My SIBO Treatment Protocol

Small Intestinal Bacterial Overgrowth, aka SIBO, is a common cause of digestive symptoms; gas, bloating, constipation/diarrhea, reflux and abdominal pain. It is also a common cause of IBS. This case reviews how you can become symptom free after treating SIBO. Also, and possibly more important, is that we do not always need to reach a “true negative” on the breath test to be symptom free and feeling great.

Episode Intro

Dr. Michael Ruscio, DC: Hey, guys. Just wanted to give you the fast facts for this episode, which is essentially me walking through my SIBO treatment protocol for a recent patient who had some very nice results with SIBO. You can see the transcript for the specifics on my protocol. It’s a little bit long, actually, for the fast facts, but you can see that along with her lab tests.

In short, we used herbal antimicrobials with biofilm agents and then the elemental diet and then a combination of the two. The more important aspect of successful treatment is monitoring by and working with your doctor in order to personalize the available treatments.

[Continue reading below]

Dr. R’s Fast Facts Summary

  • See transcript below for my specific protocol for recent patient “Christine” with her lab tests:
    • We tried herbal antimicrobials with biofilm agents, then the elemental diet, and then a combination of the two
  • The more important aspect of successful treatment is monitoring by and working with your doctor to personalize treatment
  • Principles are more important than protocols in successful treatment
  • We introduce the concept of ‘prebiotic responders in SIBO.’
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In this episode…
Episode Intro … 0:42
Episode introduction … 2:57
Patient history … 8:02
SIBO treatment protocol … 12:46
SIBO prevention maintenance … 21:35
Prebiotic responder in SIBO … 36:36

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Principles are more important than protocols in successful treatment, and we really elaborate on that concept, and I think especially for the practitioners listening, that’s an important thing to hear, and hopefully it will be helpful for you.

And then we also introduce the concept “prebiotic responders in SIBO,” which is something I’m starting to notice in the clinic.

All right. Hope you enjoy it, and I hope it helps. Thanks. Bye.

DR: Hey, folks. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. I am with here with Susan McCauley. Hey, Susan. How are you?

Susan McCauley: I’m good. And for everybody not in California, it’s raining here!

DR: I know! It’s a rare, rare event to rain, but you know, the funny thing is it was raining this morning, and then for lunch I was able to sit outside in the sun and it was nice enough to sunbathe. We’re truly blessed here. Even if it rains, it’s still sunny.

SM: I know. But it was so funny. My cats were crazy! They usually are used to going outside in the backyard, and they ran outside and ran right back in! They forgot what rain was!

DR: Yeah, well, I’m sure there will be a whole news piece about the rain. I think we talked about this one previous episode, but being from Massachusetts and living through snowstorms—

SM: Oh, I’m sure you laugh at us!

DR: It rains here and people are like, “Oh, my God! There were rolling blackouts, and we stocked up on water and amenities.” It rained for a day!

SM: Well, they had on the news this morning how many outages. I was like, why are there power outages?! It rained a half an inch!

DR: It’s crazy, I know.

SM: I’m excited because this is one of my all-time favorite topics that we talk about, so what do we have in store for today?

My SIBO Treatment Protocol - siboDR: Yeah, we end up talking about this a lot and, I guess, for good reason because it is a common condition. We’re going to talk about SIBO today, but I wanted to address some questions about a recent case review that went out in the newsletter a few weeks ago—or by the time this podcast goes out, it’ll probably be a month or so ago. I just recorded a case review with a patient, and we essentially talked about how well she’s doing and how she has overcome her symptoms, and we also introduced a concept of someone being able to have a positive lab value on SIBO but be free of symptoms. I introduced that concept, and then people lost their minds, wanting the protocol. So I want to just start off by saying there is no magic protocol. I will run through what we did, but I again want to just off by making sure to say that what we did with this patient we could do with someone else and get a terrible result. We shouldn’t think “protocols.” We should think “process.” We should think “fundamentals.”

And while I’m on my soapbox here, let me just go a little longer! I think one of the most challenging things for someone who is trying to become skilled in functional medicine or natural medicine or what have you is learning how to think for themselves. Unfortunately, much of the education is expert driven, meaning we go to X expert’s seminar or we go to see X guru, and it’s more about following the leader in a lemming-like approach, using their protocol rather than thinking about what are the fundamental principles that we need to tackle. So I’d like to start off with a quote from Emerson. I used to think it was Ralph Waldo Emerson, but it’s actually Harrington Emerson, and it reads, “As to methods, there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.”

SM: That is a really good one, and I think it speaks to what we’re talking about, that we need to understand what SIBO is and how it works and what the underlying mechanisms are instead of rotely following some supplement protocol.

DR: Exactly, and along those same lines, to think for yourself.

SM: Mm-hmm.

DR: There may be a treatment that is well documented to work well which may work terribly for a patient. In fact, one of the concepts that I’ll introduce at the end here is something I’m starting to term “prebiotic responders in SIBO,” and this completely flies in the face of everything that we think regarding SIBO treatment, yet some patients have done very well with this. This is something I’ve stumbled across as I’ve thought through these things critically, as I’ve listened to what my patients have reported back to me, and I’ve thought for myself through these things. So, yes, thinking for yourself and not following protocols is hugely important because that will enable you to evolve. We can give you the best protocol in the world today, but in three or four years, things may change, right? And so if you’re just dependent on that protocol, if you don’t evolve, if you don’t grow, you will die. And the same thing happens with how you practice. You have to be constantly growing and evolving, which requires you to think.

Anyway, let’s get into the meat of the matter here before too many people just tune out and send me hatemail.

SM: Turn us off!

My SIBO Treatment Protocol - christineDR: Yeah! So this patient—and we’ll put the link if you want to view the video conversation between this patient and me. I think it’s really nice just to hear her discuss the changes and the improvements that she noticed and everything. I think that will be helpful for people, so we’ll put the link in here.

And I should also mention, while we’re on the podcast here, if you’re subscribed to the podcast but you’re not subscribed to the newsletter, I would definitely subscribe to the newsletter because, of course, this lady’s case review didn’t go out via the podcast, and we have quite a few articles that are going to be coming down the pike, too, that won’t be released via the podcast either. And then all the research highlights that go out through the newsletter, so definitely if you’re on the podcast subscription list and you’re not on the newsletter, I think it would behoove you to plug in there.

SM: So where do they go sign up? Is it just at DrRuscio.com?

DR: Yeah, it’s just the homepage for DrRuscio.com in the upper right-hand corner. On the right side there there’s a newsletter box, and you just plug in your email, and then you’ll start getting all the updates.

SM: Cool.

Patient history

DR: So this lady presented as a 39-year-old female with a fairly long history of gastrointestinal complaints and some other complaints. Some of her chief complaints were food reactivity, overweight, insomnia, bowel irregularity tending toward constipation, fatigue, problems with mental clarity, headaches, constipation, and chemical sensitivity. Sorry, I said constipation twice, but these are not uncommon presentations. A very common presentation. And she had actually done Steven Wright and Jordan Reasoner, their leaky gut cure protocol or course, and she had improved from that, but then she had regressed. And so she spoke with them and they said, Well, if the protocol is helping you, but you’re not able to sustain it, then maybe you need to see Dr. Ruscio and he can help figure out what’s going on.

I think that’s also a common scenario, where people jump from one self-help course to the next, to the next, to the next, and the same thing keeps being repeated. They get a little bit better and they regress, they get a little bit better and they regress, and the real travesty about what happens there is there’s not a clinician observing you, testing you, listening to how you respond, and taking notes to learn from that. That’s the one bad thing about jumping from one self-help course to another. Those are such prime chances for a clinician to observe and listen and learn about that particular case. I just want to throw that note out there for people. It really is well worth investing time to work with a clinician because that can really provide the clinician with a lot of valuable insight and information.

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When we initially worked up this patient—we’ll call her Christine. That’s her first name, and she’s in the video, so I feel OK saying that since it’s already on the video and she’s fine with that! When we first worked up Christine, we performed a SIBO breath test, the lactulose-provoked hydrogen/methane breath test, and her initial values—and I’ll put the pictures of her labs in the show notes—but we did her SIBO lab and we also did a comprehensive pathogen screen through Quest. Now, everything through Quest came back clear, but SIBO came back positive, and she had a peak value of hydrogen of 29, a peak value of methane of 84, and a combo peak of 113.

SM: For people that don’t know what those numbers mean, how high are they out of the norm?

DR: Well, the way I like to grade these for patients is on a scale of mild, moderate, and severe.

SM: OK.

DR: I would consider this a severe case of SIBO with methane being the main gas positive.

SM: OK.

DR: Specifically, we don’t want to see hydrogen above 20, we don’t want to see methane usually above 3, so of course, 3 to 84 being her level—

SM: Wow, that’s huge!

DR: That’s why I would call this severe. And we don’t want to see the combo gas above usually 15 to 20 also, and so that’s why we see that positive there.

Again, her hydrogen 29 peak; methane 84 peak, very high; and her combo 113; so this is definitely a severe case of SIBO, and this can actually be one of the most challenging presentations, being the methane predominant, because methane is one of the harder to clear. I think pretty much every doctor that treats SIBO has noticed the same correlation or the same finding, which is methane is harder to see a response in compared to hydrogen. Does that mean that you can’t see a response in methane? Absolutely not, but it’s just the harder of the two gases.

SIBO treatment protocol

DR: So what did we do for treatment? We put her on a probiotic-prebiotic combination known as Primal Defense, which has a moderate amount of prebiotic, and it also has some lactobacillus bacteria, some saccharomyces bacteria, and some spore-forming bacteria. And we also had her on some enzymes. We had her on Digestzymes from Designs for Health, which is a blend of hydrochloric acid and pancreatic enzymes and bile. And then finally, we also had her on a straight hydrochloric acid supplement, and that was only because she had previously noted she did better on hydrochloric acid. I typically will not put someone on a straight dose of hydrochloric acid unless I think they really need it. In her case, it seemed like she needed it, so we started off with that.

And then the specific SIBO treatment, we used two different antimicrobials in the first month, and in this case—and there are a few different herbal protocols I use for SIBO, so I hate to not give people something to blindly follow, and to tell you the truth, guys, does it really matter, in my opinion, if you’re using one herbal blend versus another? I don’t really think so. This comes down to principles rather than methods. The herbal protocol we used in this case the first month was GI Microb-X from Designs for Health dosed at six a day along with oregano oil from Designs for Health dosed at six a day. The second month, we used OrthoFlora Yeast six capsules a day, and we used ParaBotanic Select, which is by Moss, at six capsules a day also.

Then, in addition with that, I added in allicillin, and I forget which allicillin. I believe it was Allimax Pro, which is the highest-dose, best-priced allicillin I’ve been able to find. And I added in with that samento and InterFase Plus.

Samento, also known as cat’s claw, and InterFase Plus are both biofilm agents, and this was back when I was randomly allocating patients to either receive antibiofilm treatment along with SIBO treatment or not receive antibiofilm treatment. I’m no longer doing this because we’ve collected enough data and I’m now happy to say that we’re working to crunch the numbers with a biostatistician, and we’ll hopefully be submitting this for peer review and then publication in the near future. And as soon as I have the numbers back from the biostatistician, we’ll probably do a follow-up podcast and I’ll give you the straight talk on what effect we saw or did not see. My initial inkling is that the biofilms don’t really make a huge difference in the treatment of SIBO. I could be wrong in that, but that’s just from my quick purview of the data and the numbers in Excel. I don’t think that the biofilms make a huge difference.

SM: Do you think the mechanism for that is that the overgrowth isn’t one of those sneaky ones that tries to protect itself like H. pylori does with the biofilms to protect itself to live, that they’re just there and the biofilm doesn’t need to be disrupted?

DR: Yeah, it may be that the bacteria that participate in SIBO are not as prone to forming biofilms, or it may be that because the small intestine is a much more volatile environment that biofilms never have a chance to fully establish.

SM: Mm-hmm.

My SIBO Treatment Protocol - SIBODR: It could be because of the acidity difference in the small intestine compared to the large intestine compared to the stomach, as you mentioned with H. pylori, that being where H. pylori is going to predominantly reside, of course.

Yeah, we could certainly speculate as to the mechanisms. I’m not really sure what exactly would be happening there, but what I’m chiefly concerned about is, does it seem to make a difference in the clinical outcomes, because even though this is only two additional compounds to add, this may add another $200 or so to treatment, and if someone has to be treated two or three or four times… right now these things really start to multiply, and coming back to the quote I opened with, if my principle is to try to find the minimum amount of treatment needed to realize the maximum effect, I’m going to apply this same principle to things like adrenal support, to things like nutritional support, to things like hormone support, and that will manifest itself in thousands of dollars more or less of treatment for a patient over the course of their treatment.

SM: And I think with InterFase Plus, just with my personal experience because I’ve taken it in the past, is that the compliance… it’s not an easy supplement to take with that second dose being usually in the afternoon, and it has to be on an empty stomach. So it’s like, “OK, I have to eat lunch, I have to set a timer, I have to take it, and then I have to set another timer,” because it has to be on an empty stomach, so I wonder if that plays into it as well, how compliant patients can be with it.

DR: Right. Well, I have patients take the biofilm agents along with their antimicrobials.

SM: Ah.

DR: Because here we come back to this position of principles and fundamentals and practicality. I’ve had patients do it both ways. Have I ever seen it make a huge difference one way or the other? No. Do some patients get an upset stomach when they take everything on an empty stomach? Yes. Have I then had them take it with food and still seen many infections clear? Yes. So just through a little bit of thinking for myself there and testing a previous assumption, I’ve pretty much ruled out the fact that these things have to be taken on an empty stomach to make a huge difference.

SM: That’s interesting because I’ve always been told that the antimicrobials don’t need to be taken on an empty stomach but the InterFase Plus you need to make sure to take it on an empty stomach, so I’m going to start playing around with that.

DR: You know, the best treatment is going to be the one that the patient is consistent with.

SM: Right, exactly. I used to do some amino acids with clients, and the adherence, the compliance was absolutely dismal because they had to take them on an empty stomach. And I think it was Kalish that said you don’t really need to take them on an empty stomach if you can’t get compliance.

DR: Exactly. Yeah, I remember Dr. Kalish saying that also, and I made note of that, and I said, “Hmm. That’s interesting. I wonder if this is going to apply to other things.”

SM: Yeah.

DR: And certainly I think it does. I think sometimes in this functional and natural medicine space we make way too big of a deal of stuff, and sometimes we just need to calm down!

SM: I know.

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DR: All right, so that’s what we did. We had two antimicrobials for the first month, two different ones for the second month, and then the allicillin with the biofilm agents administered for the duration of the two-month treatment. And it was striking to see that after that, everything was completely normal. Now, when I say “everything,” I mean her SIBO retest came back completely normal. Hydrogen was normalized and methane was normalized. And for methane, that is a remarkable shift, right?

SM: Mm-hmm.

DR: Now, what I could do is blast this all over the internet, shout it from the rooftops, and try to make myself sound like a big deal, but what I’ll tell you is sometimes you see a miracle with treatment, and sometimes you’ll do the same thing for someone else and you’ll see, like, a 4-point shift. OK? Just because there was this great result here, I don’t want people to think this is the magic protocol and you have to go to great lengths to do this. In fact, if you’re struggling with SIBO, I would recommend that you don’t do the protocol I just went through, but rather you find a good clinician to treat you because the real magic here is in a clinician being able to figure out what treatments work best for you.

SIBO prevention maintenance

DR: So after that, she was pretty much asymptomatic, meaning she had no more symptoms and she was in a great place. We kept her on the probiotics and the enzymes and the acid that we mentioned from before, and then we reverted to our SIBO preventative strategies just like we’ve talked about in many other podcasts, which would be low FODMAP along with a prokinetic—in this case, we used Iberogast—and then we monitored her. And a couple of months later, she started to symptomatically relapse, and when we retested, her methane was back to 43.

SM: Hmm.

DR: So we treated again with the same protocol, and this time we only saw a 10-point reduction in the methane, but her symptoms were much, much, much better. So we then decided to do the elemental diet because, of course, we were seeing a diminishing return with the herbals in this case. After doing the elemental diet, her methane then came down another 10 points, but her hydrogen now was positive again. Her hydrogen had been negative up until now, and all of a sudden, the methane went down another 10 points, so now she’s at about 23, so she’s still positive for methane, but all of a sudden, the hydrogen shoots up. Her symptoms were doing very, very well, though. In fact, her symptoms were almost completely ameliorated at this point. So I’m saying to myself, “Hmm. She’s still positive, but symptomatically she’s doing great.”

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Then we treated one more time with the elemental diet, and we followed that by a course of herbal antimicrobials, and her symptoms went from just a few that were still kind of lingering to all gone. But when we retested—and this will be her final retest that will be in the notes—she still had a hydrogen of 40 and a methane of 38, yet all of her symptoms were gone. And this is the main thing I wanted to introduce with the video that Christine and I put out, which was—in my opinion, anyway—you can have a positive SIBO test and still be fully asymptomatic.

Now, that wasn’t just a snapshot in time. We’ve been following her three months since that retest, and she has maintained all of her improvements. And I want to tell you more about the treatment that we did… her maintenance program, I guess I should say, not really treatment, her maintenance program. But let me just check back in with her symptoms. She had no more food reactions. She had lost a little over 40 pounds.

SM: Wow.

DR: Her sleep was much better, her bowels were regular, her energy was back, her mental clarity was improved, her mild headaches were gone, and her chemical sensitivities were gone. And she says in the video she feels better now than she did when she was 25.

SM: Oh, wow. That’s great.

“We kept her on the probiotics and the enzymes and the acid that we mentioned from before, and then we reverted to our SIBO preventative strategies just like we’ve talked about in many other podcasts…”My SIBO Treatment Protocol - tweet e1540485375388

DR: Now, one of the things I discuss in the video is, depending on how I was framing this for her, she could feel like a failure and she could be walking around with chronic fear that, “Oh my god, I still have SIBO positive,” right?

SM: Mm-hmm.

DR: If I had framed this the wrong way, this could be looked at as almost a failure. I mean, yes, her symptoms are better and she’s happy about that, but I see in my mind a different type of provider, that type of provider that, I think, is hard on patients, which the dialogue would look something like this: “You’re still positive. We have to keep going with treatment. You have problem in your gut, and that problem in the gut could cause autoimmune conditions, and you may have degeneration of your brain or degeneration of your thyroid,” blah, blah, blah, and just have a patient who feels like shit about themselves—pardon my French—but because this is framed the wrong way, the patient now feels bad about themselves and has this lingering fear. I can’t overemphasize how damaging I think that can be.

So what we’re doing with Christine now is we’ve reverted to something that Dr. Steven Sandberg-Lewis introduced at the year before last’s SIBO Symposium, which he termed “cyclical low-dose antimicrobial therapy.” Essentially—and this probably comes from Dr. Sandberg-Lewis just thinking for himself and thinking through this practically—what we’ve now done with her is we have her on one antimicrobial agent at a time at a very low dose. So she may be taking two oil of oregano pearls a day for a month, and then we’ll switch to another herbal antimicrobial, and that seems to be working very well right now in conjunction with Iberogast in preventing relapse.

My SIBO Treatment Protocol - intermittent fastingNow, something else that she’s doing is if she feels like things are getting kind of funky, she will periodically do a one-day liquid fast using the elemental diet, and I think the main utility here is more antiinflammatory than it is anti-SIBO. Fasting has been shown to be a very effective antiinflammatory tool, and now, if you want to really get all distracted with mechanisms—which I don’t think we should; I think we should focus on the clinical presentation and how this works for a patient clinically—but a mechanism here could be that by using the one-day elemental diet periodically, that’s helping to have an anti-inflammatory effect. We know that the interstitial cells of Cajal cannot fully recover if there’s a highly proinflammatory environment, so it may be working to restore motility, but it’s working nonetheless.

So she’s three months out. Maybe a couple of days a month she’ll do one day of an elemental diet when things feel funky, and she’ll be cycling a different low-dose antimicrobial along with some probiotics, and now for a probiotic we have her on Ther-Biotic Complete, which is a lactic acid probiotic blend; we have her on saccharomyces; and we also have her on Iberogast.

Now, is she eating like a crazy person? No. She’s gone through her elimination on the autoimmune paleo diet, and she’s gone through a reintroduction of allergens, and she’s settled into a pretty diverse array of foods. And she’s also gone through the FODMAP reintroduction, and she’s able to eat a fairly diverse amount of FODMAPs, but she does find that some starches really trouble her, and so she’s just made a note of that, and she avoids these few starches. So she’s three months out. We just had a followup actually last week, and she’s still doing great. She has a day here or there where things get a little bit funky, and when she does, she does the elemental diet. But she certainly is doing—as I ran through with her symptoms—she is doing so much better than she was before. And equally as important, she’s happy with where she’s at, she doesn’t have any lingering fear, and I’ve explained to her that in some cases this low-level SIBO positive lab value is OK because we’re supposed to use these labs to guide our treatment, but ultimately they’re guiding our treatment to treat a patient, not to just blindly treat a lab value.

SM: Right, and everybody is different. Maybe for her, that’s her normal.

DR: Mm-hmm.

SM: Just because some lab comes up with a number, if she has no symptoms, then that should be the guiding factor, not a number on a piece of paper.

DR: Exactly. So she has done really, really well. And we’ve used a blend of different treatments, and we’ve seen some treatments worked beautifully at first and their lab-changing properties diminished, but their clinical utility was still maintained. And we’ve found a good mixture that works well for her.

There’s another concept I’d like to introduce, but before I do, Susan, is there anything there that you would like to ask or for me to expand on?

SM: Yeah, well, just the patience factor, I guess. People want things fast sometimes, and when you went through Christine’s story, it wasn’t a two-week thing. It was, “OK. The first protocol was 60 days, and then we had a little bit of relapse and we went again,” so people need to be patient. These things take time when we’re trying to restore the health of your body and the homeostasis of your body.

DR: That’s true, and you make a great point. We treated Christine for about a year.

SM: Yeah.

DR: And in the video I remark that she was an easy one from the perspective—and let me explain how I say “the easy one” when it’s someone who’s been treated for just over a year—her symptoms responded very well to the initial treatment, and so even a month into the first round of treatment, she was already seeing quite a bit of symptomatic improvement. Not everyone is so lucky. Some people don’t start to see improvement until the labs are normal or close to normal and then the gut has healed for several weeks after that. That’s kind of how I was. I didn’t notice immediate change when I treated my amoeba, but then my gut slowly started to heal, and I started to gradually improve week after week after week, and it wasn’t months until after I cleared my amoeba that I really saw appreciable change.

So I say Christine was an easy one because she saw improvement so quickly, but again, there are other people that they may have to go through this process of treat, retest, see some improvement, relapse, treat again, see some improvement in the labs, relapse a little bit, try a different treatment, retest the labs, finally have things at an acceptable level, and then only from once you’ve hit finally have things an acceptable level, a few months after that see improvement. And that’s why we consider a hard case not because it’s any more clinically challenging, but it’s harder for the patient to stay in the game, and that’s why I’ve repeatedly said find a clinician, and as long as you have confidence in that clinician, give them the time to work through the process because this is a process-oriented treatment. It’s not “Dr. So-and-so is going to have the magic protocol.” Now, again, that’s heavily contingent upon you having confidence in your provider, but I don’t think any provider has a magic protocol. It’s more just working through these things, trying to figure out what protocol or mix of protocols are going to work for a patient.

My SIBO Treatment Protocol - AdobeStock38603583WEBgutbacteriastomachelementaldietprobioticsSM: And then I think you made the point about finding a provider that just because you think you have SIBO because I think sometimes there becomes, like, a disease dujour, you know? SIBO is talked about a lot now. Say, you eat FODMAPs and you get gas and bloating. That’s one of the telltale symptoms. For me, I went and I had some of those symptoms, and I swore I had SIBO. I really thought I had SIBO, and I was all ready, so I went to my provider, and I said, “Test me to SIBO!” He says, “You don’t have SIBO.” And I said, “But I’m bloated.” He said, “That is your colon, and your colon is inflamed.” That’s how I got my IBD diagnosed because I had to go through a colonoscopy and all that stuff. So if I would have just listened to a podcast, and then that’s why I think you were hesitant to talk about the protocol, not to talk about it, but it may not be for everyone, especially if you don’t have SIBO.

DR: Exactly. Your point is a beautiful one. And just to kind of expand on that, there is a lot that your doctor—a good doctor—will process when you first present, right?

SM: Right.

DR: You may go online and read a list of symptoms and 8 of 10 of those symptoms you have, and so now you diagnose yourself with that condition. But there are so many conditions that have overlap with the symptoms of other conditions, that doing that is incredibly ill informed. It’s something I really want to caution people against doing. Just like you said, Susan, you may really think that you have hydrogen-positive IBS or SIBO, but you may actually have IBD. It’s a little bit different of a game, and so, yeah, it’s work going through the steps, and I get it. Seeing a doctor, especially usually the initial exam visits, can be expensive. It’s time and it’s money, and I get people not wanting to invest that, but if you’ve tried one of these self-help courses and you haven’t gotten there yet, I really think it’s worth going to see a doctor. This is the same thing I did. I had an amoeba, I tested positive, and then I thought after I treated it everything was all done, but I still wasn’t feeling a lot better, so I went and I tried to put together my own thyroid protocol and my own testosterone protocol. And I wasted a lot of money and got no better over six months, and then I finally retested and the infection was cleared.

So, yeah, it’s worth getting some help and something, I think, is really, really important for people to hear. If your car broke down and we let you into the mechanic’s shop, would you be able to fix your car?

SM: Not me!

DR: Right? Most of us wouldn’t be able to. Just because you have access to tools doesn’t mean you know how to use those tools. That’s one of the challenges in healthcare. It’s “Well, we have access to these herbs, or I can maybe ask my GP to write a script for this if I have a good relationship with him,” but it doesn’t mean you know how to use these things. It’s the same thing with the mechanic analogy.

Prebiotic responder in SIBO

DR: All right, the final point here I’d like to chime in is there’s something I’ve been observing in the clinic, and I haven’t made my mind up on this fully yet, but it’s something that I’ve been noticing in a handful of patients, and I actually just had a conversation with Dr. Siebecker. We go back and forth periodically, and we kind of compare notes, and there’s this concept that I’m terming “prebiotic responders in SIBO.”

What I’ve seen in a handful of patients is during their history—again, this is where the doctor listens to you, gets to know the patient, listens to what the patient says, hears the patient’s story—I’ve heard some patients report that they feel better when they eat more carbs. OK, so I make a note of that. And when we work these people up, we find SIBO. We find mild to moderate SIBO, not a severe case of SIBO. We go through SIBO treatment, and we get their values down, sometimes normal, sometimes just a low-level SIBO, but these patients don’t tend to respond much.

So the thing that I had in the back of my head with some of these people that noticed they felt better on a higher-carb diet, I said, “Well, maybe if we push the needle forward in that direction more, we’ll get an even better response.” And I should mention that when people have noticed previously that they do better on a little bit more carbs, I would usually have them just eat a little bit more carbs. I mean, who would have thought?! I’m not following protocol I got from X seminar. It’s like, “OK, great. If you notice you do better on carbs, that probably means you have a certain metabolism or a certain flora that needs that, so let’s go with that.” So these people would be on a little bit more carb, we’d treat them for SIBO, they wouldn’t really respond ideally, and so then I’d revert to a more symbiotic approach, where we would start doing the opposite of what you should do in someone that has SIBO, but we would start treating them with higher-dose prebiotics, higher doses of fiber, everything that kind of feeds bacterial growth, and for the handful of patients I’ve done this with thus far, they’ve responded really, really well.

The way I think about this—and again, I think about this; I don’t just follow a protocol blindly—is the gut is kind of like a garden and some people may need more weeding and other people may just need more fertilizer, to put it really loosely. But if you’re tending the garden well and you’re observing what happens in the garden, a lot of this just has to do with learning how to mind the ecosystem. So I don’t necessarily know the “why,” but what I observe is that the approach of getting rid of SIBO in some people doesn’t seem to work well, but the approach of feeding bacteria in some people seems to work really well.

This is something I’m going to keep an eye on and see if I can firm up, but so far what I’ve noticed in this regard with what I’m loosely terming “prebiotic responders in SIBO” is patients that have previously reported they do better on a little bit more carbs rather than a little bit less and have SIBO, but not severe SIBO, have mild to moderate SIBO, may do better with an approach that is the opposite of what we would typically do for SIBO. It would be an approach that really favors fermentable substrates like fibers and prebiotics.

SM: And when you’re talking about a little more carbs, you’re not talking about Wonder Bread and Fruit Loops.

DR: No!

SM: You’re just talking about a little more good real food.

My SIBO Treatment Protocol - AdobeStock58775535WEBgutstomachdietlifestylefoodDR: Yeah. Gluten-free grains and starches.

SM: You never know what people are going to take when you say “a little bit more carbs.”

DR: Thank you. Yeah!

SM: Ice cream!

DR: “Well, Dr. Ruscio said eat gluten if you have SIBO.” Yeah, I could see that.

SM: OK. Well, we’re getting near to the end of our time. Is there anything you want to leave everybody with?

DR: No. That’s really it. Hopefully this helps people. For the people that wanted the specific protocol, there are the specifics, but I’m hoping that people take away from this a more thought-process-driven approach rather than a protocol-driven approach. On the transcript page that accompanies this, if you have thoughts or feedback, feel free to chime in, and we will keep keeping you abreast of important stuff with SIBO as it becomes available.

SM: Yeah, and remember, like I said, everybody is different.

DR: Absolutely.

SM: What works for your neighbor might not work for you.

DR: Absolutely.

SM: OK, guys, thanks. We’ll talk to you next week.

DR: Thanks, guys.

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.

Discussion

I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!

142 thoughts on “My SIBO Treatment Protocol

  1. Hi Dr Ruscio. I sent you a question via Email, but that may have been the wrong way to reach out.

    My question is unrelated to SIBO, but more about auto-immunity. Do the markers for parietal cell antibodies and Intrinsic factor antibodies shut down once you start to get B12 levels up and homocysteine levels down in a pernicious anemia state? If there is an autoimmune component to this and I need to stay on injections every month for the rest of my life to keep in the normal range, then wouldn’t I want to know that before I start supplementing so I don’t have to come off and possibly relapse before figuring out that I need to be back on the B12 injections?

    Or would these antibodies not change, and therefore testing could be done later after giving the injections a month trial?

    Thanks! Looking forward to listening to this pod when I get a chance.

      1. Thanks Doc. I’ve got the B12 shipped next day air. I’ll let you know how it goes. Any idea how long it takes to improve a deficiency or to “feel” it? Different for everyone I assume.

  2. Hi Dr Ruscio. I sent you a question via Email, but that may have been the wrong way to reach out.

    My question is unrelated to SIBO, but more about auto-immunity. Do the markers for parietal cell antibodies and Intrinsic factor antibodies shut down once you start to get B12 levels up and homocysteine levels down in a pernicious anemia state? If there is an autoimmune component to this and I need to stay on injections every month for the rest of my life to keep in the normal range, then wouldn’t I want to know that before I start supplementing so I don’t have to come off and possibly relapse before figuring out that I need to be back on the B12 injections?

    Or would these antibodies not change, and therefore testing could be done later after giving the injections a month trial?

    Thanks! Looking forward to listening to this pod when I get a chance.

      1. Thanks Doc. I’ve got the B12 shipped next day air. I’ll let you know how it goes. Any idea how long it takes to improve a deficiency or to “feel” it? Different for everyone I assume.

  3. I have been diagnosed with SIBO and I find a do a little better on apples and beans. A stool test showed I did not have enough good bacteria. I think I needed the apples and beans to feed the good bacteria.

  4. Hi Dr. Ruscio,

    your scientific approach to improving the protocol like with the biofilm agents is great! That’s what we need to advance medicine.

    I remember you talking about an effect of statins on methanogens. I look forward to hearing about your experience with adding red yeast rice to SIBO treatments. When you look closer into it, there seems to be some connection between cholesterol treatments and SIBO treatments. Some herbs commonly used for SIBO treatment have also shown blood lipid lowering effects:
    Effects of berberine on lipid profile in subjects with low cardiovascular risk (2013)
    http://www.ncbi.nlm.nih.gov/pubmed/23441841
    Effects of anethum graveolens and garlic on lipid profile in hyperlipidemic patients (2007)
    http://www.ncbi.nlm.nih.gov/pubmed/17328819
    Anyway, those herbs have a lot of pharmacological actions so it’s hard to tell if there is a connection. But it’s still interesting…

    Another interesting herb is hibiscus flower. The tea has been shown to improve blood lipid profile (http://www.ncbi.nlm.nih.gov/pubmed/23333908) and is used traditionally to ease symptoms of food poisoning as well as to reduce bloating and constipation. On the internet there are even reports of people getting rid of IBS just by drinking 3 cups of hibiscus tea daily for 3 months. It has demonstrated some antibacterial properties in vitro but I’m pretty sure there are no studies on methanogens yet. Anyway, it would be great if a simple method like drinking hibiscus tea could improve SIBO treatment outcome.

    PS: Keep up the good work!

  5. Thanks for all the in-depth information. I have numbers very similar to your case study. I am one of those self treating people you mentioned and have listened to numerous podcasts about digestion and came to the conclusion that I didn’t have SIBO. I finally decided to see an ND and she suggested I test for SIBO. So your advice about enlisting a practitioner is spot on! I hope others follow this advice.

    I have one question and that is what are your thoughts about diet during herbal protocols? I understand that the recommendation during pharmaceutical antibiotics is to feed the bacteria. Is the recommendation the same with herbal antibiotics? I have seen it recommended both ways.

    1. Thanks Christine! The same principles apply when using herbs are Rx regarding diet. That being said a paper was recently published showing co-administration of probiotics with Rx was more effective than co-administration of prebiotics with Rx in treating SIBO. This is why I have all/most my SIBO patients on a probiotic. Hope this helps!

      1. Hi Dr Ruscio! I’m happy to discover you through my kindred soul Keith R, who advises me. Just listened to this. Love your style and philosophies! I am in the Kresser training right now and love geeking out over the microbiome. Can you cite this paper you’re referring to that PRO work better than PREbiotics with Rx? Is this Pharm Rx or Herb Rx? Also, is the book you refer to an e-book or a print book? I have so many questions for you so I”ll try to dole them out slowly, lol. Clinical question for now, a super high methane SIBO patient who has long term constipation, I have her on a personal protocol now (FYI I LOVE your process not protocol philosophy), and she is stubbornly still bloated, EVEN though we got her to have a significant poop daily now. The only prebiotic that has worked thus far is arabinogalactan, all others worsen constipation. Most other prebiotics take days to recover from 1 dose (i.e. poop again). Now I haven’t restested as it’s only been a week and she’s feeling better except for the huge bloat – feels (and looks) pregnant, it’s weird. Not a lotta flatulence, but some. Can’t tolerate bile or HcL (gets reflux) but bitters are working well. Iberogast did nothing apparent. Antimicrobials include: Metagenics Candi AR and BR both 2 caps bid (ouch $), DFH MicrobX 1 bid, Monolaurin (this one not my idea) 2 caps bid. No biofilm disrupters b/c egg intolerance (interfase) and I can’t decide if she need them and which one to choose. Perhaps this is a missing link? Paleo diet, not low FODMAP but avoids known intolerances (eggs, onions, garlic, mushrooms). One exception to perfection is soymilk for cream in tea. No known soy intolerance, but has sugar. Probiotics include SBOs AOR3, PA, Megasporbiotic. Prebio is Arabino 2 scoops. Also using Custom Probiotics D Lactate Free powder, and making coconut milk yogurt with it. I am frustrated to be missing the boat with the major balloon bloat. Even with pooping more than before Rx. Sorry for this crazy long comment that turned into a case study, but do you have any directions or instincts on this particular Sx? Thanks and yours truly, Laura

        1. Hi Laura,
          Thanks! See the 2nd interview I did with Dr. Siebecker for all references. I am working on both, the full book should be out early 2017, thats probably what you will want 🙂 If you see the episode ‘My SIBO treatment protocol’ it may answer many of your clinical questions. Sorry for short answers but until I get a clone its all I can do 🙂

  6. Dr. Ruscio – can you please describe the ingredients for the elemental diet that you found successful and for how long? Did you use Siebecker’s homemade elemental diet or something else? What is length of time on elemental diet that made a clinical difference in symptoms and retesting? Keep up the good work.

    Thanks,
    Molly

    1. Hi Molly. Yes we use Dr. Siebeckers recommended formulation; for 2-3 weeks. Although we have been experimenting with a better testing commercial formula. If it ends up working well we will provide an update. Hope this helps!

  7. I have been diagnosed with SIBO and I find a do a little better on apples and beans. A stool test showed I did not have enough good bacteria. I think I needed the apples and beans to feed the good bacteria.

  8. Hi Dr. Ruscio,

    your scientific approach to improving the protocol like with the biofilm agents is great! That’s what we need to advance medicine.

    I remember you talking about an effect of statins on methanogens. I look forward to hearing about your experience with adding red yeast rice to SIBO treatments. When you look closer into it, there seems to be some connection between cholesterol treatments and SIBO treatments. Some herbs commonly used for SIBO treatment have also shown blood lipid lowering effects:
    Effects of berberine on lipid profile in subjects with low cardiovascular risk (2013)
    http://www.ncbi.nlm.nih.gov/pubmed/23441841
    Effects of anethum graveolens and garlic on lipid profile in hyperlipidemic patients (2007)
    http://www.ncbi.nlm.nih.gov/pubmed/17328819
    Anyway, those herbs have a lot of pharmacological actions so it’s hard to tell if there is a connection. But it’s still interesting…

    Another interesting herb is hibiscus flower. The tea has been shown to improve blood lipid profile (http://www.ncbi.nlm.nih.gov/pubmed/23333908) and is used traditionally to ease symptoms of food poisoning as well as to reduce bloating and constipation. On the internet there are even reports of people getting rid of IBS just by drinking 3 cups of hibiscus tea daily for 3 months. It has demonstrated some antibacterial properties in vitro but I’m pretty sure there are no studies on methanogens yet. Anyway, it would be great if a simple method like drinking hibiscus tea could improve SIBO treatment outcome.

    PS: Keep up the good work!

  9. Thanks for all the in-depth information. I have numbers very similar to your case study. I am one of those self treating people you mentioned and have listened to numerous podcasts about digestion and came to the conclusion that I didn’t have SIBO. I finally decided to see an ND and she suggested I test for SIBO. So your advice about enlisting a practitioner is spot on! I hope others follow this advice.

    I have one question and that is what are your thoughts about diet during herbal protocols? I understand that the recommendation during pharmaceutical antibiotics is to feed the bacteria. Is the recommendation the same with herbal antibiotics? I have seen it recommended both ways.

    1. Thanks Christine! The same principles apply when using herbs are Rx regarding diet. That being said a paper was recently published showing co-administration of probiotics with Rx was more effective than co-administration of prebiotics with Rx in treating SIBO. This is why I have all/most my SIBO patients on a probiotic. Hope this helps!

      1. Hi Dr Ruscio! I’m happy to discover you through my kindred soul Keith R, who advises me. Just listened to this. Love your style and philosophies! I am in the Kresser training right now and love geeking out over the microbiome. Can you cite this paper you’re referring to that PRO work better than PREbiotics with Rx? Is this Pharm Rx or Herb Rx? Also, is the book you refer to an e-book or a print book? I have so many questions for you so I”ll try to dole them out slowly, lol. Clinical question for now, a super high methane SIBO patient who has long term constipation, I have her on a personal protocol now (FYI I LOVE your process not protocol philosophy), and she is stubbornly still bloated, EVEN though we got her to have a significant poop daily now. The only prebiotic that has worked thus far is arabinogalactan, all others worsen constipation. Most other prebiotics take days to recover from 1 dose (i.e. poop again). Now I haven’t restested as it’s only been a week and she’s feeling better except for the huge bloat – feels (and looks) pregnant, it’s weird. Not a lotta flatulence, but some. Can’t tolerate bile or HcL (gets reflux) but bitters are working well. Iberogast did nothing apparent. Antimicrobials include: Metagenics Candi AR and BR both 2 caps bid (ouch $), DFH MicrobX 1 bid, Monolaurin (this one not my idea) 2 caps bid. No biofilm disrupters b/c egg intolerance (interfase) and I can’t decide if she need them and which one to choose. Perhaps this is a missing link? Paleo diet, not low FODMAP but avoids known intolerances (eggs, onions, garlic, mushrooms). One exception to perfection is soymilk for cream in tea. No known soy intolerance, but has sugar. Probiotics include SBOs AOR3, PA, Megasporbiotic. Prebio is Arabino 2 scoops. Also using Custom Probiotics D Lactate Free powder, and making coconut milk yogurt with it. I am frustrated to be missing the boat with the major balloon bloat. Even with pooping more than before Rx. Sorry for this crazy long comment that turned into a case study, but do you have any directions or instincts on this particular Sx? Thanks and yours truly, Laura

        1. Hi Laura,
          Thanks! See the 2nd interview I did with Dr. Siebecker for all references. I am working on both, the full book should be out early 2017, thats probably what you will want 🙂 If you see the episode ‘My SIBO treatment protocol’ it may answer many of your clinical questions. Sorry for short answers but until I get a clone its all I can do 🙂

  10. Dr. Ruscio – can you please describe the ingredients for the elemental diet that you found successful and for how long? Did you use Siebecker’s homemade elemental diet or something else? What is length of time on elemental diet that made a clinical difference in symptoms and retesting? Keep up the good work.

    Thanks,
    Molly

    1. Hi Molly. Yes we use Dr. Siebeckers recommended formulation; for 2-3 weeks. Although we have been experimenting with a better testing commercial formula. If it ends up working well we will provide an update. Hope this helps!

  11. Hi, dr. R,

    I can’t help, but think, what if you put a patient on a real prokinetic after she cleared her sibo completely? Prucalopride for example. It’s possible that she wouldn’t have relapsed, wouldn’t need to suffer and spend money anymore. Wouldn’t that be a real success? Also, saying that she has no symptoms when she can’t eat statches and has to do elemental diet sometimes is not very accurate. That being said, I totally agree that she shouldn’t stress over the numbers, because that would only make things worse.
    I just think throwing all these supplements like enzymes probiotics is unnecessary and total waste of money in most cases and functional docs really love that. What they don’t like is proven things which help prevent relapse. Like prokinetics.

    Also, there is zero evidence that Iberogast works as a prokinetic and I don’t believe that it does, although it’s great for symptomatic treatment.

    1. There is some evidence that the main ingredient of Iberogast works as a prokinetic. Since Iberogast is an old German product one needs to speak German or translate research articles to read all the literature.
      The main ingredient ‘Iberis amara’ has been shown to increase motility of stomach and small intestine in animal studies. The motility enhancing effect was comparable to the prokinetic drugs Metoclopramid and Domperidon. The effect on large intestine motility was only very small.
      http://www.ncbi.nlm.nih.gov/pubmed/12618547 (Article in German, Abstract in English)
      Iberis amara increased the frequency and amplitude of small intestinal slow waves in a mouse study.
      http://www.ncbi.nlm.nih.gov/pubmed/15687728
      However, the other ingredients have a spasmolytic effect and rather reduce gastrointestinal motility. So we need more studies to fully understand the best use and limitations of Iberogast.

      Anyway, you seem to have had bad experiences with functional docs. Sorry about that. Even though I don’t agree with all functional medicine theories and interventions I do find these physicians very brave. And there are always good and bad ones like with conventional medicine.

      1. Hi Guys,
        I appreciate the dialogue here. Peter thanks for the references. Simas we are studying Iberogast in prevention of SIBO relapse in our clinic, we just had approved of our IRB and should be enrolling patients soon. Simas, I think you may have an inflated view of the clinical utility of Rx prokinetics, they help but not all patients and some patients can’t tolerate them. You do make a good point that many Func Med doc over-treat, this is something I hope my work will help to correct. Simas it sounds like you are frustrated, which is completely understandable, just remember there are many people/doctors who are on your side.

  12. Hi Dr Ruscio,
    I have been diagnosed with LPR, which I take to be caused by SIBO. I can’t confirm that I have SIBO, and I’m not sure where I’d get properly tested here in Taiwan, so I figured I would give a natural SIBO protocol a try to see how that impacted my symptoms. Do you have any opinion on the Fast Tract Diet by Norman Robillard. It seems like a pretty easy diet to follow and a good starting point. Could it be something to try alongside some of your recommended supplements?

    1. I am not familiar with the diet but I think you have a good idea as to what I recommend from previous podcasts and articles. Diet along with treatment is important in my opinion so I think that would be a good idea. If you are able to mail to the US in 2-3 days then you could use a US lab to do the breath test. Feel free to contact my office if you want to pursue this option. In any case, good luck and I hope this info helps!

  13. Hi Dr Ruscio,
    I have been diagnosed with LPR, which I take to be caused by SIBO. I can’t confirm that I have SIBO, and I’m not sure where I’d get properly tested here in Taiwan, so I figured I would give a natural SIBO protocol a try to see how that impacted my symptoms. Do you have any opinion on the Fast Tract Diet by Norman Robillard. It seems like a pretty easy diet to follow and a good starting point. Could it be something to try alongside some of your recommended supplements?

    1. I am not familiar with the diet but I think you have a good idea as to what I recommend from previous podcasts and articles. Diet along with treatment is important in my opinion so I think that would be a good idea. If you are able to mail to the US in 2-3 days then you could use a US lab to do the breath test. Feel free to contact my office if you want to pursue this option. In any case, good luck and I hope this info helps!

  14. Hi Dr Rusico – Do you recommend Nystain along with Rifaximin/Neomycin for methane positive SIBO? Also what can you do to prevent a relapse and what kind of prokinetic supplements/drugs do you recommend? Also do you recommend taking probiotics/s.boulardii during and/or after treatment? thanks so much 🙂

      1. Thanks so much. I will check it out. Lastly do you think there can be a connection between SIBO and geographic tongue/oral lichen planus?

  15. Hi Dr Rusico – Do you recommend Nystain along with Rifaximin/Neomycin for methane positive SIBO? Also what can you do to prevent a relapse and what kind of prokinetic supplements/drugs do you recommend? Also do you recommend taking probiotics/s.boulardii during and/or after treatment? thanks so much 🙂

      1. Thanks so much. I will check it out. Lastly do you think there can be a connection between SIBO and geographic tongue/oral lichen planus?

  16. Hello Dr. Ruscio,

    Would you be so kind and provide me with the study that claims the bacteria (SIBO) goes into hibernation/hiding if you put a patient on a SCD/FODMAP diet during the “killing” process with botanicals?
    There was also a study you talked about on another podcast about thyroid antibodies lowering dramatically after being treated for H.Pylori. Care to share?
    Thank you very much for time.

    1. Hi Frankie. To your first question, I don’t know of a study documenting this; at this point I believe it is a theory. The 2nd study is on my site somewhere if you search thyroid autoimmunity you should be able to find it. Hope this helps!

  17. Hi Dr. Ruscio,
    I’ve been diagnosed with SIBO, methane and hydrogen. I did the GAPS diet and herbal antibiotics for a month and then retested. Now I am only hydrogen dominat and am starting the herbal antibiotics again ( neem plus and Berberine) . My ND recommend the SIBO Specific diet. I have been researching SIBO like crazy but am still confused about diet DURING and AFTER treatment. I’ve read the bacteria need to be fed during treatment. Would the GAPS/ SCD diet or a paleo diet be good as long as I include a few paleo FODMAPS like avocado to feed the bacteria? Or do I need to eat a lot of carbs? I don’t do well or grains or heavy starches, yet processed gluten free foods I’m okay with. But I’d rather not eat the processed stuff for health reasons. Would a prebiotic like guar gum be enough to feed the bacteria? After treatment do I need to go Low FODMAPS?
    I know everyone is different, I’m so confused. Any advice would be great. Thanks.,
    Amber

    1. I think the idea of needing to feed SIBO during treatment has been way over stated. I will be releasing a post on this soon with more specifics. In short, probiotics have been shown to be more important when treating SIBO than prebiotics. So eat a healthy diet (paleoish) and only perform additional restrictions like low FODMAP and SCD if you need to for symptomatic improvement. Hope this helps! 🙂

      1. Thanks for responding Dr. Ruscio! You definitely cleared some of my confusion. I will be looking forward to your post on the subject!

        -Amber

  18. Hello Dr. Ruscio,

    Would you be so kind and provide me with the study that claims the bacteria (SIBO) goes into hibernation/hiding if you put a patient on a SCD/FODMAP diet during the “killing” process with botanicals?
    There was also a study you talked about on another podcast about thyroid antibodies lowering dramatically after being treated for H.Pylori. Care to share?
    Thank you very much for time.

    1. Hi Frankie. To your first question, I don’t know of a study documenting this; at this point I believe it is a theory. The 2nd study is on my site somewhere if you search thyroid autoimmunity you should be able to find it. Hope this helps!

  19. Hi Dr. Ruscio,
    I’ve been diagnosed with SIBO, methane and hydrogen. I did the GAPS diet and herbal antibiotics for a month and then retested. Now I am only hydrogen dominat and am starting the herbal antibiotics again ( neem plus and Berberine) . My ND recommend the SIBO Specific diet. I have been researching SIBO like crazy but am still confused about diet DURING and AFTER treatment. I’ve read the bacteria need to be fed during treatment. Would the GAPS/ SCD diet or a paleo diet be good as long as I include a few paleo FODMAPS like avocado to feed the bacteria? Or do I need to eat a lot of carbs? I don’t do well or grains or heavy starches, yet processed gluten free foods I’m okay with. But I’d rather not eat the processed stuff for health reasons. Would a prebiotic like guar gum be enough to feed the bacteria? After treatment do I need to go Low FODMAPS?
    I know everyone is different, I’m so confused. Any advice would be great. Thanks.,
    Amber

    1. I think the idea of needing to feed SIBO during treatment has been way over stated. I will be releasing a post on this soon with more specifics. In short, probiotics have been shown to be more important when treating SIBO than prebiotics. So eat a healthy diet (paleoish) and only perform additional restrictions like low FODMAP and SCD if you need to for symptomatic improvement. Hope this helps! 🙂

      1. Thanks for responding Dr. Ruscio! You definitely cleared some of my confusion. I will be looking forward to your post on the subject!

        -Amber

  20. Hello Dr Ruscio. I got my SIBO test results back. I did the Quintron breath test and methane was 0-1 ppm and hydrogen was 3-7 ppm. I am truly baffled…I have the symptoms of SIBO…bloating which gets worse after eating fiber, fruits, beans, etc. Also i have severe constipation and i cant live without magnesium. I have recurring fissures and hemmorhoids as well. How is this possible? i was almost 100% certain i had methane positive SIBO although the lactulose i drank for the test didnt seem to bother me and i heard thats a good indicator. Any insight would be very much appreciated. Many thanks!!!

    1. Hey Janson, sorry to hear about your testing. This is where a well trained clinician comes in. There are many things that can cause the symptoms of SIBO which should be evaluated, SIBO is definitely common but not the only cause of GI problems. Feel free to contact my office if you need help. Hope this helps!

      1. Thanks Dr Ruscio. Any examples of other conditions that can cause bloating? i dont eat dairy or gluten and take digestive enzymes with every meal as well as probiotics. Also had an endoscopy and colonoscopy and everything was negative

        Best Regards,

        Jason

  21. Hello Dr Ruscio. I got my SIBO test results back. I did the Quintron breath test and methane was 0-1 ppm and hydrogen was 3-7 ppm. I am truly baffled…I have the symptoms of SIBO…bloating which gets worse after eating fiber, fruits, beans, etc. Also i have severe constipation and i cant live without magnesium. I have recurring fissures and hemmorhoids as well. How is this possible? i was almost 100% certain i had methane positive SIBO although the lactulose i drank for the test didnt seem to bother me and i heard thats a good indicator. Any insight would be very much appreciated. Many thanks!!!

    1. Hey Janson, sorry to hear about your testing. This is where a well trained clinician comes in. There are many things that can cause the symptoms of SIBO which should be evaluated, SIBO is definitely common but not the only cause of GI problems. Feel free to contact my office if you need help. Hope this helps!

      1. Thanks Dr Ruscio. Any examples of other conditions that can cause bloating? i dont eat dairy or gluten and take digestive enzymes with every meal as well as probiotics. Also had an endoscopy and colonoscopy and everything was negative

        Best Regards,

        Jason

  22. Dr. Ruscio, what are your thoughts on using colostrum in order to reduce intestinal permeability while working on SIBO? Have you found it helpful?

    1. Hi Simas. I don’t use much in the way of gut repair nutrients as I have found that once you remove the offenders the gut heals rather quickly. Fasting and or the Elemental Diet can be powerful in helping the gut repair also.

  23. Dr. Ruscio, what are your thoughts on using colostrum in order to reduce intestinal permeability while working on SIBO? Have you found it helpful?

    1. Hi Simas. I don’t use much in the way of gut repair nutrients as I have found that once you remove the offenders the gut heals rather quickly. Fasting and or the Elemental Diet can be powerful in helping the gut repair also.

  24. You stated on a comment post back in 2015 that your office was looking into a better tasting elemental formula. Can you tell me what product you were referring to? I have been using Absorbplus unsweetened for several months as a semi-elemental diet. It tastes pretty good to me. But I didn’t know if the ingredients TRUELY fit into the elemental protocol..

    1. Hi Gay,
      More to come on this soon, we will likely to a podcast/post on this once a few details have been finalized on our end. I like AP and would classify it as a semi-elemental, which still can work well in my opinion.
      Hope this helps!

  25. You stated on a comment post back in 2015 that your office was looking into a better tasting elemental formula. Can you tell me what product you were referring to? I have been using Absorbplus unsweetened for several months as a semi-elemental diet. It tastes pretty good to me. But I didn’t know if the ingredients TRUELY fit into the elemental protocol..

    1. Hi Gay,
      More to come on this soon, we will likely to a podcast/post on this once a few details have been finalized on our end. I like AP and would classify it as a semi-elemental, which still can work well in my opinion.
      Hope this helps!

  26. Hello Dr Ruscio- I do not have SIBO (was tested 3x) and my leaky gut has been reversed. however i still have dysbiosis and i also feel like i have histamine intolerance and autoimmunity. Any gut protocols you can recommend? I purchased prescript assist and D-lactate, low histamine probiotics but not sure how i should use them and with what prebiotic (if any). I have almost daily bloating and most fibers/prebiotics just make it worse. Appreciate any tips. thank you so much 🙂

    Jason

    1. Hi Jason,

      Thank you for reaching out. Prescript Assist is a good probiotic to try. Start with the dosing on the label. Also, you may find the following link helpful regarding histamine intolerance and low histamine diet – histamine video. Tomorrow, we’ll be sharing an article to help you get started with a low histamine diet. Thanks.

      1. Thanks Dr Ruscio – do you recommend using any botanicals with the prescript assist? whenever i used prescript assist in the past i would get bloating and cramping at higher doses. Also what about adding prebiotic fiber after the flora is balanced? thanks 🙂

        Best Regards

        Jason

  27. Hello Dr Ruscio- I do not have SIBO (was tested 3x) and my leaky gut has been reversed. however i still have dysbiosis and i also feel like i have histamine intolerance and autoimmunity. Any gut protocols you can recommend? I purchased prescript assist and D-lactate, low histamine probiotics but not sure how i should use them and with what prebiotic (if any). I have almost daily bloating and most fibers/prebiotics just make it worse. Appreciate any tips. thank you so much 🙂

    Jason

    1. Hi Jason,

      Thank you for reaching out. Prescript Assist is a good probiotic to try. Start with the dosing on the label. Also, you may find the following link helpful regarding histamine intolerance and low histamine diet – histamine video. Tomorrow, we’ll be sharing an article to help you get started with a low histamine diet. Thanks.

      1. Thanks Dr Ruscio – do you recommend using any botanicals with the prescript assist? whenever i used prescript assist in the past i would get bloating and cramping at higher doses. Also what about adding prebiotic fiber after the flora is balanced? thanks 🙂

        Best Regards

        Jason

  28. Hey Dr R,

    I have a history of gut issues but my biggest problem now is severe geographic tongue. It got so bad that i can barely eat anything w/o a flare up. I lost 20 lbs as well. I feel its some kind of food allergy or sensitivity to something. Only thing that helps is rinsing with steroids and after that eating completely bland foods. Even berries and vegetables and healthy foods can flare it up. So its pretty much green beans, coconut oil, plain chicken or turkey and sweet potatoes at every single meal. Even plain bone broth flares it up. . Have you ever seen this? Any idea if there is something I can do or do i have to live the rest of my life with this horrible condition? Thanks so much!

    Best,

    Kelly

    1. Hi Kelly,
      Sorry to hear of your troubles. I have not seen this before. You may want to be screened for a B12 deficiency. You may also want to check in with a good doc for oral dysbiosis, or try something like oil pulling which is a treatment for oral dysbiosis. A good gut evaluation may also be a good idea here. Hope this helps!

  29. Hey Dr R,

    I have a history of gut issues but my biggest problem now is severe geographic tongue. It got so bad that i can barely eat anything w/o a flare up. I lost 20 lbs as well. I feel its some kind of food allergy or sensitivity to something. Only thing that helps is rinsing with steroids and after that eating completely bland foods. Even berries and vegetables and healthy foods can flare it up. So its pretty much green beans, coconut oil, plain chicken or turkey and sweet potatoes at every single meal. Even plain bone broth flares it up. . Have you ever seen this? Any idea if there is something I can do or do i have to live the rest of my life with this horrible condition? Thanks so much!

    Best,

    Kelly

    1. Hi Kelly,
      Sorry to hear of your troubles. I have not seen this before. You may want to be screened for a B12 deficiency. You may also want to check in with a good doc for oral dysbiosis, or try something like oil pulling which is a treatment for oral dysbiosis. A good gut evaluation may also be a good idea here. Hope this helps!

  30. Hello Dr. Ruscio How are you? I have had a gut imbalance for a long time and am trying to finally repair it. One thing I noticed when it all started is elevated creatinine. It has stayed at 1.4 for 13 years but now it looks like my GFR is getting lower and my BUN is creeping up. Everything is still within or close to normal range but the variation has me concerned. Can dysbiosis contribute to a sluggish renal function and if so is there anything I can do about it before it gets worse? Thank you very much for your support!

    Best Regards,

    Russ

  31. Hello Dr. Ruscio How are you? I have had a gut imbalance for a long time and am trying to finally repair it. One thing I noticed when it all started is elevated creatinine. It has stayed at 1.4 for 13 years but now it looks like my GFR is getting lower and my BUN is creeping up. Everything is still within or close to normal range but the variation has me concerned. Can dysbiosis contribute to a sluggish renal function and if so is there anything I can do about it before it gets worse? Thank you very much for your support!

    Best Regards,

    Russ

  32. Do you find it common for patients to have both candida and SIBO? Any suggestions for someone on a low budget to determine if symptoms are SIBO/yeast/leaky gut/pylori, etc?

    If someone gets constipation when using something like caprilyic acid, what steps do you take to help the body rid itself of the toxin rather than just reabsorbing it?

    Your articles are fantastic as well as the comments, very much appreciated!

  33. Do you find it common for patients to have both candida and SIBO? Any suggestions for someone on a low budget to determine if symptoms are SIBO/yeast/leaky gut/pylori, etc?

    If someone gets constipation when using something like caprilyic acid, what steps do you take to help the body rid itself of the toxin rather than just reabsorbing it?

    Your articles are fantastic as well as the comments, very much appreciated!

  34. Dear Dr. Ruscio,

    I am so grateful for you. Your thoughts on low dose antimicrobials has been life changing for me. For so long, I have tried to rid my sibo, but found out through IBS Chek (came back positive) that damage has been done to my MMC and it may take years for the nerves to regenerate. I shifted my thinking from trying to rid SIBO (did two 21 days fasts with Vivonex Plus), to trying to manage it. I have been cycling with Candibactin AR and BR, oregano, berberine, olive leaf, Atrantil (seems to have crazy affects on my hormones–the Atrantil). Anyways, what are some of the brands that you have recommended to patients for the cycling of antimicrobials which have been highly effective in keeping SIBO numbers under control? I know there may be some my body or the bacteria (keep them guessing ) wouldn’t recognize (seems like this is key) Thank you so much for all your work and caring heart. Gratefully, Heidi

    1. Hi Heidi,
      Glad this information has been helpful! You have a solid list of antimicrobials there already, allicillin might be worth trying too. My book will walk you through how to craft a personalized SIBO management plan; planed release Jan/Feb 2017. Glad your doing better 🙂

  35. Dear Dr. Ruscio,

    I am so grateful for you. Your thoughts on low dose antimicrobials has been life changing for me. For so long, I have tried to rid my sibo, but found out through IBS Chek (came back positive) that damage has been done to my MMC and it may take years for the nerves to regenerate. I shifted my thinking from trying to rid SIBO (did two 21 days fasts with Vivonex Plus), to trying to manage it. I have been cycling with Candibactin AR and BR, oregano, berberine, olive leaf, Atrantil (seems to have crazy affects on my hormones–the Atrantil). Anyways, what are some of the brands that you have recommended to patients for the cycling of antimicrobials which have been highly effective in keeping SIBO numbers under control? I know there may be some my body or the bacteria (keep them guessing ) wouldn’t recognize (seems like this is key) Thank you so much for all your work and caring heart. Gratefully, Heidi

    1. Hi Heidi,
      Glad this information has been helpful! You have a solid list of antimicrobials there already, allicillin might be worth trying too. My book will walk you through how to craft a personalized SIBO management plan; planed release Jan/Feb 2017. Glad your doing better 🙂

  36. I was wondering how much of an allicin product like Allimax Pro you would recommend taking per day for those with methane-producing overgrowth.

  37. I was wondering how much of an allicin product like Allimax Pro you would recommend taking per day for those with methane-producing overgrowth.

  38. Hey would you mind letting me know which web host you’re working with? I’ve loaded your blog in 3 completely different internet browsers and I must say this blog loads a lot faster then most. Can you suggest a good internet hosting provider at a fair price? Kudos, I appreciate it! gckgcckdbbefeacg

  39. Hey would you mind letting me know which web host you’re working with? I’ve loaded your blog in 3 completely different internet browsers and I must say this blog loads a lot faster then most. Can you suggest a good internet hosting provider at a fair price? Kudos, I appreciate it! gckgcckdbbefeacg

  40. I thought I had SIBO and treated it FOREVER and got worse. After an experimental first try with a coffee enema I discovered I had rope worms and other parasites. That was several months ago and I am still working on clearing parasites, although, they are becoming less and less. My food sensitivities are gone. My migraines are gone, my body aches are gone, my fatigue is going away, etc. etc. Sometimes when a patient doesn’t get better, look into parasites. In my case, I did herbs for a VERY long time. Nothing seems to touch these rope worms except a few things, including coffee enemas and eucalyptus. Hope this is helpful. I believe for regular SIBO, which I am sure I also had, Dr. Ruscio is spot on. I havent ruled on consulting him at some point in the future.. Love and Light. Rebecca.

  41. I thought I had SIBO and treated it FOREVER and got worse. After an experimental first try with a coffee enema I discovered I had rope worms and other parasites. That was several months ago and I am still working on clearing parasites, although, they are becoming less and less. My food sensitivities are gone. My migraines are gone, my body aches are gone, my fatigue is going away, etc. etc. Sometimes when a patient doesn’t get better, look into parasites. In my case, I did herbs for a VERY long time. Nothing seems to touch these rope worms except a few things, including coffee enemas and eucalyptus. Hope this is helpful. I believe for regular SIBO, which I am sure I also had, Dr. Ruscio is spot on. I havent ruled on consulting him at some point in the future.. Love and Light. Rebecca.

  42. Hey Dr. Ruscio,

    WHat are the common nutriceuticals you will use to help repair/strengthen the digestive lining and address leaky gut, after treating SIBO and finding the right diet? Things like glutamine, zinc carnosine, lactoferrin/colostrum, vitamin C, etc.? Any others you particularly like or find useful?

  43. Hey Dr. Ruscio,

    WHat are the common nutriceuticals you will use to help repair/strengthen the digestive lining and address leaky gut, after treating SIBO and finding the right diet? Things like glutamine, zinc carnosine, lactoferrin/colostrum, vitamin C, etc.? Any others you particularly like or find useful?

  44. How would not having a gallbladder affect SIBO? and any supplements you recommend because I dont have a supplement. A doctor mentioned taking bile salts.

    1. Bile might help, but it also might cause diarrhea. Worth a try but only continue if it clearly helps. My book will elaborate on this and walk you through use of bile in the context of SIBO.

  45. How would not having a gallbladder affect SIBO? and any supplements you recommend because I dont have a supplement. A doctor mentioned taking bile salts.

    1. Bile might help, but it also might cause diarrhea. Worth a try but only continue if it clearly helps. My book will elaborate on this and walk you through use of bile in the context of SIBO.

  46. Hi Dr. Ruscio, do you know if there are any discounts or discounted options for the SIBO Aerodiagnostics test? I’m doing everything out of pocket and would like to take the test asap.
    Thanks.

  47. Hi Dr. Ruscio, do you know if there are any discounts or discounted options for the SIBO Aerodiagnostics test? I’m doing everything out of pocket and would like to take the test asap.
    Thanks.

  48. I did an at home glucose breath test at the end of April for Sibo. It came back negative. My methane levels were 5 on the baseline and dropped to a -1 for all 3 checks ever 1/2 hour. My hydrogen was 0 baseline and went to 4,6,4 at the 30,60,90 minute marks. The test only mentioned being off broad spectrum antibiotics for 2 weeks before the test. 8 days before the test, I ended a 10 day regiment of berberine and oregano oil. I later found instructions from Johns Hopkins mentioning needing to be off antibiotics and antimicrobials (mentioning berberine and oregano oil specifically) for 28 days before a test
    Could this have caused the negative test? Also, does those methane numbers sound right?? I read that some doctors consider any methane number over 3 at anytime as positive.
    Thanks!

    1. Hi Roy,
      There is a lot of important context to consider here. Said simply, the breath testing should not be looked at without one’s symptoms also being considered. In terms of what to do, the best thing I can offer you is the comprehensive, self-help plan contained in Healthy Gut, Healthy You. This will get you much farther than treating test results.

  49. I did an at home glucose breath test at the end of April for Sibo. It came back negative. My methane levels were 5 on the baseline and dropped to a -1 for all 3 checks ever 1/2 hour. My hydrogen was 0 baseline and went to 4,6,4 at the 30,60,90 minute marks. The test only mentioned being off broad spectrum antibiotics for 2 weeks before the test. 8 days before the test, I ended a 10 day regiment of berberine and oregano oil. I later found instructions from Johns Hopkins mentioning needing to be off antibiotics and antimicrobials (mentioning berberine and oregano oil specifically) for 28 days before a test
    Could this have caused the negative test? Also, does those methane numbers sound right?? I read that some doctors consider any methane number over 3 at anytime as positive.
    Thanks!

    1. Hi Roy,
      There is a lot of important context to consider here. Said simply, the breath testing should not be looked at without one’s symptoms also being considered. In terms of what to do, the best thing I can offer you is the comprehensive, self-help plan contained in Healthy Gut, Healthy You. This will get you much farther than treating test results.

  50. Hi Dr. Ruscio. Can I use hydrolyzed collagen as my protein source for an elemental diet in place of the Jo Mar Labs 21 essential blend that you recommend? Would that make it a semi-elemental diet?

  51. Hi Dr. Ruscio. Can I use hydrolyzed collagen as my protein source for an elemental diet in place of the Jo Mar Labs 21 essential blend that you recommend? Would that make it a semi-elemental diet?

  52. When on higher doses of Candibactin, I seem to sleep longer/be more tired in general. However when coming off them I almost seem to sleep too little, even getting some crazy jet lag. Is there a reason for this?

  53. When on higher doses of Candibactin, I seem to sleep longer/be more tired in general. However when coming off them I almost seem to sleep too little, even getting some crazy jet lag. Is there a reason for this?

  54. DR. ruscio,

    I HAVE high hydrogen and low methane test. Along with a GI Map test that has results of a some virulence factors of h pylori but the h pylori doesnt register high. Doc thinks maybe from a past infection? So im on pylori plex. Also im low in lactobacillus spp and all my other normal flora are at a good level. I do have high candida thougg which we are treating with an RX antifungal for 3 wks. i have 1 daily bowel movement but they are semi loose. Id be happy to show you my GI Map along with my hydrogen dominant results to get your opinion. i get upper abdominal bloat/hardness/discomfort, and i can feel the bubbles which sometimes result in a burp. Feels like a bowling bowl is under by ribs basically. I am on VSL 3 for lacto deficiency but i feel like this makes my symptoms worse. Some of my high bacteria are morganella spp, pseudomonas aeruginosa, and streptococcus spp. please help, im so fatigued, anxious, feeling like im going to be ill forever. endoscopy showed mild gastritis was negative biopsy for h pylori. Normal elastace. Normal CT scan. What would you treat first? Am i attaching the right stuff or feeding a sibo problem?

    1. Hi Rachel,

      I’m so sorry to hear you’re dealing with this. Unfortunately, we can’t give personalized medical advice on this forum, but I would recommend picking up a copy of Dr Ruscio’s book, “Healthy Gut, Healthy You”, as it walks through how he treats these issues in his clinic and lays out a DIY protocol for overcoming them. You can find it here: https://www.drruscio.com/getgutbook
      Good luck!

  55. DR. ruscio,

    I HAVE high hydrogen and low methane test. Along with a GI Map test that has results of a some virulence factors of h pylori but the h pylori doesnt register high. Doc thinks maybe from a past infection? So im on pylori plex. Also im low in lactobacillus spp and all my other normal flora are at a good level. I do have high candida thougg which we are treating with an RX antifungal for 3 wks. i have 1 daily bowel movement but they are semi loose. Id be happy to show you my GI Map along with my hydrogen dominant results to get your opinion. i get upper abdominal bloat/hardness/discomfort, and i can feel the bubbles which sometimes result in a burp. Feels like a bowling bowl is under by ribs basically. I am on VSL 3 for lacto deficiency but i feel like this makes my symptoms worse. Some of my high bacteria are morganella spp, pseudomonas aeruginosa, and streptococcus spp. please help, im so fatigued, anxious, feeling like im going to be ill forever. endoscopy showed mild gastritis was negative biopsy for h pylori. Normal elastace. Normal CT scan. What would you treat first? Am i attaching the right stuff or feeding a sibo problem?

    1. Hi Rachel,

      I’m so sorry to hear you’re dealing with this. Unfortunately, we can’t give personalized medical advice on this forum, but I would recommend picking up a copy of Dr Ruscio’s book, “Healthy Gut, Healthy You”, as it walks through how he treats these issues in his clinic and lays out a DIY protocol for overcoming them. You can find it here: https://www.drruscio.com/getgutbook
      Good luck!

  56. Dr. Ruscio, I have a question about test interpretation. In this article you say you don’t want to see hydrogen above the 20 mark at all and methane usually above 3 but in the other article conversation with Dr. Siebecker your referring to the “increase” or “rise” of 20 or more above baseline leading to a positive sibo test. Which do you believe is more accurate to a positive test?

    1. Hi Michael,

      Great question! I’ve added it to the list for an upcoming listener Q+A episode of the podcast. Stay tuned!

  57. Dr. Ruscio, I have a question about test interpretation. In this article you say you don’t want to see hydrogen above the 20 mark at all and methane usually above 3 but in the other article conversation with Dr. Siebecker your referring to the “increase” or “rise” of 20 or more above baseline leading to a positive sibo test. Which do you believe is more accurate to a positive test?

    1. Hi Michael,

      Great question! I’ve added it to the list for an upcoming listener Q+A episode of the podcast. Stay tuned!

  58. Hi, dr. R,

    I can’t help, but think, what if you put a patient on a real prokinetic after she cleared her sibo completely? Prucalopride for example. It’s possible that she wouldn’t have relapsed, wouldn’t need to suffer and spend money anymore. Wouldn’t that be a real success? Also, saying that she has no symptoms when she can’t eat statches and has to do elemental diet sometimes is not very accurate. That being said, I totally agree that she shouldn’t stress over the numbers, because that would only make things worse.
    I just think throwing all these supplements like enzymes probiotics is unnecessary and total waste of money in most cases and functional docs really love that. What they don’t like is proven things which help prevent relapse. Like prokinetics.

    Also, there is zero evidence that Iberogast works as a prokinetic and I don’t believe that it does, although it’s great for symptomatic treatment.

    1. There is some evidence that the main ingredient of Iberogast works as a prokinetic. Since Iberogast is an old German product one needs to speak German or translate research articles to read all the literature.
      The main ingredient ‘Iberis amara’ has been shown to increase motility of stomach and small intestine in animal studies. The motility enhancing effect was comparable to the prokinetic drugs Metoclopramid and Domperidon. The effect on large intestine motility was only very small.
      http://www.ncbi.nlm.nih.gov/pubmed/12618547 (Article in German, Abstract in English)
      Iberis amara increased the frequency and amplitude of small intestinal slow waves in a mouse study.
      http://www.ncbi.nlm.nih.gov/pubmed/15687728
      However, the other ingredients have a spasmolytic effect and rather reduce gastrointestinal motility. So we need more studies to fully understand the best use and limitations of Iberogast.

      Anyway, you seem to have had bad experiences with functional docs. Sorry about that. Even though I don’t agree with all functional medicine theories and interventions I do find these physicians very brave. And there are always good and bad ones like with conventional medicine.

      1. Hi Guys,
        I appreciate the dialogue here. Peter thanks for the references. Simas we are studying Iberogast in prevention of SIBO relapse in our clinic, we just had approved of our IRB and should be enrolling patients soon. Simas, I think you may have an inflated view of the clinical utility of Rx prokinetics, they help but not all patients and some patients can’t tolerate them. You do make a good point that many Func Med doc over-treat, this is something I hope my work will help to correct. Simas it sounds like you are frustrated, which is completely understandable, just remember there are many people/doctors who are on your side.

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