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IBS & SIBO SOS™ Summit IBS and SIBO Foundations & Fundamentals

Shivan Sarna: Hi everybody. Welcome! This is the IBS & SIBO SOS™ Summit. I’m

Shivan Sarna Sarna. And I’m here with my doctor, Dr. Allison Siebecker

Siebecker.

Dr. Siebecker is one of the most influential SIBO specialists in the world.

She has an incredible following of people who are SIBO patients as well

as SIBO practitioners—well, the SIBO (small intestinal bacterial

overgrowth) and the leading cause of IBS (irritable bowel syndrome).

So, what we’re going to be talking about today is from Dr. Siebecker

decades of experience as a naturopathic physician. She has literally written

the SIBO Specific Food Guide Diet and continues to work on that and

refine it every single day. I can’t wait until the newest edition is out. And

she helped me with SIBO SOS™ Summit I and SIBO SOS™ Summit II

as a curriculum editor, as the connector between me and so many

specialists. She’s been an incredible colleague. You can tell that I’m a big

fan. And I’m so glad to introduce you to her.

She’s here to help us understand the differences between IBS, SIBO, what

are they both, what are the myths and the confusion and the clarity that

can come from really learning about these conditions for ourselves.

Hi Dr. Siebecker!

Dr. Siebecker: Hi!

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Shivan Sarna: Hi! Okay, long time coming. This is a wonderful opportunity for us to get

down to it. What is IBS? What is SIBO? What is the difference? And let’s

start, that being said, with IBS so we can help people who are here

because they have IBS, but they might not even know what SIBO (small

intestinal bacterial overgrowth) is.

And that was me. Most of the people I know who come to us to study,

they have ideas, are really struggling. And then, lo and behold, they hear

about SIBO, they test for SIBO, they have it. And now it’s like a whole

new chapter of a quest to personally try to get well instead of being in the

dark for so long.

Dr. Siebecker: Absolutely! Okay. So you want to start with what IBS is?

Shivan Sarna: Sure!

Dr. Siebecker: Okay. So IBS is a functional gastrointestinal disorder. And it’s a

symptom-based disorder. And it’s also chronic. Those are the core

definitions.

And so, symptom-based means that there’s no organic disease—actually,

that’s what functional-based really means, is that there’s no organic

disease like an ulcer that we can see clearly causing the problem. And the

symptoms-based disease, what that really means is it’s just you’re said to

have IBS when you have a group of symptoms that can actually be caused

by a lot of other things. And those symptoms are abdominal bloating,

abdominal pain, constipation, diarrhea or a mixture of the two.

At least that is the clinically accepted definition of IBS. There is an

official definition that is slightly different. The official definition is

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designed by the Rome criteria. A bunch of experts and they met in Rome,

Italy. And so they named their criteria after where they met. And they

define IBS or the Rome criteria defines IBS a little differently.

And this is something that we can go into a bit more. But this is a bit of a

controversy because there’s a difference between what a lot of doctors

clinically define IBS and how the Rome criteria does.

So, the Rome criteria is abdominal pain that is continual and chronic,

meaning that you’ve had it for six months at least from the time you’re

going to be diagnosed. And you’ve had it at least once a week in the last

three months. And it’s combined with bowel movement irregularities. And

those would be either the pain comes when you have a bowel movement,

or it’s associated with a change in the frequency or form, the texture, of

the stool—meaning constipation, diarrhea or a mixture of the two. And the

pain is associated with either eating or as you go to the bathroom.

And that is the definition. The current definition is called Rome IV

because they’ve updated it four times. And that came out two years ago.

However, what’s different here—just to go right into the main difference

here—is that criteria doesn’t include bloating. So when the belly swells

out, either it feels like it’s swelling out, or you can actually see that it’s

swelling out. Distension is when you can physically see it swelling out.

Bloating technically would mean the feeling of it swelling out even if it

doesn’t visibly swell out. [05:15]

Dr. Siebecker: Most people just use the term bloating to mean the physical swelling out.

And I’m going to just use it like that.

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So, this is a problem. There’s a difference between what the Rome criteria

is defined as IBS and what everybody else in their office defines as IBS

because we all include bloating in the definition.

I’m just pausing if you want to—I have a feeling you might want to—

Shivan Sarna: I do! I just want to say something about the word distension. When I went

to my local GI doctor—sorry, there’s a little bug or something—he just

clarified for me, “So you mean distension?”

So, what is distension versus bloating?

Dr. Siebecker: Distension is when someone can physically observe a swelling like a

balloon. And bloating is really just a feeling, the feeling that you’re

swelling out in your abdomen. And there are people who feel bloated

without it being observable. That’s just a tactical, linguistic thing. Like I

said, most of everyone uses the word “bloating” to mean either.

Shivan Sarna: Either, okay, great. I just wanted to clarify that.

And then, also, what could cause IBS?

Dr. Siebecker: Oh, yeah, I didn’t mention that. So officially, it’s unknown. It’s a mystery

disorder. And so, it’s an extremely troubling thing because, here, people

have bloating, pain, and some change to their bowel movement. And it’s

chronic. It’s going on and on.

Oh, and by the way, IBS, it can wax and wane. It can get worse, and it can

get better. It can almost seem to disappear for periods of time and come

back over the course of how long a person has this, over years.

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And also, people can switch forms of bowel movements. So some people

might have been diarrhea at one time, and then turn to constipation, and

turn back. That’s all part of IBS.

Well, here’s this group of symptoms that is very troubling. Actually, it’s

one of the most frequent causes of absenteeism from work and from

school second to the common cold. So it’s very troubling to people. It

really impacts their lives very much. And we have no idea officially what

is going on.

There’s a few things I want to say here. One thing is, first, I just want to

say how common is it. It is the most common functional gastrointestinal

disorder in the whole world. However, that really makes sense. If it’s just

a group of symptoms—bloating, pain and trouble with bowel movements

(constipation or diarrhea)—because there are many, many conditions that

can cause these symptoms. So I think what winds up happening is people

get told they have IBS when they have another condition and it hasn’t

been figured out. And so, that can make the statistics be very high.

The prevalence of IBS is anywhere from 5% or 10%, up to 25%,

worldwide, any population, somewhere in that range. That’s a pretty big

range. But getting in the 20% range is vast. That’s vast. If you compare it

to something like Celiac disease which affects 1% to 2% officially

Celiac—of course, there are people with gluten intolerance that don’t have

Celiac, that would make the number much bigger, but just for Celiac. And

then, diabetes is somewhere in the 6% to 7% range. That’s extremely

prevalent. So, you have to think about how prevalent IBS is.

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Most estimates think—the most accurate estimate—is somewhere in the

10% to 15% range. It’s still huge… huge.

So, I think what I wanted to say about the cause is we now actually think

we know the majority cause of IBS. However, that’s not been officially

declared. And I just want to bring up this concept that maybe there really

is another disorder going on, and it’s never been figured out.

Those are two very important points.

Shivan Sarna: In the other condition that might be going on, but it hasn’t been figured

out, in addition to small intestinal bacterial overgrowth?

Dr. Siebecker: That’s the one that now has been figured out to be probably the majority

cause. And it’s a certain form of SIBO. Yeah… [10:02]

Dr. Siebecker: So, shall I describe what SIBO is?

Shivan Sarna: Yes please.

Dr. Siebecker: SIBO is when there is an accumulation or a colonization of normal

bacteria that live in the gastrointestinal tract, and they’ve now

accumulated in the small intestine.

So, the gastrointestinal tract, the mouth, esophagus, stomach. Then comes

the small intestine. And after that, the large intestine, also called the colon.

And the small intestine is normally not full of bacteria. It has a much

lower amount of bacteria. Whereas the large intestine, we all know has a

lot of bacteria. And they’re good for us. They do good things. It’s normal.

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Well, it’s not normal to have bacteria, a lot of bacteria, in the small

intestine. That’s what SIBO is. It’s just the accumulation of normal

bacteria in a place where they really shouldn't be accumulating that much.

So, that’s what SIBO is.

Well, in terms of the type of SIBO that is thought to be the main,

underlying cause of IBS, that would be post-infectious IBS.

Post-infectious IBS is a sub-type of IBS that comes after food poisoning.

So, what happens is people are exposed to food poisoning. Also, other

words for that would be traveler’s diarrhea or the stomach flu.

So basically, what’s happening here is there are many forms of food

poisoning. It can come from viruses. It can come from other things. But

one form comes from bacteria. And that is the form—bacterial food

poisoning or traveler’s diarrhea—that then can, in some people (not

everybody), lead to IBS.

So, you get the food poisoning. You’re vomiting and diarrhea, acutely

sick. Awful! And then, you get better… hopefully. But in this scenario,

you do get better. And then, some time after, you develop the symptoms of

IBS.

You might actually now have constipation, whatever. You might have a

different form. For most people, it’s diarrhea.

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Sometimes, for people, they have the food poisoning, and they get better

from the really, really acute part, but it never really goes away. And now it

just lingers with it. And for some people, it goes away, there’s a period

where they’re fine, and then they get the IBS.

Well, this form of IBS—and this has been identified to be none other than

SIBO. And I can take you through that sequence if you want to hear it. But

there’s been some statistical analysis done, some papers published that

postulate that this might account for the majority of IBS that we see,

particularly the diarrhea and mixed forms (mixed meaning diarrhea and

constipation mixed together).

So, that’s pretty astonishing news. There’s been quite a lot of development

in the field of IBS.

Shivan Sarna: That’s a big deal. This is kind of exciting…getting answers after all these

years. I’m sure the doctors who see patients all the time and never know

what to say to them about their IBS are feeling hopeful.

Dr. Siebecker: Yes. Let’s hope that they’ve started to hear about this already.

Now, SIBO can come from all different types of reasons other than food

poisoning. This is probably the most common way people get SIBO. But it

has other causes.

And IBS could have other causes if we’re just saying IBS is this group of

symptoms. And as I said, there’s so many—probably over 40 conditions

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(my list has 45, more than 45)—conditions that could cause those

symptoms that you have to think about. So you could have IBS from one

of those reasons too. There’s a lot of different causes.

But officially, it is declared as unknown or mysterious. And that’s very,

very frustrating. So people have a chronic circumstance with these

symptoms, and nobody technically knows why—although now we’re

starting to have the information.

Shivan Sarna: You know, Chronic Condition Rescue is the name of the company that I

started a year or so ago because of what you just were talking

about—chronic conditions without answers—or the cures are still elusive,

or maybe natural medicine has a better way of managing it, but western

medicine hasn’t figured it out yet, and their approach is sometimes really

off-track or even more damaging.

I want to put something out there since this is a video that I know a lot of

people are going to see. And that is that managing a chronic condition can

make you feel the best you have in your life if you’ve never figured out

what was wrong with you. And that was something you taught me and

reminded me of as both of us being long-term SIBO/IBS patients. [15:17]

Shivan Sarna: And so, when I first got started, I was “oh, my gosh! I need to cure SIBO.

I need to fix it. I need to fix it. I have to have a negative breath test. It has

to be totally resolved. And I have to be well.”

Okay. Well, I’ve had SIBO probably since I was five.

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Dr. Siebecker: Me too!

Shivan Sarna: Right? What if I just felt better than I had ever, would that be good

enough?

Dr. Siebecker: Very good question.

Shivan Sarna: It’s a philosophical and a very deep, personal, intimate question. And the

answer that I shortly came to was “Heck, yeah!” So a lot of people have

things going on with them, and they just learned to manage them.

So, this is kind of like a reality check and a message of hope at the same

time for everybody who’s been struggling for a really long time and think

“Good news, you’re here. And you’re learning. We’re all in this together.

And we’re going to be taking this journey on.” But know that if the goal

mindset switch could be to manage your IBS and your SIBO in a way that

made you feel—maybe not even 100% better, even if it’s not a negative

breath test or you still are showing that you have technically IBS…

Dr. Siebecker: …or maybe everything is negative, but then you relapsed because IBS

waxes and wanes, and SIBO is chronic for many, not everybody. And so

what if you got a negative test, a SIBO test, and you’re 100% better for

some time, and then you have a relapse? But then you take care of it, and

then you’re 100% better again?

I mean, that’s annoying, but life is annoying. And there’s all kinds of—I

mean, and also, life is wonderful. But there’s all kinds of chronic things

we deal with all the time in everybody’s lives that we manage and we

often manage very well.

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Shivan Sarna: Right! I just wanted to make sure we covered that.

When it comes to SIBO—do you want to talk about this now or do you

want to talk about how we can get a diagnosis of SIBO?

Dr. Siebecker: Should we finish IBS? What do you prefer?

Shivan Sarna: Oh! Yes… no, of course. it’s so interwoven, Dr. Siebecker.

Dr. Siebecker: It is. I don’t really care where we go. Yes, you just take it wherever you

want to go.

Shivan Sarna: Okay, no, what were you going to say?

Dr. Siebecker: Well, I guess what I did want to just say is “What’s the difference then

between IBS and SIBO?” because most of everybody gets confused about

that—and it is confusing—is that IBS is a broader diagnosis in my mind.

Maybe it will become official that what we’ve all thought of as IBS is

post-infectious IBS, and then we’ll be changing our minds. But currently,

it’s broader. It just means you have these four symptoms or three

symptoms—bloating, pain, and constipation/diarrhea/mixed.

And SIBO is a cause of IBS. So SIBO is a little bit more specific because

we know what it is. It’s an accumulation of bacteria in the small intestine.

And we know the symptoms it causes. And it causes IBS symptoms. So it

can cause IBS.

So, that’s the main difference.

Now, I do just want to say one, little mind-bender thing here. For those

who are talking about post-infectious IBS, maybe being IBS maybe

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accounting for most of the IBS we all know, then you could actually say

that IBS causes SIBO. But it’s only in the framework of that scenario

pretty much.

Maybe I should just briefly explain the pathophysiology of how that

happens because it is really interesting for those who haven’t heard of it

and even if you have. I’m still interested in it. This is the work of Dr.

Pimentel and his teammates. They figured this out.

So, all the bacteria that cause food poisoning, they’re pathogenic bacteria

like salmonella and Campylobacter jejuni. They have a toxin. That’s one

of the things that makes them pathogenic. They all have the same toxin.

And it’s called cytolethal distending toxin, CDPB for short. A part of that

toxin, the B portion—so CDTB—winds up that it looks like very similar

to a protein that’s within one of our small intestine nerve cells. And those

nerve cells are called ICC cells for short. And they are crucially involved

in motion in the small intestine called the migrating motor complex. And

this is that cleansing wave. [20:05]

Dr. Siebecker: It cleans bacteria and other debris out of our small intestine downward,

sweeping it down into the large intestine when we’re not eating (so in

between meals and overnight when we’re sleeping).

And if this movement, the migrating motor complex, didn’t function, then

we would have a backup of bacteria. We would have stagnation. It’s a

warm, dark, moist environment. Bacteria would accumulate.

So, that’s what winds up happening. Our immune system, it’s like a

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mistaken identity basically, friendly fire. It thinks that now our own

vinculin (the protein on the nerve cells called vinculin), the vinculin on

these nerve cells is similar enough to this toxin, so it can be triggered into

attacking our own cells.

And so in this scenario, it’s an autoimmune problem. And then, we

decrease those cells, and then we decrease the migrating motor complex

waves, we get stagnation, and the bacteria builds up. And then, we get

SIBO. We get small intestinal bacterial overgrowth. And then, that’s IBS

because the symptoms are the same. And this is post-infectious IBS.

So, this is the pathophysiology for post-infectious IBS. This is a

phenomenal insight. We didn’t even, six years ago, fully have this

elucidated, even four years ago. So this is new information.

And off of this information, it actually leads into there is now a test for

IBS. All along, we haven’t really had a biomarker, a way to really test,

“Do you have IBS?” All we know is that if you don’t have anything else,

although that’s problematic because not always is everyone looking for

everything else, when you have these symptoms, you’re said to have IBS.

Well, what this test is—also developed by Dr. Pimentel—is a test for

antibodies against the toxin, CDTB, and against the vinculin protein

within a person’s body—so antibodies, the vinculin and CDTB. And that

is a new test. Its’ been out about three years I think. It might have been a

tad longer. And it’s available from several labs now.

Originally, it was available through Commonwealth. It is available

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through them, Commonwealth Diagnostic International. Also through

Quest. This is the United States (although Commonwealth is

international). So Quest, and then Cyrex. And then Vibrant America I

believe all make these antibodies available.

So, this test is considered to be the first screening test. It’s a blood test, a

simple-to-perform blood test for IBS. And what happened is Dr. Pimentel

checked these tests against Celiac disease, people with Celiac disease and

people with inflammatory bowel disease. That’s Crohn’s and ulcerative

colitis. And what he found was that you can be well assured that if you’re

positive for this test, you do not have inflammatory bowel disease, and

also, much less likely to have Celiac, both of those, particularly

inflammatory bowel disease.

So, if this test comes positive, you can feel comfortable knowing you have

IBS (post-infectious IBS) and not inflammatory bowel disease.

And that’s very important because IBS has always been—well, it’s a bit

controversial. But most have considered it a diagnosis of exclusion,

meaning you need to rule out and be sure they don’t have some very

concerning diseases which would be inflammatory bowel disease, Celiac

and colon cancer. And if you can rule those out and have these symptoms,

then they’re said to have IBS.

And that’s very costly, those tests. You need a colonoscopy or endoscopy.

They’re invasive and costly. They have some risks. And so now, with this

blood test, the idea is that you could do the test, and if it’s positive, you

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don’t need to go on to do the colonoscopy and endoscopy—especially in a

younger person.

IBS affects people of all ages. That’s one of the things about it. People

who are in their teen years and young, as well as old have IBS.

Shivan Sarna: Does it tend to affect more women than men?

Dr. Siebecker: We have twice as many women. Twice as many women than men have

IBS. I don’t know if that’s true for SIBO actually. I don’t know that those

statistics have been done; it might be though.

Shivan Sarna: Hmmm… so interesting…

Dr. Siebecker: Yeah. So that would be the way that you now could officially test for IBS.

Other than that, it would be that diagnosis of exclusion, like I mentioned,

and then you have the symptom-based criteria, the Rome criteria or your

own clinical.

I do want to just mention that that diagnosis of exclusion is controversial.

Officially, from Rome Foundation, they say it’s not a diagnosis of

exclusion. You can confidently make the diagnosis—this is what they

say—based on the symptoms. [25:06]

Dr. Siebecker: Now, the reason they’re saying that is because there are other studies that

show that you are very unlikely—if you do not have alarm symptoms or

concerning symptoms like blood in the stool and some other alarm

symptoms, and you’re not above the age of 50 when your symptoms

started, you’re very unlikely to show with inflammatory bowel disease,

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for instance. They do studies on this. They take a colonoscopy and they

compare.

So, they feel that you can have confidence to make the diagnosis with

symptoms and begin treatment.

And the idea behind this is they’re trying to save money for the test and

the rest. And they’re trying to get you into treatment quicker. So you don’t

have to wait. It could take months to get in for these tests. Just get some

treatment going.

And the idea here is that you start with some simple treatments like dietary

changes and maybe probiotics or fiber, things like that. You can try some

other treatments too, but you only proceed to testing if you find your

treatments didn’t help.

So, that’s the idea. There are many who are saying it is not a diagnosis of

exclusion. And then, there are others who are saying it really is still. You

don’t ever want to miss a case of colon cancer. Even if it’s a 1% chance,

we want to be sure we get those, we find those people.

So, there’s that concept. And then there’s the concept that I was bringing

up. What about the huge differential diagnosis list of 40 or 45+ other

conditions? Is anyone even looking at them?

Here’s what happens. All too frequently, somebody just comes into an

office, has these symptoms. And with zero investigation, they’re told they

have IBS. In a way, that’s what I was just saying is encouraging to do.

What we are being encouraged to do is just make the diagnosis based on

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symptoms and start treatment.

Again, I think that’s fine so long as the treatment within two months or

three months are showing significant improvement. If a person is not

showing significant improvement, then you need to start looking and

going through that differential list and testing and finding out what this

person have.

For instance, some of the things on this list would be things like

endometriosis or lactose intolerance or Lyme disease. Other things like

hypothyroid, diabetes, you’re very likely to pick those up on a screening

blood test which you’re very likely to have had performed.

But something like endometriosis, what if a person just thinks that they

always had painful periods menstruation time, and they don’t even

mention it to you? Have you asked them about that? Did you investigate?

And lactose intolerance, people can have that from a young age and never

link it, never link that their symptoms are coming directly from milk or

dairy products. So they have no idea.

So, unless you’re asking about this as a physician—these are pretty

important things that aren’t going to show up on screening blood work that

we need to consider.

And actually I forgot to mention that the symptoms of IBS are brought on

by food, a food or beverage. That’s part of the symptoms. The bloating,

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the constipation, diarrhea, mixed, or pain is because of eating (or

beverages as well).

Shivan Sarna: It’s a trigger.

Dr. Siebecker: That’s what triggers the symptoms. If a person just didn’t eat, they

wouldn't have the symptoms pretty much.

Shivan Sarna: Right. What about stress?

Dr. Siebecker: Stress is always a trigger for IBS. It’s always been a trigger. And it used to

be thought that that was the cause. It was all blamed on that. But that is

not the case. It’s a trigger.

It’s an important trigger. Stress is an important factor. We always need to

think about it. It’s a trigger for most of all diseases and disorders—not

everything, but most—especially chronic situations.

But saying stress is the cause of any disorder, there may be people that,

truly, that is the case. I think I have seen one case like that. But for the

most part, we say that when we don’t know what’s causing a disease.

That’s just what’s said about a disease until we figure out the

pathophysiology. Stress is always a trigger though.

Shivan Sarna: Of course, okay! I’m just looking at my notes to make sure we covered

everything. Oh, can we talk about SIBO diagnosing, meaning testing,

treatment, preventing relapse and a few other things, the diet?

Dr. Siebecker: Of course. [30:02] We diagnose SIBO with a breath test. And you’re

going to use either lactulose or glucose. So it’s a lactulose or glucose

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breath test. And I would recommend getting a 3-hour breath test. But you

at least want to get close to a 2-hour. And it needs to test for hydrogen and

methane gas.

And there is now a new machine that’s been developed by Dr. Pimentel

that additionally test for hydrogen sulfide. But it’s not commercially

available yet as of when we’re recording this. I don’t know when it will

be. We’re recording in the summer, late spring or summer, of 2018. So,

maybe at the end of the year, but I’m not sure when.

So, this test, the way it works is the sugar of either glucose or lactulose is

meant to feed the bacteria in the small intestine. They ferment sugar into

carbohydrates—or sorry, sugar is carbohydrates. They ferment them into

gas. And then, we are going to measure that gas because the gas that’s

produced in the intestine filters across into the blood and is expired out of

our lungs. And then we test that. We breathe out and test it.

It’s a very simple to perform test. And it’s done after an overnight fast.

It’s usually done in the morning. And it takes two to three hours to

perform. You can do it at home with the kids, or you can go into a doctor’s

office and do it.

And sometimes, people will have their symptoms triggered because we are

actually feeding the bacteria, and they’re making gas. And gas is the cause

of the symptoms in SIBO and in most of IBS actually.

So, that’s how we test for it. The interpretation is of course done by the

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doctor. But in general, we’re looking for a rise in hydrogen of 20 or more

and methane of 10 or more or even 3 or more. That would indicate a

positive test within anywhere from 90 minutes to two hours.

And then, hydrogen sulfide, currently, the way we know is that in that

third hour of the test—that’s why a 3-hour test is very important. We

actually need the third hour of the test to tell us. We would see hydrogen

at close to 0 or very, very low in the third hour—which is unusual.

The first two hours indicates small intestine on average. And the third

hour, on average, indicates the large intestine. And we should always see a

rise of gas in the third hour or in the large intestine because we have tons

of bacteria there naturally. And most bacteria make hydrogen gas. So we

should see that—not all bacteria but many.

Shivan Sarna: So, this is where the comparison to a little distillery or a little brewery

happens where things ferment, the gas is emitted, and instead of

carbonation, you’re bloating.

Dr. Siebecker: Absolutely! So you’re making hydrogen gas—the bacteria are making

that—or methane gas. Technically, it’s archaea. Our archaea are making

that. But they are microorganisms. I’m just saying bacteria to indicate

them as well. Or hydrogen sulfide.

And the way it works is that many bacteria make hydrogen. And then,

other bacteria or archaea convert the hydrogen into either methane or

hydrogen sulfide. And so you could have any amount of all three of those

gases present.

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There’s also carbon dioxide. That gas can readily diffuse and be absorbed

into the body. It’s not a gas that sticks around in our intestines, bloating us

and causing symptoms.

A hydrogen gas is associated with more so diarrhea. And in the new

studies Dr. Pimentel just put out, so is hydrogen sulfide. Whereas the

methane gas, we know, is the direct cause of constipation because it

affects the nerves and the intestines and slows the overall transit. So we

get constipation from methane.

And also, gas can cause pain, can cause nausea, burping. There’s all kinds

of symptoms that an accumulation of gas and the intestines can cause. But

the point here is just that particularly the hydrogen and the methane gas

are only made by bacteria. They’re not made by humans. So when we test

them in the breath, we can see the presence indirectly, see the presence of

these bacteria.

Shivan Sarna: Got it, okay.

Dr. Siebecker: That’s how we test for it.

Shivan Sarna: That’s how we test.

Dr. Siebecker: And so I know something you told me you wanted me to go over. What

isn’t a test for SIBO?

Shivan Sarna: Ah, yes. There’s confusion about this.

Page | 21



Dr. Siebecker: Misconceptions on SIBO. Stool testing is something a lot of people think

you can use to test for SIBO and you can’t. And it’s only reflecting the

large intestine. It is not reflecting the small intestine.

There are some things that you could tell about the small intestine from a

stool test, a functional stool test, that an alternative practitioner would do.

But it is not a way to diagnose SIBO in any way, shape or form. It’s going

to represent the bacteria in that other organ, the large intestine. They are

two different, separate organs with a valve in between them unless that’s

been surgically removed. Even still, they’re quite distinct organs.

So, to assess the small intestine, we use the breath test. [35:22]

Dr. Siebecker: The other test that doesn’t diagnose SIBO is the urine organic acid test.

It’s a wonderful test used for so many things. The issue here is it can’t

distinguish between the small and large intestines. So it’s representing

either or both. We don’t know when we get the results.

It’s still an amazing test. But it is not a diagnostic test for SIBO. The

diagnostic test is the breath test. You might as well just do that test, and

then you’ll know—especially because the breath test gives us vital

information that we need to help us inform what treatments we’re going to

choose and how long those treatments may need to go on.

Shivan Sarna: Okay. Speaking of treatments, let’s touch on that.

Dr. Siebecker: Okay, there are three main antimicrobial treatments we use; and then,

additionally, a fourth treatment, which is diet.

Page | 22



So, here’s another misconception. I know you wanted me to talk on SIBO

misconceptions. Another misconception about SIBO is that you can treat it

with an antimicrobial (so basically, an antibiotic) similar to like a urinary

tract infection, and get the same sort of response. You take an antibiotic

for five to seven days, maybe two weeks at most. And you’re done. Things

are gone. It’s over.

Well, that is not the case for SIBO. Even though we are using

antibiotics—so our three treatments are pharmaceutical antibiotics, herbal

antibiotics or elemental diet (I’ll describe that in a minute).But the reason

it doesn’t respond like a UTI, a urinary tract infection, is because this is

not an infection. SIBO is not an infection. So it’s a colonization or an

accumulation. These are not pathogenic organisms. It’s different. So, what

we’re going to be doing is just continuing to treat the colonization until we

get benefit.

And so, very often, it takes longer than two weeks because there is an

overgrowth. And we just need to champ that down to reasonable levels, so

that our symptoms go down. Whereas an infection, it’s a different thing.

There’s pathogenic organisms. We kill them. They’re gone. This is

different.

So, those are the main treatments. There’s the pharmaceutical antibiotics.

There’s two approaches here. The way we treat is based on the gases we

find because then the organisms that are making those gases are a little

different as I’ve mentioned.

Page | 23



So, if you have hydrogen-only positive, we use rifaximin. The brand name

is Xifaxan in the US. If you have methane present—so methane alone, or

methane and hydrogen, and/or if you have constipation—we treat with

rifaximin plus either neomycin or metronidazole. Metronidazole is also

called Flagyl.

When we go to the herbal antibiotics, we have to do the same thing. And

we know of two main things that help with the methane or the archaea.

And that’s allicin. That’s the antibacterial agent that comes from garlic.

We typically don’t use whole garlic because it’s quite fermentable. And

for a lot of people, it can make them gas. So we try and use the

standardized allicin extract.

And so the product we tend to use is called Allimed. I know there’s a new

company that has one out. I can’t remember the full name of them. I’m

trying to mention brands because we’re not continuing education here

where we’re not allowed to mention brands and people always want to

know. Or Atrantil developed by Dr. Brown, Dr. Ken Brown. That also, we

know, is effective against methanogens.

But the other herbs we would use would be things like

berberine-containing herbs like goldenseal, oregon grape, things like that,

oregano and neem. And these are very, very effective against the hydrogen

bacteria.

So, if you have hydrogen-only, you’d use one or two of those. If you have

Page | 24



the methane, you would add in the allicin or the Atrantil (or you could

even use Atrantil by itself).

And then, there are people who also like to do big combination formulas.

What I told you were the specific herbs that myself and most of my

colleagues tend to use. We tend to use two (at most, maybe three herbs) at

once. But other physicians like to use big combination formulas where

they have herbs that are focused at killing parasites and yeasts as well.

That’s another way to approach it. And so there’ll be a lot more herbs in

there. [40:12]

Dr. Siebecker: And then, lastly, there’s the elemental diet. And that is a powder or it

might be a premixed liquid that is supposed to be our main macronutrients

in their most digestible form, and also micronutrients.

So, the macronutrients are protein, fat and carbohydrates. So the protein is

amino acids. The fat is usually actually oil. And then, the carbohydrate is

glucose or maltodextrin. And then, we have a multivitamin. There are

vitamins and minerals in there.

And these are powders you can buy like Vivonex Plus. That’s what the

studies were done on. There’s also one called Physicians Elemental Diet

by Integrative Therapeutics. And there’s a few others.

And then, I have a homemade recipe because, originally, when we started

all these, there were mostly just Vivonex and its similar products, and they

were quite expensive. Many of my patients couldn't afford it. So I made a

recipe that is not as expensive that you can make at home. And anyone can

Page | 25


http://go.integrativepro.com/sibo-summit.html


see that for free. I have it listed on my website which is a free

informational website, SIBO Info.

And then, lastly—I’m going on a roll here…

Shivan Sarna: Yes! I just wanted to know about the elemental diet. I don’t know if you

said this, sorry. The elemental diet was originally designed for people with

feeding tubes.

Dr. Siebecker: Oh, well, there’s that form of it. But then there’s the form for taking in

through mouth. There’s forms for both.

Shivan Sarna: And then, also, for NASA. Isn’t it like for the space, the astronauts?

Dr. Siebecker: Well, it has many uses.

Shivan Sarna: I think that’s what I want to express. It has many uses. It is a liquid diet.

It’s not a typical protein powder.

Dr. Siebecker: Absolutely, it’s not a cleansing/detox formula. It’s quite specific. And the

whole point here is to rest your digestion.

Actually, the way it’s being used here, we know pharmaceuticals and

herbal antibiotics, we know that they can kill bacteria. But the elemental

diet is meant to starve them. And so the idea here is it digests so quickly, it

can absorb quickly into the body, and then not feed the bacteria. And then,

they starve. And it seems to absolutely work that way. It’s extremely

successful.

They are all. All three of these methods are very successful, with success

Page | 26



rates of close to 90%, between 80% to 90% which is astonishing for

almost any treatment for any condition. Usually, you’re lucky if you get in

the 30% to 40% range. These are very effective treatments. I was just

going to zoom on to diet in the end.

Shivan Sarna: Okay. Do it!

Dr. Siebecker: You said, “Do it all!” So…

Diet, physicians and practitioners use it in all different ways. Its main use

is to help us with our symptoms. It’s one of the best symptomatic relievers

there are. And the concept behind is, again, to sort of starve—not as

extreme as the elemental diet, but somewhat starve the bacteria of

carbohydrates.

So, these diets are all either low carbohydrate diet. Basically, they’re just

manipulating what the carbohydrates that you’re eating or not eating to try

and reduce the carbs that would feed bacteria so you don’t make as much

gas. And it’s the gas that causes the symptoms. And so then you have

some relief.

People, like I said, use it in all different ways. It may also help to decrease

the bacterial load somewhat and help us with a die-off reaction that we

could have when we’re taking our main antibacterial

treatments—pharmaceutical antibiotics, herbal antibiotics, or elemental

diet.

So, it has other uses. These diets are pretty healthy diets (very healthy

Page | 27



diets actually). So often, people, just their inflammation goes down, their

pain in other areas goes down. Their quality of life goes up so long as they

like the diet and they are happy on the diet because they are restricted. It’s

a medical diet.

So, some of these diets are like my SIBO Specific Food Guide. And then,

there’s a variant of that that Dr. Jacobi made called the Bi-Phasic Diet, the

SIBO Bi-Phasic Diet. She put my food guide into phases. There’s the

Specific Carbohydrate Diet ( called SCD for short), and the Low

FODMAP Diet.

And my food guide is a combination of those plus some of my own input.

And so, Dr. Jacobi’s diet is that same thing.

And then, Dr. Robillard has his Fast Tract IBS Diet which is really meant

for SIBO, SIBO and IBS. And then, there’s Dr. Pimentel’s. He has a diet

that’s meant for prevention, really if you’ve done either elemental diet or

antibiotics because that’s what he uses (pharmaceutical antibiotics or

elemental diet). After that, we go on a reduced carb diet. It’s called the

Cedar Sinai Low Fermentation Diet.

And you can access all of these on my website. I have all the information

about them for free there. [45:09]

Dr. Siebecker: So, these are some of the diets we might use. And like I said, all different

ways, you can use them to reduce symptoms. That’s a very important

thing for somebody who has this condition chronically. It’s going to be

one of their main management tools. And you can also use it as a way to

Page | 28



help prevent relapse.

I know that’s the last thing you said you wanted me to talk about, what

about relapse, right?

Shivan Sarna: Yes.

Dr. Siebecker: So, what the statistics show—boy, I’m just, phew, moving on. I’m going

on here.

Shivan Sarna: You’re doing great. You’re doing great.

Dr. Siebecker: Okay, let me take one more sip of water.

Shivan Sarna: Yeah. And just a reminder, everybody, this is a lot of dense information,

feel free to pause and rewind. That may seem obvious. But I think we’re in

this world of being so quick to consume all of these online information

and all social media and stuff that we don’t take a moment to sort of

breathe and absorb the information.

So, this is where overwhelmation—I think that’s a word, you know what I

mean—that’s the enemy of these types of events and these types of really

dense educational moments in our life. And I get overwhelmed. I’d have

to go take a nap.

I already know what Dr. Siebecker is talking about because I’ve been

lucky enough to study with her. And I’m already like, “Oh, my God! It’s

so much.”

Dr. Siebecker: It’s a lot. So much research has gone into figuring these things out. It’s

very dense. And I’m just speaking it all out.

Page | 29



And by the way, about overwhelm and learning, what happens is if we get

overwhelmed, we don’t take action. It’s like we heard it, but it meant

nothing. And we don’t use it and apply it to help ourselves get better or to

go to the doctor and get a test or whatever it is—

By the way, as I’m saying that, I wanted people to know in the US at least,

you can now get the SIBO breath test yourself. You can order it yourself.

Now, again, I have that information under the Resources/Testing section

of my website, the labs that you can do that with.

But I myself and really any human who’s trying to learn something, I

watch presentations over. And that is what’s required to truly learn

something. And I just wanted to remind people of that. You can’t just hear

it once and know it and incorporate it. You usually have to take some

time. Maybe watch it again or take good notes, and then read the notes

over. Repetition is how we learn.

So, I just wanted to mention that.

Shivan Sarna: I think it’s so important because you’re going to be learning a lot over

these next several days. And you probably have been spending some time

on Dr. Google. And hopefully, you’ve made some progress. And this will

illuminate a new path for you or take you deeper into your course of

action.

But it’s exactly what Dr. Siebecker just said. Take it from me, from

someone who was combination—it’s like constipation/diarrhea. I either

Page | 30



studied way too much and then got paralyzed, or took way too many tests

and then, with all that overwhelming information, led to maybe buying too

many supplements or trying too many things at once, so I couldn't really

tell what was helping me.

Dr. Siebecker: That’s a big thing. That’s a big thing, doing everything. You’re going to

hear so many people on this summit. And they’re all brilliant! And then,

you’ll want to do everything all of them says.

You have to just pick a path and move forward on the one path and take it

step by step.

Shivan Sarna: Yeah.

Dr. Siebecker: Okay, I’m going to get back to…

Shivan Sarna: Okay!

Dr. Siebecker: So, relapse… well, we said already that with IBS, that is likely. Well,

same with SIBO. The statistics are that one-third of patients will not

relapse. And there might be two ways this goes for the people who are not

going to relapse.

Dr. Pimentel calls one group one-and-done. And that is where you take

your one course of whatever. So, for pharmaceutical antibiotics, that

would be two (possibly three) weeks. For herbal antibiotics, that’s going

to be four to six weeks, one course. And for elemental diet, that’s two to

three weeks, one course. You take one course, and you’re more than 90%

better, and you don’t relapse. He calls that one-and-done.

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http://go.integrativepro.com/sibo-summit.html


And then, there’s this other category that’s more common (much more

common for me and my colleagues). And I’ve decided to name that

time-and-fine. So that is where you need maybe three course. That is

where you need maybe three courses, three rounds of treatment—three

courses. That’s acting where it doesn’t necessarily respond like a UTI. It

can take some time. You need to repeat rounds until you get symptoms

relieved and/or a negative test. And so anywhere, I would say, three or

four treatments is typical. Time-and-fine.

But then, after that, you’re 90% or more better, you tested negative, and

you do not relapse. [50:22]

Dr. Siebecker: Now, we go over to the others, the two-thirds. That’s what the study show.

They will relapse, meaning, really, what the issue there is there’s an

underlying cause in SIBO that hasn’t been addressed and now needs to be

figured out if somebody is now relapsing. And that can be hard and take

some time.

And sometimes, those underlying causes are not curable. They’re chronic

conditions, as you were mentioning, that there’s no known cure to.

However, you can manage them and feel very, very well depending.

Now, what do we do to help prevent relapses? We do two things

essentially—some form of a low carbohydrate diet. And you can do any of

those diets I just mentioned. And of course Dr. Pimentel’s Cedar Sinai

Diet was developed for just this. But you can do any of them sort of

expanded out a bit to your food tolerances because once you get that

bacteria down, you’ll be able to tolerate more foods.

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And you would do that ongoing along with a prokinetic. And we have

pharmaceutical and natural prokinetic options. Those are the two essential

things.

And there are other things you can add in like meal-spacing (it’s

something we often talk about), giving some time without drinking or

eating any nutritive, caloric items between meals so we can allow the

migrating motor complex to happen, and giving a 12-hour fast at night,

and also making sure you don’t eat about two hours before bedtime. What

all of these is aimed at is giving the chance for the migrating motor

complex to clean the bacteria out of the small intestine.

Many people have hyperglycemia where they need to eat frequent, small

meals or snacks to keep our blood sugar stable. This is common where you

have both conditions. And so then it’s a balancing act that you and your

doctor, or if you’re a practitioner listening, you can maybe try and do the

overnight one or maybe you have a space once in a day where there’s a

nice chunk.

So typically want to go four to five hours. And Dr. Pimentel actually in

this summit clarifies five hours is best.

So, you just do the best you can. This is not a hard and fast thing. People

get obsessed about this. They get obsessed about most of everything. Life

is always a balancing act. And once you understand the reasons for why

we’re doing things, you work with it to see it for yourself.

Shivan Sarna: That is so important, Dr. Siebecker. If I can convey anything else about

learning and action, it’s everything you just said about—for me, and I

Page | 33



think this is common for a lot of people—understanding why something is

important or why or what a supplement, let’s say, is supposed to do for

you. It so often leads to more compliance—comply that you would

actually get it, but then also that you would take it.

How many of us have supplements that make it to the house, I look at the

bottle, I cannot remember why I bought it even though I was told that it

was going to help me? I have pill fatigue from taking so many

supplements over time, and I’m just like, “Yeah, I can’t remember that.

I’ll look that up later.” And then, it gets lost in the shuffle.

So, the more you can understand, the more you can maintain your

motivation to keep going. That doesn’t mean you have to become an

expert, just even I can literally look at something and go, “Oh, this is

supposed to help me with my level of vitamin D.” That’s enough reason

for me. What’s enough reason for you?

So, I just wanted to remind you to connect the dots there between why and

compliance. Have you ever been to a doctor where they said, “Oh, here.

This is going to be good for you. Do this, do this, do this.” Okay, you walk

out, and you have done nothing.

Then you go to someone and they’re like, “Hey, listen. This is going to be

good for your vitamin D. This is going to be good for your brain fog. This

is going to be good for your constipation,” and you’re like, “Cool!”, you

go home and you actually use it? Even from just this one, little line, one

line of communication—

Page | 34



So, that’s the other thing. Hopefully, this will provide you with a lot of

information, so your path becomes clear, and then the compliance and the

efforts are good investments with high returns.

Anything else you want to wrap up this session with, Dr. Siebecker?

Dr. Siebecker: How much more time do we have?

Shivan Sarna: Oh, darling, for you? All the time in the world! [55:01]

Dr. Siebecker: Well, I’d like to mention what the treatments for IBS are. And I didn’t

specify the different prokinetics. I’ll just briefly mention that. We have

pharmaceutical and natural options.

Pharmaceutically, we tend to use low dose erythromycin, prucalopride

(which is Resolor or Resotran depending upon your country), and LDN

(low dose naltrexone).

And then, herbally, we have Iberogast and ginger-containing formulas.

Ginger itself, we can use, 1000 mg. at night before bed.

All of these prokinetics are taken at night before bed predominantly for the

use we’re trying to use them for which is assimilate the migrating motor

complex while we’re sleeping.

And now there’s a whole bunch of new ginger-containing formulas on the

market. We’ve always had MotilPro. That’s been around for a long time.

But now there’s also Motility Activator. There’s SIBO-MMC. Those are

quite new. And then, ProKine, I guess that’s been around for about two

years. But I only found out about it about six months ago.

Page | 35



So, these are all combinations that have ginger in them. So these are

options, either Iberogast, ginger or ginger-containing formulas.

Now, ginger is a well-known prokinetic especially for the stomach, used

for gastroparesis.

Okay, IBS treatments. Because when you don’t know what something is

caused by, then the target is unclear. And so then, usually, what you need

to do is just aim at the symptoms. And that’s never satisfying really for

anybody. So that’s where IBS has been left with. Traditional IBS

treatments are symptom-oriented.

Now, a lot of people will start with diet. And so that would include

smaller, frequent meals actually for IBS because the idea here is, really,

it’s not even so much about frequent. It’s just smaller, smaller meals

because the food is triggering the symptoms. So the less you consume, the

less triggering.

A lot of people find that to be helpful, but you know how satisfying that is

ultimately. So there’s that.

Wheat and gluten have been shown in a lot of studies to trigger IBS

symptoms. So that is a common thing to do. And one thing I must

mention. Before taking particularly gluten out of your diet, you should get

a blood test for Celiac because once you eliminate gluten, then the blood

test (and also the endoscopy) would no longer be accurate.

So, if you are interested in going gluten-free, get your Celiac testing done

before you go gluten-free.

Page | 36



That is Lisa Shaver. Dr. Lisa Shaver is speaking in my head. She is a

Celiac expert. And she’s always reminding us of this.

So, other than diet, things that people will start their IBS treatment with is

fiber, probiotics, things like that.

So then, you’d escalate up from there to things like more obvious

symptom relievers, things like Iberogast (it actually is well-studied for IBS

symptom relief and is in between around an 80%, almost to 90% success

rate especially for children which is great), enteric-coated peppermint oil

is another one. And then, there’s things like laxatives for the constipation

or Imodium which is loperamide for diarrhea.

And then, you can move on to pharmaceuticals. Those things like the

laxatives, osmotic laxatives like polyethylene glycol, vitamin C or

magnesium. So there are other things.

And by the way, on this, anyone is welcome to look at my other free

symptomatic relief suggestion guide that’s for SIBO, but it would apply to

IBS. And again, that’s free on my website underneath Resources /

Handouts.

Okay! Then we move on the pharmaceuticals. So rifaximin is actually

approved in the United States for IBS diarrhea-type, IBS diarrhea and

mixed. And the reason being is because so much of IBS is caused by

SIBO. And although they’re not using SIBO in any of the language, it’s an

antibiotic.

And by the way, rifaximin primarily works in the small intestine because

it’s bile-soluble. So it’s an antibiotic that pretty much just have a set of

Page | 37



action in the small intestine. If it’s helping a person feel better, that must

have meant they was a lot of bacteria in the small intestine, aka SIBO.

So, rifaximin is actually one of the only treatments that I know of—there

probably are some others, but one of the main ones—that has a durable

effect, meaning you take it, you stop and you’re still better. You might

relapse. Two-thirds might relapse. But at least one-third is not relapsing

after taking rifaximin. So rifaximin… [01:00:24]

Dr. Siebecker: Then there’s antidepressants for IBS. Now, the idea here is people are

thinking, “Oh, but it’s not all in my head. It’s not because I’m depressed.

It’s not stress.” That’s right. There are other reasons for using these.

They affect pain. Actually, they affect very much pain fibers, and also,

motility. So they can really help normalize bowel movement. And the

recommendation here is the tricyclic antidepressants would go for diarrhea

type IBS. And tricyclic antidepressants, they’re the older form. And they

have a bit more side effects, but still many people do fine with them. And

those are things like Amitriptyline and Doxepin.

And then, the more modern SSRI’s are more so recommended for the IBS

constipation type. And that would be things like Prozac and Lexapro.

Those are SSRI’s.

Then for constipation, there’s prosecretory agents which are a form of

laxatives. And these are things like Linzess, Amitiza and plecanatide or

Trulance—so, linaclotide, lubiprostone, and plecanatide. And this help the

body to secrete water into the large intestine. They help constipation.

Page | 38



But actually like rifaximin and like antidepressants, they help not just one

symptom. They help pain, bloating and the bowel movement irregularity.

So they help what’s called global IBS symptoms.

And then for the diarrhea type, there’s 5-HT3 antagonists like alosetron

and ondansetron. They just have some controversy with them, but they are

still (at least in the US) available.

And then, there’s a newer medicine called Viberzi or eluxadoline. And

that is a very interesting medicine. It actually is an opioid receptor-active

drug. And what it’s trying to do is take advantage of opioids ability to

cause constipation for a diarrhea patient.

But what they’ve done here is this drug has three different receptors that it

activates. And it’s not all out opioid the way that a drug would be that

would make you constipated. There’s a part of it in there that would

mediate the constipation so that the diarrhea patient doesn’t become

constipated. It simply lessens the diarrhea. So that’s Viberzi.

So, those are the standard treatment options in general for IBS. And you

can see, except for rifaximin, which is working at the cause (which is the

underlying bacterial overgrowth), these are mostly just symptomatic

controls. But these are the options.

And also, I forgot to mention for diet. The Low FODMAP Diet has been

made very, very famous for helping IBS symptoms. And many studies call

for it to be a first-line therapy.

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So, Dr. Siebecker, thank you so much. That was a fantastic, fantastic

session. I really appreciate your help. And I hope everyone continues to

learn from you and feel better. Don’t give up everybody.

Dr. Siebecker: Absolutely! Thank you.

Shivan Sarna: Thank you.

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