SIBO True Health Medical Center

Naperville, IL

Disclaimer

•  Information is for educational purposes only

•  The alternative view presented has not been established as standard care or practice

•  Clinical trials have not yet been conducted

•  Not to be taken as specific medical advice

•  All medical decisions regarding your childʼs health issues should be discussed with your health care provider

SIBO- What is it?

u  SIBO: Small Intestinal Bacterial Overgrowth

u “Abnormally large numbers of bacteria present in the small intestine, leading to impairment of digestion and absorption”.

u  Dr. Mark Pimentel of Cedars-Sinai: A New IBS Solution

u  Should be called “Small Gut Dyskinesia Syndrome”

IBS can be SIBO

u  60% of IBS (Irritable Bowel Syndrome) can be due to SIBO

u  15% of the population have IBS

u  Over 27 million people have SIBO

u  The patients diagnosed may not be treated properly in a step-by-step fashion

Bacteria found in SIBO patients:

u  Hydrogen Bacteria: E. Coli, Klebsiella, Proteus, Aeromonas

u  Produces Hydrogen gas; Diarrhea

u  Methane Archaea: Methaneobrevibacteria smithii

u  Converts Hydrogen to Methane; Constipation-stops segmental contractions of gutà slows gut movements by 60%. More methaneà worse constipation with hard, dry stools; Uses 4 Hydrogen to feed methane organism

u  Hydrogen Sulfide: Proetobacteria-Desulfovibrio piger/ species

u  Uses 5 H to produce H2S

u  Tends to diarrhea

u  May be associated w/ UC/ ASD children

u  Egg/ Sulphur smelling breath or flatus

SIBO Causes

u  Most common way is a prior Food Poisoning incident.

u  More likely to develop IBS following food poisoning if susceptible.

u  The bacterial infection can cause antibodies that attack the intestinal lining u  Bacteria produce Cytolethal Distending Toxin (CDT)b

u  Body produces antibodies against CDT

u  CDT Abs auto-immune attack against Vinculin in ICC cells:  “cytoskeletal protein”

u  Damage/Reduction to/of Interstitial Cells of Cajal (ICC): interrupts  normal neural control of GI contractions

u  Muscle + Nerve damage= u  Lack of MMC (Migrating Motor Complex)

u  SIBO

u  Lack of Disaccharidase absorption

u  (Disaccharides: sucrose, lactose, maltose)

SIBO: Causes

u  SIBO gasses consume vitamin B12, iron, magnesium & other nutrients

u  Destroys flavonoids; hydrogenates polyunsaturated oils, promotes systemic inflammation, produces nitrosamines.

u  Malabsorption, Inflammation, Leaky gut(50%), Gas production

u  This will cause a disruption in the neuronal control of Gastrointestinal contractions which will slow down the intestines.

u  This will allow bacterial to accumulate and even cause yeast overgrowth.

u  Biofilms may develop around organisms

Pathophysiology of SIBO

u  Cause: Slowing of Migrating Motor Complex (MMC)

u  MMC empties stomach and movement through gut

u  Interstitial Cells of Cajal

u  Vinculin

u  Colonic Peristalsis

Migrating Motor Complex

u  Begins in stomach

u  Proximal stomach to pylorus 

u  Pacemaker nerve cells regulate contractile activity of peristaltic  waves:

u  Proximal, middle to terminal antrum

u  Opening of pylorus valve

u  Inhibition of duodenal contractions àchyme emptied into duodenum

u  Acetylcholine opens calcium channels to initiate smooth muscle cells  (Acetyl-l-carnitine is precursor)

Migrating Motor Complex

u  Small Intestine

u  Duodenal peristaltic waves occur more frequently than stomach waves: 

u  3-4 waves for one stomach wave. 

u  Pacemaker cells initiate slow intestinal waves: longer waves going faster proximal intestine and shorter waves going slower at the distal gut. 

Eating and MMC

u  Begins 90 minutes after eating

u  Turned OFF during eating: DO NOT GRAZE

u  Kicks in ~ two hours after eating

u  Eat three meals at least 4-5 hours apart

u  Do a long fast from dinner to breakfast Cleansing Wave: Waves from stomach through small intestine

u  During night: 3-4 waves so have clean SI when waking

u  MMC 68% SLOWER in SIBO patients

u  http://www.ncbi.nlm.nih.gov/pubmed/22450306

MMC: http://www.nature.com/nrgastro/journal/v9/n5/fig_tab/nrgastro.2012.57_F2.html

Microbiota and MMC

u  Bacteria can affect MMC

u  Release of bacterial substances/end-products of fermentation

u  Intestinal neuroendocrine factors

u  Indirectly through effects of  mediators released by gut immune response

u  Bacterial components

u  Promote Motility: SCFA and deconjugated bile salts

u  Interfere with Motility: Nitric oxide production, toxic gasses

u  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093005/

Interstitial Cells of Cajal

u  Intestinal intrinsic cell-pacemaker

u  Found in esophagus, stomach, Small intestine, Large intestine, pancreas, upper urinary tract, urethra, myometrium, myocardium, uterus,  Fallopian tube, human placenta

u  stimulates slow wave causing contraction of smooth muscle in gut. 

u  Forms networks in submucosa, intra-mucosa and inter-muscular layers of gut

u  Drives spontaneous rhythmic motility- they are electrically coupled to smooth muscle

u  ICC Pacemaker

u  3 per minute in stomach

u  12 per minute in duodenum

u  10 per minute in ileum

u  3 per minute in colon

ICC

u  http://www.saudijgastro.com/text.asp?2013/19/1/3/105909

Vinculin

u  Cytoskeletal protein-Protein on ICC: found at junctions between cells and extracellular matrix

u  Helps anchor protein called “F-actin”, which helps muscles contract

u  Helps control cell’s motility

u  Helps fight off pathogenic bacteria  

u  Loss of vinculin: 

u  Prevents cell adhesion and spreading

u  Reduced stress fiber formation 

u  Fewer focal adhesions 

u  Slows gut movement 

u  Muscles cannot contract. 

Vinculin http://www.thno.org/v01/p0154/thnov01p0154g03.jpg

SIBO damage to microvilli

u  http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/dig estive-health/nutrition-support-team/nutrition-articles/DiBaiseArticle.pdf

u  Epithelial lining inflammation u  Anaerobes: endotoxin formation, direct adherence cause injury

u  Aerobes: enzymes and metabolic products cause injury

u  Blunting of villi

u  Increase in inflammatory cytokines/mediators

u  Reduced intestinal absorptive area

u  Decreases in enterocyte disaccharidase and brush-border hydrolase activity.

u  Development of intestinal permeability

u  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852716/

u  Next Slides: u  http://thumbs.dreamstime.com/z/microvilli-dettaglio-dell-intestino-tenue-

vettore-35610224.jpg

u  http://photos1.blogger.com/blogger/2881/3907/1600/normalsmallintest.jpg

Microvilli of Intestines

Blunting of Villi http://photos1.blogger.com/blogger2/3301/4292/1600/Villous%20blunting%20and%20crypt%20hyperplasia.0.jpg http://www.thefooddoc.com/yahoo_site_admin1/assets/images/celiacendophotoatrophy.39181311_large.jpg

Inhibitors of MMC

u  Gastrin/CCK—eating

u  Psychological stress

u  Atropine, Epinephrine

u  Gastroparesis

u  Hydrochloric Acid and Achlorhydria

u  Nitric Oxide

u  Morphine/Opiates

u  A mixed meal

u  Pathogenic bacterial toxins

SIBO: how do you know if you have it?

u  More than 60% of people with IBS (Irritable Bowel Syndrome) have SIBO.

u  Patient reports Gastrointestinal symptoms are temporarily alleviated after taking Antibiotics

u  Probiotics & fiber make Gastrointestinal symptoms are worse

u  Celiac patient that is not better on GF diet

u  Candida symptoms- not better after treatment

u  PPI can cause IBS- more eructation symptoms

u  Chronic constipation after opiates

u  Low Ferritin/ Iron without any other known cause (suspect H. pylori)

Symptoms of SIBO

u  Bloating, abdominal gas, eructations, flatulence

u  Upper gut gas worse after eating

u  Start day out with flat abdomen and progressively distends out, looks “pregnant” by end of day

u  Gas that can’t be passed

u  Diarrhea (Hydrogen) or constipation (Methane) or alternating

Testing for SIBO

u  Comprehensive Stool Analysis- GI Effects Genova Diagnostics

u  Identifies any overgrowth of bacteria, yeast

u  Identifies any malabsorption, low bile acids, low pancreatic enzymes

u  Identifies quantities of good bacteria and diversity of bacteria

u  SIBO breath test- Aero Diagnostics

u  Identifies which kind of bacteria is present

u  Hydrogen

u  Methane

Treatment Options

u  Prescription Antibiotics

u  Anti-candida if needed

u  Antimicrobial Herbs

u  Diet

u  Prokinetics

Rifaximin (Xifaximin)

u  Used to treat both Hydrogen and Methane + SIBO

u  May need to be combined with other prescriptives

u  Does not affect Colonic microbiome too much

u  Not water soluble

u  Can increase Bifido bacteria and enhances Short Chain Fatty Acids

u  Can be safely used for Pediatrics

u  Typically prescribed for 14 days, then SIBO breath test retested 5-10 days later

u  If bacteria not clear, will have to repeat another course before moving onto the next phase.

Botanicals: Antimicrobial herbs

u  Berberine Complex by Integrative Therapeutics

u  Neem Plus by Ayush herbs

u  Allimed drops

u  Typical course is 30 days, retest SIBO breath test 5-10 days later.

Diet to heal the gut

Specific Carbohydrate Diet

u  grain-free, starchy veggie free, lower fiber

u  Clover honey (monosaccharide okay, allows high fermentable veggies/ fruit

u  Main Avoidances:

u  Disaccharides, Oligosaccharides: FOS (fructo), GOS (Galacto), MOS (mannan), Polysaccharides: Starch/fiber—soluble and insoluble, Polyols—Sugar alcohols

u  Allison Siebecker on SIBOINFO.com

SCD: 5 Phases to heal the gut Intro diet 2-3 days: no raw fruits or veggies, no nuts/seeds/ beans; Add in Bone Broth; Typical veggie: Carrots (peeled and cooked); Fruits: grape juice, apple cider; Sweeteners: honey, pure stevia, glucose/dextrose;

u  Phase 1 x 1 week: Protein powders: Pea, rice, whey, egg; Veggies: carrot, acorn squash, buttercup squash, butternut squash, Spinach, zucchini; Fruits: grape & apple cider, pear sauce, apple sauce; Homemade milks only!

u  Phase 2 for 2-4 weeks w/o arising any sxs w/ good bowel habits: add in nuts; veggies: garlic, asparagus, green beans, mushrooms, pumpkins, artichoke, cucumber; Fruits: peach, pineapple, plum, tomato, apricot

u  Phase 3-for 2-4 weeks: adding in more veggies; Can add in Quinoa & Flax

u  Phase 4 for 1-3 weeks- for a few weeks: adding in more foods

u  Phase 5 for 1-3 weeks- education on good fats, websites on how to go forward w/ diet; Pecan bread; cookbooks

u  Then live off legal/ illegal food lists.

u  Symptoms might return if go off the SCD diet if there are issues w/ MMC-will have to stay on Prokinetics.

u  Gut can heal within 1 month. If Villi damage, may take 3-6 months to heal.

Prokinetics

u  Low Dose Naltrexone

u  endorphin receptor blocker

u  Modulates the immune system

u  Iberogast

u  5 HT4 agonist & 5 HT3 antagonist

u  Iberis amara, Angelica, Chamomile, Caraway Fruit, St. Mary’s Thistle, Balm Leaves, Peppermint Leaves, Celandine, and Liquorice Root.

u  Iberis amara: It increases the tone of smooth gastro-intestinal muscles and accelerates gastro-intestinal peristalsis.

u  Can be used in combinations

u  5-HTP

u  Stimulates Colonic migrating motor complex

Other supplements u  Probiotics- repopulate microbiome

u  Acetyl-L-Carnitine- heal nerves

u  Hericium Erinaceus (Lion’s Mane)-Mushroom- heal nerves

u  Alpha Lipoic Acid- heal nerves

u  Digestive and pancreatic enzymes-improve absorption

u  L-Glutamine-heal gut lining

u  Biofilm Defense

u  Lactoferrin- prevents formation

u  Disodium EDTA- disrupts biofilm

u  Curcumin

How can we prevent SIBO?

u  Ensure proper Gastric Acidity and Digestive enzymes

u  Ensure proper function of liver for Bile acids which help to digest fats

u  Maintain Healthy microbiota with probiotics, fiber

u  Healthy intestinal lining

u  Keep a healthy immune system

u  Maintain healthy Small intestine motility