As usual, Dr. Ruscio stays on the cutting edge of functional medicine by digging into a new laboratory test just released for SIBO/IBS. He breaks down, in easy to understand terms, the main utility for this test and the type of patient that should get this test done.
The autoimmune etiology of SIBO and IBS…..2:29
Main utility of the IBS Check Test…..8:11
- (2:29) IBS Check Test from Commonwealth Laboratories http://firstlinemedia.com/mnr/ibs/
- (10:17) Study published regarding science behind the IBS Check test http://www.ncbi.nlm.nih.gov/pubmed/25970536
- (12:44) Dr. Ruscio Radio SIBO Part 1 and Part 2 podcasts:
- (14:30) Motility (prokinetic) agents:
- Iberogast https://dr-michael-ruscio.myshopify.com/products/iberogast
- MotilPro https://dr-michael-ruscio.myshopify.com/products/motilpro
Right click on link and ‘Save As’
New SIBO Test Just Released
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The following discussion is for educational purposes only, and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking to your doctor.
Now, let’s head to the show!
Dr. Michael Ruscio: Hey, folks. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. I’m here with my good friend, the lovely Susan McCauley. Hey, Susan.
Susan McCauley: Hey, Dr. Ruscio. What’s going on?
DR: Oh, not too much. Just working on a holiday Monday, but…
SM: I know.
DR: Happy to be doing it, I guess. I had a good weekend, otherwise, so it makes it a little easier to work when everyone else is taking the day off, I guess.
SM: Yeah, and it makes it kind of a shorter week. I know my husband is on his way out of town next weekend, so I’m like, ‘Oh, what am I going to do? Planning a hike, or, you know, maybe do some cooking or meet with some girlfriends. But like for me, two holiday weekends.
DR: Nice. Congratulations.
SM: So, you have a new test to talk about today? Hot off the presses, maybe?
DR: Yeah, just…actually, about a week ago the test that tests for the autoimmunity that seems that seems to underlie the development of SIBO, that antibody test was just released. So, I thought we could talk about that.
SM: OK, yeah. So, is this a specific lab or is this at all the labs. Tell me more.
DR: So right now, this test (1) is through a laboratory called Commonwealth Laboratories. They also offer a SIBO breath test, as well as I believe they also do a fructose smell absorption test. Dr. Pimentel, who is one of the preeminent researchers in IBS, seems to work quite closely with this laboratory. So, that marker has just been released through the laboratory – it is called IDS check.
The autoimmune etiology of SIBO and IBS
DR: It’s a blood antibody test. Just to give people some background and maybe some reiteration, people that have gas, bloating, constipation, diarrhea, or a combination of the two, and abdominal pain – some of the most classical symptoms associated with IBS. Almost all the time – we cannon say ‘All the time,’ but in up to 84 percent of cases of IBS, the underlying cause may be small intestinal bacterial overgrowth. Certainly, if somebody has these symptoms, and let’s say they’ve done the first step of changing their diet, and they are still not fully responsive, screening for this small intestinal bacterial overgrowth, or SIBO as we say for short, is a very good idea. Now, as we’ve been learning more about SIBO, people are asking the question – and when I say people, researchers, more specifically, are asking the question, ‘Well, what is allowing this small intestinal bacterial overgrowth to occur in the first place?’ And again, this small intestinal bacterial overgrowth causes many of the symptoms associated with IBS, and it’s where the large intestinal bacteria can grow into the small intestine, where they can cause significant damage. They can cause all of the symptoms that we just mentioned, as well as leaky gut, similar changes to the intestinal lining that we see in celiac, which is called villous atrophy or damage to your villi or your intestinal cells, malabsorption, potentially other types of autoimmunity and other extra intestinal symptoms like brain fog or fatigue.
(It’s) certainly a big deal. Again, researchers are trying to figure out what allows this to happen in the first place. One of preeminent theories was – or has been elucidated – that if someone has a bout of what’s called acute gastroenteritis, or more simply put, food poisoning – you may have had travelers’ diarrhea, you may have eaten some bad food, you may have had the stomach flu, you either throw up or have diarrhea or both. When that happens, the immune system has to come in and clean up whatever pathogen or virus is causing these problems. The immune system usually does that and people usually recover from food poisoning or stomach flu within a couple days to a weeks. But some of these people then later on the line start to develop residual symptoms that never seem to go away. “You know, ever since I went to Mexico and got food poisoning, I’ve been a little bit gassy.” Right? That’s what it may look like clinically. And what may happen during that whole process is, as the immune system comes in to clean out that initial pathogen or bug, you start to form antibodies. Specifically what we think happens, (and) we have pretty well mapped out in terms of what happens is, some of these pathogens form or release toxins – the specific toxin is CdtB or Cytolethal distending toxin B. And this toxin can cause cross-reactivity with sources with…I should say it this way: The pathogen, the bad guy, releases this toxin, and the immune system starts making antibodies to kill this toxin or to get this toxin. But, that toxin looks very similar to a tissue of our own body called vinculin. Vinculin is part of the intestinal cells that help to regulate motility, or the ability of your intestines to pump food down the line. When that motility or that pumping of the food, becomes disrupted, then you can get things slowed down or backed up. It’s kind of like when running water becomes stagnant, it becomes stagnant and fostered bacterial overgrowth. The same thing happens in the intestines – when we have this event where the body starts attacking vinculin, these cells that help regulate motility or food moving through the intestines, then intestinal motility becomes impaired. That allows bacteria to overgrow and then you end up with SIBO. So, it’s kind of a mouthful. Susan, any clarify questions you’d like ask, or comments you’d like to make there?
SM: No. So, this kind of brings to mind the reason why SIBO might keep coming back, then? I’m sure you’re going to touch on this, but if it’s affecting the motility and we don’t address the motility, we can clear the SIBO. But if there are still motility issues, the bacteria is just going to grow back.
DR: Yes, and you ask an incredibly important question, and I want to address this very directly now to help people get one of the bottom line, important pieces. Every time a new test comes out, we have to determine how we use that test.
SM: And that was one of my next questions when I started taling about the test because some of these tests…so we have an answer, but what does that do to treatment or what is that do to the course of the orgainism going to do?
Main utility of the IBS Check Test
DR: Right. And know that autoimmunity is one of these your flash button terms that people tend to really go crazy on, and I think sometimes this is area where over testing is really done. I think some of the of the really robust autoimmune panels are really interesting, but they don’t really tell us a whole lot about practical actions we can take from those tests. I want to be very clear in saying that this test’s main utility appears to be a screening tool to differentiate inflammatory bowel disease from IBS.
SM: OK, so inflammatory bowel disease are things like Crohn’s disease, ulcerative colitis – they are autoimmune in nature as opposed IBS, which is a collection of symptoms that they really can’t fit into any picture, and so they give you the term IBS.
DR: Yes, but we’re learning that they actually may both have autoimmunity components…
DR: …it’s just different autoimmunity, right? Because someone that has, let’s say, ulcer colitis may have autoimmunity against what’s called saccharomyces cerevisiae, which is a type of healthy commensal bacteria.
DR: Whereas, people with IBS autoimmunity against these vinculin cells.
DR: So, now that we’re learning more about IBS – we’re learning IBS, yes, may actually also be autoimmunity, so we should maybe clarify that…
DR: …IBD has been historically known to be autoimmune. We are now learning IBS may be autoimmune. But the question is, can we use this test to treat the autoimmunity? From the published data, no. It really doesn’t suggest that at all. What this suggests is it’s a screening tool because the specific antibody that are tested in this test help separate out people who have IBS from people who have IBD. Part of how the research study (2) was performed to help validate this test was, researchers tested a group of people who had IBS, a group of people who had IBD, and a group of people who were normal healthy controls. They found that the anti-vinculin antibodies were significantly higher in those with IBS, leaving the researchers to conclude we can use this tool is a way of determining, ‘OK, Mary Sue has chronic diarrhea. Does she have IBD or IBS? We’d rather not scope her because that’s fairly invasive and uncomfortable if we don’t have to. What if there was an early screening tool that would help us determine if this person has IBS, and then should therefore potentially follow-up with a breath test, or IBD and needs to follow-up and maybe do more invasive testing like intestinal colonoscopy, anoscopy, and maybe a biopsy?
DR: Does that make sense?
SM: It seems to be that IBS maybe the term, because now we’re kind of zeroing in on what in reality it might – SIBO with these antibodies that maybe 85 percent that were zeroing in instead of just a collection of symptoms are actually getting it (to) land on a term that is a little better than IBS.
DR: Yes, I certainly think a lot of the community is going in that direction. Typically for me, the way I look at this is, if someone has the symptoms that are associated with IBS, and they first change your diet, and they are non responsive to diet, the second thing that is the top of my list is SIBO, absolutely. I really want to be careful in making that qualifier because what would prevent people from doing is rushing to do this test because it’s going to provide them some answers, in terms of a better way of treating SIBO. So, if you’re someone with chronic small intestinal bacterial overgrowth, I don’t really know how much clinical or treatment benefit you’re going to derive from this test. All it does is tell us that you probably have one of the underlying causes for the condition we know you have already anyway.
SM: Which we should be treating anyway. I want to refer people to…we have two SIBO podcasts (3a, 3b) which we walk you through all the different ways – from diagnosis, to treatment, to the killing phase, to the maintenance phase, and through that. So, we are addressing the motility function in those phases.
DR: Yes. The well-established SIBO treatment algorithm does take this into account. I think most providers who are well-trained in treating SIBO are addressing motility. My own thoughts on this, which, of course, are reinforced by some of the published literature in my clinical experience is, I think a lot of motility can restore itself just through general health practices. I believe we do talk during that two part series on SIBO at some length about how we can recover the health of these cells. Things like inflammation have a pretty big impact. And even things like antioxidant status. So, it may be a rationale there for a short-term antioxidant, or definitely just eating a healthier diet that’s more antioxidant rich, like fruits and vegetables…
SM: I was going to say lots of vegetables and fruits.
DR: Yeah. Just by changing someone’s diet to get off of inflammatory foods, eat more anti-inflammatory or antioxidant-rich foods, and treating any other bacteria or pathogen in the gut that may cause inflammation. I think people have a fairly good likelihood to really help restore a lot of the motility on their own. And then, of course, there are motility agents like ginger, MotilPro (4a), (and) Iberpgast (4b). And then there’s erythromycin, or low-dose naltrexone, which are pharmaceuticals that also be used. So, there are some good options for other ways of supporting motility.
But again, will this test tell you something in terms of treatments? Not to my knowledge at this point. It’s a screening tool. I want to really be clear emphasis that for people because I don’t want people to do a test that may not really help them, or build it up like a test that will help them. I am sure somewhere there’s going to be…this test is going to be misinterpreted and promoted under the guise of really being able to help with treatment.
SM: Yeah, I could see people running to get this test to say, ‘Well, I have the gas and bloating and then I’m going to run. So now I know that I have an autoimmune disease and now I know that I’m going to do the autoimmune peleo diet and, you know, what else am I going to do? I’m going to get tested for SIBO, you know. But, aren’t those things we would try anyway?
DR: Exactly, exactly. So, I’m fine with someone doing the test if they just understand what it’s utility is. What I really want to try to help people not do is have a false hope.
DR: Like, ‘My God, if I can just do this test, I can figure out my chronic SIBO. Trust me, I totally understand the frustration that can occur when someone has any kind of gut infection, as someone who suffered for well over a year with mine until I was truly able to get rid of it. I understand the frustration. I just want to help people not get misled into thinking that this test can help with that.
SM: So, if you do get the test, and you do have the greater amount of antibodies – you might have some antibodies anyway if you had the bout of food poisoning, correct? Because, isn’t it the antibodies for the CDTV.
SM: So, you get these results; what are you going to do different? Is there anything different than people are going to do besides just going to the standard SIBO treatment? Or is there any way to dampen the antibodies, to repair. (Is there) anything different that we would do?
DR: There’s not really anything different that we would do. And again, this this test has its main utility for someone who has diarrhea – it hasn’t been studied in the application so much for constipation. It’s main utility seems to be for diarrhea. And, the main reason for this is because the study was looking at patients with A. diarrheal-type IBS, and then B. because people that have chronic diarrhea, it could be caused by IBS or SIBO, kind of using those two almost interchangeably now. Or it could be caused by inflammatory bowel disease. So, when a patient initially presents to a doctor office, one of the things that the doctor has to figure out is, is this diarrhea being caused by IBS , aka SIBO, or by IBD, inflammatory bowel disease? Again, what this test will do is help steer the doctor in whichever direction.
To answer your question more directly, Susan, is there anything differently we can do? Not really, no. This test doesn’t…it’s not designed or doesn’t report data that changes the treatment, really. It is just an early screening tool to help us get to a diagnosis more quickly.
DR: So, it’s got great utility from that perspective. And it may save someone from needing to undergo endoscopy colonoscopy.
SM: Yeah, and those aren’t fun. I’ve had a colonoscopy, so it’s not a fun thing to go through. The prep, especially, is just miserable.
DR: Yeah, and I don’t want people to think that that I’m saying that this is not a good test. I think this is a great test, and I think Dr. Pimentel has done some unbelievable work here by pioneering this. I just don’t want people to think it can do something different than what it’s designed to do.
SM: I don’t think we’ve posted the episode yet, but we did an episode on autoimmunity and B12. The clinical treatment for that was giving B12 shots.
SM: So, there’s nothing to this that’s similar to that then.
DR: No, not to my knowledge, anyway. And one of the things I would like to do at some point is try to get Dr. Pimentel to come on the podcast. I’m not sure if his schedule will permit that, but I will be at the SIBO Symposium a weekend after this recording takes place, and I’m hoping to run into him there and see if we can get him on.
SM: Oh, that would be awesome.
DR: Because there are some things that I’m curious to know, and I’m not sure if he has pulled these out yet. I’m sure he at least has his own ideas in terms of how the levels of these antibodies change over time. That’s something I’d be very curious to know. There’s definitely great correlation data showing the higher level of antibodies, the higher the level of SIBO and IBS. I’m curious to know how these levels change over time and if as he’s been doing this research they have uncovered any other novel treatments in this area.
SM: That would be a great podcast.
DR: Yeah, yeah. So, fingers crossed…
SM: Yeah, I’ll keep my fingers crossed.
DR: So, those are some of the main points. We will put the link in the show notes for where that test is offered and available, and also the study that was recently published (indecipherable) and the science behind the test, along with a few other show notes. And I’ll put a link in there for a couple of the motility agents (MotilPro, Iberogast) I mentioned.
DR: And, Susan, was there anything else that you’d like to add? Or, any other things I should mention that I haven’t yet?
SM: Let’s just give people just a abroad…so in conclusion, if somebody’s listening to this and they are, like, trying to figure out, ‘Do I need to talk to my doctor about this test?’ That’s usually the people I know a lot of times – this is how I use it when I first got into listening to podcasts. Every time I heard a podcast, I wanted to get the test.
DR: Right, right. Good point.
SM: And in nutrition school, too, anytime they talked about a condition, don’t you know, I felt like I had it, and I guess that’s very common.
DR: Right, yeah.
SM: So for people that are listening now: If you have a SIBO diagnosis now, probably not a test you want to go run out and pay for.
DR: Exactly. I just don’t know how that would help the person at all, really. So, the person at the point time this test is ideal for is someone that has chronic diarrhea, or what we would term diarrhea-predominant IBS.
DR: And they are looking to figure out – Is the underlying cause of this diarrhea and this IBS symptoms SIBO, or could it be inflammatory bowel disease? And, by doing this test, you can help turn that fork in the road where, if this test comes back positive, then it’s almost certain that you have SIBO.
SM: OK. And so, if you’re further down the road, and you’ve already gotten SIBO diagnosis, you’ve already tested your gut for infections and parasites, and you do have a SIBO diagnosis, you don’t have to go back to this test and get it. It’s not going to tell you anything different.
DR: Exactly. Yeah, it really won’t tell you anything different, in terms of treatment, because all the available treatments that we have that would effect this in any way, one would already be doing as part of the proper SIBO treatment.
SM: OK. And you wouldn’t need to know whether you had the antibodies because you don’t really need to know if you have any a definitive autoimmune diagnosis, because we pretty much now know that SIBO has autoimmune properties.
DR: Exactly, exactly. And, even if these antibodies are elevated, again, it doesn’t really change the treatment for someone who has a SIBO diagnosis and is already undergoing treatment.
SM: Right, because we still want to the diet, the lifestyle, the killing phase, the maintenance phase, the low fodmap during the maintenance phase – all those different things.
DR: The only thing that we could maybe speculate to say this could help with this, this may provide additional rationale for having a prokinetic agent, for using a prokinetic agent. That would be the only difference, but usually it’s not that hard of a call. I don’t think…if someone has a very mild case of SIBO that’s been only present for a short while, I find those patients oftentimes don’t even need a prokinetic agent – they just kind of breeze right through. It’s the patients who have had more chronic, lingering, challenging, hard to treat, recalcitrant, whatever you want to call it – SIBO, chronic SIBO. That’s where the prokinetics seem to be much more important.
The only other thing that you could maybe squeeze out of this test would be an enhanced rational for a prokinetic. Again, clinically I think just based on the severity of the case you can decide if a prokinetic is needed.
SM: So, here is the $24,000 question, or the $200 question: Have you used this test on any of your patients yet?
DR: I have not used it yet. I’m certainly considering it. But, my thought process on this is: If someone presents in my office with diarrhea, the first thing we’ll do is change their diet.
DR: You know, that will work for maybe 30-50 percent of patients, right? If their diet has already changed or…if we change their diet and nothing happens, or they come in with their diet (and) it’s already healthy – like the paleo diet…
DR: …then we may want to try a dietary tweak or two, like going to the autoimmune protocol, trying a probiotic, trying a digestive enzyme, maybe trying something like low fodmap or SVE in conjunction with doing a screening for SIBO. Usually what happens there is, we either find SIBO, or we don’t. If we find SIBO, we treat it and we go through the exact process that we laid out in the two-part SIBO series on this. Then what I find is some people will not fully respond after SIBO is cleared.
DR: And then I screen for IBD.
SM: Uh-huh. I have picked out – I did a YouTube video about this about a year-and-a-half ago, when I started to notice this relationship – where what happens is, because the person has changed their diet because, maybe, they’ve gone on a probiotic, because they’ve also cleared SIBO or any other kind of gut infection, they’ve so successfully managed their IBD, that it isn’t severe enough to flag a gastroenterologist to do an investigation.
DR: So it’s a very low-level IBD that can manifest as these few symptoms that just don’t seem to fully respond. We’ll do the antibody screening for IBD, and we’ve picked out a number of cases that have been positive and have responded very well to some of the herbal anti-inflammatory and other treatments for IBD. I don’t want to get too tangential into IBD – I think we should definitely do a podcast specifically to IBD. But I there are some very effective treatments that have…that are natural that have been used in comparison to the conventional medications and shown to be equally as effective.
SM: And some of those conventional medications for IBD are very…invasive wouldn’t be the right term, but they carry a lot of side effects.
DR: They do.
SM: The biologics.
DR: Yeah, the secondary and tertiary-level treatments are very powerful amino suppressives and have some other side effects that can be a big deal. Yeah so, that’s how this whole thing fits together for me. Do I need an early screening tool separate out one from the other? Not really, at this point. If this becomes available from LabCorp and Quest, and I can have a patient do this as part of their secondary blood screening, or even their initial blood screening, then I think I would definitely do it. Right now, to have someone do a unique blood draw for a different lab and go through the rigmarole of that, I don’t think it would worth the fuss at this point. But, I am certainly open to it. And, as we learn more, I may amend that opinion. But right now, that’s kind of how I see this fit into the whole clinical picture.
SM: Cool. So I think that’s a great…this whole episode has been a great reality check, so when we get all these new tests that come out, everybody, we kind of want to jump on the bandwagon and start testing away. I think sometimes we do need that reality check – what is it going to change in our approach? Is it going to make a drastic difference? Is it going to make any difference?
DR: I think for the people that this is going to be really great for – unfortunately will not be a lot of (those) people listening to this – will be your really unhealthy cousin…
DR: …who doesn’t eat well, doesn’t take care of their body at all, and they go to their conventional gastroenterologist, and that doctor is trying to figure out, ‘Is this IBS, or is this IBD?’ quickly.
DR: For that population of people, I think it may really save them from a lot of unnecessary poking and prodding, and hopefully get to an IBS, and hopefully a SIBO diagnosis, more quickly.
SM: So, this is another question for you: Are the conventional medical professionals going to be using this test?
DR: You know, I hope so. I know it’s new…
SM: So, maybe, five years from now?
DR: It’s really hard for me to see how well it will be received. I mean, the doctor who has pioneered this, Dr. Pimentel, is, I think, a very highly respected gastroenterologist, so…
DR: …it’s not like this has been developed by someone who doesn’t have the right credentials, right? He is a gastroenterologist who is at a major center and has published a lot of research. I think from a credentials standpoint, it’s there. And, I guess the other questions are the potential financial ability to prevent unnecessary healthcare spending. That’s something that I don’t have a lot of good data off the top of my head in terms of how many people are unnecessarily screened for IBD.
SM: Right, how many colonoscopies, and endoscopies, and upper GI series, and all the different things you can have?
DR: Right, but I’m guessing that this is going to save a substantial amount of unnecessary G.I. studies like that. Off the top of my head, I don’t know how expensive this marker is, but I don’t believe it to be very expensive. I’m assuming it’s $100 to a couple hundred dollars at most. I’m hoping this will catch on and help people like your unhealthy cousin that doesn’t take care of themselves and maybe needs an early screening tool to help figure out IBS or IBD. So, we’ll see.
SM: Any last…any wrap up? Any last words of wisdom to leave us with today?
DR: No, I just want to reiterate that I think this is a great cast…again, I want to be clear and say that I think this is a great test and I’m very excited that this test has been released. Also, we have to contextualize for whom is this test appropriate? And when is this going to be appropriately used? Hopefully we’ve helped people see that this test has a time and a place, and just because it’s a new autoimmunity marker, doesn’t mean everyone and their mother needs to go out and do it.
SM: Cool. Well, thanks for giving us all the information. I’m sure going to file this away in my ‘Need-to-know-for-the-future’. I have clients with SIBO.I have friends with SIBO – to make sure they don’t run out and spend the money to get a test that they might not need.
SM: OK. Thank everybody!
DR: Thanks, guys.
SM: Have a great day.
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