travel through the stomach because of that really acidic environment.
So if you don't have enough stomach acid, or if you're on a PPI, then you've lost some of that ability to neutralize. And one of the things with SIBO is that the majority of the bacteria that is found in SIBO... are coming from the oral cavity and the respiratory tract.
Panacreatic enzymes, as she had talked about, those are also going to offer some of those antibacterial properties. Bile acids definitely also have that antimicrobial aspect to them. The small bowel motility, so Dr. Jacoby mentioned the migrating motor complex, which is that little sweeping mechanism that helps to sweep debris through and keep everything moving in a downward fashion. Um, ileocecal valve is that valve that helps to prevent that backflow from the large intestine to the colon and then our immune system. So these are the factors that keep the microbes in check.
And so just as these, any deficiencies in these are going to predispose somebody to developing SIBO. It's also going to show up as patterns in a stool test, a biomeffect stool test. If you know what to look for, um, because again, you've lost some of these digestive check.
points. So you're going to cause imbalances in the small intestine, which is then going to translate to imbalances in the colon. So just to reiterate, again, biome effects is not going to confirm the presence of SIBO. It's going to inform the potential. So you're not this, these patterns that I'm showing you guys tonight are not going to say that this person does or does not have SIBO.
It's just going to give you clues that then may inform your next decision on whether or not you bring in a SIBO breath test. So she discussed some methane producers. We have methane in here. There's also the phylum level Uriarcheota. These are where all of your archaea live, which are the microbes that produce that methane.
Also, there's a phylum called synergistes, which tends to be elevated with low stomach acid. So people who are on PPIs, or if they've lost some of that ability to make enough stomach acid, maybe they have H. pylori.
You'll see that elevated. Um, disulfovibrio is a hydrogen sulfide producing group. So if this is in excessive amounts, you might have a higher level of hydrogen sulfide. Um, and then, oh, here we go. And then we have, um, and these are showing, showing in different ways.
So urearacuda is in the phylum section, um, methanobacteriaceae is at the family level. Cause we look at family levels in biome effects. Um, but then we also have the function of methane production.
So when it comes to methane and hydrogen sulfide, we're sort of looking at a couple of different areas to confirm its presence. There's continuing on with patterns, things like E. coli and Klebsiella. These are two species that are very common in SIBO.
They're the predominant species in SIBO. So if you're seeing them elevated again, you cannot confirm that they would necessarily be elevated in the small intestine, but If they are elevated in the colon over the amount that's typical, um, that might make you think about what the balance could be in the small intestine. And if these are present, then that, that could be a SIBO pattern.
Same with the filia what's worth. Yeah. Um, this is a hydrogen sulfide producing microbe. This is a microbe that loves fat.
So when Dr. Jacoby was talking about her case that, um, where the high fat diet seemed to be causing some issues, I would expect that. that may be a factor for somebody who has bilophilia and then they may have some higher hydrogen sulfide production if they have higher levels of these hydrogen sulfide producing species in the colon. And then the streptococcus group, these are elevated with low stomach acid.
So again, usually if you're seeing high staph or strep, those would also go along with low stomach acid patterns, which would then... be a risk factor for developing SIBO. So just if we're going to summarize what you might see on a stool test, if someone also has SIBO would be this here in the summary. Now there could be more, but this is just sort of what we've seen clinically and based on what some of the research would show with, with some of the patterns that can go with dysbiosis and digestive insufficiencies.
So if you see these patterns, And you also have somebody who is presenting with clinical symptoms. So constipation, diarrhea, bloating, maybe they have a lot of these risk factors like food poisoning or adhesions. They have, you know, maybe history of abdominal surgeries.
You would probably want to follow up with a SIBO breath test to confirm that they do in fact have SIBO and then be able to address it from there. So if we think through this, what are we looking at? The biome effects, like I mentioned, is looking at the colon. So it's looking at the large intestine where the small intestinal, or we call it a small intestine microflora imbalance or our SIBO test that's looking at the small intestine. So having both again, it's just looking at that entirety of the intestinal tract to really better inform where you want to target your interventions.
And then of course, of course, looking at the root causes because SIBO usually doesn't just show up because the body decides to make more bacteria. SIBO shows up as a symptom of some other root cause that's causing it. So you always want to look at what that root cause might be and look above the small intestine, sometimes below, you know, definitely there's, you know, parasites or something like a migrating motor complex issue, but this would be what you'd want to be thinking about.
So for biome effects, when you're thinking about, do I use this or not go back to what the dysbiosis risk factors might be for that particular patient. So do they, are they excessively using alcohol? Are they, have they had a history of antibiotic use?
Um, are they stressed and we have a stressful lifestyle? Are they excessively exercising? Cause exercise, um, in excess, especially endurance type activities can really cause imbalances in that. in those intestines. And then with that bacteria, smoking, obviously poor sleep, standard American diet, and then glyphosate exposure.
We know glyphosate can alter the microbiome in a negative way. And so these would be some other dysbiotic risk factors. Dysbiosis is going to cause leaky gut and leaky gut then can trigger that inflammation and an immune response. So these are going to be your people who are coming in with more systemic issues beyond just digestive complaints.
A biome effects test is also going to give you that broader overview of the functions of the microbiome and then also look at what could be optimized. And it's a good first step. I know many of you were saying, you know, do a stool test first and then do a SIBO test after that if warranted. And so that's definitely an approach that you can use. So it's great for people who are coming in with multiple issues.
So whether it's metabolic dysfunction or nervous system disorders. or liver health issues, it's a great first option because then we can see how is the microbiome possibly contributing to some of those concerns and possibly contributing to that leaky gut. And it helps with driving more specific testing that should be done.
Now a SIBO test, the way I kind of think of it is it's that more targeted testing. So it's much more specific. So you'd go through those questions of does my patient have daily chronic bloating, cramping, and nausea. So it's not going to be cyclical.
SIBO doesn't decide to cause symptoms on a Tuesday or a Wednesday and then be fine. You know, Thursday, Friday, it's going to be every day and it's going to be chronic. Um, usually they're going to have some level of bowel movement abnormalities.
So whether it be diarrhea or constipation or alternating between the two, um, they also tend to not do well with carbohydrates or fibers. And so you If you have someone who comes in and they're like, I started eating healthier and I'm eating more fiber and my stomach is just killing me and I am feeling worse. That would be something I'd be thinking about if they have a diagnosis of IBS, because IBS is really just this, you know, kind of vague diagnosis.
I believe it's about 60 to 80% of SIBO is now, or 60 to 80% of IBS actually has SIBO as an underlying root cause. So Yeah. It's highly likely if someone is coming in with a diagnosis of IBS that they probably have SIBO at some level, not everybody, but it's definitely worth looking at. If they have the patterns suggestive of SIBO, they're worse with fruits and vegetables, makes their symptoms worse. And if they've tended to do a lot better with more refined grains versus whole grains, then again, there's less fiber there for the bacteria to ferment.
And so they may feel better with more refined carbohydrates. Um, if they have a history of not tolerating probiotics or prebiotics, that's another telltale sign. And then of course, if they have a history of food poisoning, um, I think it's, you know, about 12% of food poisoning goes on for post-infectious IBS and SIBO. Um, but food poisoning causes about, or is an underlying root cause for about 60% of the SIBO cases.
So when we're thinking about root cause of SIBO. food poisoning is certainly something you want to be adding into your assessment to see if that's part of that clinical history. All right.
So start here. I'm going to walk you through my little algorithm and take us, you know, this is sort of my own, it's a clinical art to, to how you think through a patient case. And of course everyone's different, but this, if you're newer to this, or if you're wondering, how do I choose this might help. So First of all, look at your patient and is the primary symptom or the primary complaint GI? If it's daily GI symptoms, then I would probably go with a SIBO test.
If it's more cyclical or periodic, then I would go with a biomeffects or a stool test. Now, if you have a patient who's coming in with other symptoms, maybe with or without GI symptoms, again, go back to the frequency. If they have GI symptoms, go back to that frequency and start back up here.
So again, go back to, is it cyclical or is it daily? And that can inform on which tests you may want to go with. Now, if you have, through your assessment, identified that there are several SIBO risk factors present, then you may want to consider a SIBO test if they're having GI issues, because you want to see if maybe that's a factor that you want to be dealing with and how do those risk factors, to what severity are they causing that SIBO to occur? Now, if they have dysbiosis risk factors, so the ones that I was mentioning earlier with the alcohol use, the stress, and you've done a biomeffects test, and then you're seeing SIBA patterns present, then you may want to do a SIBA breath test. Now, yes, there are going to be people who fall into all these categories, and there are going to be more complex patients that you are going to have to kind of tease through that.
But this can be some of the thought patterns and thought process that you can go through to if... You know, you can't get both tests at the beginning to try to decide which one you want to go with to, to inform your decision. So what are some practical solutions? This is the microbiome labs protocol that will kind of go through the core products of why you might use them and how they can be used if someone has SIBO.
And then I'll talk about if you are choosing to do antibiotics or antimicrobials or an elemental diet, how you can also utilize these along with those therapies. So let's first talk about HU58. This is a very high dose, high potency Bacillus septalus HU58, which in and of itself is able to secrete about 24 different natural antimicrobial byproducts. And some of these can target those very common pathogens in SIBO like E.
coli and Klebsiella. It also can help with ammonia production, with lowering the ammonia. And this is something that can be elevated in someone who has SIBO, since ammonia is part of that proteolytic or that protein fermentation through the utilization and metabolism of glutamine. And so if someone has a really high ammonia on their biome effects test, and they also have SIBO, this is a great option. And there's actually a study that was done on it that showed that lowering of ammonia in patients who had hepatic encephalopathy.
So this would be an option. Mega IgG is another great option. Dr. Jacoby was mentioning this shift that happens in SIBO, which is a gram-negative shift. And if you're familiar with gram-negative bacteria, you know that they have as part of their cell membrane, a component called LPS or lipopolysaccharides, which is basically a fat sugar, lipo being fat, sugar being saccharide.
And so these are highly immunogenic. If these LPSs are able to pass through the intestinal barrier and get out into circulation, they have been linked to a wide variety of metabolic imbalances, mental health challenges, cardiovascular issues, insulin resistance, fertility struggles in both men and women, you name it, there's probably a study that links LPSs and endotoxins back to it. And so one of the things that IgG is really great about doing is helping to bind and neutralize those LPSs.
And so it's a great strategy for those who have SIBO, because if they have SIBO and they have this gram-negative shift in the bacteria, then they're probably producing a lot more of these LPSs. And so we want something on board for that. Megaguard is an herbal blend that is a combination of artichoke, GutGuard, which is a very specific type of licorice extract that has a lot of really wonderful anti-inflammatory properties. And then it has ginger.
And I will say this is one that I really like to use because people can feel a difference pretty quickly. It can, it's a, it's a very nice, gentle prokinetic. So it can be utilized as part of a CIVA protocol to help with that gentle encouragement of gastric emptying and small intestinal transit time.
to support the MMC unless they have adhesions as Dr. Jacoby was saying. So if someone's feeling worse with this, that might be again, looking back to see if they have a risk factor, whether it be a C-section or some sort of trauma to their intestines or to their abdominal area, that they may need to have those adhesions addressed before being able to go through and do a prokinetic, but this is a really nice option to help to gently encourage. biliary flow, and also motility for those that have SIBO. So it's great for constipation and bloating. And also for if someone's having a lot of upper GI symptoms like reflux, or if they have H.
pylori, which can be another root cause of SIBO, it's a great option for that. And then FODMED is a, it's a digestive enzyme blend. That's very specific. So this is not a broad spectrum digestive enzyme. It's not going to have your brush border enzymes or your pancreatic enzymes like Dr. Jacoby was mentioning.
This is really much more targeted towards just helping to break down those FODMAPs. So it's going to have a combination of beta galactosidase, which helps to break down lactose, alpha galactosidase, which helps to break down our very long chains of oligosaccharides or, you know, very long fibers. It also has exo and endo inulinase, which helps to break down some of those FODMAPs that are a part of like garlic and onion. Um, it also has glucose isomerase, which helps to convert fructose to glucose. It's more easily absorbed, um, and then pectinase.
And this is not intended to be a long-term solution. It's really more of a symptom management tool, but it can really help if you have someone who's following a low FODMAP diet, or they're following a biphasic diet. Um, if you're wanting to try to expand some of those foods, or if they're wanting to try to bring a few of those options back in, um, or if someone just can't adhere to that diet. for whatever reason, this can help to modify some of those symptoms and allow them to still kind of keep a larger, more expanded diet. So it's, it's helpful in that way.
It's also has a delayed release cap. So it opens in the small intestine, which is where you want your enzymes to be. It's not going to open up the before then.
So we recommend just for use two to three months maximum. Cause we, again, if it's breaking down those long fermentable fibers, We don't want that long-term because we eventually want somebody to tolerate those fibers and feed their beneficial microbes in the colon. So that's why we say maybe just two to three months maximum for this.
And then Zembium Dual, which is, has been out for a couple of years now, but it is our dual strain, which has a combination of bifidolongum 35624, along with bifidolongum 1714. The 3564 has been extensively studied in IBS. And so, um, again, it's very effective in helping to alleviate the symptoms of IBS and help with modulation of the bowels and those bowel movements. Um, whereas the 1714 is more for the brain.
So this is our gut brain access, um, product. And what's interesting about SIBO is there are studies that show that SIBO affects the way that tryptophan is metabolized. So when we think about neuroinflammation, so we think about depression and anxiety and brain fog and difficulties managing stress. Part of that comes from having a higher level of neuroinflammation.
And one of the things that can, that can cause that is if tryptophan is going down the more pro-inflammatory pathway and SIBO really does drive that there've been studies that show that more pro-inflammatory byproducts are in SIBO and those that have SIBO versus those that don't. And when undergoing SIBO treatment through things like rifaximin, you actually can shift those inflammatory patterns and, or those inflammatory by-products, and you can start to see more of an improvement in their brain function and their brain symptoms of depression and anxiety. So if we can do that through also supporting it through the sphincter long gun, 17, 14. we can start to help reduce that neuro inflammation and improve that gut brain access function. That's very common in those that have SIBO.
So if we put it all together, if you have somebody coming in and they are diarrhea, predominant IBSD, and maybe they're hydrogen dominant on a SIBO breath test you could bring in restore flora, which is a blend of spores plus some Saccharomyces boulardii which can be helpful for diarrhea along with the HU 58. with the mega IgG, which is very effective for diarrhea. And then the mega guard, just maybe one cap per meal. If you have constipation predominant, um, or IBSC or methane dominant on the breath test with constipation, then you would do the HE 58 with, um, mega mucosa. And the reason I say that is because sometimes there are people who feel that the mega-IgG gives a little bit of a sensation of constipation.
Um, and so what I have found to be helpful clinically is actually do two doses, do a double dose of the mega mucosa for those that have constipation. So you're still getting those IgGs. You're still getting that beneficial, um, IgG on board to help with those LP, the binding of the LPSs, but you're not going to be, um, causing that sensation of constipation for people. Now, some people do great with IgG when they're constipated, but if you have someone who is seeming to struggle.
Um, with the IgG, then you can have them do a double dose of mega mucosa. And for whatever reason that doesn't cause the constipation to, to feel worse and then, um, have them do the mega garden. You can go up to two caps per meal with mega guard.
Um, I don't recommend you start there. I would recommend that you start low and go slow as you work your way up. Um, but that can be a way that you can, um, help with the management of those symptoms.
Now, if you're choosing that you want to use antimicrobials or go with a prescription antibiotic, Um, you could then use alongside those, the restore flora just to help with, um, preserving that microbial balance, or you could use HU 58. Um, I would say if someone's tending to be more constipated, I would go with the HU 58. If they're struggling more with diarrhea, I would go with the restore flora. So you may want to customize that based on your patient's symptoms with the IgG and then the mega guard. So those would stay the same. And if you're having them do an elemental diet.
Um, you can, if they're having die off or if they're having, um, a lot of diarrhea along with that, um, I've had people, um, who have done the mega IgG along with it, um, and just put it in the shake and they've done really well. Um, so starting low and slow, so maybe just a half scoop a couple of times a day, and then gradually increase that to a one scoop a couple of times a day, or just as needed again. You just would want to monitor your patient and ensure that you're not going too quickly with that ramp up and only using what's necessary. But it can be helpful in just alleviating some of those symptoms, especially if they're struggling with diarrhea.
So in summary, we can say that SIBO is a condition that really affects many of our clients. And it oftentimes is going to show up or masquerade as IBS in your clinics. But if you can identify it. And if you can recognize the symptoms and then use proper testing to identify then the best course of action to take with that client, then you can really have better client outcomes and satisfaction. So please give feedback.
I'm going to leave this up for just a second. Give us feedback on the talk, on our talk, on my talk and on Dr. Jacoby's talk. We'd love to get your feedback.
because we will look at this and it helps to inform us for future events. So feel free to either scan the QR code or you can go to that link and then enter the code gut. And that'll allow you to answer a few questions, brief questions.
It should only take you five minutes. And then we'll look at that and gather that information. So really would appreciate any feedback you have for us around the content of this presentation.
And I just wanted to mention a couple of upcoming educational events. We have Lacey Hall, who is going to be giving a presentation with full script on the 21st around how to select a probiotic. We'll be at a forum in Las Vegas in December.
And then we have our next mini keynotes event in January, starting in January with a woman's health focus. And so that's going to be really exciting. We'll be discussing all things women's health, and then please save the date.
If you haven't been to our... uh, MBKS or our microbiome keynote symposium that will be in Nashville, uh, next year in September at the grand Hyatt. So just wanted to put that on your radar.
Cause we really have a wonderful event with lots of wonderful education and speakers, uh, to pioneer the microbiome, um, and discuss all things new and upcoming with microbiome health. So with that, we will go into Q&A. And we will, I have gathered some questions, and Dr. Jacoby and I will just have a wonderful little conversation here.
And I'll try, I see that there's some questions in the chat. I'm going to start with the questions that are in the Q&A box. And then I'll go to the chat. Okay, so Dr. Jacoby, what you were talking earlier about there are some patients or there are some studies that show that Synthroid or T4 medications may actually cause SIBO. So what would be your recommendation if somebody is on something like a Synthroid or a T4 medication?
Well, I've had that happen a few times. People come in with T4 only medication. And I practice in a country where I'm not a licensed physician, so I can't prescribe medications.
But I recommend that they get a different prescription to see if there's any improvement in their symptoms. So that's the easiest and, you know, labs permitting to change the prescription. Um, going back to some of your cases.
So there was in your first case with a male patient with chronic SIBO and mold, um, who was on the two courses of Zyfaxan, um, and had, and then on the two week elemental diet with a flatline, what made you suspect mold or SIFO over hydrogen sulfide? Um, so Remember that it wasn't a flat line to begin with. He had very, very, very high levels of hydrogen. So it's always in the context of the previous lab that you would consider a flat.
Like if you have somebody who comes in with chronic diarrhea and you do a SIBO test and they do flat line and flat lining is a really subjective. Well, we haven't really defined. You know, we don't have any guidelines to help us other than a flat line consists of hydrogen not reaching higher than two or so and zero to zero to two and methane being more or less zero.
And that wasn't really the case with John. But it's a good question because he did have a lot of burning symptoms, which can kind of. nudge you towards hydrogen sulfide, but the classic SIBO hydrogen sulfide will have diarrhea. And that was not his primary complaint.
He did get diarrhea from the elemental diet. And that to me was a clue because the elemental diet is high in glucose and his symptoms just all worsened with that. And to me, that is more of a mold and candida issue potentially. And especially with...
upper soft palate sort of mucosal burning. I often think of either issues around eosinophilic esophagitis or SIFO and candida. And luckily that turned out to be the issue. There's a lot of confusion around hydrogen sulfide because essentially we only have one lab in the country that offers hydrogen sulfide breath testing, which... To me, that's not good enough.
You know, that doesn't mean we have actual real testing available for that. And stool testing is, like what you were saying, Alicia, gives you little clues, but we cannot draw any conclusions from that. So, yes, as a practitioner, we are left to take educated guesses and hunches as well as, you know, sometimes trial and error.
So. For me, it was the total symptom picture and the presentation that then finally was like, there's got to be a mold issue. And SIFO is so prevalent in SIBO.
You know, Dr. Rao did a study a few years ago about that 25 to 30% comorbidity. I find it often higher, but I see the very chronic, difficult cases that have failed everything. So I do see a lot of SIFO in conjunction with SIBO.
And just for everyone here, just as a list, there's also very specific symptoms that go along with hydrogen sulfide generally. So what are you looking for when you see a suggestive SIBO breath test? Maybe it's a flat line or close to flat line.
What are some other maybe hydrogen sulfide specific symptoms that you're looking for that we can look at? So, I mean, classically, you're going to look for rotten egg smell, sort of, you know, erect. ruptations and flatulence, but that's not always the case.
You know, I have seen hydrogen sulfide cases rampant without that symptom. And we now know it's, you know, there's lots of players in the hydrogen sulfide game. It's not just the sulfovibrio, it's fusobacterium, it's lots of other organisms that can actually upregulate the hydrogen sulfide pathways. So it's an interesting concept.
And my... thought on these chronic cases is that there is an issue around hydrogen sulfide metabolism. And there is... some thought around why the body is wanting to upregulate hydrogen sulfide production for different reasons for the purpose of getting sulfur, which is integral in many pathways.
So it's a complicated issue. I think if you really want to nerd out on SNPs and going down the genomic pathway and also different kinds of issue around thiols. and sulfur containing issues, then read Dr. Nye's book, The Devils and the Garlic, which is kind of an odd name, but it's a great little book that you will go down the rabbit hole of hydrogen sulfide. And I've had some success with that with my chronic patients. But to get back to this issue of flatlining, a lot of people get confused on that.
And having a test that goes from hydrogen in the 160s to... down to three is not a flat line to me necessarily. And importantly, and Dr. Pimentel talked about this as well.
I, I, you know, I have some differing opinions from Dr. Pimentel from time to time, but in this case, he really talks about that hydrogen sulfide SIBO, they have really bad diarrhea, like 10 loose bowel movements a day type of situation, you know, so. A little bit less than microscopic colitis, but it's pretty strong. So to have just burning symptoms alone is not enough for me to be convinced that this is hydrogen sulfide.
Yeah, it's usually going to be more systemic and more issues than just that. So many providers are using combinations, including Wormwood. Are you?
And if so, do you have a dose and a length of time that's necessary? Yeah. So I actually gave a presentation about wormwood at one of the SIBO conferences, probably eight years ago now or so. And I went through a lot of the different herbal and I'm in Australia now.
So I say herbal. I don't say herbal. You know, it feels weird to me to say herbal. So anyways, there are many different antimicrobials that will be very effective.
And. As naturopaths, I think we're very educated in the use of antimicrobial herbs. And wormwood, artemisia, is a great one. I don't use it in every formula, but that formula that I've written out for John, I can't even remember now what I put in there.
But this is the opportunity to really customize that formula for your patient. So if you have burning, you can put in... demulsions if you have you know you can just customize it with with what you're doing so in the the dose of artemisia really depends on the strength of tincture or or capsules etc so as we have we have a saying in australia how long is a piece of string right so it's it really depends case by case but i love using herbal tinctures because because you can customize it and because it is so great for proximal SIBO.
But to answer your question, yes, Artemisia is one of the many herbs that works really well. We have the most data, I think, on berberine. So berberine-containing plants are really wonderful because they also have this mucous membrane tonifying effect.
So there's lots of benefits for that. You can customize it based on whether or not you have people that really have a damaged brush border. There's so much you can do with tinctures. Sorry to be so not specific with dosage.
But that's also the art of having that herbal training, being able to customize. It's not a one size fits all. Do you do anything differently for your Ehlers-Danlos patients? So Ehlers-Danlos is, it's really on a spectrum.
I have patients that were really disabled and have this problem with pretty much GI collapse when they're standing up versus lying down. And that's advanced, right? I have people that are at early stages or never will progress.
So it really depends. You know, I've tried a lot of things around connective tissue strengthening issues. And that, I think, is... potentially a way to help slow down the progression.
I've not seen any reversals of anything. So it's really about case management. And Alana Guggenheim in Seattle is an amazing expert. She's a naturopathic physician.
But she's booked up for two years. So don't try to get your patients on that waiting list. But she's done also some courses for practitioners. So check her out.
I think that's a really helpful way of understanding this condition a lot more. It's apparently as prevalent as celiac disease. So I think we all need to understand more about this connective tissue disorder.
But again... It's a real spectrum of how that, like some people have very little symptoms and some have, are very debilitated. Yeah, definitely. And think about with Ehlers-Danlos too, there's oftentimes like mast cell activation pots, there's usually very often.
The advanced cases. Yes, yes. The advanced ones can have real dysregulation of lots of things and it's difficult.
It's really difficult. If methane and hydrogen sulfide are not elevated on biome effects, is it unlikely that SIBO is an issue? You know, that's, that's kind of a hard one to answer because there could be either, could it be maybe they're hydrogen dominant SIBO, you know, if they're having a lot of diarrhea. So if they have a lot of the risk factors or if they have, because if you think about what, what can be elevated in SIBO, you have methane, you have hydrogen sulfide and you have hydrogen.
And so just, you know, if someone's struggling with a lot of diarrhea, Um, they may not have hydrogen sulfide or methane on their biome effects, but that might not be the case of what's going on in the small intestine. So again, just remember, you're looking at two different areas of anatomy. So it's possible maybe that they don't have SIBO, but I wouldn't, I would go off of their clinical presentation and use that really to inform along with maybe some of the other patterns that I was mentioning, um, to see if, if that really, you know, is. something you should investigate or not. So, um, Karon said from his previous videos that SIBO testing is only 50% accurate.
So curious if MBL is doing it with more accuracy. Um, and I'd love to hear your perspective on kind of what you think. And I think with, there's no test that's going to be perfect. Um, and I wouldn't say it's 50% accurate.
I would say that it's, it's more accurate than that. And we do have data to say that it is. Um, but there's an art to it. There's an art to interpreting SIBO testing.
It's not as simple as, as just saying it's positive or it's negative. There's an art. So I think you have to have training and understanding how to learn the patterns and the nuances of the SIBO testing. And for example, like Dr. Coley was saying, you know, kind of looking at your methane levels and, um, you know, correlating the patterns of the test along with the clinical symptoms of the patient to then say whether yes or no, this is positive or not. And Dr. Jacobi, I'd like to hear just if you have any thoughts to you on just sort of accuracy of SIBO breath testing.
Yeah, I do have a lot of opinions on that. Actually, I've seen, you know, tens of thousands of breath tests. I own a breath testing lab. I talked to practitioners about it.
It's definitely more accurate than 50%, I would say. I understand the concern of And I do think that SIBO is overdiagnosed. You know, I do think that we always have to use the lab tests in conjunction with a patient presentation and their story and their symptoms.
Just like I showed with this case of Ellen, we resolved her methane without having to go by the book of reducing that methane below 10. In my course, the SIBO Mastery Program, which is a certification program, I go... in depth about these different patterns and what the flatlining, how to really diagnose that and, and all of that. So it is an art, as you say, you know, it, um, and there's always this tendency to go with the numbers, uh, but you have to kind of put it all together. And that's, that's where the art comes in.
Definitely an art to, to interpret. Um, let's see, would you use FODMAPE for someone with SIBO and pancreatic enzyme deficiency symptoms on a pancreatic enzyme, oh, on pancreatic enzymes. You could now remember your, it's two different things.
So FODMAPE is really just specific for helping with that fermentable fiber, those FODMAPEs, those highly fermentable carbohydrates. It's really an enzyme blend that's specific for helping with those versus someone who's like you said, on pancreatic enzymes, you know, they're not going to compete with each other. It just may help with the tolerance for some of those other foods. So you could, you could use that. They're just, they're just different enzymes.
Um, let's see, is the FODMAP digestive enzyme still effective for food metabolism? If the capsule needs to be opened and taken with water due to difficulty with swallowing capsules. So part of the magic of the FODMAPE is that it has that delayed release capsule. So opening it probably would not be very as effective as taking it whole.
So I would, I would suggest that you want to look at maybe another way to support this person because the, you're going to get the best efficacy if you keep that capsule whole. So it's able to get to that small intestine. Um, so someone's asking about the process cost of the new breath test through MBL. Um, definitely just, um, let's kind of bring that offline, but talk to your rep about that.
And we can, we can definitely help you through that if you're curious or feel free to email, um, you know, email your rep afterwards and they can get in contact with us and we can help you through that. Um, and then what if, oh, and what of Hashimoto's and taking levothyroxine? Can there be a complaint? relief or reversal?
And if so, what would be the protocol? I've never seen a complete relief of SIBO with just thyroid medication, to be honest. You know, I think at that point, you have different microbiome patterns have been set up maybe over years, and you can't, if you just switch up the medication, I wish it was that easy. I really wish it was that easy.
But it's, it's not so. I think it's more about the prevention of recurrence once you cleared SIBO after you potentially change the medication. And we know, you know, the way I always think of thyroid, and Hashimoto's is of course a little different, but you know, there's sort of this element of the emergency brake being pulled when something is going wrong. And that's the role of reverse T3, really.
So... Rather than overriding that, it's addressing the issue that's pulling the handbrake to begin with, and then correcting the thyroid pathways. It's sort of my approach. Let's see. I'm going to look through, I'm looking through the chat here.
Do you see issues with the ileocecal valve malfunction as a primary issue that can be permanently resolved? I've seen it very rarely that it is the only. The only reason I have seen it, and that often shows up when people have had appendectomies and there's scar tissue around the ICV that causes a permanent opening. And the idea is, or the concern is that there's retrograde motility from the large intestine into the small intestine, so more distal SIBO.
It can happen. I don't see that very often as the only thing. But it does happen. And I have a how to release the ileocecal valve maneuver video on my website. So you can check that out, too.
That's that's a good one to have anyways, because it teaches the patient how to release it. And it's a it's a daily before bed kind of maneuver that the patient does themselves. Yeah. And I've actually watched that video. It's the, it's the, you use your leg and you sort of do this rocking, right.
You sort of do this little leg maneuver. Yeah. You have to traction just right.
Yeah. Yeah. It's like a two minute video.
It's really, it's helpful. Um, uh, let's see. Um, so someone's asking about if biome effects looks at mycotoxins.
Um, so it looks at the phylum Ascomyota, which is where we have all of our fungi. and mycotoxins, that's the phylum that those all live. So if you have someone who has elevated Ascomyota, that definitely be thinking about mycotoxins or falling up with a mold test or, um, CFO, um, Candida testing, because that those would be where those microbes are going to reside.
Um, could food poisoning causing SIBO possibly be a parasitic issue? So, um, no. Well, I shouldn't say that so glibly. There is one protozoan, the Giardia, that has been linked to the migrating motor complex damage through this same pathway that we discussed where a patient gets a food poisoning with one of the bacteria that we know causes food poisoning, Campylobacter salmonella E. coli.
those organisms release silo-lethal distending toxin B and the body makes an antibody against that, which very much looks like vinculin, which is an integral component of the MMC. And that's how we end up with autoimmunity against our own migrating motor complex. I have not seen parasites that cause this.
And, you know, I would say I would add to this that I personally have not seen 60% of SIBO be caused by this pathway of infectious IBS, so post-infectious IBS. I have not seen that to be the case. So maybe that's my patient population, but that's not my experience.
It is common, and that's why it's important to always ask about it. But as I've just mentioned in my presentation, there's lots of different contributing factors that can really entrench a pattern and cause this SIBO overgrowth. So yeah, to answer your question about parasites, it's not been my experience.
Let's see. So someone's okay. So my understanding is do not give me Do not give Megaguard to those who do not have constipation as it can create loose stools. So what's interesting, so what's interesting about, you know, prokinetics versus laxatives is there's definitely a difference between the two. So prokinetics like Megaguard or any of your natural ones that have like artichoke ginger, that type of thing, those are going to work on the upper gut.
So like stomach emptying, small intestinal and transit time. Not as much on the colon. So I personally have given Megaguard and I have given Proconnex to people who have diarrhea, especially if they have hydrogen dominant SIBO, just because it helps more with that coordination of motility.
It's not going to be like a magnesium or a Neuralax or these laxatives that stimulate phalonic or they pull water into the bowels to stimulate a bowel movement or encourage a bowel movement. So. I've used Megaguard in those that have loose stools. I wouldn't say that it's common that it causes loose stools.
So I haven't had much of an issue with that in my clinical practice and just in, you know, other practitioners, but that's not to say that there isn't someone who might have that reaction for one reason or another, just because maybe you have a more sensitive patient, but I wouldn't avoid it necessarily in those cases. Because if you need help with encouraging that migrating motor complex to work more efficiently, you want to be doing that so that SIBO isn't, it's more likely that you'll kind of reduce that SIBO. Let's see, can you just use Enviome at one per day?
You could, the steady dose is the two per day. So, you know, we wouldn't, you couldn't guarantee the same kind of outcomes with the one a day, but you could if that's all that. somebody's able to do.
If let's see, if a patient has worsening depression, brain fog during a kill off stage of a parasite with a dual help, I have taken IgG and I feel like it disrupts my sleep. I love IgG, but this was a side effect. You could try that for sure. I mean, it might be, it could help with that neuroinflammation. It could help with some of the brain fog and some of the gut inflammation as well.
So that's one of the things with three, five, six, two, four, that strain, it helps with reducing visceral hypersensitivity. That's the main mechanism of action on that with IBS is it helps to lessen that visceral hypersensitivity. And so it just, it helps with the, um, the GI in that way.
And then it has that 17, 14 that could maybe help with the, um, depression, but, you know, you could also think about maybe other binders as well. Um, so maybe like charcoal or, um, I'd another type of binder if you're not able to tolerate the IgG, but dual could be a good adjunct as well. Can you open the HU58?
Yes, you can open the HU58. If you take an antimicrobial, how far apart do you recommend to take probiotics? And I'll let you also kind of contribute what your thoughts if you're Dr. Jacoby, but you know, it depends on for me kind of, and I've heard various things and I've heard Dr. Seebecker actually talk about this and I'd be curious to know what your thoughts are, but. I also have heard that with probiotics and natural herbals, spacing is not as much of a concern because there's actually a synergy that can happen with the probiotics and the herbals.
And so you're not having to worry so much with spacing as you would a prescription antibiotic. Is that your experience? Yeah, I agree with that for sure. And there's lots of different reasons for that and different antimicrobials.
target bacteria in very different ways than antibiotics. But I've not had an issue with spacing. When you're dealing with something where you have to give a lot of products, it just becomes a full-time job for that patient to try to space. So I don't really worry about that when it comes to antimicrobial. I might make an exception with, well, I don't even know if I can mention these things, so best not to say.
Yeah. I mean, it's okay in Q&A if you want to mention it. Yeah.
Well, like, you know, sometimes, well, no, it's all right. It's, it's, I don't even know if it's available in America, so it's, it's all right. Yeah.
Okay. What ages in children is the BAMFX applicable? So we do our reference ranges.
The sample population does go as young as five. So we have what they, what they're using as a reference ranges does include. include children as young as five. I will go as low as two.
But you have to then interpret it a little bit differently, because the microbiome of a child, especially a young child is very different from an adult. So you can't, you have to kind of know and understand the patterns of what the microbiome looks like in children, and look at it through that lens, versus through just looking at the reference ranges. So you just the interpretation is a little bit different, but but we do as part of that sample grouping to create those reference ranges go as low as five years old. Someone said your son told you that his farts smell like rotten eggs. So maybe yeah, do some testing with him.
So okay, so this is more of a sort of a practical application with the parameters around testing. So this person is asking, why is the GI gastroenterologist recommendation, say avoid everything four weeks prior to SIBO testing, no antibiotics, bismuth, herbs, is your SIBO? Oh, do we have a SIBO test that have significant worth of things to avoid for weeks?
Yeah, so I know you have your own one in Australia. So you know, what's your prep? And then I can kind of tell what our Yeah, so the main ones is antibiotics for obvious reasons, right? So we want to actually have a proper regrowth to demonstrate that SIBO is present.
And then also the colonoscopies, typically you have to wait a month before the breath is. Those are really the main things. And then there are some probiotics that have been shown like the Bifido, which one was it now, I have to look it up, but there's, it's on our prep sheet that to avoid certain probiotics. because they have actually shown to be reducing methane on a breath test.
So yeah, so those are, I'd say the main things. And we have, you know, we have a really stringent prep diet, because the more stringent you can make it, unfortunately, the better results you actually have with with test interpretation. And so we have a pretty stringent prep diet, and all that.
So Yeah. Yeah. I would say prep is probably one of the most important things with SIBO because if you, if you don't prep properly, then there can be some alterations. It's going to be very confusing. You're going to have a high baseline, which basically makes the test, you know, very difficult to interpret if at all.
Yeah. Yeah. So prep definitely is important.
And yeah, we, we kind of, we have a very strict as part of our SIBO testing, a very strict diet as well. um, very strict, um, parameters around, you know, as far as like how, how long you have to be awake before testing and teeth brushing exercise, exercise and all of that. So, so yes.
And that all comes with the kit. Um, but yes, obviously you don't want to be on antibiotics and bismuth and, you know, antimicrobial herbs, just because you don't want to be reducing, you want to be getting a good baseline when you're doing that first test. So, um, so yes.
Um, do you have anything at times about 10 minutes? So do you have an opinion? There are a couple of people who are asking about like the food marble and all of that.
Yeah. So, um, you know, I've had conversations with Alison and other practitioners about the use of that. And I think it's got a place, but not for the diagnosis of SIBO. It's good to, to kind of monitor direct response to food, um, if they're fermenting it, but as an actual SIBO test, um, I have not relied on that at all. I've had some people that had it when they came to see me and we used it as a way of reintroduction of different FODMAP containing foods on the biphasic diet.
So that's been useful. But again, it's not been consistent enough for me to be fully on board with that. Any thoughts on L-glutamine? Well, L-glutamine. you know, is, can actually, I've had a lot of people react to high dose glutamine, which is so disappointing because it's like such a great cheap product.
You can, you know, add scoops of it to your protein shake and all of that. But when somebody is really, really activated and especially if they have a lot of SNPs, there can be some reactions and It's not the norm, but it can happen if you go into the 5 to 10 grams twice a day or so, it can happen. And then the super sensitive, of course, will react to everything.
And they are so dysregulated that they produce glutamate pretty quickly and become quite anxious and things like that. So I always titrate that with them and don't usually. added in until much later. Yeah.
And glutamine definitely, you know, if someone has a lot of those ammonia producers, that's one of the things that's, you know, on bum effects is you can see that elevated ammonia, which then can obviously put more pressure on the liver can tax the detox pathways can cause some, you know, mental clarity and brain fog issues. So yeah, glutamine is something you kind of want to be mindful of in this population with that. So, so Yeah. Brittany's asking in the Q&A, how can you assess for ileocecal valve dysfunction?
And what would be your approach to that? So first of all, it's hard to describe, right? Because it's a physical manual maneuver that you do on a patient and assess if there's pain and restriction. And I think I go into that. I can't remember now if I go into that.
But in other videos, I do. And a great... The resource for that is Stephen Sandberg-Lewis.
I had him come over to Australia and teach a whole day on physical assessment and maneuvers because he's very good with different maneuvers. Also, the hiatal hernia maneuver, which is so important. So that's also a course that's on my website that you can watch that teaches you how to actually do these physical assessments and how to correct.
them so that's yeah that's difficult to describe on on a video here but it's you know mostly what I mostly have people do is that video that I talked about before where it's just a maneuver and have them do it for a couple of weeks it can't hurt them um and and you will know that it's working if all of a sudden and especially in the in constipation types it's it's really helpful you Yeah, definitely, definitely check that out. It's very easy. People can do at home. Let's see, how do you best? So there's a couple of questions about kind of intestinal lining.
How do you support the mucosa? Would you support intestinal lining for a few weeks before starting a SIBA regimen or a SIBA treatment? You can, I mean, that's our mega mucosa is great.
And I didn't mention it in kind of the acute phase, but, you know, definitely bring that in to help because SIBO is going to be part of that trigger for. you know, intestinal permeability and damaging the mucosa and definitely disrupting enzyme function. And it just causes a lot of chaos because you have this overabundance of bacteria giving off these byproducts that can be very inflammatory when it's going on in the small intestine, which doesn't have the anatomy set up like in the colon to handle that kind of bacterial load and those byproducts.
So making mucosa can be helpful just to support that mucose that mucus. barrier and that mucosal lining, it does not contain glutamine. So that's one of the things if you have someone who has high ammonia producers or high ammonia pathways, you can utilize that without worrying, or if they just can't tolerate glutamine.
Cause there's a lot of gut repair products that have glutamine and megamycosis does not have that. But when do you, Dr. Jacoby, do you have an, I know it'd be case by case, but when do you kind of bring in your gut repair, your intestinal lining? Well, actually, um, I, you know, it's a real integral part of the biphasic approach.
And one of the reasons I developed the biphasic diet and protocol is because, as I mentioned, I didn't want people to walk out with 20 supplements. And a lot of times when people come to me the first time, or let's say they come to you, they're what could be considered a straightforward SIBO case, where they're bloated, they're, you know, have all the classic IBS symptoms, and you have them just do the like you do the breath test it's positive and you just put them on the first phase of the biphasic protocol which is really really strict FODMAP avoidance which gives gives you example diets etc and I do add in mucosal repair and digestive support that is phase one of this protocol is actually not the killing phase because when somebody as you mentioned Alicia is so inflamed and their brush border is so damaged from SIBO gases. And then you add antimicrobials to that. I just found that the die-off was so significant that this approach, where you actually just support the mucosa and reduce the food for the bacteria, people would already come back.
If they had simple SIBO, they would come back. after, you know, four weeks, and they were like 90% better, many of them. And then you can add in the antimicrobial phase, and then add in a few of the FODMAP. So it's a really, it's a great little protocol to help also with management of too many supplements. Definitely pill fatigue for some of these people.
So, so yeah, so hopefully that answers your question in terms of how you can support the mucosal and intestinal lining. Let's see, we've got a couple more minutes. So do you find that burning bladder often shows up as a SIBO related symptom?
No, not often. And of course, we think of hydrogen sulfide SIBO. First, it's a really classic symptoms. I forgot to mention a lot of other symptoms with hydrogen sulfide, we were kind of stuck with a rotten egg, which isn't always happening.
But Burning symptoms are pretty common with hydrogen sulfide overgrowth. And that is not just SIBO, right? You can have also LIBO, where you have hydrogen sulfide production that's really, really way over the top. So that can then result in joint pain, in headaches, in burning symptoms.
And in the large intestine, hydrogen sulfide overproduction can actually cause constipation. So in the small intestine, typically it causes diarrhea. And in the large intestine, we see more, more, or it's more, in my experience, more associated with constipation.
Yeah. And do you look for the things like the numbness and tingling, the light sensitivity? Yeah, I don't see that that often, you know, so yes, in those extremes, but that's also could be a lot of different things right right so it could be mold could be could be absolutely would be my first thought or dysautonomias right so um it's a complicated soup of of things but once you actually start to tease it apart and you can see how it's once you have all the parts you can see how you how it's not that difficult you can move between these different places anyways yeah Let's see, I think our last question is, have you used Alinea as a treatment for SIBO instead of standard antibiotics?
So no, not directly for SIBO. So Alinea is nitrozoxanide, usually used for parasites. But I've had patients have been given the Alinea for parasites and their SIBO symptoms resolved. So that, you know, I do think that there's a lot we don't know yet. There is sort of this over, well, I wouldn't say overemphasis.
Well, you know, online, the influencers, they all talk about parasite cleanses and stuff. I just have not seen parasites to be as big a deal as a lot of, you know, hype out there. And particularly around blastocystis and diantamoeba fragilis.
I think those two are often... made culprits that aren't necessarily the case. We have a lot of evidence now that blastocystis, for example, is a normal part of the microbiome and actually an indication of a healthy microbiome.
I have blastocystis. I live in a house with a rainwater collection. And how many possums poo on my roof?
I don't know, but that's probably where it comes from. But there are seven substrains of blastocystis and only one is considered to be. pathogenic.
So it becomes more complicated with that. But to get back to the question about Alinea, I think it definitely has its place. And I've seen people get real benefit from it.
But I've also seen it not like it. In theory, it's not. for or in practice it's not really for SIBO yeah yeah and I agree with you the blastocystis is they call that an apex predator where they actually can help with diversity and encourage diversity of the microbiome versus being a detriment so sometimes it's just an innocent bystander that you happen to see if you're you know doing various types of stool testing and it's not the cause and it's not something you really want to go after so yeah yeah I actually did a really great podcast for those of you listening with Jason Horlach who is who just lives half hour from me now. So we're in this little hub of a little pocket of microbiome experts, but a great podcast on the SIBO doctor podcast about blastocystis.
And, you know, how, how often it gets gets mistreated. Yeah, definitely. All right. Well, we are on one minute over.
And so we'll wrap up our q&a for tonight or for you for this. for your morning. But thank you so much again, Dr. Jacoby, really appreciate you coming on and sharing your wisdom and bringing your cases and just having a wonderful little dialogue around SIBO and gut health. So, and thank you all for joining us live.
And if you're watching the recording, definitely check out the recording and the slides, if you'd like to refer back to it. So, and again, if there's anything administrative where you'd like to. I just want to thank Dr. Jacoby for reverting real fast and going live and sending me a recording.
So I really appreciate you being here and for everyone in the chat. Thank you for your questions. And I apologize again for all the little technical difficulties.
Our next webinar is going to be in January. We'll send emails out for that. And I promise it will be smooth sailing.
Fingers crossed. But thank you again for everyone attending. And we will get the recording out to you and the slides as well.
have a good night thanks everybody