What is the Best SIBO Treatment Plan?

SIBO algorithm with Dr. Allison Siebecker.

Dr. Michael Ruscio: Hi everyone. Today’s show is with Dr. Allison Siebecker. I believe this is her fifth time on the podcast and if you’ve caught any of those interviews, you know that I clearly have a lot of respect for her and feel that she is one of the few clinicians I very much see eye to eye with. We discuss her new course called SIBO Pro, which I’m excited about because we desperately need better training in the treatment of SIBO. One of the things that we discuss during this interview is how she supplies an algorithm and if you read Healthy Gut, Healthy You, you know how important an algorithm is. It literally gives you the scaffolding or the system through which to apply the available treatments and that is the difference between success and failure.

Just to articulate the importance of an algorithm I’ll use the example I’ve used a few times now that we’ve had a number of reports of people who’ve seen a few different doctors, even functional medicine doctors and haven’t been able to improve their health until they’ve gone through the protocol, the algorithm in Healthy Gut, Healthy You. Well if you’re a clinician looking to have an algorithm for SIBO, Dr. Siebecker’s course provides that for you.

We talk about the depth of her algorithm. She even goes so far as to give clues as to when to consider things like adhesions or limbic retraining and even tips that go as far-reaching as how to correctly order a barium swallow if you’re suspicious of it and want to rule out adhesions in a patient. So very insightful and I think clinically informative podcast with Dr. Allison Siebecker.

Also, if you’ve been enjoying the podcast, please don’t forget to head over to iTunes and leave us a review. This is how you help the podcast reach more people. There’s a good chance that you may have found us through iTunes. For us to make our way in front of new faces and start sharing the information that we share in the podcast, which I feel to be very important, we rely upon reviews to help drive us further and further into the realms where people are searching for health care podcasts. So I deeply appreciate any review you can write for us there. And with that, we will now move to the interview with Dr. Allison Siebecker.

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Episode Intro

DrMR:  Hi, everyone. Welcome back to another episode of Dr. Ruscio Radio. This is Dr. Ruscio. Today I am here with my good friend and one of the few people I agree on almost everything with, especially regarding SIBO and IBS, Dr. Allison Siebecker. Allison, welcome back to the show.

Dr. Allison Siebecker: Thank you, Michael.

DrMR:  It’s always great having you here. Like I mentioned a moment ago, and as I’m sure our audience is accustomed to hearing me gripe about, there’s a lot in the field that I don’t agree with, and it’s so refreshing when you and I have a chance to talk because you and I seem to really agree on almost everything, which is rare.

I think it’s because we share this perspective of being highly evidence-based, but also not evidence-limited and definitely not making things more complicated or more expensive than they have to be, which is why I’m excited about the SIBO course that you’re releasing because I think we desperately need better education on SIBO.

I want to make one clear distinction just before we jump in because this is something we were talking about before we started the recording, which I think is absolutely worth underscoring, better education doesn’t mean new or different or complicated or complex. In my experience, one of the most prevalent factors that thwarts both patients and clinicians alike from getting results is reinventing the wheel and getting distracted with the newest theoretical mechanism, whatever you want to call it, and they don’t understand how to apply good foundational clinical science.

In my opinion, it’s the personalization of the clinical science that leads to success, whereas so much of the field is this fictitious, elaborate application of every superfluous mechanism test, bell and whistle that almost always leads to a suboptimal outcome. I have a practice of patients that have proved that, as I know you do, Allison.

I really want to leave here with an endorsement for your course because the way that you think, unfortunately, is rare, and we desperately need more of this in the space. I’m giving you some pretty big expectations to live up to as we expand upon your course, but I have no doubt that you’ll do that with ease. I just want to lead with that also thank you for your perspective, because sometimes I feel like I’m crazy because I feel like so many people are looking at the stuff through the most complicated and convoluted lens possible. That’s why, again, I’m just really grateful for you and the work that you’re doing.

Importance of Treatment Algorithms & SIBO

DrAS:  Thank you so much, Michael. As usual, I couldn’t agree with you more about our educational component and our paths in the field. I really do like to keep things streamlined with patients and keep things moving forward simply and step-by-step. That’s what I’ve tried to do and what I believe I’ve done in the SIBO Pro Course. I share a treatment algorithm, and it’s very, very organized. I’m trying to help people know how to handle this often very tricky situation. When you run into tough spots, know where to look and where to go next, like a step-by-step sort of thing, because as you know, that’s all I do.

I might be one of the only practitioners that I know of that just specializes in this one thing, which is SIBO. Like yourself and so many of my wonderful colleagues do way more than that, but I just do this one thing. So I know a lot about it and I want to share what I’ve learned. That’s the whole point of the course.

Also, I’m passionately into education because I’m into empowerment. I’m into empowerment for patients because I’m a SIBO patient. I’m into empowerment for practitioners because obviously knowledge is empowering, but not convoluted knowledge. Like you were saying, streamlined, simple, broken down.

I’ve taken the time to synthesize it, because the thing of it is that we hear all the time from our patients the difficult circumstances they have that they encounter with doctors who are not educated, practitioners who are not educated, and who are not able to help them. And so, that’s really the whole point, is the whole point of really a course like this or education in general for me, from my perspective, is to help patient outcomes. That’s really what I’m trying to do by helping practitioners know how to do that.

DrMR:  That’s why I think the algorithm becomes so important because really, coming back to my opening remarks, it seems that so many clinicians, or if you’re a kind of do-it-yourself patient advocating for your own healthcare, you become lost amidst this plethora of different options, different treatments, different tests, even worse, trying to treat with different mechanisms.

It sounds simple, but when you understand a treatment algorithm, and why the book Healthy Gut, Healthy You has been able to help people who’ve seen three, four, five functional medicine doctors because we lay out an algorithm. That helps you organize your thinking and give a sequence to your treatments.

So what’s great about the SIBO Pro Course is you’re obviously taking the algorithm to another level because it’s a professional training algorithm. But whether it be an algorithm in a book meant for the lay public, as in Healthy Gut, Healthy You, or a more robust algorithm meant for clinicians and doctors, as in the SIBO Pro Course, having the algorithm helps ground you from, “Oh, here’s a new speculative tidbit,” and where do I put that into the greater approach?

This is what eludes so many people. Oftentimes the way you could picture this is it’s an inverted pyramid. People are focusing on the apex of the pyramid, which is … And let me delineate. There an evidence-based pyramid. That’s not what I mean. I’m more so picturing a treatment hierarchy pyramid where you’re most important treatments are at the bottom at the tip of the pyramid would be your most speculative and inferential treatments.

Those are the ones that have the lowest likelihood of helping people because they’re either newer or less well-researched. That is where so many people tend to focus. This is why an algorithm is so helpful because it helps anchor you amidst all this new information coming out, which is interesting, sure, but we have to have a way of organizing it into the greater treatment plan. Of course, this is what the algorithm really helps us to do.

DrAS:  Exactly. Having a plan in your mind and knowing what the steps are to take. It’s so important particularly because, if anybody listening is like you or me, we see a lot of complicated cases and it can get overwhelming really fast. You take their history down and it’s like, “Oh my gosh, there’s so many things wrong. Where do I go? What do I do?” Now, in the case of SIBO, it gets more streamlined because, obviously I’m teaching about just one condition, but even still it can be very confusing and there are a lot of choices.

So it’s really important to have a plan. Also one of the biggest problems that I see with practitioners treating SIBO, what I’m hearing from the patients, because like yourself, I see people as referrals. So I have the failed treatment maybe three or four times and then they come my way because their practitioners do not have key pieces of information and are not working it through. People give up too soon and I understand why they might give up because if what they’re doing isn’t working after one month or maybe even two months, they may think I need to switch what I’m doing. That’s right.

But the problem is then they’re lacking the other options. They’re lacking a lot of foundational information. So, I mean just for example, now people who are generally educated in SIBO may know this, but it still shocks me how many people don’t know. Is something to me, as simple as the fact that when somebody does a test for SIBO, which is the breath test and they have positive methane, there’s a different treatment. No matter what you’re using, whether it’s pharmaceutical herbal antibiotics, the treatment is different.

If you don’t know what that is, then you haven’t treated it. And so just as an example, I saw someone recently who thought they were a really tough case of SIBO who had done four treatments and none of them had been for methane. And so she thought, “Well, I’m an incurable case with SIBO.” Because the information was lacking.

DrMR:  I fully agree in the sense that people tend to give up too early or… And I’ve made this comment in the podcast a number of times. People are looking for one therapy to deliver all their results. They’re not thinking about how to work this algorithm or the way I’ve described it before in the podcast is you start with one therapy and that may yield a 30% improvement and then you stack on top of the other therapies and you create this personalized plan. But it’s the algorithm that helps you realize that you’re on the right track and working through the right kind of sequential steps in the therapeutic process. I have this conversation almost on a weekly basis with these cases that come in, like the one you’re describing and say that they’re a complex case or XYZ.

And oftentimes I report back to them. I think you’ve been doing a lot of the right stuff. It’s just you haven’t had any organization or any follow through guiding the process. It’s been haphazard. Antimicrobials, elemental diets, immunoglobulins, dietary changes, probiotics, and it’s just like they’re throwing stuff against the wall, looking for the 100% resolution, not kind of coming at it from this biome cultivation, environmental restoration sort of approach.

DrAS:  They need a methodical approach. I mean, if everything goes great first time out, sure, then you don’t need to worry about anything. But if that’s not the case, which is not the case for at least two-thirds of the cases of SIBO, then you need to be methodical. These are all points we go over. And in fact, what you were just talking about, you speak about in my SIBO Pro Course, because you did a guest lecture in the course. I have two versions of the course and one of them is called interactive, where there are office hours with me and you get guest lectures, one of those with you.

DrMR:  Oh, perfect. Well, there you go. If people want to be bored by my algorithmic spiel, they can tune in there.

DrAS:  It wasn’t boring at all. It was phenomenal because it was in the part where, talking about that base of the pyramid where we talk about foundational treatments that come before you move into the antibacterial, antimicrobial type treatments. And I was getting your two cents on what you like to do, which is absolutely fascinating.

DrMR:  Perfect. Well, again, we see eye to eye here on this as we do many things and you mentioned the treatment algorithm and that’s going to really be the scaffolding that ties together and organizes all these treatments. While we’re in the realm of treatment, and I know there are maybe 1000 things you could touch on here, but are there any other kind of pearls or insights from the course that you think are worth at least touching on?

Insights from the SIBO Pro Course

DrAS:  There are so many. So a few would be, in terms of treatment, to have more than one tool in your toolkit, that’s what I teach. Because like I say, if everything goes great, sure, no problem. But once you start running into problems, things are not immediately resolved, you need to have options. So I go over lots of different tools. I think that’s a really, really good tip and it’s a place that can be a problem for a lot of people depending upon their training. Because various types of training have philosophies that go with them. So an MD or allopathic training might be a pharmaceutical approach only and against natural so to speak.

And naturopathic might be only use natural and herbals and don’t use pharmaceuticals. And so that can be a real problem when you start. When you’re really trying to help patients and you start running into problems with their care, you need many tools and so if a person is open to accepting other tools, then things are going to go better. That’s one tip I would say right off the bat.

We already talked about the methodical approach. Another thing that I would point out that a lot of the people who have taken the Pro Course so far have actually been writing in that it was one of their big takeaways was the piece about prokinetics. That was interesting to me to hear them writing in about that. Many people have not been trained in prokinetics and don’t know that they can have a place and where they can have a place and how to use them. So prokinetics are used after antimicrobials and SIBO treatment when we’re trying to sort of hold the gains we’ve made while we’re assessing, and also once all the treatments have been handled and they’re better and we’re trying to prevent relapse. There’s various approaches here and we discussed that in the course, whether to use them, or not to use them, how to use them. But they are a really, really incredible tool most especially for very chronic cases, people who have so to speak, incurable underlying causes, which many people do. They’re a whole spectrum of people with SIBO. There are easy cases and then there’s people who have things like Ehlers-Danlos syndrome, which is not rare. That’s actually not a rare disease even though a lot of people don’t know about it.

And I know you’ve done a lot of work on your podcast to educate people about it, but that is a condition where the connective tissue becomes lax, so there’s just not going to be proper movement in the intestines. Constipation’s a huge issue and SIBO could occur.

So a person like that, that’s an incurable condition. It doesn’t mean it can’t be managed very well, such that there are very few symptoms, but SIBO is always going to be an issue that needs to be managed in people like that.

The course, obviously I’m teaching about from easy cases to hard cases. So in somebody like that prokinetics are going to be very, very helpful because they do not have the muscular tone to do the movement they need to do and prokinetics can help stimulate that. So there are all kinds of treatment tips in there. And I have a lot of charts and I have a desk reference, I guess you call a PDF ebook that so far the students and the participants are saying that’s one of their favorite parts. And they just keep it up on their computer while they’re working with patients because they refer to it so much. Because so many people have SIBO and so many of these docs see so many people with SIBO. So anyway, those are a few tips. I’m sure you’ll have comments on many of these things.

DrMR:  Yeah. Many comments kind of run through my head. I guess the one that I want to echo is understanding how to manage these chronic cases. And I even think there’s an important distinction here to be drawn. This is more me being speculative than an evidence-based and research agreed-upon statement, but in my perspective anyway, there’s a difference between a chronic case and a complex case. And I think what happens is some of the chronic cases kind of think their way into, eventually forming the belief that there are complex case and using Ehlers-Danlos as an example, some of those cases may just have a predilection towards drifting back to SIBO due to the lax nature of their connective tissue and doesn’t necessarily mean anything is wrong or broken. But they may need some periodic touch-up therapy.

I always use this analogy, so pardon to my audience if it seems trite at this point, but if someone had a really bad knee injury in college, they may have to periodically do some stretching and strength and exercises to keep the knee and balance aligned and to prevent pain. And if they get lax with those things, they may notice some knee ache starts to return and realize, “Oh yeah, I have to get back to strengthening my knee again” and they do some other stretches, some of the exercises, and they get back to being asymptomatic. I think that the same thing can definitely happen with some of these like cases. But when you don’t understand that as a clinician, it throws you off.

If you’re not able to have the narrative that I just outlined with a patient, they tend to get thrown off thinking in a very kind of fear-based fashion. Not understanding that, yeah, there’s just a little bit of a pain, a residual knee injury, if you will. Nothing wrong, nothing necessarily broken. Just something I’ve periodically got to do a little bit of a touch-up work for. When you understand as a clinician you don’t get so concerned that you’re missing something huge or mismanaging the case and the patient has an understanding that there’s nothing wrong or broken.

I think that’s more beneficial perhaps even for the patient because there’s a tendency when symptoms return, and I’m sure Allison, if anyone can appreciate this, it’s you. You’ll sometimes get the, “My SIBO is back.” Almost like they have a return of some sort of carcinogenic issue and that fear likely is more damaging even than the recurring symptoms. So would you agree with that Allison or modify that at all?

DrAS:  Oh, absolutely of course. It’s such a huge issue, the fear in SIBO because anxiety is one of the symptoms. So it’s just such a natural place for people to go unfortunately with SIBO is, it’s almost like a PTSD sort of thing.

They just really have been traumatized by the symptoms and it’s so upsetting to them because of the anxiety. The anxiety makes it so much worse. It’s not just, “Oh, I have some constipation.” There is intense fear and anxiety around that.

And so that’s another reason why treating the SIBO’s so important because we then calm the anxiety down but also why you can see it so easily return with a relapse. But these sort of attitude adjustments are very important for us to talk about and talk about head-on and consciously with patients because we don’t need to stress ourselves extremely over this.

I’ve had SIBO for a very long time, since I was five, and I don’t think about it as any terrible thing. I think that’s another thing that’s very disturbing to me to hear about. I don’t participate in patient chat groups on SIBO, but I hear about it, and I hear a lot of people saying that they feel like they have a life sentence when they get diagnosed with SIBO, like you were saying, like its a carcinogenic. It’s not fatal. Yes, there’s suffering involved and sometimes it’s very minimal suffering and sometimes it’s more severe.

But the thing of it is, SIBO in and of itself is not that hard to treat if you have the proper education and you know what you’re doing. Yeah, there’s times where you have to, it takes a little longer and you have to work things through. Of course, there are always circumstances like that. But it actually is a condition, I think with a very good prognosis in terms of life quality and symptomatic relief because it’s kind of a simple situation. There are these excessive bacteria in the small intestine and maybe some in the large intestine for the methane type. But the thing is is that just if there’s too many of them, they’re in the small intestine as we know, they can ferment carbohydrates that we eat and then that causes the symptoms.

And so if you can just get that bacterial load down, all these symptoms go down. It’s not that hard really. Once you just have a clear path and you know what you’re doing and you understand what treatments work for which situations. So it’s actually a condition.

While it can be very tricky, the whole point of me making a course and doing all the educational things that I do is to try to make it less tricky and show that we can help people get better. I mean, the symptomatic relief goal that I shoot towards and that I’m almost always able to achieve with patients is 80 to 90% symptomatic relief. So it’s a really good prognosis.

Now if we’re talking about chronicity, yeah, that prognosis is not so good because it’s two-thirds of cases are chronic. But then you put it into perspective like you just did. So you just do some management things. Maybe you’re just taking a prokinetic. Some people don’t even have to be on that restrictive of a diet. Then occasionally there’s a relapse and we deal with it. It’s not that terrible really. Why is there this whole life sentence thing about it? I think part of it is the anxiety that comes with SIBO, which we can calm, and also I do think that there can be, and this is always a delicate area to talk about, but there can be a negative side to a lot of the so-called support groups and chat groups. Which on the one hand you can have wonderful support, but on the other hand it can be a little negative.

DrMR:  I fully agree and I think the unfortunate situation with the last comment you made there about the support groups is at least from my estimation, it seems that those who have the most chronic and severe cases tend to hang out in the chat groups the longest. So there’s almost this selection for the worst cases. You could also make the argument that those people may have the most lacking support structure with their doctor, clinician, family or friends. And so you have this compounding effect where the most chronic cases who also have the least amount of support and then couple that with those people being the ones who may need the most room to vent emotionally aggregate on these chat groups.

This is why I end up seeing as I know you do also Allison, patients will come in after internet reading thinking that things are far, far worse than they actually are. And I think a big part of what we need to do as clinicians is just give people some reassurance and be purveyors of a more reasonable way of looking at these things. Which can be quite helpful for patients to pull them out of that lurch of worry and despair.

DrAS:  Yeah, exactly.

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DrMR:  In the course, I’m assuming under the realm of more chronic end or complex cases, are going to touch on adhesions. Is that an area that you venture into or at least warning signs for when to make an adhesion referral?

Chronic SIBO and Adhesions

DrAS:  I do actually four hours a little bit more than four hours.

DrMR:  Let’s define that, I think our audience probably knows what adhesions are, but let’s give the quick definition and I would just want to say that we’ve seen a few cases even from Cedars, who I think does generally good work and making the referral for adhesions was the difference between chronicity and resolution. So this is definitely something that you would think even after someone going to Cedars, they would’ve had this evaluation, one of the best medical centers for SIBO arguably in the world, but for whatever reason, that was overlooked. This is something that even your complex or chronic cases coming from very respected medical centers may have had this overlooked.

DrAS:  Okay. There’s so much to talk about here. First off, adhesions are basically scar bands that form inside the body. They can form in various places and they’re meant to be healing, the body makes them for repair. They’re there to repair after infection or injury, that sort of thing, inflammation. But they have a very strong tensile force of pressure and they can bind things up, they can cut things off, they can basically compress parts of the intestine if that’s how they’re laying or formed. And that’s where they can cause SIBO. They can actually cause a partial obstruction in the small intestine, allowing bacteria to backup behind it.

They’re very common. It’s not to say adhesions are common because you know, infection and injuries, and inflammation are common. But that’s not to say that all adhesions cause SIBO. But in anybody who has SIBO, we have to think about that. So as I was just mentioning, I spend a little more than four hours going over all of the underlying causes of SIBO in the SIBO Pro Course because obviously that’s our deepest level that we can get to. So anybody who’s chronic, anybody who has a chronic case of SIBO and as you mentioned earlier, we want to take a look at that and say, are they really chronic or have they just not had proper treatment?

First, let’s handle that. But let’s say there really are chronic. When you have a chronic case, once you know they’re chronic, we need to look for the underlying cause. I wouldn’t necessarily say you have to… This speaks to your unnecessary tests prologue that you began with. I wouldn’t say we’d have to start testing every possible underlying cause when you first see somebody, because you don’t even know if they’re going to be chronic.

Like, let’s get a little treatment going and let’s see what if after one treatment there are 100% better and then six months later they’re still better and 12 months later they’re still better. I wouldn’t jump right into that. Let’s just see how it goes and if you find that they’re chronic, then you begin investigating the underlying cause. Adhesions are, I would say, the number two most common underlying cause of SIBO. Number one is food poisoning and that causes an autoimmune situation that damages the nerves in the small intestine and decreases motility. So we get stagnation. That’s number one.

Number two is adhesions that are somehow causing a partial obstruction of the small intestine. So number two underlying cause. We go over all sorts of ways to test for it. I describe the testing and various treatments. I’ve actually been investigating other treatments that I’m not fully talking about yet, but I’m learning about. So I’ll just use that as a teaser and let you know that coming down the pike I should have some more treatments to offer. I don’t like to talk about anything until I really see that it’s proven.

DrMR:  But it’s a tough balance because sometimes I’m excited about something and so I always try to at least let our audience know. I’m just dabbling with this. It’s a little bit early for me to be able to say.

DrAS:  It’s theoretical. But anyway there are various treatment options for adhesions.

DrMR:  Sorry Allison, one little interjection there. Because this might be in our audience’s mind. We recently had Jason Wysocki on – I believe you actually connected me with Dr. Wysocki – and he’s doing a therapy different but similar to what they’re doing in Clear Passage. Any thoughts on his work, any kind of delineation between the type of referral? I know that’s getting a little bit granular within the world of adhesions, but just wondering if you’re drawing any clarification there?

DrAS:  Do you know the name of what he’s doing, is it structural integration?

DrMR:  He mentioned in the podcast, I actually have to go back and listen to that. It’s a term I hadn’t heard before.

DrAS:  I’m not sure that I know exactly what technique he’s doing to be able to comment on it, but I know there are different manual techniques even besides the WURN technique, which is what she used to Clear Passage that can work, so really worth looking into. Some people who are trained can diagnose adhesions with their hands with a physical exam. They can feel them and tell…

And the other test would be a barium swallow specifically if we’re looking for the small intestine, you have to drink barium down and they do a test. That way we can visualize… You don’t see adhesions that way. That test shows the flow of contents through the small intestine. But you can see if there’s an obstruction and there’s other clues in there.

That test actually just because I brought it up, I want to mention that if anyone’s listening and is thinking of getting that test or if your practitioner wants to order it, you have to put special instructions when you order that test because radiologist will perform it subpar, so to speak for what we need in unless you ask for what you need. So what we need to do is to write on there “rule out adhesions and with multiple spot films to visualize each segment of bowel, multiple spot films, and positional changes”. If you write that down then you will get a proper exam. Because I have definitely seen patients who have had that test done and it did not reveal adhesions only to go later to get it done in the proper way and then it did reveal them. So it has to be done correctly.

And basically what you’re looking for there is many pictures being taken, more than like four or five pictures being taken. So it’s a very valuable test. I think it’s a bit more subjective when you go to someone who’s been trained to use their hands. But then again there’s subjectivity in all tests.

I’ve been able to find a lot of people that have adhesions with that test. So either way, but adhesions are, like I said, the number two underlying cause of SIBO. Obviously, in the course, I’m just going to spell it all out for you. Give it to you step by step, what are the tests, what are the things we need to look at in what sequence and everything that I have to share I share there. I’m so interested in increasing SIBO literacy is what I’m trying to say now because of how much I hear from patients who are undergoing unnecessary treatments or ineffective treatments. And I just would really like to get that information out there.

DrMR:  Well I agree with you wholeheartedly. I think we maybe have an awareness that exceeds our clinical capacity. And it’s not that our clinical information isn’t there, it just seems that, X, Y, Z bloggers information tends to permeate fairly far, but really good competent clinical training doesn’t seem to match the spread of that information. So, again, pretty much why we’re having this conversation because I think we need more literacy out there. So again, one of the 99.9 points we agree on.

Emotional Support for SIBO

One of the other things I wanted to ask about is referrals for emotional support, but I guess more concretely limbic retraining for those who seem to have had quite an emotional stress or fear burden, is that something that you’re also factoring into the algorithm?

DrAS:  Yeah, actually I have a whole lesson on that and all of the options that I’m aware of. Most of the options I’m aware of, I share. A whole thing on limbic retraining and how to help that, how to help vagal healing of the vagal nerve is certainly an issue in a lot of SIBO cases. I don’t think it’s needed in all SIBO cases obviously. Sometimes it’s more simple and easy, but for the more difficult cases that can be very, very helpful. There are many different modalities we can do. I know you and I have talked before about options like DNRS, Dynamic Neural Retraining System from Annie Hopper. That’s one a lot of people are using and I’m hearing really good reports on, so that’s encouraging.

There’s obviously therapies that can help like EMDR therapy, which has been proven effective for PTSD and I’ve seen some very, very good results with that. There are so many other options and I have like two slides of options. I go over it in a whole lesson. It’s in my course and it’s something that’s very, very important that I think a lot of us are thinking about more for are very sensitive, very complex patients and getting… We’re hearing really good results when people are doing this.

DrMR:  And I’ll echo that. I’ve been referring solidly, probably at least six months for limbic retraining and it’s rare. If you’re a clinician who is being honest, objective and not drinking your own Kool-Aid, it is rare that you will, 75% of the time or more have patients report “very helpful” when you ask them how did that treatment go. “Very helpful”. That’s a strong claim for a patient to make. Usually, you get, “Yeah I’m feeling better.” Or sometimes you’ll get the, “Yeah I may be feeling better.” I may be feeling better usually equals no change because there’s always this little bit of placebo imparted in any recommendation that we make. So when you hear the majority of patients say, “That was very helpful.” That really makes me perk up in my chair and listen. And that’s what I’ve been seeing with limbic retraining.

Again, like you said Allison, not for every case, but for the cases that maybe have a separate document of their health history and they’ve been taking fervent notes and you ask them about their diet and they can go on a 10-minute diatribe just about their diet, and I don’t say that flippantly more so just to point out for some of these patients are giving their health so much thought that it’s just really kind of skewing them out of balance.

This can be, in my opinion, almost a lifesaver for these patients because there’s only so much we can do with the terrain, with the gut. If that’s being done absent of these other changes in the brain and limbic system that need to be addressed, then it can be very hard to get the clinical wins that we’re looking to get.

I believe we have, coming down the pike here soon in our clinician’s newsletter, a case study where the exact intervention needed was limbic retraining. That was pretty much just, here’s a chronic/complex case, then from doctor to doctor. The missing piece was just limbic retraining. Clinicians definitely pay attention to this because there are definitely those cases out there that you don’t want to be one more of the slew of doctors they have to bounce from. You want to hopefully be the last one in that cascade who finally in cases like this got them the final two recommendations I needed to get well.

DrAS:  And Michael, do you have one or two forms of this that you’re using?

DrMR:  Yes, DNRS and The Gupta Program.

DrAS:  The Gupta Program?

DrMR:  Yeah, The Gupta Program and then Annie Hopper’s DNRS. I’ve had one patient who has done both and more than one time. I believe I had a second patient who’s also done both. DNRS takes a little bit longer. It’s a bit more, I don’t want to say superfluous, but robust and verbose in his descriptions. But it also seems to perhaps be a touch more effective. The Gupta Program is more concise and to the point. And I think for people who are busy type A-ish that might appeal more. So they both seem to work. Maybe Gupta is more concise. DNRS might be a little bit more verbose but maybe a touch more effective for those who really have kind of deep needs. Now that that’s just based upon one or two patients who’ve done both. But it’s rare in my opinion that you have one person who has done both to give you that kind of comparative perspective. So I guess why I feel comfortable sharing that.

DrAS:  Oh I didn’t know about that one. So thank you.

DrMR:  Yeah, there’s a number out there and I think it was actually Chris Kresser who turned me onto DNRS so I have to give him a thanks for that because that was definitely something helpful to have in our repertoire. So clearly this is a comprehensive treatment algorithm. And again, I want to just draw that same distinction that complicated and superfluous is not the same as clinically accurate and comprehensive.

Unfortunately some of the training programs that I’ve seen, they would have you believe, ooh, this new novel finding where there’s not even any human outcome data to support is the reason why your complex cases aren’t responding and this is how you get them well. Newsflash, that works in my experience almost never.

But what does tend to work is exactly what you’re outlining which is here are the therapies that we have evidence for that are well-studied but more importantly here are the scaffolding for how to apply them effectively. Really great that you have all this kind of packaged to kind of take a lot of the thinking out of it. Obviously there’s going to be thinking involved but if you can help give them guideposts for where to direct your thinking in decision making, it’s a massive win.

One of the things in that thinking process is also testing and again there’s probably so much we could touch on here and we have talked about the barium swallow instruction, which is fantastic. Is there anything else with the testing that you feel important to mention… I shouldn’t say is there anything else. Are there maybe a couple choice items that are worth touching on?

One, I’ll throw out there as an idea. It seems that patients are now coming in with far too generous of an interpretation on their SIBO breath tests. I had one patient from Stanford who had a CH for methane and hydrogen positive, combined gas positive of 20 at 140 minutes and Stanford told her that she had SIBO, which was quite remarkable because I would think Stanford would at least be familiar with the diagnostic guidelines. Now take that with a grain of salt because that was vectored through a patient and the patient could have misunderstood, but this patient was also pretty darn sharp so I’m fairly certain she didn’t misinterpret.

Whatever the case may have been there, these incorrect reading of SIBO breath tests seems to be one of the sources of confusion. Any thoughts on that and or anything else that you think is worth just kind of briefly showcasing here?

SIBO Testing

DrAS:  Absolutely. In fact, this is something that I recently became aware of that I didn’t realize, which is that I always interpret breath tests myself with my own criteria that only varies ever so slightly from the North American breath test consensus criteria. However, what I didn’t realize is how many practitioners out there have not been trained in interpretation guidelines and are just relying on what the lab report says.

DrMR:  Oh no, that would be a big miss.

DrAS:  Horrifying. That’s just not acceptable because the labs vary. Many of them aren’t using the North American breath test consensus. They’re all different. So when I started doing breath test interpretation, it was, I guess 10 years ago or longer, I can’t remember when. And there was no standardized criteria. There was no North American breath test consensus. Rome consensus wasn’t even out. And labs and studies and doctors all had different criteria. So I took a look at all those and then I went to work and being a specialist in SIBO, that means every single patient I see has SIBO, unless they don’t. But I test every patient because you can’t diagnose it without testing it.

That’s a whole other issue because the differential diagnosis is about 45 conditions large, meaning that the symptoms you cannot diagnose SIBO by the symptoms. So anyway, I was testing everybody and then pretty quick I learned how to interpret breath tests. And then obviously I see my results. If I decide they do have SIBO, if I treat them and then I can see what happens. So I basically developed the criteria on my own so to speak with my colleagues, because this is all I do.

Then when the North American breath test consensus came out, I was very, very pleased to see such a huge agreement between what I do and what they do. And I can tell you what’s different. But because I came from that perspective, I didn’t realize how many physicians don’t have any kind of criteria. If they haven’t taken any of my lectures or listened to any of my podcasts or been on my website, which by the way is SIBO info for those of you who don’t know, I just didn’t realize there were so many people out there relying on the lab report only.

So it’s a hugely important factor. I would say if you don’t know anything, use the North American breath test consensus guidelines. Just do that and I’ll tell you what’s different with what I do, but basically don’t rely on what the lab says, don’t even look at it. It doesn’t even matter.

You should be looking at the table and the graph and doing your own evaluation and on your own deciding a positive or negative do not rely on that lab report.

DrMR:  Yeah, I mean that in and of itself I think is huge. I’m glad you mentioned that because sometimes it seems so basic in my mind not to include the lab printout results as part of your interpretation that I’ve almost forgotten about that because, at least for two years now, I don’t even look at their interpretation because yeah, you’re right. I mean they’re not using any contemporary guidelines, which is fine. I don’t expect the labs to change the algorithm that the computer uses to spit out its automatic report. I think the labs are more so concerned about quality, calibration, customer service, insurance, billing if they’re doing that. They may not want to get in the middle of, well, are we going to use North American or Rome or what have you. But it’s really incumbent upon the provider to do that. So yes, that would be a huge first hurdle for us to clear in terms of SIBO advice. And again, sad but true that this is something that needs to be remedied in the field. DO NOT USE the lab results when SIBO testing use

DrAS:  Yeah. So I’ll just briefly tell you what’s different. The main thing is that North American breath test consensus I think goes to… I can’t remember right now, and I haven’t looked at it recently, but I think they go to 90 minutes for hydrogen as what they would consider to be positive for the small intestine and they use a rise of 20. And I don’t think 90 minutes is sufficient. I think what 90 minutes is good for is for research, for when you’re publishing research, you need to be absolutely certain that it’s in the small intestine that you’re talking about. There can be no controversy. That’s what 90 minutes is. No controversy. But I am not publishing a study. I’m trying to help patients and people have different transit times.

The 90 minutes is about when you swallow this substrate, how long will it take to move through the small intestine and then get into the large intestine. Then we’re trying to see the gas that’s made in the small intestine versus the large intestine. So two hours is what I use and I’m well aware that some people could have shorter transit times and some people can even have longer transit times of their small intestine so that it would even be over 120 minutes. And that’s what I mean about interpreting the test yourself.

If you’re armed with the proper knowledge and training, you can do a much better job. You don’t want to use some black and white cutoff. And I would not recommend using 90 minutes. What I do is I look at the test and I see is it positive by 90 minutes. And I have to say in a majority of cases it’s already positive by 90 minutes, but I don’t want to miss the case where it’s not, where it’s positive after 90 minutes. So then I’m using my brain and my interpretation criteria and I actually use 120 minutes.

And when we look at the small intestine transit times, when somebody has SIBO, well I will say on average they’re usually somewhere around 100 minutes or so. So they’re already longer than 110 minutes, something like that when you look at all the various studies and methods. So you can see why 90 minutes makes it sure that you’re in the small intestine. This is, I’m talking about the trends of time for the small intestine here. But when you look at the studies of when somebody has SIBO, that transit time goes up.

This is, I’m talking about the trends of time for the small intestine here. But when you look at the studies of when somebody has SIBO, that transit time goes up.

So certainly I’d want to go at least to 100, 110 minutes, but if now the transit time is going up because usually they’ll cause SIBO a slow motility in the small intestine. Then that means it’s more time. So I want to factor that in. So that’s the first thing. And then the second thing is that I don’t go by a rise of 20 and this is for hydrogen. I go by 20 absolute with various that are caveats and patterns that I have to rule out to make sure that’s correct. And I won’t go into a big long reasoning of that. I’ll basically just tell you, it’s from my own clinical assessment of maybe 5,000 breath tests that I’ve interpreted and seen the patient follow through with.

DrMR:  Yeah, and I think we maybe have some nuanced differences in how we interpret this, but I think we generally come to this same conclusion, which is not looking at them black and white. And then also I think more importantly, it’s not to say that we couldn’t offer antimicrobial therapy as a treatment empirically for someone who is negative for a SIBO breath test.

DrAS:  Oh yeah. Absolutely, there’s plenty of others… I mean there’s like 40 other conditions they could have, some of which might be bacterially or microbe caused viral parasitic, absolutely.

DrMR:  And part of what Richard McCallum has helped to find and he was in the podcast, for our listeners now maybe roughly six months ago, there also may be a degree of dysbiosis. It may not even be frank SIBO, but there could be just this imbalance and theoretically-

DrAS:  That seems interesting because… may I jump in?

DrMR:  Yeah, please.

DrAS:  Because when I heard him present on this at one of the conferences, and now I may have this wrong, but my take on it was, it was about the cutoff he was using. And so he’s actually still using 10 to the fifth to define bacteria per colony unit in a small intestine to define SIBO. And that has actually changed. Now it’s been changed to 10 to the three and that was in the North American breath test consensus and… But he hasn’t changed his criteria. So he’s now calling between 10 to the third to 10 to fifth dysbiosis when all the rest of us are calling that SIBO.

DrMR:  Well that’s good to know.

DrAS:  I have listened to his lectures and I read his papers and I actually questioned him about this and we were all very confused and we’re like, “Why do we need a new name for something that we’re all calling SIBO?” So that’s just my interpretation of that. However, even putting that aside, of course there can be dysbiosis. I mean that’s something we all know about anyway. Oh and Michael, I remember the other thing I wanted to tell you about. I was there talking about hydrogen and not methane. The interpretation from methane is completely different and that’s very, very important to know that that has changed and it’s you use the whole three hours of the test.

That’s another thing I don’t think you’re doing the best you can do if you get a two hour test and also you need 10 tubes, so a three hour 10 tube test really will help you so much more as a clinician with your interpretation.

If you are shortening it to two hours or shortening the tubes you are missing information. You get so much more valuable information, particularly where you need the three hours and the 10 tubes is for methane and for assessment of hydrogen sulfide until that test becomes commercially available, it’s not yet commercially available. So we have three types of SIBO, hydrogen, methane, hydrogen sulfide. Although the methane type SIBOs trying to be renamed as methanogen bloom because the nomenclature doesn’t quite match. So methane, it’s totally different. It’s three hours and breath test consensus is 10 or above. Is methanogen overgrowth or methanogen bloom.

And what Dr. Pimentel has used for a very long time is three or above, so long as there’s constipation. So that’s the way I do it, is from three to nine. So long as they have constipation, I would consider that positive. From 10 or above it’s positive by North American breath test consensus no matter what symptom they have.

DrMR:  Well, you make a really interesting point with the McCallum study, I’m actually going to have to circle back to that and see what cut off he used. I want to say it was 10 to the four-

DrAS: It actually might’ve been 10 to the fourth, now that I’m thinking about it, Michael. I think it was, and we were all questioning him over like, “Why didn’t you just use the 10 to the three?” But actually it’s because it’s the same thing. Is because he’s doing research and he wants to know… This is what he said anyway in the conference. He wants no controversy. He wants his research to be irrefutable.

DrMR:  Sure. I mean you can make a case for that, because if he’s trying to make a irrefutable case, then taking the most conservative stance allows them to do that. And that ultimately is good on the one hand because it’s harder to counter argue. But then, yeah, it’s a balance. It’s hard to always determine where you want to strike that balance.

DrAS:  Yeah. And actually I want to say when he was talking at the conference, this was a year and a half ago in New Orleans, SIBOcon, he was actually saying what he is really interested in studying is the jejunum. So he’s not checking the ileum. He’s not trying to represent that which I care very, very much about. So that’s the lowest portion of the small intestine because that is where SIBO is the most common and in my patient base, that’s what I see on testing and it makes sense because you know there’s a large amount of bacteria there in the large intestine. If there are motility issues, it can start to back up.

So that’s the lowest portion of the small intestine because that is where SIBO is the most common and in my patient base, that’s what I see on testing and it makes sense because you know there’s a large amount of bacteria there in the large intestine. If there are motility issues, it can start to back up.

DrMR:  Just to clarify for the audience you had the stomach, then the duodenum, then the jejunum, then the ileum and the ileum is kind of the end of the line and that’s where some of these proximal end of the small intestines, SIBO cases may occur and I’m believing that the reason why McCallum maybe focusing on the middle section of the small intestine, the jejunum is he was finding oral bacteria settling into the small intestine and causing SIBO or dysbiosis, however you want to term it.

DrAS:  That’s absolutely right. Yeah, I think that’s fascinating research. I actually recommended him for that conference, by the way, because of his papers on oral bacterial overgrowth in the small intestine.

DrMR:  Yeah, and this may tell us why we see such a high association between SIBO and hypothyroid. If we understand that about 20 to 30% of Hashimoto’s patients, which is the autoimmune attack that causes hypothyroid, the most common cause of hypothyroidism in the West, 20 to 30% of those Hashimoto’s patients will have autoimmunity to their antiparietal cells and diminished hydrochloric acid secretion because of that. The hypothyroid causing low stomach acid and the association between hypothyroid and SIBO is interesting. And this might be part of what McCallum is perhaps even unbeknownst to him uncovering with the oral bacteria, taking residence in the small intestine and causing this either seaboard or dysbiosis.

SIBO-Thyroid Connection

DrAS:  This is such a good point and that might be possibly the third most common reason for SIBO or maybe at least in the top 10 is hypothyroid. And we know how common hypothyroid is.

DrMR:  It’s also important to point out, in that study of of 1,809 patients where they found the factor most closely associated with SIBO, was hypothyroid even more associated than PPI therapy, or surgery to the stomach or the intestine. That association held true if someone was hypothyroid without medication or was hypothyroid and was medicated and thus had normal hormone levels. So I don’t think we can say, well, if you’re hypothyroid you have slow motility because this held even for patients who were treated with thyroid hormone and had normal levels of blood thyroid hormone. So it’s likely at least based upon this initial data that there is some non-motility mechanism at play.

DrAS:  That is so interesting. We had a fascinating lecture from my friend Dr. Gary Weiner on thyroid, hypo, hyper and SIBO. He’s was a specialist in both, thyroid and SIBO. And he reported that he would sometimes see cases of SIBO normalized when thyroid was treated and then he would sometimes see that it didn’t. SIBO, that’s sort of sort of goes with what you’re saying. I would imagine there’s cases where it was… Well,it really wasn’t about the motility and then there are cases where it was and when it got it normalized and he said you just, you weren’t sure it could be either way. You don’t know, but you have to normalize thyroid anyway, and then you see what happens for the SIBO.

It was a very fascinating report that he had. He’s seen a lot of cases. The other thing that was really fascinating about his lecture was that he was making a case that it’s bidirectional because I have really never known which is which.

And I think what most of the papers have indicated is that the hypothyroid comes first and then you get SIBO. But he was also showing that it could be you have SIBO and that causes hypothyroid.

DrMR:  Yeah. I’m seeing probably the opposite of that. I should clarify that, I’m chiefly someone who focuses on the gut. I’m also very interested in the gut thyroid connection. So I do see these cases that are kind of on the fence of gut and thyroid, but because of that, it’s fairly likely that I’m seeing a certain population of cases that are being treated for thyroid and are still non-responsive. But that being said, I think we really need to not look to thyroid medication to remedy gastrointestinal symptoms. And the reason I say that is I’ve seen a number, and for those who are following the podcast, you know how we have just been inundating you with these case studies, either mine or Dr. Robert Abbott or Dr. Joe Mathers that have all shown these patients who just go on thyroid medication to thyroid medication to thyroid specialist to thyroid specialist and they’re never able to achieve symptomatic resolution or normalization of their thyroid hormone levels.

Then they can see both of those remedied when they address their gut health. So if someone is truly hypothyroid and you put them on medication, I would not be looking to that to resolve their gut issues, especially when we know in models of dairy-free and lactose intolerance, Gluten-free and atypical celiac, and then treating H. pylori and those with H. pylori, that those patients can see a normalization and sometimes a reduction of the dose of medication that they need. There’s pretty compelling evidence showing us that in those with gastrointestinal maladies, we’ve got to get those addressed in order to have consistent absorption of the thyroid medication. And so even if you wanted to make the argument that improving thyroid hormone levels will improve the gut, if the gut is a rate-limiting factor because levothyroxine is exclusively absorbed in the small intestine, then how can we fully remedy a thyroid hormone case if we’re not also taking steps to improve their small intestinal health, which is the window through which they absorb the thyroid hormone.

DrAS:  I have nothing to say on it because I’m not a specialist. I leave that to you.

DrMR:  Okay. So yeah, and I am open to the bi-directional relationship. It’s just we’ve seen so many cases where the thyroid is emphasized at the exclusion of the gut. Unfortunately, that hasn’t led to great outcomes, but certainly, I think we’ve got a lot more there to learn. But I think great news for those of us who are operating in the gut because it shows us that we can help these thyroid cases who I think are another underserved population who are out there in internet reading, getting scared and need help. So even for those doctors listening to this who might be specializing more so in the thyroid, I would consider a good SIBO training course because that can really help some of these non-responsive thyroid patients.

DrAS:  Oh my gosh, it’s so true. Thank you for that segue back to the course, because from my perspective, anybody who’s seen chronic illness is going to see lots and lots of SIBO and therefore you need to know how to deal with the SIBO. And really that would be my biggest takeaway.

More About the SIBO Pro Course

DrMR:  Yeah. No, I think that’s a fantastic takeaway. Will you tell people a little bit more about the course? Obviously you’ve told them a bunch about the nuts and bolts, but where do they go, how do they sign up, any other kind of logistical comments that you want to make?

DrAS:  I believe you will post a link down below that directs them over to where they need to go. The website is siboprocourse.siboinfo.com but you’ll have the link there and that’s where you’ll get the information. The basic structure is that it’s offered in two formats. One is self study and that’s just as the name sounds, you get access to the materials, you work through it on your own. And the other one is called interactive but you can also work through it on your own. But I have a suggested schedule there. An eight-week schedule that I’ve devised. And also the biggest thing is it has office hours with me so we can go over patient cases and also any questions that arise. And I do those office hours through 2020. So you have ongoing help, as you’re implementing the material and in case you weren’t exactly following the schedule.

And then that one also has study guides and weekly quizzes that are optional but just to enhance learning, the study guides are sort of show you the main take-home points and you can answer them as you watch the lessons. And one other sort of nuts and bolts thing here is that the… It’s video lessons that show me lecturing with PowerPoint alongside of it and the lectures are short. We did that intentionally so that people wouldn’t need a huge chunk of time to sit down and watch it. They’re usually about 10, 15 minutes long lessons. So you can watch them on your lunch hour here or there or here there fitted in and the course platform allows you to check off the classes as you move through so you know where to pick back up.

That’s really important to me because obviously, practitioners have very busy schedules. Then there’s a lot of materials that come with it, like the desk reference booklet, handouts, algorithms, and all sorts of other handouts. I’ve got handouts for brands. I did get it approved for CME for 20 hours, but I know not everybody can use that. But for those who can, that’s there. And because of that, I’m not able to mention brands in the lecture. So I’ve got handouts of various brands that I’ve used with success, that sort of thing. That’s the basics.

Episode Wrap-Up

DrMR:  Awesome. Well Allison, I think it’s a great offering that you’re giving people, like we’ve been harping on. SIBO education is not where it could be and where it should be. You have my full endorsement, as the audience knows because this is your fourth or fifth time on the podcast. I really respect your work and again, just want to let our audience know that if you’re looking for a good SIBO training course, I would definitely check this out because as you know, there are very few people that I’m really confident that they’re going to be practical, they’re going to be evidence-based, they’re going to be cost-effective, they’re going to have an algorithm and not getting distracted by the shiny butterfly of the new and novel and speculative.

And so for all those reasons, Allison, you have my full support and I look forward to perusing the course. I have a login and I need to kind of go through it myself because I’m sure there is a lot in there for me to pick up. And I want to thank you again just for taking the time to speak with us and for putting together this course, which I’m sure was not easy, but I think it’s going to help a ton of people. So just thank you so much.

DrAS:  Thank you so much Michael. I really appreciate it.

What do you think? I would like to hear your thoughts or experience with this.

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