Key Takeaways- NCNM SIBO Symposium 2015

What a wonderful, informative, thought-provoking weekend!  I spent this past weekend at the 2nd Annual NCNM SIBO Symposium learning a myriad of information about digestive conditions- specifically IBS & SIBO.  While listening to the presentations, I kept a keen ear out for information that relates to individuals with chronic relapse, to those with sulfur/thiol intolerance, and additional testing to help reveal underlying causes for SIBO patients.

I have scoured through my notes to present to you some of my key takeaways from the presentations:

1) Stress is NOT the trigger/cause of SIBO, but it often plays a role in the manifestation of the condition.
Dr. Pimentel shared that a study has been conducted on soldiers sent overseas to regions such as Afghanistan & Iraq. The study showed that stressful circumstances such as shooting a gun or experiencing a major injury did not correlate with the subsequent development of IBS.  However, patients often indicate that stress exacerbates their IBS/SIBO symptoms and practitioners find that patients who are able to integrate strategies such as yoga, meditation, massage, etc. into their healing journey experience greater improvement than those who do not.  Therefore, it seems that stress does not trigger IBS/SIBO in the first place, but it may worsen symptoms.

2) Finding the right prokinetic often requires experimentation, but here are some tips to lead you in the right direction:

Pharmaceuticals: often required due to greater efficacy than natural options

  • Resolor (prucalopride)– highly effective for individuals with constipation, but contraindicated for those with diarrhea due to invoking slight motility of the large intestine rather than just the migrating motor complex (MMC)
  • Low Dose Erythromycin– frequently used for both IBS-C and IBS-D due to affordability and availability.  Currently, there are no studies on potential impacts on the large intestine commensal flora.
  • Low Dose Naltrexone– potentially beneficial for those with autoimmune conditions, however, many of the physicians did not find it to be a strong enough prokinetic unless combined with other options

Herbals: sometimes used in conjunction with pharmaceuticals

  • Ginger– a remedy traditionally recommended for nausea, ginger is effective at stimulating gastric motility i.e stomach emptying (Ming-Luen, Hu et al 2011) so it may be helpful for individuals with gastroparesis.
  • Iberogast– a combination of herbs that appears to be highly effective for nausea.  This formula has been used for decades in Europe as a remedy for a myriad of digestive complaints ranging from nausea to acid reflux, bloating, constipation, diarrhea, and more.  It was indicated as a safe option during pregnancy.
  • D-limonene– one of the presenters shared this as a prokinetic option, but it did not seem to be widely used among practitioners.  It has been used clinically to dissolve gallstones, provide relief from GERD, and induce phase 1 and 2 liver enzymes which could help protect against cancer (Sun, J. 2007).

3) Biofilm disruptor may be unnecessary in SIBO treatment
Many SIBO experts have not seen an increased benefit when adding a biofilm disrupting agent to their SIBO treatment protocols.  It was expressed, however, that biofilm disruptors may be more beneficial in the treatment of SIFO (small intestine fungal overgrowth) such as with candida albicans.  It was discussed that stool testing may not be reliable for ruling out candida.  One suggestion was that if a stool test is negative for candida, but an antibody test is positive, it could indicate the presence of SIFO specifically in the small intestine.

4) Hormone imbalances and birth control pills may be at play in some SIBO cases
I find it very fascinating that the number of women afflicted with IBS/SIBO far outnumbers the number of men with this condition.  I have suspected that oral contraceptive pills may have played a role in the development/worsening of my GI symptoms.  My friend, Emily, who shares similar skepticism about the connection was brave enough to submit a question to the panel of SIBO experts regarding this issue.  The experts shared that they clinically see hormonal issues and SIBO go hand and hand and that it is certainly possible that oral contraceptive pills could be a factor in SIBO.  I was curious about this issue and stumbled upon a couple of fascinating studies on this issue.  An article titled “Sex Hormones in the Modulation of Irritable Bowel Syndrome” indicates:

“Sex hormones may influence peripheral and central regulatory mechanisms of the brain-gut axis involved in the pathophysiology of IBS contributing to the alterations in visceral sensitivity, motility, intestinal barrier function, and immune activation of intestinal mucosa” (Agata, Mulak et al 2014)


5) Heavy metals as a potential underlying cause of SIBO

I have suspected for a while now that heavy metals (specifically, mercury- due to my high thiol sensitivity & high levels of mercury on my hair test) could be one of my underlying causes, but I never had a scientific explanation until now.  Heavy metal toxicity causes oxidative stress (which my Organix test showed that I have) which can lead to delayed gastrointestinal motility- i.e. constipation (Rana S.V. et al 2014).  One of the biggest controversies with heavy metal testing is how to test the body burden accurately.  At the SIBO symposium, I was able to speak with a Cyrex representative about the Array 11.  It appears that it tests for immune reactions to mercury toxicity (among other toxins) rather than just the presence of the toxin.

6) The infamous hydrogen sulfide- more to come later this year!
Dr. Pimentel shared a very exciting notice regarding the third type of gas produced in SIBO- hydrogen sulfide.  He promised that there would be more information on sulfate-reducing bacteria sometime this year- perhaps it could be testing?!?  As some of my followers may be aware, the connection between sulfur intolerance and SIBO is one of the areas that I focus much of the content of my blog.  Plan to hear more in the future!

Don’t forget to subscribe to my blog for future updates!

Thanks for reading! =)

Article titles & links to the sources listed above:
Effect of ginger on gastric motility and symptoms of functional dyspepsia
D-Limonene: safety and clinical applications
Relationship of cytokines, oxidative stress, and GI motility with bacterial overgrowth in ulcerative colitis patients
Sex differences in irritable bowel syndrome: do gonadal hormones play a role?

Thai Lettuce Wraps

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Caution: raw vegetables can be problematic for individuals with poor digestion.  This recipe is intended for individuals who have reintroduced raw veggies or are using this recipe as a way to see if they are ready.  Dr. Siebecker recommends remaining on the SIBO diet for 1-3 months before introducing raw veggies (see SIBO Food Guide).

I have always been a big fan of Thai food, especially salad rolls with a delicious peanut sauce.  Unfortunately, there are all sorts of ingredients in those that I can no longer eat (rice, garlic, peanuts, sugar, soy, who knows what else!).  Here is my take on SIBO-friendly salad rolls, also known as Thai Lettuce Wraps.

This recipe is perfect for the end of the week for several reasons: butter lettuce lasts a while if you leave it attached to the stem, the sauce is super quick and easy to make, and the filling ingredients are flexible which allows you to use up any veggies left in the fridge.

Enjoy!

Ingredients:

Butter lettuce leaves (approximately 3 large leaves)- the loose bunches are easier to pull apart without breaking the leaves

1/5 or 1/4 lb chicken or turkey breast (cooked to your liking)- I like to bake mine at 350 degrees for about 20-30 minutes

Sauce (all you have to do is add the ingredients to a bowl and stir):

1/4 c finely chopped fresh Italian parsley (approximately 1/2 c loosely packed before cutting)

1/2 teaspoon finely grated ginger

2 T salted almond butter (or unsalted and add some sea salt)

1.5 teaspoons coconut vinegar (substituting apple cider vinegar should be fine)

1.5 teaspoons walnut oil

1.5 teaspoons coconut aminos (this is a soy sauce alternative that can be found at natural grocery stores)

Optional Filling Ingredients: thinly sliced cucumber, beets (boiled then thinly sliced), shredded carrots (these might be too hard to digest), sliced tomato (nightshade- might cause inflammation).

The Delicate Carbohydrate Balance with SIBO

Carbohydrates are the most frustrating and confusing part of the SIBO healing process.  Bacteria in the small intestine LOVE carbohydrates and they express their love by leaving you bloated, gassy, experiencing abdominal pain, and with all the other lovely gastrointestinal symptoms.  Here is the confusing part: bacteria do not love all carbohydrates equally.  See Low FODMAP.  For example, I could eat 20 grams of carbs worth of carrots (about two large carrots) and feel just fine (as long as they were cooked).  If I exchanged those 20 grams of carbohydrates for some bread, or even some onion or fruit, we would have a very different picture on our hands.

If you analyze Dr. Siebecker’s SIBO Food Guide, you may notice that the high carbohydrate vegetables are the ones that tend to be prohibited.  Unfortunately, I was not able to touch many of the items in the SCD legal/Low FODMAP category without symptoms. The foods that I ended up being able to eat were all very low carbohydrate.  For about five months (May-September) I was using my digestive symptoms to determine whether I was eating too many carbohydrates.  The problem with this method was that I reacted to almost every carbohydrate, reducing my carbohydrate intake to only about 20 grams per day on average.  This was much lower than the recommendation I had received from my SIBO specialist of 60-100 grams daily, but I hadn’t realized it because I did not sit down and count out my carbs.  I really wanted to re-introduce more carbohydrates, but every time I did, my skin became itchy (which I had been told was a manifestation of leaky gut) or I would hear fluidy noises and feel tenderness in my intestines during my nightly abdominal self-massage.

My fatigue over my five month extreme low-carb expedition became worse and worse.  My T3 stopped converting to T4 effectively (resulting in free T3 levels as low as 1.8 L in July), but my TSH was also low (.58 in July).  I had signs of both hypothyroidism and hyperthyroidism at the same time.  My own research, consultations with my doctors, unsuccessful experimentation with T3 supplementation, and successful experimentation with carbohydrate reintroduction led me to realize that I was suffering from Euthyroid sick syndrome.  I was starving my body of carbohydrates, so it was reacting by making me so fatigued that I wouldn’t expend much energy.  It is pretty much the equivalent of turning your phone on “battery saving mode” (and keeping it there for 5 months) when you need to make it last a few extra hours.

One day, incredibly frustrated by my fatigue and tempted by the guest chef cooking delicious gluten free quinoa salad and almond torte in front of me, I caved.  I ate small portions of both of these items and have not turned back since (well, at least not in my quest for carbohydrate challenging).  After indulging, I was sure that I would pay the price the next day with symptom flare ups.  I waited and waited, but nothing dramatically out of the ordinary occurred.  My intestines were a little fluidy and tender, but for the first time, I had no itching from the grains.  I thought it was a fluke, so a couple days later I purchased a New Cascadia Gluten Free Baguette and ate a couple of slices each day.  Sure enough, my itching was gone.  My digestive system gave me a little bit of trouble, but it wasn’t unbearable.  My brain started functioning somewhat normally again- I could concentrate on my homework, comprehend things, and remember things better.  I had more energy (although not completely back to normal).

I am trying to think of what could have led to my miraculous tolerance of selected grains and more carbs (I am now averaging about 60 grams per day).  Did my immune system suddenly kick in because of a nutrient IV I received two days before?  I had done these four times before without this effect.  Or could it be the four days of sulfur-food avoidance and two days of chelated molybdenum that cleared some of my methylation pathways?  Read more about that here.  Perhaps it was the combination of the two?

Whatever the reason, I am thrilled by my renewed ability to function and I am hopeful that I am moving in a positive direction.

Another step forward occurred with an ileocecal valve manipulation from my SIBO specialist on Thursday (two days ago).  She said that my ileocecal value appeared to be stuck open.  She worked on some very tender points and moved some things around.  Last night, during my intestinal self-massage, I experienced NO tenderness and hardly any fluidy noises.  This is quite a miracle considering all the things I ate yesterday that I am “not supposed to”: 10 hazelnuts, 1/2 bunch baby turnip greens, 1/2 small sweet potato, 2 baby turnips, 1/2 very small bell pepper, 1 teaspoon cocoa powder, 1/2 teaspoon honey, 1/2 cup cooked white jasmine rice.

I am very thankful to be surrounded by such talented and caring doctors, to have parents that will do anything to help me heal, for a boyfriend who maintains a positive outlook when I feel hopeless in my health struggle, and for the supportive instagram community of individuals enduring similar health challenges.

Symptom Timeline

I have compiled a timeline of events and symptoms that I believe are related to my SIBO.  My hope is that by sharing my experiences, people will be able to find similarities to their stories and add to the wealth of knowledge about a condition that is really just beginning to be understood.  Also, I hope that people who think they may have a more mild case of SIBO are able to find help earlier in their journey than I did so that they do not have to go through the many food intolerances and health challenges that I am now facing.

2009: Emergency Room Visit for Toxic Shock Syndrome.  I was given Vancomycin (an antibiotic) to which I had an adverse reaction, causing my entire body to become extremely itchy and red.  Medical students were coming in to look at me and I was told I had “Red Man’s Syndrome” (a histamine reaction to the antibiotic).  I developed seasonal allergies (a histamine reaction) in 2009 after this incident.

2011 (September): Began taking contraceptive pills

2012 (March): First visit to a gastroenterologist due to digestive issues- primarily gas and constipation.  Eliminated dairy with some relief.  Celiac test came back negative.

2012 (December): Horrible acute abdominal pain that kept me up all night and lasted about 24 hours.  I went to the pediatrician’s office and she sent me to the emergency room for suspected appendicitis.  Pain went away on its own.  CT scan revealed no problem with appendix and doctors ultimately had no answer for me.  They instructed me to follow a low-residue diet for a couple of weeks.

2013 (March): Second visit to the gastroenterologist for gas and alternating diarrhea and constipation.  She tried to prescribe me a colon relaxer.  I never took the drug and instead turned to the naturopathic route.

*Saw some relief based on naturopathic recommendations, including acne clearing up somewhat.  Treatment protocol included acupuncture, fish oil supplement, probiotic, digestive enzyme, no gluten, no dairy, no soy, and no legumes.*

2013 (August): Stopped taking contraceptive pills due to suspicion that they were contributing to my digestive issues.  Also, I did IGG/IGA allergy testing which indicated that I had several food allergies including eggs yolks and whites (which I was eating a fair amount of at the time).

2014 (February): Tested positive for SIBO via a lactulose breath test from Commonwealth Labs that revealed hydrogen gas of 72 ppm & no methane (however, SIBO specialist suspected methane due to my symptoms and believes the test was not sensitive enough to pick it up).  Somewhere around this time, my acupuncturist noted that my ileocecal valve was malfunctioning (discovered during abdominal massage based on the sound that my ileocecal valve was making when pressed on).

2014 (Late March/Early April): First round of Rifaxamin (two week course).  No prokinetic taken afterward.  Began SCD diet immediately after finishing antibiotics.  Also, took probiotics twice daily.  SIBO symptoms returned within two weeks.

2014 (May): Comprehensive stool testing from Parasitology Center Inc. revealed no existence of yeast or parasites (or any other abnormalities other than bacteria).

2014 (May 12th): Began elimination diet (low FODMAP, SCD, AIP) which was very low-carbohydrate.  By week three of following this protocol (combined with recommendations from SIBO specialist in early June), I was having daily bowel movements that were like type 3 on the bristol stool chart rather than type 1 or nonexistent (when my symptoms were really bad, I was only have one bowel movement every 4 days).  I also began to experience amenorrhea around this time.

2014 (May 19th): Onset of brain fog/fatigue symptoms (word-finding difficulty, trouble concentrating & reading, clumsy & unbalanced walking, slow brain function, feeling “out of it”, running into and dropping things, losing track in the middle of doing or saying things, tired, lethargic).  Very severe for a few days until I received a nutrient IV.  However, symptoms returned within a week and subsequent IVs did not provide the same relief.  Fatigue & brain fog have continued to worsen ever since this onset of symptoms.

2014 (May 23rd): Blood work (comprehensive metabolic panel, T3, T4, & CBC) revealed the following were out of range: BUN (too high), BUN/Creatinine ratio (too high), albumin (too high), and free T3 (too low).

2014 (Early June): Appointment at the NCNM SIBO Center for Digestive Health.  SIBO specialist had me start taking cod liver oil, STOP TAKING PROBIOTICS (shocker, I know!), and increased my dose of neem herbal antibiotic to 6 capsules daily.  Also recommended that I remove pork and coconut products from my diet (I have since reintroduced coconut oil without symptoms).  After this appointment, my bowel movements became better and my itching mostly disappeared.

2014 (July 25th): Follow-up blood work showed that all levels returned to within the normal range, except for my free T3 which dropped even lower (in correlation with my fatigue) to 1.8L.  My glucose level also dropped from 76  to 71 mg/dL (still within normal range, but on the lower end).

2014 (July 17th-August 2nd): Second round of Rifaxamin.  Although I had more itching while taking the Rifaxamin, there were some days where I had two bowel movements (that is a good thing).  After completing this round of antibiotic, I began taking neem herbal antibiotic (4-6 per day) again.  I trialed spaghetti squash, blueberries, and homemade almond milk (all of which produced a histamine reaction).  However, I continued to have daily bowel movements and hardly any itching.

2014 (August 11th): Began taking Resolor prokinetic (not covered by insurance because it had to be shipped from the UK- cost is about $3 per day on my current dose).  While taking neem & resolor, my bowel movements actually felt like they had complete emptying (first time this has happened in years).

2014 (August 23rd): Ran out of neem herbal antibiotic.  Still having daily bowel movements and minimal itching, but bowel movements no longer feel like complete evacuations.

Next steps: My insurance company denied my request for another round of Rifaxamin (this time was going to be with Neomycin to address suspected existence of methane-producing bacteria).  Instead, I will be taking herbal antibiotics (allimed & neem) for 2-4 weeks while continuing the prokinetic (Resolor).  One new symptom that I am curious about is that my intestines have been making more growling/gurgling noises than ever before.  I am curious whether this is a good or bad thing (or neutral).  Let’s hope that I can figure out what is at the root of my fatigue and also clear up my SIBO enough that I can reintroduce foods without having a histamine or digestive reaction.