Practical Steps to Consider, with Dr. Allison Siebecker and Gary Stapleton
There is a third type of SIBO (besides hydrogen and methane-based SIBO) that currently does not have a test available: hydrogen sulfide SIBO. In fact, it can sometimes look like a flat line on a lactulose or glucose SIBO test. What can patients and clinicians do with the resources available? Guests Dr. Allison Siebecker, Gary Stapleton, and I discuss the testing methods available to assess and validate your likelihood of hydrogen sulfide SIBO, and their experiences in the clinic and in the lab, respectively. You’ll also learn some treatments that have shown promise.
Dr. Michael Ruscio, DC: Hi everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. Today I’m here with Dr. Allison Siebecker, and Gary Stapleton from Aerodiagnostics. And man, I wish we had been recording earlier because I think of all the good stuff we already talked through before we even started recording this call.
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Dr. R’s Fast Facts Summary
Hydrogen Sulfide Small Intestinal Bacterial Overgrowth (SIBO)
- Hydrogen sulfide is a new gas being studied as a cause of SIBO
- Specific hydrogen sulfide test not available as of August 2019 (in development)
Current Method to Detect
- First, test for SIBO using a breath test
- Second, verify the test was performed correctly: did you drink the solution, lab prep, etc.
- If results show flat line (no rise after 100-120 mins):
- AND you have below symptoms, it may be hydrogen sulfide SIBO
- Consider adding hydrogen sulfide specific treatment
- Should be coupled with flat line result above
- Chronic presentation of:
- Digestive complaints (diarrhea, constipation, bloating, gas, etc)
- Pain (abdominal/visceral, pancreas & bladder, joint pain)
- Sensory (photophobia, intolerance to noise, tingling in extremities, numbness)
- Histamine & salicylate intolerance
- Feel “toxic” (hydrogen sulfide is a toxic gas that can damage nerves or mitochondria in excess)
- Sulfur-containing foods and supplements worsen symptoms (Epsom salts, garlic, MSM, berberine sulfate, etc.)
- Rare: gas smells like sulfur (or “rotten eggs”)
- Caution: don’t expect magic pill
- Remember other healthy gut foundational practices like diet & probiotics
- You may not need to overly specialize on hydrogen sulfide treatment
- Low-sulfur diet
- Bismuth with other SIBO treatments (herbs, antibiotics)
- Antibiotics with -mycin (ex: Clindamycin, but does have C. diff risk – Dr Siebecker prefers herbals)
- Bimuno prebiotic (start slow)
- Lactobacillus plantarum LP8
- High-dose oregano
Today we’ll be talking about hydrogen sulfide SIBO, what we can do in regards to treatment and testing, and what we may want to be cautious regarding. And I really want to underscore that point. By now I’m sure the audience is accustomed to me looking at things in this way. Just because something is new doesn’t mean it’s better, and doesn’t mean it’s going to be helpful.
Now it’s also not to say that everything new we should be looking at incredibly circumspectly. But what I think happens all too often—certainly the majority of the time—is a clinician or a patient overlooks tried and true therapies. Meaning they can’t master what they already have at their disposal. So they go for the new and novel, at the expense of what we already know can work. It’s just getting the available therapies to work takes time, thought, follow-up, personalization.
Sometimes it’s easier to say, “Ooh, look at this new thing,” and jump to that thing. But unfortunately—after cleaning up so many of these patients who have been jumped to the new and novel with their provider—I’ve come to realize that we have to start with what we know works first. And then, very cautiously and parsimoniously, consider expanding outward to other therapies.
What is Hydrogen Sulfide SIBO?
So again, we have Allison and Gary here. Where should we start this conversation? Maybe we should start with defining hydrogen sulfide SIBO for people who haven’t heard of it… I’m sure most of our audience has. But SIBO (small intestinal bacterial overgrowth) may underlie a number of digestive symptoms, gas, bloating, abdominal pain, diarrhea, constipation, termed loosely.
But what’s interesting about SIBO—and many a gut condition—is we’re now understanding that imbalances in the gut can also manifest extra-intestinally. So, brain fog, fatigue, potentially high cholesterol and weight gain and higher blood sugar, joint pain, skin lesions. That’s just to name a few. So this conversation is relevant to almost anyone listening.
It’s not a guarantee that almost anyone’s symptoms are being caused by the gut. But it is tenable to say that almost any symptom could be driven by a problem in the gut. And this is where SIBO enters, which I’m sure most of us have heard about. But there’s this new gas which may be able to be tested, to tell about a different type of SIBO: hydrogen sulfide SIBO.
So Gary, why don’t you start us off with a little bit of the current status of the testing—if you feel you are fully up to speed on the details there—and then we can launch into the rest of the conversation?
Gary Stapleton: Yes, thank you, Dr. Ruscio. And I appreciate that both Dr. Ruscio and Dr. Siebecker are participating in this conversation.
Status of Hydrogen Sulfide SIBO Testing
This spun out of an initial conversation that Dr. Ruscio and I had regarding the noise level around hydrogen sulfide and hydrogen sulfide SIBO. And as with many that are listening (and those here on this podcast), we always look forward to new technologies, new approaches to evaluating SIBO, and whether or not there are applications to that in treatment.
However, as Dr. Ruscio clearly pointed out in the introduction, we need to be cautious that we don’t jump from an approach that we’ve used in large part to actively deal with patients suffering from SIBO globally, to newer technologies that may be very exciting and new in research situations, but have not been necessarily tested, nor has the technology been validated to really lead us.
And why is this important? Because there are many patients that are suffering from SIBO. And the noise level about hydrogen sulfide right now is confusing them. We’re getting a lot of those calls in the lab. And what we’d like to do is level set what we know today. We know that hydrogen and methane breath testing for SIBO is very accurate if done correctly both by the patient, by the laboratory, and by the interpretation of that data.
And the way that that occurs is, a patient presents and they have chronic postprandial symptoms. I have to underscore this. Chronic postprandial symptoms mean it’s not going to be mostly or generally or somewhat I have these issues. I’m going to have any of the following and more: bloating, cramping, nausea, joint pain, restless leg syndrome, rosacea, other skin lesions, some other things that we’re learning about SIBO.
Dr. Allison Siebecker, ND: Diarrhea and constipation.
GS: Right. Yes, absolutely, Dr. Siebecker, thank you.
So you’ll have these, and it doesn’t matter if it’s Monday morning, Thursday afternoon, or Sunday evening. And it doesn’t matter if you eat a hamburger or if you eat a pancake or if you eat something else. Generally speaking, if you eat, you’re feeling these symptoms. And why? It’s so basic. It’s so simple. If you have bacteria where it doesn’t belong, which is in the small intestine… The small intestine is supposed to have less than 10 to the 3 colony forming units of bacteria. The large intestine, way more than 10 to the 5. So if you have bacteria where it doesn’t belong and you eat something, the bacteria isn’t going to say, “On Monday I’m going to eat it and I’m going to ferment that and produce gas, and that’s what’s going to result in symptoms.”
It’s going to say, any time I feed it—doesn’t matter if it’s morning, afternoon, evening, it doesn’t matter what type of food—generally speaking, it’s going to ferment. So when a patient presents and they have these chronic postprandial symptoms (as that definition is), then we know to test.
And why do we test? There are so many symptoms that look like other things. Could be parasites. Could be fungal. Could be mold. I mean, it could be celiac. It could be so many different things. We need to validate, is this bacteria in the small intestine where it doesn’t belong, or is it not? Are we dealing with methane? Because we might choose to treat differently if we are dealing with methane.
And now the exciting opportunity is—when the technology becomes available and when it’s not in research mode, when it’s actually been a large-scale study across multiple geographies and anatomies across the globe—is it standard? Can we reproduce the event, where we can measure hydrogen sulfide and detect it? Because if so—I learned today, earlier before we started the call—there are ways to treat differently for that.
However, we are, by and large, diagnosing SIBO based on the tried-and-true, time-tested, globally utilized hydrogen and methane breath testing, where we validate that from a gas perspective. Now we go back to the clinician and say, do we have the chronic postprandial symptoms? Yes. Now we’re talking about SIBO. Now, we can begin discussing treatment options.
So that’s the current state. And my position here is primarily with hydrogen sulfide. I’m very excited. I’m an independent laboratory. I utilize a branded device and branded kits because they’re the best that I’ve come across. If there’s newer technology, I would assume that manufacturer and others will come up with it. And we can use technologies to augment what we’re currently using, as long as it works.
But we don’t want to confuse these patients. They’ve been sick for so long. We want to know whether or not we’re dealing with it from a hydrogen and methane perspective. And when the technology and the validation of that technology has proven itself, then we’ll incorporate that and hopefully even improve further where we’re at. So, I’ll pause.
DrMR: Well said. Allison, anything that you want to add there?
DrAS: No, you take it away.
The Flat Line in Hydrogen Sulfide SIBO
DrMR: So to my knowledge—and I haven’t checked in the past couple months—there have only been one or two studies looking at hydrogen sulfide SIBO. And they have been exciting. They have found that patients who perhaps may otherwise be negative for SIBO may be positive for hydrogen sulfide.
Although if I’m remembering some of the details correctly, you oftentimes see an overlap between being traditional SIBO-positive and hydrogen-sulfide-SIBO-positive. So I think you have to be careful not to hold this out as, every case who is negative on a SIBO breath test has hydrogen sulfide as the cause.
DrAS: Well, actually let me jump in here.
DrMR: Yeah, please.
DrAS: I’ll just mention, if a person has a negative and you’re thinking it could be hydrogen sulfide, the first thing to look at is to see if it’s a flat line test or hydrogen sulfide test. And we do have a way to interpret hydrogen sulfide currently in breath testing.
But you do need to have a lactulose breath test, not a glucose. And it needs to be a three-hour, because it’s the third hour that’s vital here. What we’re looking for is zero or close to zero. So in my interpretation, I’ll go up to six for hydrogen and three for methane, for the whole three hours of the test. And particularly for hydrogen in the third hour, that’s sort of the keynote: we should see the hydrogen rising because there’s bacteria in the large intestine. Third hour represents the large intestine generally.
And if there isn’t a rise there, if we see zero or close to zero, then that’s when we call it a flat line or low fixed. And then we think it’s hydrogen sulfide. And the reason why is because we’re not yet testing for hydrogen sulfide. We don’t have that technology. So we can’t see that gas, but the hydrogen is getting converted into hydrogen sulfide and no methane is being made (because methane also uses hydrogen). And so all that hydrogen is going to hydrogen sulfide. So we just see nothing or close to nothing.
That’s how you could, first off, decide what looks kind of negative. It’s not really. It’s a hydrogen sulfide. So that’s one thing we can do. I think where the excitement is coming from for the new technology is that Doctors Pimentel and Rezaie—they’re the ones who have invented this technology and are doing the research—had told me that somewhere between 60 to 70 percent of people who are actually positive for hydrogen sulfide with this new technology are not a flat line. So we’re missing a majority of these people. So I think that’s probably where everyone is getting excited.
Now, I think what that would mean is we’re missing some people who maybe are showing a negative and they really do have hydrogen sulfide, because they’re not showing a flat line. Then the other thing would be, there are people who have positive hydrogen or methane, but they also have hydrogen sulfide, and we’re not seeing that. And there are different treatments for hydrogen sulfide. So, personally, I think where this comes in are really tricky challenging cases that haven’t made sense or you’re really scratching your head. But I think that’s a minority ultimately.
DrMR: Hence this functional medicine, which is taking the small cropping of treatments that are often reserved for the minority. And then those are used way too commonly. Again, not to bring this back to the same concept over and over again, but I’ve been absolutely shocked at these cases that come in and say, “Well, I’m a chronic case,” and they’ve seen a few conventional doctors, a few alternative doctors, but oftentimes the approach has had huge gaps. In terms of, was the diet dialed in, was the appropriate probiotic protocol used, were the appropriate antimicrobials used, was an elemental diet potentially used, have immunoglobulins or something of that nature been used?
So many of the chronic cases, sadly, appear to be chronic because the provider hasn’t had the requisite knowledge in how to really get in there and use the available tools appropriately. So they’re not so much chronic because they need some new novel treatment, but they’re chronic because the level of precision the clinician has had hasn’t been up to snuff to help them get over this.
GS: Yeah. And Dr. Ruscio, if I could jump in on a few things…
DrMR: Yeah, please.
GS: So first of all, what Dr. Siebecker was saying I absolutely align with too, and everything you just mentioned. A couple of things with this.
Be Sure to Validate a Flat Line Test
Number one, with regard to the flat line, let’s start there. The flat line hydrogen and methane breath test, if prep was done correctly and if you have chronic postprandial symptoms… Why do I keep saying this about prep and chronic symptoms? You could have a flat line test. And guess what the number one reason is for a flat line test? 60% of the time (I’ve done 34,000 tests), it’s because the patient did not consume the glucose or lactulose. That’s why it’s flat. They never fed it.
And most of the lactulose in the United States is a syrup. Guess what? You’re supposed to mix it with water and they don’t. This makes up 60 to 70 percent of flat line. So, just because you have a flat line, it doesn’t necessarily mean it’s hydrogen sulfide. We have to ask a series of nine questions to ascertain whether or not it’s a true flat line, where one might suspect hydrogen sulfide. And then we further validate on the research that Dr. Siebecker did, that Dr. Ruscio is going to supply, and they’ll talk about this in a moment. It’s a series of secondary questions.
So we get a flat line hydrogen methane breath test. Then we have chronic postprandial symptoms. So we think we’re still dealing with a SIBO patient, but we have a flat line hydrogen methane test. First thing we do is validate via the questions. Did they actually drink it? Did they drink it with water? We might not have a rise in the colon with lactulose because they were on elemental diet. Because they had diarrhea that flushed it out. They could not have a colon. We have patients that have heavy doses of laxatives that can sometimes flush.
So we need to validate a flat line first, then go to the secondary questions. Part of which are the ones that Dr. Siebecker highlighted for all of us, and thank you to her. Which are: does the patient suffer from tingling of the hands and feet, do they have photophobia, intolerance to noise, visceral body pain, do they have the odorous gas, that river bed or rotten egg odor? Then we zero in and revisit the chronic postprandial symptoms. The clinician might treat. They might add something different because they might feel that it’s hydrogen sulfide, like bismuth, something that Dr. Siebecker just alerted me to. So they might treat that differently. But these are the validations.
There are two other quick things I just wanted to mention, and Dr. Ruscio just hit on it. These large research centers are doing extraordinarily good work. Their patient populations are so different. A hundred patients that go through their center are different than a hundred patients off the street. The prevalence of this are going to be different. They’re seeing the sickest of the sick. They’re drawing folks in for that purpose and that’s who’s seeking them out. And please correct me, Dr. Siebecker or Dr. Ruscio, if I’m wrong, but you have to understand, these research centers have a different patient population than the clinician that’s in private practice in Nebraska or New Jersey or New York or Florida. So we have to keep that in consideration for the prevalence of this.
And then the last thing I’ll say is, when folks are doing studies with regard to hydrogen and methane breath testing, please, please know that if you’re doing it right, it’s all about the prep and the devices used, closed capture devices, and how the laboratory does it. I’ve seen so many various prep guidelines out there. If you are utilizing a generated prep that you didn’t validate… The only validation I’ve ever seen is chicken, fish, eggs, white rice sometimes, and white bread. If you use that, that’s been validated. If you use highly absorbable foods, that hasn’t been tested.
So if you prep with that and that food makes it to the colon, you could have gas, but it’s colonic gas. And that’s possibly where you’re getting some of these “hydrogen sulfides,” and still have some gas. Is it really hydrogen sulfide? Is it colonic gas? It depends on if the prep was done right, the appropriate laboratory work was done right, the right devices. If you use an open capture that doesn’t have data on it, we don’t know what we’re measuring. Is it the air from the mouth? Is it the air from the room? So all those things. Sorry to dump so many things for the folks listening here, but these are important factors when we talk about this.
DrMR: Okay. So let me zoom us way out. Here’s what I think this breaks down to. If you’ve tested for SIBO and your test is negative or it’s a flat line, the first thing you should do is double-check that you did the test appropriately. Irrespective of all these details, first thing, double-check that the task was done the correct way. Now, if you did, in fact, prepare correctly and you are negative for SIBO, you may want to consider hydrogen sulfide as the culprit.
However, the testing for this is not yet available. It should be available maybe in 2019 or at least early 2020. But from what I’ve been told it will not be available for a distance test or a mail kit or do-it-at-home kit. You’ll have to do it in the office of the provider, which makes it significantly less convenient, because now you have to hang out for three hours at a doctor’s office. However, you can consider treating for SIBO or presume SIBO, and potentially add some nuance to that treatment that is hydrogen-sulfide-specific. Are we in agreement that that’s kind of a high-level hierarchy to help organize all these thoughts for people?
GS: Yes, I absolutely agree with that.
DrMR: Okay. Because we’re throwing out a lot of details here and I think the clinicians are probably loving this. I just want to make sure we don’t lose our lay audience, who are saying, “Oh my God, all these details are way over my head.” So that’s how you can think about sequencing these different interventions.
DrMR: Hey, everyone. I’d like to thank Aerodiagnostics, my favorite SIBO lab, for making this podcast possible.
Again, Aerodiagnostics is the SIBO lab I use in my clinic. They have impeccable organization, customer service, test quality, and support. Regarding support, if you’re not highly proficient in reading SIBO labs, Gary definitely offers the best clinical support I’ve ever come across. He goes over labs in detail and offers insight analysis and really goes above and beyond.
Aerodiagnostic offers cash pay and insurance billing options, and they do a terrific job at keeping costs low and billing easy. They offer accounts for clinicians and direct-to-consumer testing. Aerodiagnostics, again, is my go-to SIBO lab. Aerodiagnostics, check them out.
Now, Allison has done a terrific job of putting together symptoms that appear to be associated with and may indicate hydrogen sulfide SIBO. So what you could do, as we look at this whole process, is first verify that your test was done correctly. Two, if your test is negative, consider hydrogen sulfide.
I would also contrast with this list of symptoms. If you’re exhibiting a lot of these symptoms, that increases the probability that the underlying cause of your symptoms may be this hydrogen sulfide SIBO, which could mean some nuanced changes in how you treat SIBO. I don’t think the SIBO treatment is vastly different. And we can get into the treatment differences in a second.
You’re going to be in the ballpark with SIBO treatments, and then there are some nuances you can add to it. So it’s not like you’re going to do things vastly differently. But we’ll come back to that in more detail in a moment.
Symptoms of Hydrogen Sulfide SIBO
Allison, why don’t we go into the symptoms that one may want to be on the lookout for, that indicate that hydrogen sulfide SIBO may be present?
DrAS: Okay. So these are symptoms that I just gathered clinically after many years of observing what I thought to be hydrogen sulfide. And why did I think it was hydrogen sulfide? They almost always had a flat line test or near to a flat line. And I was also using another test that at the time was very inexpensive, way back then. It was a urine test developed by Dr. De Meirleir—who focuses on hydrogen sulfide in the context of myalgic encephalomyelitis (another name for that is fibromyalgia)—in Europe.
So this is a non-validated test and a patient told me about it. And I just began running it because it was so inexpensive. I thought it would help with confirmation. I’m not even going to share any more about that. Honestly I’ve stopped using it because it became more expensive and I’m not so sure about that test. Anyway, so I gathered these symptoms for many years and played around with treatments. I think it might’ve been six or seven years before I even started teaching about hydrogen sulfide in special classes I would do with physicians. And I think it was about three years ago I started bringing it in.
So here’s what I gathered. They could have your standard SIBO symptoms. So that’s bloating, abdominal pain, constipation, diarrhea. Now, before I go on, let me just say that I uniformly saw constipation in my hydrogen sulfide patients. And then lo and behold, I had never shared my data with Dr. Jacobi, but we got together and shared our data and she had the same experience as I did, constipation. It was actually starting a year ago in spring, that’s when the first research studies were coming out with this new technology, and they were finding diarrhea. And then the spring again, multiple studies came out, diarrhea. Or maybe not, maybe it was all from last year. I can’t remember.
So this really confused both of us. And when we talked to Dr. Pimentel about it, he said what it could be is that methane is present, but it’s a level that is below detectable by the breath test machine in parts per million. And this is something he’s actually been talking about for many, many years and reported on for many years. So it could be that there’s methane present at the same time, and methane is usually more dominant than hydrogen sulfide. So maybe it’s pushing someone towards constipation.
This is just theory. It’s just talk. So we have to see how this pans out. We really don’t know. And once we can get all the gases tested we might be able to make sense of this.
So I guess what I want you to know is that diarrhea is what the research is showing, and mine and Dr. Jacobi’s clinical experience is showing constipation. By the way, one other theory could be that when hydrogen sulfide is in the large intestine, it causes constipation. There are actually a couple of research studies, not about SIBO, that show that link.
Okay. So moving on in the symptoms, I’ve seen bladder irritation or interstitial cystitis. But usually it’s more like I asked, “Do you have irritation when you’re urinating? Is there increased frequency? Is there an urgency but then you can’t void very well?” That sort of thing. Also, a pain in the area of the bladder. And photophobia is not something that I’ve seen, but it’s in the research. And so is intolerance to noise. So that’s light and noise intolerance. But the other thing that I’ve seen is body pain. This was really more like muscle pain, like that idea of fibromyalgia, and not as much joint pain, but more muscle kind of pain. Then the hands and feet and fingers and toes can have tingling or numbness.
And by the way, how did I gather these symptoms? It’s because patients were reporting all their symptoms to me, that turn out to have a flat line. And I just looked at all the patterns of all my hydrogen sulfide patients. So a lot of them have this. And in terms of sulfur types of foods or supplements, a lot of them are worse from an Epsom salt bath, because that’s magnesium sulfate. So their actual digestive and all of these symptoms like the neuralgia and the body pain would get worse, which is unique. Because you’d think an Epsom salt bath would help pain and things like body pain.
So I would see that, and also supplements like MSM. Or sometimes I’d have patients that thought they were trying to treat their SIBO and they’d bought berberine sulfate, and they’d get worse. Sometimes they’d be taking allicin which comes from garlic, and that’s sulfur-containing. Sometimes that would make them worse. And then some of these patients would have worse food intolerances all together. And it was like they had both histamine and salicylate intolerance on top of their SIBO food intolerance. So very severe, difficult food intolerances.
What I very rarely saw, just a couple of patients, was the sulfur-smelling gas, like a flatulence where people say a rotten egg smell, but basically a sulfur smell. And I think I had one patient report it from burping. But for me in my clinical experience, that’s quite rare. And overall they feel sicker than other SIBO patients. So hydrogen sulfide, when it’s in excess, is a toxic gas, like actually literally toxic. It damages nerves and mitochondria. So it’s truly toxic. People use that word “toxic” like an adjective. But I mean it medically. So it makes sense that these people present generally sicker. And they often actually say, “I feel toxic.” It’s really interesting.
So those are my clinical symptoms I’ve gathered over time and I just share them. And what I was thrilled to learn from Gary is that as he’s been sharing it—he talks to lots of clinicians—he’s finding it’s ringing true. So thanks for that, Gary!
GS: Absolutely. And I was going to add that, for the benefit of the listeners, it’s absolutely working out. This is what we do. We talk with clinicians every day and we call on every single flat line test, whether it’s a glucose or lactulose, we call on it. We want to see if the patient, number one, did the test correctly. And then number two, do they have chronic postprandial symptoms? If they do, then we yield to Dr. Siebecker’s work here, and we’ve been validating that they are hitting on one or more of these.
And most importantly, they treat, and guess what? Patients are resolving. The symptoms are resolving. So we’re seeing it. It’s not a study. It’s just that we’ve been doing it and we’re in excess of, as I mentioned, over 34,000 tests. So we’re seeing this really play out.
The Role of the Lab in SIBO Testing
The one thing that I just might add, Dr. Siebecker, if I may—and please, Dr. Ruscio and Dr. Siebecker, correct me if you feel differently—I’ve always felt strongly about either glucose or lactulose. And I felt strongly because I wouldn’t offer it if I didn’t feel it was good. And there are many listeners that are clinicians that, unfortunately in the United States, don’t have access to lactulose. For glucose—and Dr. Goldenberg sent me great points, updated points, regarding this—by the Rome working group in 2009 showed a 71.7% accuracy, but more importantly, more newer work like Sellin is showing that 8 out of 25 patients with chronic diarrhea showed rapid transit, and they’re finding glucose absorbed distally. They’re finding it in the colon and there’s more work.
There was another work by Lin and Massey showing 48% of people with positive glucose hydrogen breath tests at 90 minutes had a rise after that with glucose. I can go on. But my point with this is, flat is flat, and I would not disagree whatsoever with Dr. Siebecker that it’s highlighted in lactulose tests. That’s because you expect a rise.
So the problem is not on the clinicians, not on the patients. It’s on the lab. The lab has to say, when we’re going to deliver a result to a clinician, if it’s flat—whether it’s glucose or lactulose—do I call that clinician, have that conversation? Do I take my time to do that or take the easy way out and just send the results?
When I see zeros, ones, twos, threes parts per million with glucose, we’re picking up the phone. We’re calling to be sure that, one, they drank the glucose, and then we’re going to start asking if there are chronic postprandial symptoms. And then we’re going to go to Dr. Siebecker’s work here. And the clinician is diagnosing hydrogen sulfide SIBO, regardless of glucose or lactulose. I know there’s a preference. I understand it but I think if I didn’t feel strongly, I wouldn’t offer it as a laboratory owner.
DrMR: And this is one of the nice things, Gary, about the way your lab operates. There have been days when I’ve been like, “Boy, I’m getting another call from Gary or an email.” And your customer service is sometimes almost hard to keep up with, because you are that thorough. So just for people, this is not something that Gary is just paying lip service to and not actually doing. When you use Aerodiagnostics, they are very robust with their clinical support. I’ve said that many times before. But certainly, you do a great job there.
I think for the clinician who needs that feedback, this is a great service to the field. Because the last thing that we need is a clinician who’s just shooting from the hip, in terms of how they’re interpreting a SIBO breath test. Because unfortunately then, what ends up happening is, we get all these non-true-positive cases that are told that they’re positive. And this is really disheartening, because then these patients end up getting treated and treated and treated and treated, never to really feel much different or see their labs changed, because they were treating a false positive all the while.
GS: Right. Thanks for that. And I hope it came through that I don’t disagree one bit with everyone’s desire to have lactulose, for the very reason that Dr. Siebecker stated. It makes my job much easier, cuts down my calls. But if I’m seeing flat with glucose, I have to ask the same questions. Because 60 to 70 percent of the time, it’s they didn’t drink the substrate! It has nothing to do with flat line. And we get it back in the lab. It comes back with the specimens. It’s pretty funny actually.
DrMR: That’s alarming, but not surprising. So one of our Instagram posts went out today. The videos are only 60 seconds, talking about the connection between depression and the gut, and how roughly 50% of people who either went on a low FODMAP diet or used a probiotic saw an improvement in their depression. And at the end of the 60-second video, we provide a link with the specific probiotic recommendations based upon this gut-brain connection. And one lady said, “What probiotics do you recommend?”
And I just monitor Instagram periodically, but I replied on this one and said, “Really? At the end of the video there’s a link that takes you exactly to those probiotics and also a screenshot of the probiotics that we recommend.” And she goes, “Oh, I didn’t watch the full video.” It’s 60 seconds. It’s not that long of an ask!
In any case. I understand people not reading, people not being patient and being maybe a little bit impetuous. But again, zooming us way out, it’s great that we have some of these symptoms that can help steer this process. I’m trying to help patients and providers make as much sense out of this as possible.
Special Hydrogen Sulfide SIBO Treatment?
The next thing that logically comes to mind is, okay, how do we treat hydrogen sulfide any differently? This is an area where I am certainly open. But I would suspect if we had comparative data, we wouldn’t see a huge amount of change, if we used nuanced hydrogen-sulfide-specific treatments compared to standard SIBO treatments.
And again, I’m happy to update my opinion there as the data evolves. But as an example, just looking at the SIBO biofilm data that we collected, yes, we did show a measurable benefit that was statistically significant—where the people who are treated with SIBO herbs plus antibiofilm agents had a greater reduction in hydrogen than did patients treated with SIBO herbs—but it didn’t really seem to be clinically meaningful. And combine that with… there was one study using, I believe, rifaximin, in the treatment of hydrogen sulfide SIBO. They showed improvements both symptomatically and with the lab results.
So yes, there are things that may be more active against hydrogen sulfide. But I’m unclear and wary as to whether we need to really make our SIBO treatment that much more complicated. And if the appropriate treatment course was designed for a patient, they would see the symptomatic resolution they’re looking for. But Allison, let’s go through some of these. Bismuth is one that comes up. I believe we discussed this on the podcast a while ago, that for suspected hydrogen sulfide SIBO, you could add in bismuth to synergize with antimicrobials.
But Allison, any particulars that you’re looking to? And I should add one other thing. A low-sulfur diet can be helpful. Again, I don’t need to see any kind of lab evidence of hydrogen sulfide SIBO to trial a low-sulfur diet. What I’ve found is for patients who have this predilection toward carbs—they like carbs, they like starch, and they don’t do that well with meat and lots of vegetables—I’ve observed that patient type may simply do better on a lower-sulfur diet. And so we’ll have them run a one-week trial, and that’s adequate to help us piece that together.
So that’s just something that you can look at, some early dietary clues. If you tend to not do well on lots of meat and lots of vegetables, and you feel better when you have some carbs, some starch, maybe some rice, that indicates to me, okay, let’s do a one-week trial on a low-sulfur diet. And if that’s really helpful, then we can continue forward with that. But Allison, what are your thoughts regarding the best way to maybe tackle hydrogen sulfide SIBO?
DrAS: Sure. Well, first off, I didn’t know what to do all those years ago. And so I asked what Dr. Pimentel and Dr. Weinstock were doing. They were both saying, you just treat it the same way you would have before, you treat the presentation, meaning constipation versus diarrhea. Because that’s pretty much how we separate out our SIBO treatments, with the diarrhea usually going with hydrogen and the constipation usually going with methane.
Well, I did try that for many years on many patients and I personally found it to be unsuccessful. Now, what could have been going on here is that I’m seeing the more challenging patient group, which we know I do just because I’m a specialist. I see people after they’ve seen other doctors. So they’re more challenging cases.
So to your point, Dr. Ruscio, it could be a large amount of people would be handled very well by that. I asked Dr. Weinstock about that, and he said that approach had been very successful in his experience. And I think he even presented a case at one of our symposiums like that, and I just never got success trying that. So that’s always the kind of thing that’s going to happen. So what would that be? That would be rifaximin for the diarrhea type or rifaximin plus neomycin or metronidazole for the constipation type. And then we have the herbs that we separate out.
That didn’t work for me. So I went hunting. I contacted Dr. De Meirleir’s lab, and the lab director sent me a list of antibiotics that could be used, based on the hydrogen sulfide producing organism that you find. And in this case, they were doing stool testing to find it in the stool. Most of those are actually aminoglycosides, not all of them. They have the mycin on the end of the name of them. And I have some patients report to me some very good results from doctors who had prescribed them Clindamycin. But Clindamycin has a very high C. diff rate. I personally don’t feel comfortable using it. I haven’t prescribed it, but I’ve had patients report to me multiple cases of success with hydrogen sulfide SIBO and that antibiotic.
So then as I read some more, I saw that bismuth can also be used. There’s a study that used it and it had a very successful rate of treating it. But they only did it for like seven days. The study was three to seven days. And I tried that on a lot of patients, and what I found is, it would just immediately come back and I could perceive it just wasn’t long enough.
And then when I started going out to our normal time frames—a minimum of two weeks, if not a month—and usually a month, then we were starting to see better results. There are also studies of using bismuth with antibiotics of your choice, really. One was done with Cipro. But really, you could just add it to whatever you were doing.
So how do you get bismuth? It can be compounded. The dose was 524 milligrams, four times a day. So it’s basically about 2000 milligrams a day. It can be compounded, but you could also buy it over the counter. Pepto-Bismol is bismuth. However, that comes with salicylic acid, which can be damaging to the stomach lining. So I don’t like the idea of using that long-term at all, personally. There are also some supplement products that have bismuth in there. One is by Thorne and there’s another one, Paul Anderson’s one. It’s by Priority One, I think. It’s Biofilm Phase-2 Advanced. And Thorne, I think, is Pepti-Guard or something. I might be getting this wrong. I’m doing it out of memory! But they have bismuth in there.
Unfortunately the Thorne one has a lot of other of their mucilaginous polysaccharide herbs that sometimes can aggravate SIBO. Then there are some herbs that we could use. High-dose oregano. For a while there, I couldn’t tell, is it helping methane? Is it helping hydrogen sulfide? Never did feel quite sure it really did help methane, but I’ve had a couple of cases where the hydrogen sulfide was successfully treated with high-dose oregano.
And then one other one I want to mention—empirical, clinical—is nitazoxanide. So that’s Alinia. And I have seen cases get better from that. So what I’ve actually seen work, my own self, is nitazoxanide, high-dose oregano. Those would be separate. And bismuth, either alone or in combination. That’s what I’ve seen work. For the high-dose oregano that I’m using, I’m using the emulsified one that’s in a dry tablet form. That seems to be a little bit better tolerated for a lot of people.
And this was not my dosing regimen. It came through a patient through Dr. SSL for some other purpose. I think it was originally for blastocystis. So anyway, it’s five tablets of Biotics ADP. Five of those tablets, three times a day for 10 days, and then drop down to three tablets, three times a day for 20 days. So I’ve seen that work.
Now, there are some other things that are shown in the research that I’ve never tried, like lactobacillus plantarum LP8. There’s actually some research with the GOS prebiotic Bimuno. We have to be very careful with that though, because that can aggravate. I would start it slow, be careful. Zinc acetate has some research, and also soy isoflavones, and a Chinese herbal preparation. And those came from Dr. Jacobi’s research. I haven’t tried them, so I don’t know. So those are some things to think about.
GS: Can I just ask a question? Would you ever consider just making that part of your herbal regimen in general, or when you have the chronic postprandial symptoms and a flat line? Or what are your thoughts about just adding in some bismuth—or something like that—to your approach to treating SIBO, generally speaking, based on the fact that we can’t measure hydrogen sulfide right now, and you don’t know you’re dealing with it? Is it cost-prohibitive or…
DrAS: It can be. I have a colleague who tried using it for methane. It seems like nitazoxanide can work on methanogens. It seems like a lot of the things that can work on hydrogen sulfide can work on methanogen. It’s pretty interesting. And he said he was finding bismuth to be successful in cases of methane.
I haven’t tried it yet. So I can’t report. It’s like hearsay from another person. So that could make sense. I don’t think it would be necessary, if it was a hydrogen-only clear case and you’re not concerned about hydrogen sulfide, right? But yeah, that could make sense.
And oregano is a standard combination I use. I usually use two herbs at once when I’m treating SIBO. And I would often use berberine and oregano, so you could increase that dose and just presumptively do that. I think that could make sense.
GS: I only ask because of what both you and Dr. Ruscio have said on this call. Let’s say this technology isn’t out for a while, so we need to do something in the meantime. Let’s say the technology does come out, but it’s only in office and it’s not something that offices want to buy because of the cost of the technology. So is it a “I have a positive SIBO, I’m just going to check on the hydrogen sulfide symptoms, the tingling of the hands and feet, the photophobia and intolerance,” all the things that you’ve already reviewed? Do you then almost reflex to those questions to determine whether or not you should go that way, since the testing hasn’t caught up with us yet? That was the reason for the question.
DrAS: I think it’s very reasonable. And one other thing I didn’t say, that I always like to say as a disclaimer, I’ve also seen all of those things—that I just said I’ve seen work—not work in hydrogen sulfide patients. And that’s the case for absolutely everything I’ve ever used to treat SIBO. I’ve seen phenomenal successes. It doesn’t matter what we’re talking about. I could sit here and name 25 agents: rifaximin, and go down the line. I’ve seen them all work and I’ve seen them all fail. So I just don’t want someone to be like, “But she said this works for hydrogen sulfide.” It’s always hit or miss.
DrMR: Yep. And Gary, I think you made a good point, which is—trying to come back to that process that I outlined earlier—first, test and if you’re not sure if the testing is negative or flat lined, double-check that you’ve done the test appropriately. And then second, if you’re negative or you have this flat line pattern and you have some of those hydrogen sulfide symptoms, consider adding in the hydrogen-sulfide-nuanced treatments to the gut treatment protocol you’re going to use. So if you’re going to treat SIBO more empirically, then you consider adding these in. And that seems to me to be really the best way to go about this.
Don’t Expect a Magic Pill
The other thing that—at least for right now until we have better data—I just want to again remind the audience of is, a good gut-focused or SIBO-focused clinician should be able to help you navigate this. At least in my opinion, I don’t want to paint this picture that if you’re struggling with symptoms, that knowing you have hydrogen sulfide SIBO is going to be the one thing that’s going to take you from highly symptomatic to totally fine. Because you will most likely need an experienced clinician or a good program to work through to rebuild your gut health, which would include things other than just, “Okay, we’re going to use bismuth plus high-dose oregano.”
It’s rare that I see, for a patient who’s pretty ill, that just one thing breaks open the entire case. But rather, what it oftentimes looks like is, we need to string together a few different therapies. We might get a 20% gain from one and then another 20% gain from another. Then we do this right and we get enough of these therapies integrated in sequence together. That’s when we start to really see the notable level of improvement, where now someone is 70, 80, 90 percent improved.
And I think, unfortunately, it’s the instinct of a patient to grasp for this one straw that is the thwarting factor. But oftentimes there is no one straw. It’s a number of straws that have to be woven together to have strength and to be able to lead to that improvement that we’re looking for.
This does come back to a philosophy of improving one’s gut ecology. Which is, yes, we need to help weed out some of the things that we don’t want there, but we also have to support the gut ecosystem, if you will, to encourage balance. We’re not just trying to kill stuff, we’re also trying to help repair, and make the soil—from which these organisms either grow or don’t grow—the most favorable that it can be.
GS: Absolutely, no magic pill. Yup.
DrAS: Beautifully said.
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DrMR: Okay. Let’s go to some closing thoughts. Gary, anything that you want to close with?
GS: Well, I think I’ve talked quite a bit. I appreciate that. I think the closing thoughts for me are, we as a treating community—being a diagnostic but mostly clinician and patient together—have had a lot of success diagnosing and treating SIBO.
And yes, there is some newer information, possibly some newer devices that we could augment to improve it even further. But by and large, we’re having a lot of success based on everything that we’ve discussed. And I do feel like if the right laboratory work is done, that provides the data to the patient and the clinician to make the right diagnosis decisions. Working hand in hand, that’s what you’re able to glean from the data that we provide you.
DrMR: Love it. Allison?
DrAS: Yeah. As a doctor treating SIBO, I feel that we absolutely need all three gases. We’re working one-third blind here and we’re in the middle of an age of discovery here in SIBO. It’s amazing how far we’ve come and we have farther to go.
Look at this. We haven’t even been able to test for a third gas. So, I feel like it’s essential in a basic way. But the problem is it’s so brand new, hasn’t even hit the market yet commercially. It’s going to take years to do two things, validate it clinically, which is the point that I think Gary was really great in making. We’ve got to see how this pans out, right? And second, become widely available. It’s not going to be effective until it’s just as widespread as hydrogen and methane testing.
It needs to be available, every machine, every lab. And when that happens, then we can really talk. But that’s going to be years and years. So we just have to wait. It’s coming. And in the meantime, while we’re waiting, there are the points that you’ve all been making and that I’ve been making too. Let’s use the flat line. Let’s go through the checklist that Gary has made, to make sure before you decide it’s hydrogen sulfide, etc. We have things we can do right now. And we’re going to have to do them for quite a few years.
DrMR: Yep. And I think if we hit the mark here of helping the person listening to or reading this understand that there’s not this magic bullet of hydrogen sulfide SIBO, it’s not here yet, and work with their doctor, work with their clinician, consider some of the process in the hierarchy that we laid out earlier, that can get them moving forward.
And let’s not call up the lab (I don’t know if they’re in Germany) where there’s a urinary hydrogen sulfide test and put all of our eggs in that basket. Let’s not start reading everything on the Internet that we can about hydrogen sulfide SIBO and making every treatment based upon what we eat, and all the supplements that we use totally centered around that. That would just be so speculative that the margin for error on that would be very high.
So it’s new. It’s exciting, and hopefully there’ll be more useful here to come. But for right now, I think we’ve laid out some good guidelines for people to follow. If you follow those simple guidelines—even though sometimes it’s hard when you’re not feeling well, you’re looking for anything to make you feel better—I think you have the highest probability of using the hydrogen-sulfide-SIBO-nuanced treatments to your benefit. Also at the same time guarding against not getting pulled into a gutter of therapies that have no relevance to your gut, and maybe even spinning your wheels.
And if we hit that mark, I think we’ve helped people with this podcast, and I’m pretty confident that we’ve done so. Allison, will you remind people of your website, in case people wanted to hear more from you?
DrAS: Yes, it’s siboinfo.com and it’s a free educational website.
DrMR: Awesome. And then Gary, your website and anywhere else you want to point people?
GS: Sure, thank you. Aerodiagnostics.com. And I often point patients to Dr. Siebecker’s site and Dr. Jacobi’s site, trusted, well-valued across the board, and to Dr. Ruscio’s podcast for information. That’s where, when many treating clinicians are requesting, “Where do I go for these answers?” I send them to the experts. We don’t answer them. We’re there to be the specialists on the diagnostic end.
DrMR: Sweet. Well, Gary, Allison, thank you for this roundtable. Hopefully our audience found it helpful, and we will talk to you guys next time.
DrAS: Thank you.
GS: Thank you..
What do you think? I would like to hear your thoughts or experience with this.
Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.