Updates on Hydrogen Sulfide SIBO & SIFO

Intro:

Welcome to Dr. Ruscio radio providing practical and science-based solutions to feeling your best. To stay up-to-date on the latest topics as well as all of our prior episodes, please make sure to subscribe in your podcast player. For weekly updates, DrRuscio.com. 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.

DrMichaelRuscio:

Hi everyone. Today I spoke with Dr. Preet Khangura and we discussed hydrogen sulfide, SIBO, and small intestinal fungal overgrowth, or SIFO. First, and I’m excited about this, very recently, a trio-smart gas test was released, meaning it can test hydrogen and methane, as you’ve probably heard, these are the traditional gases that are tested for in a SIBO breath test, but now we have the ability to finally test hydrogen sulfide gas also. So we discussed that new test. We also discussed some of the symptoms associated with hydrogen sulfide SIBO, some of the treatments for hydrogen sulfide SIBO. These are all just inferences because the science here is very, very early. We also discuss small intestinal fungal overgrowth and the testing and treatment for that. Again, all of this to be taken with a major grain of salt because these clinical entities are new.

DrMR:

They’re only recently discovered, there is very limited data. So we tried to really frame all this as such so that people don’t run away with, Oh my goodness, I heard this one symptom associated with hydrogen sulfide SIBO and now I’m going to just lock on that and not think about anything else. That being said, there are cues and clues that we can look to help steer the diagnostics, interpret the diagnostics, and, more importantly, navigate the array of therapeutics available to improve one’s got health. So that’s a general synopsis of what we covered. One of the things regarding hydrogen sulfide SIBO that I suspect will be proven is that it’s less important what the “best treatment” is. What is more important is knowing how to, and achieving, the personalization of the available gut therapeutics to the individual. This is one of the things we see in the clinic very often. Where an individual will flounder for years because they’ve been pursuing the “magic” treatment. They’ve never had someone who’s kind of quarterbacking the approach and personalizing the therapeutics to that individual’s gut. Almost like how do we fix this garden if we’re looking for a monotherapeutic intervention to heal a dying garden, that really is probably a bit myopic. We need to do a global assessment. Is there adequate sun? Is there adequate shade? Is there adequate water? Is there adequate nutrition? So that is how I think, as the research evolves, we will see the optimal outcomes with hydrogen sulfide SIBO. It’s not to say we’re going to turn a blind eye to any novel findings, but the novel findings are the micro that have to be interpreted more in the context of the macro. This is why I will be continually referring you to Healthy Gut, Healthy You.

DrMR:

If you need that game plan, that will help you on the road of personalizing the available therapeutics to your gut, healthy, good health to you was a three year process of me distilling everything I know. And all of the research I’ve come across down into a guide to army with the knowledge that you need to regain and optimize your gut health. Okay. So with that, we’ll now go to the conversation regarding hydrogen sulfide SIBO and the SIFO. Hi everyone.

Dr. Preet Krangura – Background

DrMR:

This is Dr. Ruscio, DC. Welcome back to another episode of Dr. Ruscio radio. Today, I’m here with Dr. Preet Khangura and we are talking about SIFO, small intestinal fungal overgrowth, and also hydrogen sulfide SIBO. So definitely something we’ve discussed before, but always good to be abreast of updates. Also, let me apologize. I’m traveling and I don’t have the most control over my saudio. So you will likely hear some background noise today. I apologize in advance for that. Preet, welcome to the show and thanks for being on.

DrPreetKrangura:

Thank you for having me on.

DrMR:

So your work was kind of a claim from some people who have gone to a conference that you’re recently speaking at and I have to actually apologize, I’m not sure what conference it was because there are so many people who tell me about conferences they’ve been to. Would you give us kind of the background on the recent conference you were presenting at and then also on your own kind of clinical and educational background.

DrPK:

Sure. So the conference is the AAMP conference that was held in August. It was supposed to be held in May in Scottsdale, Arizona, but because of everything going on with COVID, there was delay on it. Then it was converted to a 100% online conference over a weekend in August. It was very specific to gastrointestinal disorders. So over the weekend, I lectured on a few different topics, including SIBO breath testing and the latest research behind it. As well as the real analysis of the research on SIBO breath testing. I also lectured exclusively on SIFO and GI fungal dysbiosis in general, but also on hydrogen sulfide SIBO, which I nicknamed “the other SIBO”. A lot of people might look at it that way, because up until very recently, there has been no breath test for hydrogen sulfide SIBO.

DrPK:

I say very recently because the machine that Dr. Pimentel’s team has been working on was just released in the United States about a month ago as a kind of a soft launch. So some breath testing for hydrogen sulfide SIBO is going to be available for the public soon, but that’s the conference I spoke at. In general, in my practice, just in case people are wondering where I practice, I’m actually up in Canada. In Victoria, BC, Canada, and I’m a naturopathic physician. I have a very, very strong focus in gastrointestinal disorders, including SIBO and SIFO and I’ve been treating SIBO on pretty much a routine daily basis for at least six years now. I see it often in practice, it’s a very common condition. I also work with Canada’s leading SIBO lab, called SIBO Diagnostics, and I provide complimentary consultations with doctors that use the lab for their SIBO testing.

Breath Test for Hydrogen Sulfide SIBO

DrMR:

Awesome. Let’s start with what I think is the first time our audience has heard this announcement, which is that there is now available a SIBO breath test that assesses all three of the gases: hydrogen, methane and hydrogen sulfide. Trio-smart is the name of the test. Thankfully they have both a glucose and a lactulose test available. We’ve just started using this in the clinic. I don’t want to reach too far here, but one of the things that we’re going to attempt to do is run, most likely an IBS symptom inventory and run the trio-smart breath tests, pre and post treatment intervention. I don’t want to say too much about what the treatment intervention is going to be, but that’s our aim right now. We’re ironing out some of the logistical details, but our goal is to be able to demonstrate if a given treatment works for hydrogen sulfide SIBO.

DrMR:

We are also hoping to demonstrate, what I suppose we could term as the diagnostic yield of the hydrogen sulfide aspect of the test. Meaning how many patients who have symptoms and test negative for hydrogen and methane will test positive for hydrogen sulfide. It’s not the only way to perhaps adjudicate the effectiveness of this test or the utility of this test. But it’s one question that we’re attempting to answer to see how often the hydrogen sulfide gas is the one that you need to assess. I believe one study found that it may be as much as 30% of patients. I could be mis-recalling part of that detail there, but that’s some of what we’re hoping to do at the clinic. I am curious how your experience has been with this test thus far, if you’ve even been ordering. Like like you said, it’s only recently become available, so it’s kind of fresh off the shelf.

DrPK:

Yeah. Actually I have not been able to use it yet. I was in contact with the trio-smart people actually last week and for a couple of different reasons and right now they are not making the test available commercially to Canada. So, as of right now, I won’t have access to it. I’m hopeful that I will sometime in the near future. But it is a big step in the right direction. Up to this point, it’s been more so kind of clinical hallmarks that we look for in patients to suspect hydrogen sulfide SIBO. I can definitely get into a lot more of those details here in a bit. Having a test that is accurate will go a long way. A lot of patients and yourself I’m sure have been told and seen clinically the hydrogen sulfide SIBO patients might have very low flatlines of hydrogen and methane on the hydrogen and methane breath test.

DrPK:

That is true because of how hydrogen sulfide bacteria very efficiently use up hydrogen gas and compete with the methane archaea for hydrogen gas. So it can lead to flatlines. However, what I see clinically and there is a research paper that came out in January this year, showing that many patients with hydrogen sulfide SIBO, don’t always have flatline results. I do see that clinically because I have a significant amount of patients that have the hallmark hydrogen sulfide, the clinical hallmarks, and they still will show positive hydrogen breath test or even positive hydrogen and methane breath test. I will treat them specifically for hydrogen sulfites, SIBO with very specific agents, and a lot of those hydrogen sulfide hallmarks go away. In those cases, I know that it did not lead to flatlines, but what we do know is any time there’s hydrogen sulfide bacteria growing in any sort of amount in the small intestines, especially in a good amount, there will be some masking of the real hydrogen and methane levels because they will use hydrogen as a big fuel source, no matter what.

DrMR:

Great point, and this is why we’re going to be collecting the data that we’re collecting. Just so we can have a little bit more specificity in our understanding in terms of isthe flatline a good indicator or are symptoms a better indicator? One of the challenges when we’re at this point in the discovery process, there have been criticisms of the flatline, as you mentioned, and there has also been criticisms of some of the clinical signs. I think those criticisms are justifiable in the sense that they’re probably not going to be a hundred. So then there are criticisms, and we’re trying to figure out is the observation occurring in a high enough percentage of patients where it’s something clinicians should be paying attention to, or does it only occur in the vast minority of patients and therefore is not something that the clinician should be paying attention to. These are all just kind of unknowns, which is both frustrating and exciting. Because there’s a lot to learn, but it’s also a question of how do we best grapple with this?

DrPK:

Yeah, I, a hundred percent agree because you’re going to get those cases that might test positive for hydrogen sulfide SIBO on the breath test, but they didn’t really have the clinical hallmarks. So you weren’t really suspecting it until you did that test. But when it comes back positive, you then know that it does exist in that patient’s case and you do, very much need to address it.

Clinical Hallmarks of Hydrogen Sulfide SIBO

DrMR:

Speaking of the clinical hallmarks, we discussed in the podcast before, there’s kind of a cropping of these. One is sensitivity to light, another is kind of egg like putrid smelling flatulence. Do you want to run down the hallmarks? If you have any kind of nuance on, if you feel some of those are more or less indicative, although I don’t know how we really know that because, no one’s really done the studies yet to correlate. But whatever insights you have there, I’m sure our audience would like to hear that.

DrPK:

Yeah. So you already mentioned one. This is one that I ask every single patient, even if they don’t have excessive amounts of flatulence as part of their case. I’ll ask, when you do pass gas, is it that very pungent, rotten egg smelling gas routinely? Not just once in awhile, not just if you eat just eggs and then every other day it’s okay, but routinely is it very rotten egg or sulfur smelling. Then I always follow that up with the question about unexplained halitosis, unexplained bad breath that they can’t shake. Not just “morning breath”. The reason for that is if the hydrogen sulfide SIBO is high enough up in the small intestines the hydrogen sulfide gas that’s produced in their intestines can come up into the stomach of the esophagus and land in the mouth and it can give a very off smell in the mouth as well.

DrPK:

A lot of times the patients don’t really know. If they live with anybody, I’ll ask, and sometimes it is embarrasing for them, but I’ll ask them to ask people they live with do they actually have gas that smells that way? Or have they noticed that person has bad breath quite often. These can be big clinical hallmarks and it sounds funny when you ask patients these questions in some cases, but it is important. It can allow you to suspect maybe hydrogen sulfide SIBO, but when you treat hydrogen sulfide SIBO properly, one of the first things I see that gets better when patients report improvements is that pungent smell is gone. Before I even ask, they’ll say, Hey, just wanna let you know, due to this treatment my flatulence smells normal now, or I don’t have any very much smell at all, or that bad breath has gone away. These are kind of day to day embarrassing symptoms for patients.

DrPK:

So they will notice differences when treatments work well. So once again, it’s anecdotal, it’s clinical, it’s not research-based, but definitely something to go by. But other things you can suspect for hydrogen sulfide cases would be, for example, loose stools and diarrhea. Now there are many cases of loose stools and diarrhea, including potentially hydrogenic SIBO or other dysbiosis or food intolerances, the list goes on and on. But in hydrogen sulfide cases, we will see a good amount of IBS-D. So irritable bowel syndrome with diarrhea, but it’s not always true. I’ve had many cases of hydrogen sulfide SIBO, suspected cases, where they actually have chronic constipation. Dr. Allison Seibecker, who I co-lectured with at this recent conference, she mentioned that she saw that in her practice quite often as well.

DrPK:

And it’s because it’s not so simple. If someone has hydrogen sulfide SIBO, but they have, let’s say a significant methanogenic overgrowth as well, which is very much correlated with constipation, the constipation still may occur, even though they have hydrogen sulfide SIBO along with the methanogenic SIBO. So yes, diarrhea can be used as a potential hallmark, but it’s not a end all be all by any means. Other things I ask for in a patient’s history would be, with their SIBO like symptoms, do they get recurrent UTIs, especially in the female population. This is because a majority of UTIs, not all, but a majority are caused by hydrogen sulfide producing bacteria like E. coli and Proteus and Klebsiella pneumonia and Citrobacter species. What I see clinically is that a lot of patients with recurrent UTIs and gut symptoms, is that they very much can go hand in hand if there is a hydrogen sulfide dysbiosis, or overgrowth going on in the gastrointestinal tract.

DrPK:

So potentially asking about recurrent UTIs. History of heavy antibiotic use. The reason why this is important is because a lot of hydrogen sulfide bacteria are notoriously resistant to many antibiotics. So when a patient has a heavy antibiotic use in their history, a lot of times these guys get left behind. Most of the hydrogen sulfide producing bacteria are dysbiotic opportunistic bacteria, like the Klebsiellas and Citrobacters and Proteus. So when they have a chance to overgrow after antibiotic use, they tend to do that. So a lot of times that can give someone an increased chance of having these guys flourish in the gastrointestinal tract. Another question, and it depends on where you practice, because this question may not be important. But if you practice in an area where well water is used by people, always ask if they are on well water. Why? Because well water can be a big source of hydrogen sulfide producing bacteria.

DrPK:

Of course, a lot of people now have like UV light filtration to kind of sterilize their well water, but a lot of people don’t. So I’ve seen that history as well. So that’s just a list of things I’ll ask. Of course, there are other things you can ask as well.

DrMR:

You know, it’s a great rundown to give people some kind of gauge. Again, audience take this with a grain of salt because we’re still early here in our understanding. The reason why I say this is just picturing the patient that comes in and says, well, I have sensitivity to light and I also have foul gas so I have whole hydrogen sulfide SIBO. Then they cling to that diagnosis and irrespective of any other evidence, they’re just kind of married to that. So just keep a balanced perspective in mind, especially if you’re not feeling well. I understand sometimes you feel like you’re grasping for straws. That’s fine. Be aware of this, but, but don’t let it totally skew and dominate your thinking.

SIBO Tunnel Vision

DrPK:

That’s exactly it. You know, when I do my SIBO seminars, I do a lot of continuing education seminars for doctors on SIBO and dysbiosis, and the one thing I’ll tell them is SIBO is very prevalent, but please do not get into SIBO tunnel vision. Regardless of the form of SIBO. Just SIBO tunnel vision in general. Someone can get a positive SIBO test and then not just the patient, but the clinician can also then focus primarily just on SIBO as the root cause. For a lot of these patients, it really is the root cause behind their issues.

DrPK:

However, SIBO can just be a part of the picture. If you get into that SIBO tunnel vision, you could be missing out on a lot of these other important things that need to be uncovered and be part of the patient case. One thing just came to mind as well. Another hallmark you can look for in hydrogen sulfide cases is do sulfur containing foods trigger the worst kind of symptoms? This even includes things such as red meat or eggs, where as in a typical SIBO patient, red meat or eggs, unless they’re intolerant to those foods, should not cause many symptoms because they’re not high in fermentable fibers or fermentable sugars that the hydrogen bacteria feed on. Red meat is high in sulfur content and eggs are high in sulfur content. So I also also ask some of those questions as well.

DrMR:

Oh, that’s a great point. So, you know, again, there’s this shading in for people to look for, and I think you make an excellent description of something we should avoid, which is the SIBO tunnel vision. So hopefully this is helping people with some items to cue in on, but not to tunnel into.

SponsoredResources:

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Treatment Options

DrMR:

Let’s use the recurrent UTIs as a segue into treatment options. That observation is encouraging for me, knowing that a few different studies have found that probiotic administration can reduce recurrent UTIs. I don’t want to make too much of a parallel conflation or inference here, but it seems somewhat reasonable to infer that if we know that hydrogen sulfide SIBO can cause recurrent UTIs, and we know that certain probiotics taken orally can reduce UTIs, then there might be this commonality of probiotics being able to rectify disruptions in the gut flora, namely, but not limited to hydrogen sulfide SIBO. Now that hasn’t yet been demonstrated, but that’s maybe one encouraging observation. The reason why I throw that out there, and I’m curious to get your thoughts on this and any, any pushback of course is welcome. My hope and my inkling is that the treatment of hydrogen sulfide SIBO will not be demonstrably different than personalizing the available therapeutics for a SIBO patient at large. Meaning we have to figure out what diet works best for them. For some of those people, for some gut patients, a higher carb diet, which oftentimes also tends to be lower sulfur may feel better for them. Probiotics potentially in a lot of cases or herbals. We have other therapeutics like elemental diets and immunoglobulins. So my thinking is that what will be more important is mastery of treating the individual kind of holistically and personalizing the available therapeutics to their gut. I don’t anticipate that we’ll find that Rifaximin is grossly inadequate, but only that another antibiotic works or a certain herb is really helpful, but another herb is an abysmal failure. I’ll be open on that as the data evolve. But that’s my inkling is that this will be more dependent upon a mastery of all of the available therapeutics than just a single theraputic. What is your take there? Do you have some observations that would counter that or would you modify that at all?

DrPK:

No, I do agree with a lot of that. Actually I was just recently listening to, I think one of your latest podcast, about other causes of abdominal distension and the breathing and the diaphragmatic distention. You mentioned somewhere in that podcast, because you brought up diets a minute ago, about how people get stuck on these absolute diets. A strict, absolute low FODMAP or absolute SCD diet or low sulfur diet and how this can actually add more stress to the person and actually lead to worse digestive symptoms. And I wholeheartedly agree. So when it comes to these diets and what works best for the patient, you’re right, it comes down exactly to that patient. Not just what foods may trigger their symptoms, but how is that patient wired. Are they that Type A personality where if they decide to do something, they have to go 100% in, and then if they deviate from it, it adds actually stress to their lives because they feel like they may have failed themselves or failed the therapeutics.

DrPK:

And therefore that adds stress to the digestive system and puts them into sympathetic overload. So I just wanted to quickly touch base on that, because I 100% agree that no absolute diet is the best for all SIBO patients across the board. Really what it comes down to is finding the right therapeutic for resolving the issue. Let’s say if it’s a SIBO case, this overgrowth of bacteria in small intestines and doing your best to allow those agents to work. I won’t spend too much time unless you want me to today to talk about this, but one thing that I would definitely educate doctors on is that the number one thing that can stop treatments from working is a microorganism biofilm production. And so biofilm production has to be addressed with most of these cases with a proper biofilm disrupting agents.

DrPK:

There are a lot out there that claim they can work well, but there’s only really a select few that work significantly well. Outside of that, you brought up Rifaximin. I use Rifaximin quite often in SIBO cases and Rifaximin has been shown to eradicate hydrogen sulfide bacteria at a pretty good level. The thing is they have to be overgrowing in the small intestines for Rifaximin to work beause that’s primarily where it’s active as opposed to the colon. It definitely is not going to be active in the urinary tract. So if it’s a hydrogen sulfide case, yes, Rifaximin is an option. However, what I have found as well, that can work and it’s different for every patient, not just based on how they’re wired and this and that. It’s also based on bacterial resistance and susceptibility, but I’ve found two very basic antibiotics can make a world ofdifference in hydrogen sulfide cases very quickly.

DrPK:

One of them is Amoxicillin/clavulanic acid. The other one is Trimethoprim sulfa. Now I don’t give both at the same time, but if I do use one of them, I’ll just prescribe one and I’ll only prescribe a five day course. A lot of doctors, when they hear that they’re like five days? That’s next to nothing. Don’t you have to use 14 days? Like Rifaximin or maybe even more. But what I have found in practice over the years is that let’s say amoxicillin clavulanic acid is going to work against the hydrogen sulfide overgrowth. I tell patients that we’ll know within five days, if we’re on the right track, because when it works, it works extremely quickly. So I don’t have to prescribe a long course of an antibiotic that I’d rather not prescribe a long course for.

DrPK:

If it looks like we need to do a repeat course, cause we got the ball rolling in the right direction, but it’s not complete resolution yet. Then we’ll likely do that repeat course, if it’s done safely. Now this, this is the pharmaceutical realm, but that’s one thing that I’ve noticed. For some patients Amoxicillin/clavulanic acid will work significantly better than Rifaximin or Trimethoprim sulfa will work the best out of the three. This is specific for hydrogen sulfide SIBO. If there is a hydrogen sulfide dysbiosis in the colon, which is different than SIBO, growth, there can also be very problematic for patients. I talk a lot about this in my seminars is that some of these hydrogen sulfide producing bacteria are very dysbiotic in the sense that they’re very entero-toxic. For example, Proteus, Citrobacter and Klebsiella are all entero-toxic bacteria and even if they’re flourishing in the colon, where they’re supposed to be low on bacteria, you can also have a lot of inflammation and diarrhea and gas and connection with auto-immunity. That’s where I think the connection with UTIs comes from. If they’re flourishing in the large intestine, more so than maybe the small intestine. Basically the therapeutics really does come down to the patient. Naturally, compared to hydranogenic/methanogenic SIBO, there are, I’d say less herbal anti-microbials that can work against the hydrogen sulfide bacteria because once again, they’re notoriously resistant to a lot of agents. So one thing that I tell doctors that sounds kind of strange because we’re usually taught to use this herb for UTIs, but the herb Uva ursi. Uva ursi is well-known for specific UTI infections, but it’s because this herb has a very specific target of hydrogen sulfide bacteria.

DrPK:

It’s quite narrow in spectrum and it goes after those bacteria the best. Like I mentioned earlier, a lot of UTIs are caused by hydrogen sulfide bacteria, the same guys that can overgrow in the intestinal tract. So I actually use a very concentrated version of Uva ursi in hydrogen sulfide cases because it will hit them in the gut and I do see pretty good success with it. Then there are a few other natural agents as well, but you know, that’s kind of the long short of my answer on the therapeutics. Of course, things like the elemental diet and things like that can definitely be useful in hydrogen sulfide SIBO.

Treating with Alinia

DrMR:

That’s fantastic and there are a number of follow ups that I am kind of spattering to try to get out here. Do you feel that Alinia could be helpful here? The reason why I ask is something that Dr. Illana Gurevich and I had discussed on the podcast before, where in some of these recalcitrant cases, they may actually have a parasite and that Alinia may benefit those patients. Now there’s a little bit of context here, and this is something that our audience will see more coming down the pike. There recently was a study published, looking at DNA based stool testing methodology. Ws we’ve made the point of numerous times in the podcast, they found a fairly high, false positive regarding parasites. That’s the backdrop against which to say one of the things that some are doing when there’s a nonresponsive GI patient is, running a more advanced stool test, in this case could be a PCR DNA based stool test, which I think is justifiable, but we have to be careful about the false positives. At the same time, let’s say then a parasite is found and the patient is then given Alinia and responds to the Alinia.

DrMR:

It is possible that that parasite was actually a false positive, but the Alinia is helping them. So the question is, what is the Alinia doing that’s helping the patient? Perhaps what’s happening in some of these cases is there’s hydrogen sulfide present. I’m not sure if Alinia would act against that. I don’t think anything has obviously been published about it, but do you have any thoughts on that observation?

DrPK:

With Alinia? I’ve never used it personally in practice, but I do know some docs that are very interested in it. You’re right in the sense that if it works, did it really treat a parasite or did it maybe treat something else that it just hasn’t been shown to treat so far? There are some crossovers with some of these anti-microbial agents. A classic example is metronidozole. You know, it’s antibacterial and antiprotozoal. You’re right. You don’t know exactly what you treated, but yes, it’s more of well known to be an antiprotozoal agent. Your remark about the stool test and DNA test is exactly right. DNA testing in the stool can lead to a lot of false positive, not just the parasites, potentially a bacterial growth as well.

DrPK:

You know, I’ve seen a lot of these DNA tests run where patients had Campopylobacter jejuni infection eight years ago and they run it this DNA test now, and it’s still showing off the charts levels of Campopylobacter jejuni. These DNA fragments can definitely be kind of left behind for many years. So it is tough with some of those stool tests to really use them as a really confirmed test. But you’re right, some cases need more of that type of testing. If I’m doing stool testing, a lot of times I’ll do a culture and DNA combination or even just a culture. There are negatives to just doing stool cultures as well. You can’t culture all bacteria. Some bacteria are much harder to culture, of course, when you’re looking for bacteria.

DrPK:

So when it comes to Alinea, it’s just like when I talked about Amoxicillin/clavulanic acid or Trimethoprim sulfa is that, you know, I stumbled across that as therapeutic options for hydrogen sulfide SIBO because I kept seeing on UTI susceptibility reports, those two antibiotics are typically run to see if they will work? And they do work for a lot of the hydrogen sulfide UTI infections. Then on stool tests over the years, I was seeing that any time that hydrogen sulfide bacteria will culture on the stool test, dysbiotic ones, the lab would run a susceptibility report that either Amox/Clav or Trimethoprim sulfa would typically work. Sometimes both. Sometimes they’re resistant to one, but the other one works or sometimes they’re both work. I just started seeing this pattern so I just started putting this into action in my practice and I started seeing these very significant results. You know, who’s to say that won’t happen with Alinia, it could be any other antibiotic or herb or whatever it might be.

Herbs, Silver and Other Treatments

DrMR:

Right. Okay. Regarding the herbs. Outside of Uva ursi is there anything else that you think is particularly helpful? You know, again, presumably audience take this all with a grain of salt, cause this is just early inferences, but are there any other herbs that you suspect are more helpful for hydrogen sulfide?

DrPK:

Hmm. So one’s actually not an herb, but silver can be useful in a lot of cases. It’s not always useful, but more times than not, it can help. When I say silver, a lot of people know the term colloidal silver. There’s a newer version of silver on the market now called silver hydrosol, which can be even more antibacterial than standard, classic colloidal silver. It is very, very safe and in 48 hours, it’s completely eliminated out of the body and 24 hours about 98% of it’s eliminated. So silver hydrosol formulas can work pretty well. A lot of times I’ll use silver hydrosol with Uva ursi. If I do just a natural treatment and I’m just focusing on hydrogen sulfide overgrowth, grapefruit seed extract can definitely work in some cases. I’m not the biggest fan of grapefruit seed extract though. So I don’t ever have it at the top of my list.

DrPK:

There is a lot of controversy over grapefruit seed extract and a lot of it has to do with the studies that show that the solvents used in the extraction process are really what’s making the product anti-microbial. So is it really that natural? Even if it isn’t, maybe it’s still safe to take. I try to avoid very broad spectrum anti-microbials when possible, because you want to do more good than harm of course. So even with the Amox/Clav or Trimethoprim sulfa, they are decently broad spectrum. That’s one reason why I don’t like to give a long course to begin with, because we may not need a long course.

DrPK:

If it’s not working after five or six days, typically it’s not going to work and I’ve seen that in my practice for hydrogen sulfide cases. So silver, grapefruit extract, technically yes, and Uva ursi. One thing that I see in practice is that at times when you use the right kind of oregano, it can actually do a number on hydrogen sulfide SIBO, but a lot of times it fails. So that is another option. I use a form of oregano called ADP oregano, which is an emulsified oregano tablet specifically. I believe Dr. Siebecker also uses that one exclusively, and I see much better results with this oregano than other oreganos. So oregano is a potential option. A lot of the other anti-microbials we use for, let’s say, hydrogenic and methanogenic SIBO, the hydrogen sulfide bacteria, most of the time are resistant to it. We know that sometimes through stool testing, cause we’ll test some of these herbs on susceptibility reports, but also just from clinical practice. I’ll notice a lot of stuff I use for other forms of SIBO don’t really touch the hydrogen sulfide suspected cases.

Diagnosing SIFO

DrMR:

Gotcha. Okay. Shifting gears now to SIFO. Again, harder to pin down diagnostically and this one much more difficult because there’s not the recently available tests as there is for the hydrogen sulfide SIBO. It can be tested, but usually this is in a research setting or more by a conventional gastroenterologist who is going to do a biopsy of small intestinal fluid. You know, are there any tacit windows you’re using to establish if someone has small intestinal fungal overgrowth, perhaps blood antibodies? Candida antibodies? Again, that would have to be taken with a grain of salt, but are you looking at anything particular as a potential diagnostic for SIFO?

DrPK:

So you’re right. Diagnosing SIFO or just gastrointestinal fungal growth even in the colon, can be tough. People think, is there a breath test for it? The problem is, let’s say candida species, they produce carbon dioxide as well. We produce carbon dioxide. So you can’t really do a breath test for that because can’t distinguish where it’s coming from. What is from them and what percentage is from our own respiration?So then you can look towards these other tests. I’ll start with the antibody tests. The antibody tests, I think, are not the greatest, because if you’re checking for IgG antibodies, that could be from a previous infection of a candida. So just because it’s elevated doesn’t necessarily mean they have a current overgrowth of candida in their intestinal tract.

DrPK:

It might mean that, maybe it’s coincidentally correct. But it doesn’t necessarily mean that. IgM can be run too, although not a lot run IgM candida antibodies. IgM will be spiked at the beginning of a an overgrowth or infection, but you have to get it timed properly. Usually these patients where you suspect overgrowth, they’ve had it for quite some time. So it’s not just that it started within a week of them seeing you or anything like that. Stool testing. Some stool tests are an accurate check to see, in two ways. They can culture someone’s stool for yeast species, fungal species, but they can also do a microscopic count for yeast growth just in general, just to see if there’s a significant amount of yeast cells coming through. These still can lead to false negatives because if someone’s fungal growth is higher up in the small intestines, so it is truly a SIFO case, small intestinal fungal overgrowth, and there’s not much growing in the colon or that one stool sample to gave did not pass a lot of yeast with it, then you may not get the culture and you may not get the right microscopic count. So that one, I’d say in my opinion, is one of the more accurate tests, but I still don’t run it to really confirm. I’ll usually base fungal overgrowth cases based on suspicion. I should mention organic acid testing. There are some yeast specific metabolites that can be checked for on the organic acid test, but that’s quite an expensive test to run just to find out if they have yeast. If you’re looking for a great screening test for many other issues in the body, or to reveal some other issues, including mitochondrial issues or nutritional status and your transmitter levels potentially, then yeah, you can run the test and maybe if you see something like Arabinos elevated, which is a yeast specific metabolite that maybe you can then use as a specific diagnostic marker.

DrPK:

So basically I’ll kind of base it on more, once again, clinical hallmarks, and it can be tough because yeast overgrowth in the gut can lead to a lot of the same SIBO symptoms of distention and cramping and potentially poor bowel movements and symptoms such as that. I will say, I do believe SIBO is a much more common cause behind those symptoms than yeast. I think the biggest reason is that when someone has a yeast overgrowth compared to a SIBO case, a bacterial overgrowth, the bacterial overgrowth is going to outnumber the amount of yeast overgrowing, just because there’s so many different species of bacteria in the human gut. When it gets to an overgrowth level, it’s usually quite extensive.

DrPK:

So I do believe SIBO is a bigger cause behind those symptoms, but some digestive cases can have fungal overgrowth as a big cause. So I look for other things such as do they react very poorly to sugar or alcohol and not just digestively because that can also be a SIBO symptom. Also outside of the gut, because the one big thing that is well known about candida species is they produce many metabolites. When they are in their very virulent multicellular form, one of the metabolites they produce is acetaldehyde and a acetaldehyde is actually classified as a neurotoxin. If there is a significant growth of these guys in the small intestines and you eat a bunch of sugar, drink a bunch of alcohol, that’s their primary fuel source, it’s those two things. They will produce carbon dioxide from this, but they will also produce a acetaldehyde and this can lead to things like significant brain fog or headaches orlow mood and depression and things such as that.

DrPK:

So looking for hallmarks such as that. Now once again, it’s not black and white, if you say, yes, I react pourly to sugar. Well maybe it’s because of yeast. Maybe it’s because of blood sugar issues, maybe it’s cause it’s actually feeding some SIBO and it’s leading to some outside the gut symptoms as well. So I look for things such as that then of course, I also look for things such as heavy use of antibiotics and their history because obviously that’s gonna allow yeast to flourish potentially. Did they start to get yeast like symptoms after going on an oral birth control pill or do they have significant estrogen dominance type of picture and potentially yeast symptoms? Because estrogen dominance has been well-proven to allow candida to flourish. Or are they on long-term corticosteroid immunosuppressant therapy, which can cause yeast to flourish.

DrPK:

So it’s not simple. I would definitely give it that, but I do look for certain hallmarks. Then when I do suspect yeast and I do actually know they have SIBO or I suspect they have SIBO, I do like to separate the treatments. So then I know what I’m treating. So when I do a yeast treatment, I try to use as specific yeast treatments as possible. So if the patient improves, I know what I treated and I know what was leading to what symptoms well.

DrMR:

Amen to that. I’m a big advocate of trying to be as discerning as we can with our treatment.

DrRuscioResources:

Hi everyone. This is Dr. Ruscio, DC. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to drruscio.com/Resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of. The fact that we deliver, cost-effective, simple, but highly efficacious, functional medicine. There’s also my book, Healthy Gut, Healthy You, which has been proven to allow those who’ve been unable to improve their health, even after seeing numerous doctors, be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our probiotic line, and other gut supportive and health supportive supplements. We now offer health coaching. So if you’ve read the book or listened to a podcast like this one, or are reading about a product and you need some help with how or when to use, or how to integrate with diet, we now offer health coaching to help you along your way. And then finally, if you are a clinician, there is our clinicians newsletter, the Future of Functional Medicine Review. I’m very proud to say, we’ve now had doctors who’ve read that newsletter, find challenging cases in their practices, apply what we teach in the newsletter and be able to help these patients who were otherwise considered challenging cases. Everything for these resources can be accessed through drruscio.com/Resources. Alrighty, back to the show.

Managing the Variables

DrMR:

Just one of the things as a kind of relevant aside that I feel that clinicians and patients really struggle with and it’s one of the reasons why those who aren’t seeing the results that they want to see are not seeing the results that they want to see. It’s a simple problem, in my opinion, of variable management. There are too many things being done, too many things changing at one time to really get a read. And so after months of treatment, you come away with a big “I don’t know” because so much is happening. I mean, people tend to have some background flux in how they’re feeling and their symptoms naturally. So you’re already trying to contend with this natural bit of fluctuation in how someone feels and through that fluctuation, get a read for improvement. Sometimes yes, improvements are so obvious that they can’t be missed.

DrMR:

That’s really, I think what all clinicians are aiming for, but there is that little bit of a backdrop that potentially confounds the read. If you’re then doing dietary changes plus methylation plus adrenal support plus anti-inflammatories plus gut-directed antimicrobials plus binding agents, it can be very, very difficult to discern what’s driving the patient’s improvements. So yeah, I fully want to second your approach of going a bit slower and trying to do one thing at a time, because it does really help to clear the read.

DrPK:

Absolutely.

Effective SIFO treatments

DrMR:

With SIFO treatments themselves, are there any there that you’re finding or suspecting are particularly effective?

DrPK:

Yeah. So once again, this is going to vary from clinician to clinician, but what I see work the best in cases where I suspect fungal growth, or I know there is. For example, if I have a stool test and it’s definite fungal overgrowth. There are significant levels there. Pharmaceutically I’ll use nystatin quite often. Nystatin is a non-absorbable, antifungal agent, doesn’t touch bacteria. So there’s no risk of over eradicating beneficial bacteria in the gut and it’s non-absorbable so it is relatively quite safe. I use the capsule version for gastrointestinal issues and I go fairly high dose, you know, about 3 million units a day. So 1 million units, three times a day for a minimum of a couple of weeks to begin. But a lot of yeast cases, even if you start to see improvements, they need much more than a couple of weeks of treatment.

DrPK:

Yeast is just very opportunistic by nature and they do produce biofilm when they cohabitate with certain bacteria species, just like bacteria species do. They’re also just opportunistic by nature. So they want to keep hold of their land, if you will. Where with a lot of bacteria, in overgrown SIBO cases, especially non-dysbiotic bacteria, they’re just kinda over pooling for reasons we didn’t have time to get into today, but they’re just kind of there. They’re not really opportunistic, so when you do hit them with something that works, so you can clear them fairly quickly. With yeast, they’ll multiply faster and in the presence of artillery that you come at them with, they produce more biofilm. So nystatin I like because it is non-absorbable, and yeast is quite susceptible to it.

DrPK:

If there’s a CIFO case and they have fungal growth in the colon, while it’s going to hit them in both areas, because of the fact that it’s non-absorbable. So I will use nystatin quite often, but I do use it very often with some natural agents. One of my favorite natural agents to use, for yeast is monolaurin, monolaurin supplements. Monolaurin is lauric acid, which is an extract from coconut oil, with a mono ester attached to it. Like most people know coconut oil is quite antifungal because three of the fatty acids in coconut oil are all antifungal. Lauric acid, folic acid, and caprylic acid. Monolaurin, the supplement version, some good research behind it, showing that it can definitely eradicate yeast growth in the body and in the gut by disrupting the membrane. But monolaurin also decreases biofilm as well.

DrPK:

So even if you have them on a bile disruptor, or if you don’t, just using a monolaurin can help with that. It’s been shown to slow the reproductive capabilities of yeast, which is a very important part of yeast treatment, because like I was mentioning, they are opportunistic and they will do what they can to survive. So monolaurin, I’ll use with nystatin and very often, a lot of times on its own, but other antifungals I’ll use as well. Caprylic acid is a very well-known antifungal agent and nothing wrong with using it and I do use it in some cases. You know some clinicians give patients MCT oil, that’s 50% caprylic acid, 50% capric acid, which is also antifungal. You can get very large amounts of these two fatty acids by using MCT oil. The problem is how far down does it get. Will it eradicate fungal growth further down where it may be needed? That’s where the supplement versions of caprylic acid might be better. There is some evidence that show things like calcium caprylate, magnesium caprylic acid can get further down the GI tract. So maybe that’s the benefit of using the pills, but then you got to take a lot of the pills to get the right amount. You want to aim for about one to three grams a day of caprylic acid to really be therapeutic. Another one that’s been thrown to the wayside over the years, but it’s been around for decades and it’s a natural agent is tenendosoic acid. Tenendosoic acid is a castor oil extract, so another fatty acid and it’s been known to be extremely antifungal for decades.

DrPK:

It was one of the original antifungal creams years ago. You can get it as a supplement. The company Thorne makes one. It has a funny name called formula sf722 or something such as that. They are little soft gels and this has been well-proven to not only kill candida, but also inhibit it from producing the Haifa. The little legs that come out from the cell body to attach to the intestinal lining or wherever else in the body. It can actually inhibit that production. So it helps in two ways. Now the one thing I’ll say about tenendosoic acid is you do have to take a good high dose of it. So between 200 and 250 milligrams, three times a day. That’s probably four or five of the soft gels, three times a day. So a lot of times we’ll do some sort of combination with that. My most common combination would be nystatin with the monolaurin. I’ve found good success for that.

Episode Wrap-Up

DrMR:

Awesome. Well, good rundown there on SIFO testing.Very, very limited what we can actually test,some treatments. I think we’ve done an excellent job here of running through hydrogen sulfide CIFO trying to make sure that we prevent people from, as you said, having tunnel vision regarding either one of these and making sure that even if the symptoms resonate with an individual, they don’t just limit themselves and pigeonhole themselves into their thinking or their therapeutics. So this has been a great discussion. Is there anything that you’d like to kind of leave people with in closing? Also please tell people about your website or where they can kind of track you down on the internet.

DrPK:

Sure. So, first and foremost, I just want to thank you again for having me on your podcast. You do have a lot of great guests on, so I’m very flattered to be asked to be on your podcast. The one thing I’ll just leave for the listeners out there is that things such as SIBO, SIFO, the way they’re termed and the way they’re written about online, quite often, it makes it seem very fad. They are really not fads. These are real disorders that real people have and we have to get away, you mentioned this earlier, from blueprint treatments and absolute diets. We have to treat the individual. Obviously, that’s a big part of functional medicine, naturopathic medicine philosophy. Yes, we have a list of things that we can use, but every patient’s going to be different.

DrPK:

So, to any patients out there listening, if you’ve tried SIBO treatments and they failed on you, it doesn’t mean you’re going to have SIBO for the rest of your life. You just got to find a clinician that is going to be able to find out what is needed in your case and how to prevent further dysbiosis and prevent relapse and all those great things to do after you get rid of someone’s dysbiosis. As for myself, you know, here in Canada, like I said, I do work very closely with SIBO diagnostics and we do provide testing for any Canadian clinicians across Canada. We’re located here in Victoria, BC, and I do provide complimentary consults to doctors testing through us to talk about their SIBO cases and their results. If any clinicians out there are interested in my full-day seminars, my latest 6+ hour SIBO and dysbiosis webinar is still available at www.supersedingsibo.ca/

DrPK:

So that is a very in-depth course that I did last year in 2019. It covers anything and everything about SIBO, including details of hydrogen sulfide SIBO. Also, I do touch a little bit on CIFO in that seminar, but it’s primarily more SIBO related. I go over a lot of case studies. I personally learn the most when I hear doctors go over their specific case studies, because then you get to see the individualistic treatments and I did try to provide very unique cases for docs to hear about. So they know what to look for.

New Speaker:

Awesome. Well, you’re a busy guy, which I can relate to and I just really appreciate your thoughtful approach to this. I think we need more and more providers like ourselves, linking arms trying to steer people away from the edge. You’ve made many comments toward the end point of personalized, but non-heretical, overzealous fearful sort of thinking. I think, if nothing else, if we can all get on the same page there, it’ll start to rectify some of the aberrancies that are budding in the field. It’s been a real pleasure chatting. Thank you again for coming on.

Outro:

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