sibo, sifo, candida, and co-conditions: every …...i've been lucky enough to attend...

SIBO, SIFO, Candida, and Co-Conditions: Every Patient Should Know About Masterclass

with Dr. Satish Rao

Shivan Sarna: Hi everybody. Shivan Sarna here with Dr. Satish Rao. And I am very grateful for his time, his energy, his brilliance and sharing it all with us. This is a class, a masterclass, from SIBO SOS® and Digestion SOS™ on SIFO, small intestine fungal overgrowth. You can see on the screen Dr. Rao’s incredible—just a few of the lines of his resume. He’s a gastroenterologist. He is at the Medical College of Georgia. And is it Augusta University? Is that the name of the university? Dr. Satish Rao: Correct! Shivan Sarna: …in Augusta, Georgia. As you can see, the Neurogastroenterology & Motility Director. That’s a great title, one of the many that you have. I really love hearing from you, love learning from you. I've been lucky enough to attend conferences where you've presented. I know you have some brand new papers and studies that have just been released that we're going to talk a little bit about. I'm going to let you take it away in the presentation with slides. Everybody, if you haven't gotten into your portal yet, know that these slides are in the portal for you to download. And the transcripts and the recordings will be there. If you're watching this on the day of the presentation, they'll be there within seven days. If you're watching this after that, they should be in the portal right away for you. Okay! Thank you, Dr. Rao. Take it away!

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Non-Transferable Access Provided to SIBO SOS® Speaker Series Chronic Condition Rescue

Dr. Satish Rao: Thank you, Shivan. And good afternoon to everybody on this webinar. It is a pleasure to be here. I’ll share with you some of the new knowledge and developments, and some historical aspects of this condition… and really, my thoughts and how we've been approaching this problem for the last 20 years or so. I'd like to thank Shivan and their entire team for hosting this event and for bringing all of you to this knowledge. And hopefully, this should help you individually as patients, but hopefully also give you the knowledge that you need to share it with your physicians and healthcare providers so that they can help you to get better. So that's our goal. So, Shivan has given me a large assignment. I could probably spend one day on each of these topics, small intestinal bacterial overgrowth, small intestine fungal overgrowth, the role of Candida, and how this can lead to really devastating GI symptoms. So, these are the objectives that I've set forth for this presentation: to primarily discuss why and how people experience gas and bloating symptoms; Second, discuss what are the common symptoms and patterns of symptoms; And what are the tests that are currently available to us, particularly breath tests and its clinical utility, and a somewhat more invasive tests where we go down with an endoscope, take juice from the small bowel and aspirate the juice, hunting for potential microorganisms that may be causing these symptoms; And more importantly, talk about several new tests in these arenas; We will also talk about diagnostic tests for SIFO which is a relatively newer condition in this area. People have talked about Candida and so on for years. But we never really fully understood this. But I think our group has done some nice work that I would like to share with you; And most importantly, treatment of SIBO and SIFO; And lastly, a new potential problem that we've encountered in the last five to seven years where there is a link between SIBO and SIFO with brain fogginess, a common enough symptom whose prevalence, I sincerely believe, is rising fast in the population. We'll talk about that.

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So, tall order… we’ll try and see how much I can do justice to all of these in the next 45 minutes or so. First, let's talk about what causes bloating. And here in this particular slide, if I can start at the top right-hand corner, we have SIBO and SIFO (small intestinal bacterial and fungal overgrowth) which is the crux of this presentation. But if you look right next to it, if you have a problem causing obstruction to flow of gut fluid, stool, gas and so on (maybe from cancer, maybe from a stricture or narrowing, or a twist in the bowel), then you will get bloating. [05:25] Likewise, if you have a sugar intolerance, carbohydrate intolerance such as lactose intolerance, fructose intolerance, fruit sugar, fructan (which is the sugar that is present in wheat and onions and garlic and so on), or you have hypersensitivity in the gut— In other words, there is minimal or no distension, but you feel bloated, you feel full. And that's because the nerves inside your gut have become very sensitive, and they are firing away messages informing the brain that something catastrophically is going wrong in the gut. But indeed, there is nothing catastrophically going wrong. These are alarm symptoms or alarm mechanisms built in the body to warn us of some impending danger. But these nerves are normally dormant or asleep, but they've been woken up for some reason, and they are now firing away even when normal things are happening in the gut. This is the phenomenon of hypersensitivity. In other words, you're more sensitive than normal individuals who also have the same level of distension. They don't feel it. But patients who are hypersensitive feel this normal level of distension. That is what we mean by hypersensitivity. There is a less well-known and somewhat rare condition called abdominophrenic dyssynergia. What happens here is, normally, when we eat a meal, the stomach is full, the belly distends, and the diaphragm (which is the muscle that separates the heart and lungs from the belly organs) normally rises up. So the diaphragm rises and the abdominal wall slackens a little bit, but it's fairly fine. But in people with dyssynergia, there is incoordination of this. And instead of the

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diaphragm rising, the diaphragm tends to go down, and the abdominal muscle wall really relaxes and bloats out. So there is this abdominal phrenic or diaphragmatic dyssynergia. Lastly, at the top, patients who are constipated—either because the colon is very lazy and not able to move stool, or in those who have what we call dyssynergic defecation where the act of pooping is abnormal. Unbeknown to them, they are retaining stool inside the body. And they are not able to empty completely. This is a condition that I and a few others described about 25 years ago. So, both of these conditions that is stool retention, likewise gas retention, that can also lead to bloating. So, these are some of the very common causes of bloating that I and my colleagues normally strive to identify. And if present, we can treat them effectively today with a number of treatments. Let me delve into this patient’s story because I think this may resonate with some of you out there. And any cases that I discuss usually are cases that I've actually seen in my practice. This was a 67-year old retired engineer with a history of Reynaud’s. Reynaud is where you have blue fingers, gastroesophageal reflux disease, joint stiffness. He presented with about an 18-lb. weight loss and significant bloating and intermittent diarrhea. The patient was on several medications including Diltiazem which is a blood pressure medication, Xanax for sleep, Lansoprazole which is a PPI drug for heartburn and reflux, a stool softener and a multivitamin. The patient had a number of tests—endoscopy test, stool tests, et cetera. And the CT scan, all of these, were normal. And typically, I would ask my physician colleagues, “How would you advise? What test can you do? They've already had a lot of tests. And so, which one?” And this is the question that I usually pose to my colleagues: “Would you order another colonoscopy? Would you give this patient probiotics? Would you give them an empirical trial of antibiotics? Or would you order a lactulose hydrogen breakfast or a glucose hydrogen breath test?” So, these are some classical questions that I would pose to one of my medical colleagues.

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Here, I think the correct answer would be to perform a glucose breath test rather than doing yet another colonoscopy. This is what we did in this patient. This is a profile of a glucose breath test. What we do in this test, I'll describe momentarily. But just let me walk you through the results of this test. [10:16] On this vertical axis, we have hydrogen and methane gas shown in parts per million. On this horizontal axis, we have the time scale. So, this is the baseline before the patient drank any glucose. The patient has very little hydrogen and methane, somewhere about 0 to 5 ppm. About 45 minutes to an hour, there is an abrupt increase in hydrogen. And along with this, the patient reported diarrhea, the symptoms that the patient has been experiencing for a long time. And over the next one and a half hours, you can see that the hydrogen values climbed all the way to 100 to 110 ppm. This is an abnormal glucose breath test. And this test reveals two things: Number one, there has been fermentation of the glucose in the upper part of the small bowel, leading to excess gas production. Additionally, we reproduced the patient's symptoms of diarrhea. So this was both a diagnostic test reproducing the patient's symptoms and showing a rise in breath hydrogen, giving us a diagnosis of small intestinal bacterial overgrowth. So, what is SIBO? And what is SIFO? Medically, I think this is the most appropriate definition where we define SIBO as “the presence of excessive number of bacteria and/or fungal organisms in the small bowel, leading to symptoms of gas, bloating, abdominal distension, abdominal pain or diarrhea.” Normally, the small bowel is relatively sterile, particularly the upper half of the small bowel where there is little or no organisms. The lower half may have a small amount. Now, remember, the small bowel is about 19 to 20 ft. long. So, in the upper third, the upper half, there should be virtually nothing. Secondly, we define SIBO or SIFO when we can harvest or grow bacteria with a particular level of confidence at a particular count. Here, we use a definition of a thousand organisms per ml or

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colony forming units per ml. If we can find a thousand or more, then we call this SIBO or SIFO in our conventional clinical practice today. So, let's talk about what are the symptoms that patients with SIBO report commonly. This is in a survey of 139 patients that we reported. You can see, some of you who are listening in may be experiencing all of these symptoms. The most common symptoms are pain, about 78%; cramping, 84%; bloating, 81%; 65% to 70% had fullness and nausea; about half reported vomiting; again gas, nearly 80%; and about half had either diarrhea or constipation. These are the common symptoms that patients with SIBO report. We have now done five different studies. And these data are fairly reproducible across the studies. And these are by far the most common symptoms. So, what are the factors that are naturally given by God to protect us against SIBO because, normally, there is very little bacteria as I’ve said before? How does this happen? Well, we are all eating food that is sometimes contaminated with bacteria and so on. But the acid, hydrochloric acid in the stomach, is a very important defense mechanism. It virtually destroys and sterilizes the food that we eat. So the gastric acid protects the small bowel against infection and colonization. The second important factor is this migrating motor complex. So here, in this little chart here, we have multiple colors—the red, green, magenta, blue, et cetera. What you see is pressure activity that was recorded from a normal, healthy individual in the stomach and in the small bowel. Every 90 minutes, as long as we fast, there is a recurring cyclical activity called the migrating motor complex. It has three components, the most active component is what is shown here where, in the stomach, it beats about three times a minute. These big, green things you see, those are called giant antral contractions. And then, the next two are in the duodenum; and the last two are in the jejunum. And there is this very strong phasic, tonic activity that moves and sweeps through the small bowel, cleaning up the small bowel. This is called the intestinal housekeeper. As long as we fast every 90 minutes, this recurs in all of us. [15:34]

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If something has happened to this MMC or migrating motor complex, either because there is a nerve disease in the gut, a muscle disease in the gut, or there are medications that you're taking, or something has disrupted this, then we have lost the housekeeper. When we no longer have a housekeeper to keep the house clean, thus bacteria will all accumulate, causing SIBO. The gut produces a lot of mucus. Mucus has a lot of bactericidal or anti-bacterial effect. Then we have lipopolysaccharides which is the lining of the cell wall tight junctions. They all prevent the bacteria from invading the gut, gut immunity. And last, but not least, there is a gatekeeper between the junction of the end of the small bowel and the beginning of the large bowel. The end of the small bowel is called the ileum or terminal ileum; the cecum is the beginning of the large bowel. At this junction, there is a valve. The valve acts as a one-way gatekeeper, allowing food that has been digested to enter the large bowel and stopping the large bowel bacteria or poop from backing up into the small bowel. If this valve is dysfunctional or has been removed or compromised by surgery or what-have-you, then bacteria from the colon can easily invade the small bowel, causing SIBO. So, these are some of the protective factors and how manipulation of these factors may cause SIBO or SIFO. So, what have we found in some of our studies? People who use proton pump inhibitors—very good drugs, very useful and effective for treatment of gastroesophageal reflux disease and ulcer diseases and so on. But unfortunately, they are just too powerful and strong, particularly in chronic use, because you are diminishing and decreasing acid production. In other words, you're weakening the acid barrier. Thereby, you're allowing bacteria to sneak through the stomach and colonize the small bowel. Likewise, the MMC is disturbed and there’s small intestinal dysmotility;

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Diabetes is a condition where your immunity and your gut motility is compromised; previous gut surgery; people who are immune-suppressed or on steroids; people who have muscle diseases such as scleroderma or Ehlers-Danlos Syndrome or other muscle problems where the gut motility or the gut muscle is weak; pseudo-obstructions; people previously who've had a colectomy where, many times, the ileocecal valve that we just talked about is compromised. And there are some patients in whom we really don't know why, but something has changed their gut function, leading to SIBO. So, here is a study that we published where we looked at two important factors. PPI use, can it predispose to SIBO? Yes. In this study, you can see, when compared to those who are not using PPI, those who use PPI had clearly a two-fold increase in the prevalence of SIBO. Likewise, in patients who had normal motility versus patients who had abnormal motility, there was a significant increase in the prevalence of SIBO. Here, we also looked at people who have normal transit time or a delayed transit through the small bowel. This was measured by using a wireless motility capsule study. And once again, you can see there is a two-fold greater increase in the prevalence of SIBO in patients with slow transit in the small bowel. And the odds ratio was almost three-fold higher. Here is the information about the colectomy story that I shared with you earlier on. So we took a group of patients who had colectomy and another group who had no colectomy. And you can see, when compared to controls, there was no SIBO in 64%. But 36% of patients (these are all coming with gas and bloating) had SIBO or SIFO. Whereas in the colectomy group, you can see that almost 66% had SIBO or SIFO as shown in this slide. So, colectomy predisposes to SIBO. [20:00] So that, if you like, is a little background to why you get SIBO, how we protect our gut, and what are the factors, if they are weakened, can lead to SIBO.

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How do we go about investigating SIBO? Well, this is what we as physicians and healthcare providers should be doing: we really need to take a detailed history, talk about the patients, look at predisposing factors and conditions that I've just mentioned. And one other way to investigate is really to maybe give them a trial of antibiotics. I'm not a big fan of this approach because you're then on a slippery slope as to where is the baseline. Was it really a diagnosed SIBO? Or was it something else that caused gas and bloating? But I think it is not unreasonable if a healthcare provider does not have access to a number of tests that I have access to consider this as a one-time trial of antibiotics to see if a patient’s symptoms respond to antibiotics. If so, there is a diagnostic clue that maybe SIBO is the cause of that gas and bloating. Stool tests are not useful for SIBO because bacteria in the small bowel stool test usually reflect bacteria in the colon. The breath test is the most common way today for diagnosing SIBO. We’ll talk about the breath test in a minute. We have two commonly widely done breath tests—the glucose breath test and the lactulose breath test. I will talk about endoscopic-assisted glucose breath test momentarily. And then, what is considered the gold standard approach is to actually get the juice. For example, if you have burning urination, or you have a cough and you're producing sputum, or you have a sore throat, what do we do? We get a throat culture, we get a sputum culture, or we get a culture of your urine… send it to the lab. If the lab grows bacteria or an infection, we diagnose the infection. And we treat it appropriately. Likewise here, the best gold standard approach would be really taking the juice from the small bowel, culturing it, and then using that as a basis for diagnosing SIBO. So, the breath tests are easy. They're practical. They’re objective. And they're very easy to do. Here is what we do in our lab here. These protocols are for a number of breath tests, not just the SIBO test. The third in that is the bacterial overgrowth or the SIBO test where we use 75g of

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glucose, dissolve it in 250 ml. of water, we take a baseline breath sample, and then after we administer the solution, we continue to measure every 15 minutes for two hours. And then, we have fructose for people with fructose intolerance. For lactose, we use this. And for fructan, that is what we normally use in our lab. Now, prior to this, we asked our subjects to report abdominal symptoms. There are nine symptoms that we use. We have validated this questionnaire. And I was mentioning to Shivan earlier, just before we started, we have now developed a simple app (that will be available in the App Store hopefully within the next couple of months or so) that you can use to score these symptoms at home and maintain a prospective diary that you can then share with your healthcare providers who will then have an objective way of assessing your symptoms, both for diagnosis. And after an intervention or treatment, they can see what response you've had or you've not had a response. So, this would be a very useful way of quantifying the frequency of symptoms, the intensity, and the duration of these nine common symptoms associated with gas and bloating. So, in terms of the breath test, we have our patients report or answer the questionnaire. We then have them discontinue PPI, laxatives and drugs that affect motility for a week. And also, diet, the day before, we keep them on a strict low lactose, low fructose-containing, low fat food without vegetables and fiber. They need to brush their teeth, et cetera, before the test. And then, they need to fast overnight. And during the test, we recommend no exercise and no smoking. They come into the lab. They blow into one of these especially made tubes where we collect expiratory breath sample. It’s important. It’s not the beginning or the middle, but really, the end of the breath sample is what we collect. That sample of air from there is then plugged into one of these machines that are widely available (Quintron is one popular machine that we use, but there are others that are available). And then, this gives a read-out of the breath hydrogen and methane and CO2 levels. [25:05] One of the challenges we have is there are different kinds of gases that are produced inside the gut. The most common gas that we've been measuring for over 30 or 40 years now is hydrogen.

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Another important gas is methane. So, inside the gut, we have hydrogen-producing bacteria and methanogenic organisms. Methane is produced by another family called archaea. Archaea are organisms that evolved even before bacteria were born evolutionary-wise. So, they also produce methane. They consume hydrogen and produce methane. And these methanogenic organisms can colonize the small bowel leading to SIBO. We've also recently started testing—particularly Dr. Pimentel’s group has really pioneered this, the hydrogen sulfide technique. And we can identify a lot of patients who can produce hydrogen sulfide, which sometimes what happens is— I mean, just to give you a reason why this is so important… earlier on in a breath profile, I showed you a hydrogen rise. Some people, in the olden days when we were not measuring methane, they would get a very flat curve. Although the patient would have a lot of symptoms, we would assume that that patient did not have SIBO. But now, in the same patient, we measure hydrogen and methane, the hydrogen is flat, but the methane goes up because they are producing a methane rise, not a hydrogen rise. Likewise, there are today several people whose hydrogen and methane is flat because they’re producing hydrogen sulfide. And now, with the addition of this third method of breath testing, we can detect even more patients who may have SIBO. But given our current clinical use, we only have hydrogen and methane, in this very large study that has just been published as a matter of fact this week in the Digestive Disease and Sciences (the largest study to date) where 1300 patients underwent 2300 breath tests, 733 patients had a glucose breath test, and what you can see here is about 33% of these patients were positive for SIBO, 67% were negative for SIBO. That is the best result we can get from this test. There is a limitation of this glucose breath test because glucose is richly and avidly absorbed in the proximal small bowel. So, glucose will only go maybe up to 6 ft. in the small bowel before almost all of the glucose is absorbed in the small bowel.

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So, if you have bacteria within the upper 3 to 6 ft., you'll pick it up. If you have bacteria further down, unfortunately, this test cannot pick it up. On the other hand, for the lactulose breath test, lactulose is another synthetic sugar which is non-absorbed in the gut. And when you take it, it goes unchanged through the stomach and small bowel. It reaches the colon where it gets fermented. And it’s often used as a drug for laxation and for treating constipation. We and others have found that if you give lactulose in the presence of bacterial overgrowth, prematurely, lactulose (which is the sugar) gets fermented by the bacteria in the small bowel, producing a rise in the breath hydrogen curve. As you can see here, within 30 minutes or so, there was a significant increase in the breath hydrogen level. And that happened because of bacterial fermentation. So, this is another test that is commonly used for identifying SIBO. I'm going to skip these two slides, and then move on and talk about another method if this video plays. So this is the method we use for identifying SIBO if the breath test is negative or if I want to truly quantify and identify what kind of bug is causing the SIBO, or if I wish to identify SIFO, the fungal overgrowth. There’s no breath test for fungal overgrowth. This is the only test which is aspirating juice from the small bowel. So, to do this, what we do is the patient is sedated. The patient is already sleeping. I have an endoscope, which I've already placed in the second part of the small bowel (the beginning of the small bowel or the second part of the duodenum). I then wear sterile gloves here. We have this special catheter called the liguori—a very fine, thin catheter which I'm preparing. [30:03] So, what we will do is we would pass this catheter through an endoscope into the small bowel. And then, using sterile precautions, we draw between 2 to 3 ml. of juice which is then picked up in this syringe. The syringe is capped with a sterile cap and immediately transported to the microbiology lab where they will be cultured for bacteria and fungal overgrowth. But when you culture, what kind of bacteria do we pick up? There are a whole host of bacteria that are on this slide that we picked up in this report that we published about seven years ago, all

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kinds of what we call aerobic and anaerobic and gram-positive and gram-negative bacteria that we pick up in the lab. So, here is a breakdown of a group of 124 patients who came with unexplained gas and bloating symptoms and what was the [yield] of duodenal aspirate and culture in this group? On the left-hand panel, you can see that we grew a positive test in 62% of patients. And there was no overgrowth in 38% of patients. What was the breakdown in the 62% of patients? Twenty-five percent had pure SIBO. That is bacterial overgrowth. About 20% had pure SIFO or fungal overgrowth. And another 20% had a mix of both SIBO and SIFO. So, that is the expected prevalence of SIBO/SIFO when you do the culture. Now, what about the breakdown of the different kinds of bacteria? What you can see here is the majority of the bacteria we tend to grow are so-called aerobic bacteria (that is they need a lot of oxygen). And about a third of them are anaerobic. And in an even smaller group, there is mixed aerobic and anaerobic culture. The question that many of you may be asking is, “Well, Dr. Rao, you first talked about the glucose breath test. Then you talked about aspirate. Well, how good is the glucose breath test?” I said the yield is about 33%. But how good is the agreement between a positive glucose breath test and culture? And here is the agreement. In our hands, in about 65% of the cases, there is good agreement between glucose blood test and culture. But in about, as you can see, 35% of patients, only one of these tests is positive, either the glucose breath test or the duodenal aspirate and the culture. So let's assume both of these tests are negative—glucose is negative and the aspirate is negative. Could the patient still have SIBO? Yes. And the reason why it's negative is because we are only either aspirating or using glucose that is only gathering information from the proximal 3 to 5 ft. of the small bowel. What about bacteria in the middle part of the small bowel? What can we do?

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So, we have tried a different method where, during endoscopy—here, you can actually see me holding the endoscope. Here, the subject is sleeping. And what we're doing here is we're infusing the glucose solution through the scope 3 ft. feet down the small bowel. What we’re trying to do is we're trying to cheat the gut in a way, trying to get the glucose to profuse the small bowel beyond what normally happens when you drink the glucose solution. This is called endoscopic-assisted glucose breath test. Here is a patient who was negative for glucose breath test and culture. But after we gave them the endoscopic test, you can see there is a significant— The green line is the oral glucose breath test. You can see, this is the glucose breath test flat curve. But when we gave the same glucose endoscopically, there was a significant rise, indicating that this method is picking up overgrowth further downstream. And we were able to show this in a much larger sample of patients having a positive. And this is what we call distal SIBO as opposed to the proximal SIBO. Now, there are several exciting new methods of identifying SIBO. Here is one capsule detection technology that's coming out of Australia, where you can swallow this capsule, and instead of really collecting a sample of air, this, as it goes down, actually has its own ability to measure. And then, it sends that messages through into this little recorder that is handheld outside the body. And we can get this kind of hydrogen and curves. [35:05] Another new capsule which I'm truly excited—and we are the first site in the world to first actually test this (we will start this testing next week as a matter of fact)—is this unique capsule with a little window. What happens here is the patient swallows this capsule, and it has a method of detecting whether it's in the stomach or in the small bowel. Once it is in the small bowel, this window opens, a little wick comes out of this window, it starts sampling the juice in the small bowel for 15 minutes. And then, this window closes. You will eventually pass the capsule. But meanwhile, what is inside this capsule is a highly sophisticated microbiology laboratory. It has all the capabilities like in a regular lab. It cultures or quickly identifies the genetic fingerprint of bacteria through RNA analysis. And it gives out a

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report such as this and a quantitative report of colony-forming organisms, whether there are aerobic organisms (if there is mirabilis, E. coli, Streptococcus mutans and so on and so forth). So, it's a very sophisticated new method of detecting SIBO and SIFO. Now, can you differentiate patients who have SIBO or SIFO based on symptoms? Here is the best evidence for that, a study we did with 124 patients. And you can see, the purple are those with SIBO. The magenta or orange-ish color is culture negative. The blue is SIFO. And these are the mixed SIBO/SIFO group. You can see that the prevalence of symptoms are identical for pain, chest pain, bloating, gas, et cetera. So, based on symptoms alone, whether one is positive or negative, we cannot differentiate the patients. You really have to rely on testing, one of the tests that I've described. What about treatment? Ideally, you want to do some form of aspirate or this new capsule technology that I mentioned so that you know exactly what bug or combination of bugs there is, and also get the lab to tell us what antibiotic this particular organism is susceptible to and use that information to guide treatment. But this is a far cry because, with breath tests, we will not know and so on. But with aspirates, whenever I get a positive aspirate, I get this very vital information. And therefore, I'm much more successful in my treatment because I have this key information as to what bacteria it is and what it is susceptible to. And therefore, we get much better eradication of bacteria. But I know it's not always possible. Not everybody does this. And hopefully, if more people do it—or this newer technology may make it more accessible in the future. What about antibiotics? I use a number of antibiotics based on the culture results, primarily amoxicillin, metronidazole, ciprofloxacin (although I’m using less of the floxacins now because of concerns of toxicity), sulfa drugs, cephalosporin and rifaximin… a whole host of drugs we use.

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Here is an example of what kind of culture reports I would get. In one patient, a 56-year old, with gas and bloating, with an aspirate, the patient grew E. coli, 10,000; Klebsiella pneumonia, 10,000; gram-positive Bacillus, more than 100,000. And my lab gives me a report. It is resistant to ampicillin, sensitive to propicillin, et cetera. And I use this chart to guide me about the appropriate treatment. What about rifaximin? It has been shown in several studies to be effective. Here is one study were rifaximin three times a day was compared with tetracycline and shown to be more effective in improving symptoms of gas and bloating and so on compared to tetracycline. Here’s another study where a high dose of rifaximin was compared with a lower dose. And the higher dose provided more normalization of the breath test than the lower dose. And in terms of do antibiotics truly normalize SIBO as assessed by breath test. Yes, it will. The data is still not the greatest. There are a small number of samples. But clearly, overall, there is evidence to support its reduction. And finally, how effective are antibiotics, any antibiotic on the left-hand panel versus Rifaximin? So, both groups are clearly effective. As you can see, the ratio is in the favorable range for both of them in terms of improving symptoms. One of the final questions that many times I'm asked is: “Well, we've identified SIBO. We’ve treated SIBO. How do we prevent this from coming back?” [40:02] Now, this can be a challenge sometimes. Here is a list of some things that we can do. Well, eliminate as far as possible or minimize the predisposing causes. For example, if someone is taking PPIs and the indication is not clear cut, I would remove this drug altogether; If someone is on drugs that are slowing motility, for example opioids, if there is a way we can mitigate that, either through drugs that now have the ability to neutralize the opioid effect on the gut or remove opioids, then we can do that;

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Then antibiotics and antifungals for patients with long-term SIBO/SIFO for problems. Then I use something called cyclical antibiotics where I will give them repetitive courses, low doses of antibiotics to prevent the development of SIBO and SIFO; And the third would be to use non-chemical plant-based antibodies and antifungals such as oregano oil, berberine, et cetera (there are several that are available). These are less toxic; also not as potent as chemical antibiotics, but may be useful in preventing relapse; And lastly, the role of diet, highly controversial but maybe there are questions. We can talk about that. Here's another story of a 45-year old lady with weight loss and a history of a previous peptic ulcer disease and strictures. The glucose breath test was normal. Then what is going on with this lady? Well, what kind of culture should you do? Here, we did a culture of the small bowel using the same methodology I described. And we grew a high amount of two different Candida—Candida glabrata (10,000), Canada albicans (more than 1000). So, this is the best example of SIFO where bacteria tests were all negative (GBT, et cetera). So, fungi can also colonize the small intestine. And we're seeing hundreds of thousands of growth of fungi in the small bowel. Although when we look endoscopically, just as I showed you in that picture, the lining looks perfectly normal—yet it is teeming with fungus. We've shown this now in three separate studies, that up to a quarter of our patients with unexplained GI symptoms have SIFO. And so here in this study, our goal was to determine where the SIFO happens. We looked at the symptoms. And as I showed before, really, symptoms do not differentiate between those who have SIFO and those who don't. A quarter of the patients have SIFO (as shown in this particular slide). But what happens in other areas—and this is what it is. If you have thrush on your tongue, or you have thrush in the esophagus, this is how it looks, this white coating or whitish discoloration. But

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in the small ball, this is completely normal. I know you've seen some little, white things. That is just water bubbles that are being reflected by the light. But this is not an infection. Normally, the gut lining is very clean. Several kinds of Candida and aspergillus, et cetera, can colonize the gut. And this is the yield of what we found in our sampling. The majority, 97% had Candida—Candida albicans, torulopsis glabrata, penicillium species. And the yield, as you can see, more than a thousand in about 42%, more than 10,000 in 40%, and more than a hundred thousand in about 20% of these patients. So, what about treatment of SIFO? There are three classic groups of drugs that we use. First are these azole group—fluconazole, itraconazole and posaconazole. Then we have some more which are more potent, also more toxic, caspofungin and anidulafungin. And then, even more potent are amphotericin b and so on. But nystatin is an oral available drug. It belongs to this class of polyene macrolides that can also be used very easily by most doctors. So, what are the various factors that can influence the treatment of SIFO? Well, the severity of the disease. Patients may have some intolerance or allergies to certain fungal organisms where there are several other organs involved other than the gut; underlying immune status (whether they are immunosuppressed such as they are on steroids or they have diabetes or HIV or so on); and then the type of Candida strain. All of these factors may influence SIFO. A quick word about this fungal biofilms that some of you may have and may ask this question… these are like a gel matrix that are produced by bacteria as a protective mechanism. And so, you really need drugs that can break down this matrix, that can penetrate, and thereby destroy the organisms. And I think that may be very important. [45:22] So, to conclude the SIFO section here, approximately a quarter of the patients with chronic unexplained GI symptoms of gas, bloating, they have SIFO. Symptoms alone cannot differentiate it. The only method that we can use today is aspirating and culture from the

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duodenum. And whether symptoms improve our treatment of SIFO however needs further careful analysis. Let me go to the last part of my presentation where I mentioned talking about this brain fogginess issue. This, we have now seen in several hundred patients. So here is a story of one of the first patients who came to see me. One year history of progressively worsening bloating and severe distension. It looks fairly straightforward SIBO or SIFO. Immediately after a meal, the patient would become distended and distressed. But then, there was this new symptom. The patient would get severe fatigue and brain foggy and tired. I have not come across this before. Vaguely, people report this. But this was intense enough to this bank executive that, inadvertently, the executive signed off some high value checks to some of the customers. So, the patient was on PPI, statins and insulin. He had been taking a recurrent course of probiotics to help this bloating and severe distension. A doctor thought she may have IBS, “So, why don’t you take probiotics?” which initially seemed to have helped. But then, thereafter, she didn't know, so she continued to use it. Standard tests were all negative. Here, to further understand this unusual combination of bloating and brain fogginess, we did more than a simple glucose breath test. Here is a glucose breath test profile. Clearly, there's a significant rise in hydrogen. But we also measured an important metabolic product called d-lactic acid. This is normally produced in very tiny amounts in the body. When we measured it in this lady, we saw that there were slightly higher levels to begin with, but a significant elevation, along with reproduction of cramping, bloating, headache, and brain fogginess. Her symptoms were reproduced along with a significant increase in d-lactic acid. So, this lady had metabolic acidosis induced by something that is fermenting in the gut. And we now know that one of the important things that can cause this is Lactobacillus.

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Unfortunately, the probiotic that this lady used colonized in the small bowel. And when she ate a normal meal containing glucose, the Lactobacillus was fermenting the sugar in the diet and producing large amounts of d-lactic acid. We have limited ability to clear d-lactic acid. And as long as d-lactic acid persisted in the body, the brain was foggy. Once the kidneys were able to clear that, the brain fogginess also cleared. We went on to study a large number of these patients now. This is a paper that we reported last year that garnered a lot of press. And here, you can see that there was significant reproduction of brain fog during the breath test in about two-thirds of these patients. And in terms of medication that these patients who had brain fog were using, almost all of them, 30, were using probiotics. Some were on large doses of yogurt. About a 30 were on PPIs. And a small number were on opioids and some other supplements. We stopped the probiotics, decreased or eliminated yogurt for a short while, aggressively treated them with two to four courses of antibiotics. And you can see not only their brain fogginess, but their global symptoms significantly improved. So, to sum up, if a patient comes to me with unexplained bloating and gas, we have two options. We can perform the breath test that we discussed, or you can really do a therapeutic trial with an antibiotic. If the trial of antibiotic is negative, I would encourage everybody to review the diet. Look at a food diary. Alternative medicine use PPI therapy, gum use, over-the-counter medications, et cetera. But if they're unresponsive, look about probiotics and acidosis. Think of visceral hyperalgesia and dyssynergia. And then, you can treat them appropriately. If you go through the paradigm of breath testing, there are a number of breath tests. We typically start with a glucose breath test. If that is positive, we don't do any of the other tests, wait for treatment of SIBO. And if SIBO has taken care of the symptoms, they don't need any further testing. [50:09]

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But if they still have persistent symptoms, then we look for sugar intolerance—for fructose, lactose or fructans. Again, if these tests are positive, we identify the sugar intolerance or bacterial overgrowth through this testing. If there is a sugar intolerance, then we will put them on an exclusion diet or an enzyme or supplements. If it is bacterial overgrowth, then we would treat them with appropriate antibiotics like I’ve discussed before. So, my final slide for you… all bloating and gas is not SIBO. I think we tend to equate SIBO as the cause. It is not always the cause of bloating and gas. It is an important message. But a significant proportion will have this. If you're not responding to traditional treatments of SIBO, think of SIFO, think of sugar intolerance because these are other common causes of unexplained symptoms. Glucose breath test is a useful first test for SIBO. But clearly, even today, the duodenal aspirate and culture remains the gold standard. The endoscopic-assisted breath test or the wireless capsule methodology are all newer tests that are evolving and need for validation. Prevention is going to be important for those who have a diagnosis. Look at medications that they may be taking, such as PPI’s, opioids, et cetera. Sometimes, patients may need cyclical courses of antibiotics or antifungals. And then, optimal approaches still need to be worked out, but maybe there is room for herbal antibiotics, diet, environmental issues, and so on. Lastly, a word of caution… I use probiotics in my practice in very specific indications. But probiotics may not be a panacea for everything. It may be harmful, as I've alluded to, and it may well be a cause of brain fogginess in many patients. So that is something I would like to bring to your attention. Thank you very much for listening. And Shivan, it's off to you. I look forward to engaging with you in a fruitful dialogue and helping our folks who are on this webinar. Thank you very much for listening. Shivan Sarna: Oh, my gosh! That was fantastic. Thank you so much. I jotted down a lot of questions myself. And we have a lot of questions to get to.

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Q&A with Dr. Satish Rao

Shivan Sarna: Okay! Quickly, before we continue with everybody else's questions, in terms of reducing relapse, are you a fan of prokinetics?

Dr. Satish Rao: Absolutely! The challenge though is what prokinetic and how long and how useful it is.

So, in the United States today, we have three drugs—erythromycin or azithromycin (which is an antibiotic in small doses. It’s a good prokinetic. It works in the stomach and the small bowel region. It can be effective in small doses). Metoclopramide has a lot of problems, side effects. And the nausea is its main effect, but it’s also a weak prokinetic agent. And the most recent is prucalopride which has been approved by the FDA for treating constipation but has been clearly shown to accelerate small bowel and gastric emptying time. It can be effective.

Lastly, Tegaserod, which was approved, removed from the market 10 years ago… and it’s back! It’s just been re-approved by the FDA. And it's already in the market for IBS, constipation, et cetera. But nonetheless, it is another good prokinetic that I’ve used extensively in the early 2000s very favorably and safely.

So, we have these for compounds that we can use.

Shivan Sarna: The last one, is the brand name was Zelnorm?

Dr. Satish Rao: Yes.

Shivan Sarna: Is it still Zelnorm?

Dr. Satish Rao: I think it is still Zelnorm… although I'm not a hundred percent sure. I believe it still is Zelnorm.

Shivan Sarna: And what was the name again of the non-branded…? It’s not…

Dr. Satish Rao: Prucalopride?

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Shivan Sarna: That’s Resolor or Motegrity.

Dr. Satish Rao: Motegrity, yeah. In the US, it’s Motegrity; it’s Resolor in Canada and others.

Shivan Sarna: And what’s the original name of Zelnorm?

Dr. Satish Rao: Tegaserod.

Shivan Sarna: Tegaserod. Okay, great.

I used that in the early 2000s before I even knew I had SIBO… and loved it! I’m so glad it’s back.

Dr. Satish Rao: It is back… as of last month.

Shivan Sarna: Excellent! Breaking news here, people. Okay.

And then, when it comes to probiotics, do you know if there's a way to get a d-lactate-free probiotic? You know how some of them produce all that?

Dr. Satish Rao: I think, predominantly, all strains of lactobacilli clearly are more likely to produce d-lactic acid. bifidobacterium also does it, but not to the same level as lactobacillus. It has a much lower propensity to produce d-lactic acid, but it does.

There are some strains of bifidobacterium, particularly the strain that’s in the Align Probiotic, is less likely to cause it. But other strains of bifidobacterium can colonize and cause these.

But those I think are, by far, the two large strains. Also streptococcus, which is in some of the probiotics, they can also cause it. So, all of the ones that are currently available in the probiotic formulations can predispose (although bifidobacterium is the least).

Shivan Sarna: Okay. And then what do you think about soil-based probiotics? Why are you smiling?

Dr. Satish Rao: No. No, no. You got to tell me about soil-based in the sense that what are they continuing?

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Shivan Sarna: Oh, I can go grab a bottle in a little bit. I didn't know if you had an opinion about those, like Megaspore, these soil-based spore probiotics that a lot of people really—I’ve certainly been helped by them as well.

Shivan Sarna: So, you have to educate me on that. I'm not familiar. I know spore-forming things, but I'm not familiar what organisms they are. Maybe we can talk about it.

Shivan Sarna: Okay, that would be great. Okay.

Our dear friend, Kiran Krishnan who you probably see at the conferences—or if you haven't met him yet, we need to connect to you guys.

Okay, let's see. Alright, take a breath, everybody. I know that was a lot.

“They contain bacillus strains.” Thanks, Carlene.

Dr. Satish Rao: I see…

Shivan Sarna: Bacillus indicus and HU36. I'll get you some info on it.

Dr. Satish Rao: I think bacillus also produces d-lactic acid if I'm not mistaken.

Shivan Sarna: It may.

Dr. Satish Rao: I think it does. But I’ll have to check. That's my recollection. All of this data I’m going over a year ago. And we did very serious searches for this. So…

Shivan Sarna: Understood… understood, okay…

[05:15]

Shivan Sarna: Let's get this out of the way. There is or is not a stool test for Candida?

Dr. Satish Rao: No. The answer is if you do a stool culture, there is a high likelihood of finding Candida. Just like if you do a skin sweep and take a skin culture and do a test, you will find Candida because normally there is Candida both in stool and on the skin.

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The challenge is trying to fathom out whether a person has excess Candida either in the colon or in the small bowel. And unfortunately, the stool culture is not a reliable method of identifying it because even normal people will excrete Candida in their stool.

So, it is not going to be easy to tease it out because it is a normal commensal in stool. So I think that is a challenge.

So, we don't know whether that is a cause or effect, or it's a normal organism that's growing in their stool. I think that remains to be the challenge. And that is why, whereas normally, there is no fungus in the small bowel—there shouldn't be any fungus in the small bowel—if you're picking it up in this amount, it clearly is pathogenic and is causing problems.

Shivan Sarna: And what do you think about the organic acids test when they have high levels of arabinose? Are you familiar with that?

Dr. Satish Rao: Keep going on… what did you say?

Shivan Sarna: Okay, I'm doing this for my memory now. There’ll probably be a question about it. But they think that if you have that, it’s a higher likelihood that you have systemic Candida.

Dr. Satish Rao: Oh, I see. I'm sorry, I'm totally oblivious to that test. No, I don’t know anything about it.

Shivan Sarna: Okay. And then, what about the GI-MAP stool test? Are you familiar with this test?

Dr. Satish Rao: Uh-uh… no…

Shivan Sarna: Okay, no problem.

Okay, so I'm just looking here. Karen and Betty, those are your questions.

So, I'm going to take a couple of live questions, but then I can't take any more because we have over 200 pre-submitted. So, I'm sticking with the ones that are pre-submitted. However, this is very appropriate, and I think it has also been pre-submitted. And this is about PPI use.

“When taking a PPI for only one or two weeks, is that enough to be a risk factor?”

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Dr. Satish Rao: I don't think so. I don't think a short course of one to two weeks of PPI will predispose anybody to SIBO/SIFO.

Shivan Sarna: Okay. And then, what do you think about a therapeutic trial fluconazole (Diflucan) to diagnose SIFO?

Dr. Satish Rao: It's not unreasonable. I think it's okay if you have symptoms that have not responded to standard antibiotics and so on, it is not unreasonable to go do a trial of a couple of weeks or so. But I wouldn't recommend repeat trials without definitive diagnosis. I mean, a single trial is okay. Empirical trial is fine.

Shivan Sarna: And when you say trial, like some people, they go to the doctor for a vaginal yeast infection, and they get one Diflucan? And then, other doctors will give Diflucan to a patient for a month.

Dr. Satish Rao: So, my usual SIFO treatment is 100 mg. once a day for three weeks. I think you will have to treat longer than two weeks in order to get rid of SIFO from the small bowel. So, a small but prolonged course is what is important.

Shivan Sarna: Okay. And from Gigi, back to the probiotics: “Since Saccharomyces boulardii is a good yeast… is it controversial? Is it good for people who have SIFO or suspected Candida?”

Dr. Satish Rao: So yes, saccharomyces is a better organism. But you know, even that has been shown to create this rare condition of this punch drunk syndrome scenario where it also colonized. There are at least two or three case reports now in individuals. And they presented to the ER as if they were drunk, and they never drank anything. And I think that has also been shown to colonize in the gut and cause this.

So, none of these, I would say, are foolproof. But in measured amounts, in appropriate—

[10:01]

Dr. Satish Rao: So, I'm not totally opposed to probiotics. What I mean is that they have to be given under physician/healthcare provider direction for a limited course of time. And that I think is the key. Assuming the probiotics are like a multivitamin that you can take without any adverse deleterious effects I think is wrong. That is what I think is critical…

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…which is what happened to all of these patients. Sometimes physicians advocated them (many times, they read in the public media). They felt that this is good for so-called digestive health. They are having GI symptoms, so they started taking it, little realizing that the same probiotic has actually contributed or worsened their problem.

Shivan Sarna: As far as nystatin goes which is a very popular drug for Candida and SIFO and all that, can you take it indefinitely? What's your usual usage of that?

Obviously, this isn't medical advice, everybody. Talk to your doctor. Share the information with them. But we're just getting some guidelines and things to discuss with our practitioners.

Dr. Satish Rao: So, that's a very good question. So nystatin is very good for the esophagus, especially in a swish-and-swallow, I use a lot of that and so on.

I have some concerns about nystatin being an effective agent in the small bowel because it may well lose some of its properties through the stomach acid. It may actually either breakdown and so on. I've also talked to my pharmacist. We've really done a lot of search. Unfortunately, there's very little information about nystatin.

Nystatin is meant to be in the gut. Very little is absorbed. So it's mostly topical in its effect. And it acts in the gut mucosa. There is very little research to back it up and say, “Well, if you give it orally, can you see good concentration of nystatin in the small bowel?”

That kind of experiment, typically, the way one would do that is take patients who have, unfortunately, had an ileostomy for whatever reason. They’ve got a stoma at the end of their small bowel. You give oral nystatin, pick up these fluid that's coming out and see what is the concentration of nystatin in that fluid at the end of the small bowel.

If we can detect sufficient concentrations of nystatin in that output, then confidently, we can say, “Yes, nystatin will be useful.”

But that kind of information is lacking in the literature. So it is not my go-to drug for non-esophageal Candidiasis. But some patients have either resistance or symptoms or allergies or side effects to fluconazole. And my next drug is either itraconazole or nystatin for them. Nystatin is much cheaper; itraconazole is expensive.

Shivan Sarna: Got it! And do you ever mix nystatin with Diflucan?

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Dr. Satish Rao: I'm not the biggest fan of any mixing of any drugs because you compound cost and you compound side effects. So, if one is not working, I would rather just give the other one.

Shivan Sarna: Okay.

Dr. Satish Rao: But they can be combined by the way. You probably wouldn't combined fluconazole and itraconazole or ketoconazole because they're all the -azole group. But as I mentioned in the very beginning of the SIFO treatment slide, nystatin belongs to a completely different mechanism by which it attacks the fungus. So yes, they can be combined because they're using two different mechanisms for killing the fungus.

Shivan Sarna: Okay. Lorraine says she has a client who needed four plus Betaine HCl, hydrochloric acid, a protein meal since getting methane SIBO. Here's the problem. Although she's cleared SIBO, she cannot get off the betaine HCl without her stool changing and cramping. And two, I read that HCl fuels methane SIBO, so it may trigger a relapse or continued bloating.

Dr. Satish Rao: You know, this whole methane story is continuing to evolve. And we are all working—Mark is working together with me and others—trying to figure out, first of all, why have we really developed methane, which we don't know.

Second of all, how can we minimize the methane in the colon as well as in the small bowel? The only study that we've done—there are two studies out there. And one, we’ve combined rifaximin with neomycin, and we showed that the combination of rifaximin and neomycin was more effective in reducing methane lower in the gut.

[15:05]

Dr. Satish Rao: The other study that Mark has done is with a new form of statin which is now undergoing clinical trials.

So, those are the only chemical means that we have understood so far of reducing methane. From the HCl story that you mentioned, I have read some anecdotal stories about that. But I do not have any proof to support or advocated its use.

So, I don't know why. It may be helpful. It may equally be unhelpful. But we don't know.

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Shivan Sarna: Time will tell. Okay, burning tongue, have you seen that as a symptom of SIBO or Candida?

Dr. Satish Rao: Candida, yes; SIBO, no.

Shivan Sarna: Okay. Gastritis perhaps?

Dr. Satish Rao: …as a symptom of SIBO?

Shivan Sarna: No, no, the burning tongue as a symptom of gastritis?

Dr. Satish Rao: No.

Shivan Sarna: Okay. So, it could it be thrush Candida?

Dr. Satish Rao: Well, I think, yes. I think burning tongue can be a symptom of thrush, Candida. It can be a symptom of zinc and other multivitamin deficiencies. It can be a symptom of Celiac disease. It can be a problem of oral infection. A number of other conditions can cause this burning tongue syndrome. So those I think are more common ones that I know of. And we've treated people with those problems.

Shivan Sarna: Okay. Kristine, I hope that helps. I know that must be very uncomfortable.

Dr. Satish Rao: Sorry, if I can add one thing… you know, methane can be a culprit here although I don't have much proof on that. So there are three common methanogenic organisms that we talk about. One is called Methanobrevibacter smithii. This is the most common GI methanogenic bug.

There's another one called Methanobrevibacter oralis. The oralis is the one that we find in the mouth. And it is possible that that methane organism may cause this. And so that may be something. I just want to throw it out. I don't have proof, but I think that may be the only connection that I can think with the SIBO story.

Shivan Sarna: And we're talking about a burning tongue versus a swollen tongue.

Dr. Satish Rao: Correct.

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Shivan Sarna: Okay. And have you ever seen anything about a swollen tongue in any of these gastro issues?

Dr. Satish Rao: No, not in SIBO/SIFO, no.

Shivan Sarna: Okay. This is the other end of the track. So it’s understandable why people could have these issues.

Okay, if someone has cleared SIBO, parasites, reduced heavy metal, eats organic, reduced stressed, and still has significant bloating and slow weight gain with moderate calories, where do you focus?

So, SIBO cleared… bless you! Parasites… fantastic, gone. Heavy metals, reduced. Organic… yay! Stress, reduced. Still bloating and slow to gain weight, what do you think?

Dr. Satish Rao: I think two things to think about. One, they may fall into that group of hypersensitivity, which we’ve talked about. So, the bloating is because the nerves of the gut are still firing away. And they are still sensitized. And so, maybe they may need temporary help. They've already done all the right things—reduced stress, they are trying to relax and so on. But the nerves have not completely calmed down yet.

As I said, normally, we have these nerves and these receptors that are dormant and they don't wake up. But someone that’s had a nasty gastroenteritis or some form of stress or whatever has woken up these receptors. Once they wake up, it's hard to put them back to sleep. So, they will sense normal things and they’ll keep firing away if there’s some catastrophic—it’s like a fire alarm that's constantly growing although there is no fire.

And so, how do you reset that fire alarm? I think that is where the challenge is.

So clearly, the one approach I would now take would be low doses of antidepressants for a three- to six-month trial to try and suppress this hypersensitivity. And that may also help with gaining weight.

Shivan Sarna: Oh, very interesting. And when you're talking about the low doses of antidepressants, is there a particular kind, like the dopamine or serotonin?

Dr. Satish Rao: All of them I think. We have to really look at each symptom. There's no blanket drug. And we have to look at other issues as well because someone who's got a little touch of

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diarrhea, let's say, or loose stools in a day, may benefit more with the tricyclics group of antidepressants. Someone who's already constipated, tricyclics will constipate them more, so you may have to look at the SSRI group or SSRIs with the norepinephrine group of compounds.

[20:05]

Dr. Satish Rao: So, I tailor it to each individual patient. But the key is low doses. And if they have no side effects, to persist for a minimum of three months. That, I think, is the principle to remember.

Shivan Sarna: So, in my hot little hand here, I have my low dose naltrexone. What about that for these conditions?

I know it's a mild prokinetic. It has helped me cure my fibromyalgia and clear psoriasis for my scalp—which is practically impossible, so it's my friend. But what about that for just bloating in general? I just think of that as, like you were saying, low dose antidepressants. So I was thinking…

Dr. Satish Rao: So, naltrexone doesn't have any antidepressant. It's just an opioid antagonist. So the main effect it will have is, yes, it will have a prokinetic effect. And especially, the methylnaltrexone will not cross and get absorbed in the gut. It will not cross the blood-brain barrier. So no opioid analgesic effect, if you like. And also, no opioid brain effects. So that's an advantage with that.

Shivan Sarna: Okay, I'm such a fan of it, so I wanted to get your opinion of that.

So, from Marivi: “Recurrent SIBO constipation and Candida due to mold and mycotoxins,” which she being treated for. It might be a man, I'm not sure, sorry, “…for the natural antifungal herbs and binders. So, using natural antifungal herbs and binders, will I continue to have SIBO and Candida until I get rid of those mycotoxins? I can't seem to get rid of the SIBO, bloating and weight gain no matter what.” And she/he—sorry, Marivi, I know you’re here—is out of the mold.

Dr. Satish Rao: So, what I'm hearing is that they have tried traditional treatments. I assume they've been diagnosed with SIBO and SIFO, or maybe it's a clinical diagnosis.

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I would probably say that it is time that they stop the treatment (unless it's going to severely jeopardize their health) for at least a six-week period, and then have a proper diagnosis done. This is the kind of individuals where I think we should not persevere with treatment without a definitive diagnosis.

I would stop, give about six weeks to two months. If there is SIFO, it will come back in the gut, and someone will have to properly investigate that. Come to either our center or some other center. Any gastroenterologist who can do this, have a proper diagnosis. It’s only then I think we should talk about treatment.

Shivan Sarna: Okay, so she has been diagnosed, but I'm just checking that it's for SIBO or SIFO because she is here. And I hope I'm saying your gender properly.

Okay, what is the conventional GI doctors diagnosis tool for MMC dysfunction? And is it necessary?

Dr. Satish Rao: So, that is a very hard diagnosis to make. Very few doctors—I think up and down this country, we probably have maybe about 10 or 15 centers that actually measure the migrating motor complex.

We do it. It is not an easy test we have for MMC. It's a slightly uncomfortable test. We place a probe with multiple pressure sensors. I showed you that example from one of my patients. And so, we leave this catheter in at our place for 24 hours or 48 hours. And then, when the MMC happens, it creates a pressure activity flow. And that's how we diagnose this.

There is no other simple way of diagnosing it today other than putting a pressure manometry catheter inside the gut.

Shivan Sarna: Okay. And by the way, that video that wouldn't play, maybe you can send it to us. We’ll put it in the portal, so people can see it.

Dr. Satish Rao: Yeah, I think it should have played on my computer. I don't know why it didn't play. But I'm using a new computer, so I wonder whether some of those videos didn't get transferred from my old computer. So I was surprised. But sure, we can…

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Shivan Sarna: Thank you. Okay, Karen, look what I've done. I usually try not to ask for additional things because, as soon as we get done, people start emailing me, “Where's that video?” Give us a week everybody. Love you! Just give us a week.

Okay. So, I guess the question that Marivi has (and a lot of people have) is if you still have mold and mycotoxins, do you have to clear that before you think SIBO will go away?

Dr. Satish Rao: You know, that's a very good question. I sincerely believe you should. I'm actually seeing this increasingly in my practice as well. And I have not paid attention to this. But I think a number of my patients are coming forward having made this diagnosis. They’ve made some connections at home.

[00:25:15]

Dr. Satish Rao: They've gone and have had people come and evaluate the mold in their homes. They have identified that that may be one other way by which they're getting the mold inside their body. And they've actually had to leave their home for a week or two weeks, have their houses cleaned for mold and whatever—their ventilation systems all changed and cleansed. After that, going back. And I would report several patients have had dramatic improvement in their health with that.

So yes, both treatment (maybe prolonged treatment), plus addressing potential for mold contamination in particularly older homes and so on, and having that changed (or being able to change their home), that may be another positive thing for them to do.

I know it's not easy to change homes, but it may be something to consider.

Shivan Sarna: Also, we have a masterclass with Dr. Ami Kapadia talking about mold and SIBO and SIFO. Do you know Dr. Kapadia? If you saw her face, I bet you would recognize her from conferences. She’s an MD who works with Dr. Ilana Gurevich in Portland, Oregon.

Dr. Satish Rao: Oh, yes. Yes, now I'm familiar with her.

Shivan Sarna: Yeah, she's lovely. And she had mold exposure in medical school…

Dr. Satish Rao: Oh, boy!

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Shivan Sarna: …and has gone through this incredible journey. And she has been helping a lot of people too.

Yes, I told Dr. Rao to bring food because it's three hours. So, have your snacks, everybody. Eat up, drink up, take your stretch breaks and all of that. These are long sessions.

Do you believe that SIFO or LIBO or Candida are impacted in general—which I think you've just said—by molds—yes, you've seen people get better when they clear the mold; but also, by parasites or the presence of heavy metals.

Dr. Satish Rao: So, those are additional issues. The parasites, I would think, if they are present, they should be identified. Today, we have a very simple test—which was very challenging, identifying parasites. We would do the standard stool test for ova and parasites. Now, these stools had to be freshly collected and stained and examined for the presence of these ova and parasites. Unfortunately, stool collection is very challenging. And they are not taken to the lab very quickly. So we’ve had challenges.

Now, this new test called the stool panel test is excellent because that is no longer relying on the actual presence of the parasite or its eggs. But it’s relying on the presence of the parasites’ genetic materials, DNA and RNA.

So, this test picks up seven parasites, roughly nine bacteria, and another seven viruses. One stool sample gives us all of this information—23 different bugs can be identified. It's called the GI stool panel.

Shivan Sarna: The GI stool panel. And is that like Quest or LabCorp and it’s new?

Dr. Satish Rao: No, I’ve been using it for almost seven or eight years. Including C. diff, it picks it up.

Shivan Sarna: Is it Quest?

Dr. Satish Rao: I think LabCorp. Yeah, they will all do it.

So, this is one test. So it's a great test because you can pick up parasites, bacteria and viruses with this test. And we use it increasingly in our practice because we do identify a lot of infection,

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and we can treat that. That, I think, is the best test today for general common podcasters. We're looking at giardia, amoeba and things like that.

There are some rarer parasites which I think will be more difficult to identify with this test. And for that, I think, still, the traditional ova and parasite test may be important.

Shivan Sarna: So there's two. There’s the ova and parasite. And then, there's a new one which is called what?

Dr. Satish Rao: GI stool panel.

Shivan Sarna: Okay, GI stool panel. Hey, if you guys can get your insurance to pay for it…?

Dr. Satish Rao: Oh, yeah, I think insurance pays for it.

Shivan Sarna: And maybe some of the functional and naturopathic doctors are not fans of the ova and parasite. But I wonder if they know about the GI stool panel because what we hear constantly is, if it tests positive, you definitely have it. But if you test negative, not necessarily.

Dr. Satish Rao: Right! I mean, amoebas and the giardias and so on, the likelihood of a negative test is very, very small if you have the infection. But other parasites, whether it’s pinworms and tapeworms and so on, there, I think the likelihood of a negative test is high because they are excreted in stools and so on in a periodic manner.

[30:23]

Dr. Satish Rao: For example, pinworms, usually, they make their appearance in the middle of the night. And that's why many people wake up screaming. And they actually migrate all the way to the end of the anus. And I know in my own home, my daughter when she was five, she screamed and screamed in the middle of the night. We said, “What is going on?” And she couldn't even—she was in so much distress that she couldn't find out. And then, eventually, she said, “Oh, there’s something hurting me in my back end. And so, I had to really gently take a look at it. And lo, and behold, there was a pinworm there.

So, we took it out. Then I knew she had pinworm, and we gave her the treatment—you know, two doses of mebendazole. And two weeks later, the two doses, she was cured for life!

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Shivan Sarna: Oh, thank God!

Dr. Satish Rao: So, I think that dose can be a little challenging.

Shivan Sarna: Yes, you have to pay attention to the cycles for sure.

And Bee: “I have a recurrent rectal yeast infection, often external, accompanied by constipation and flatulence. I've taken nystatin… not effective. I’m a bit afraid to take the two-week course of fluconazole as I'm sensitive to many meds.”

So, what would you say to people who are afraid of some of these drugs?

Dr. Satish Rao: I think, clearly, I assume this person may have taken oral nystatin rather than topical nystatin. And if it was topical, then I think it's not going to work anyway at this stage. So she may consider oral nystatin if it hasn't been done—and in inadequate doses for at least a two- to three-week trial because nystatin is not absorbed from the gut and may really have some beneficial effects.

But clearly, fluconazole, to be honest, I have really have had problems with fluconazole—very, very rare there is an allergy. So, I think it's a very safe drug.

The only challenge with fluconazole is there’s a drug-drug interactions. Ketoconazole has got slightly more drug-drug interactions, but fluconazole has.

So, if they're on certain drugs, particularly other antibiotics and so on, they can affect. Likewise, if you're on blood thinning drugs and so on, it can affect. So you just need to talk to your physician and to the pharmacist, and they can guide you.

But generally, I found fluconazole—I’ve probably given thousands. It is very safe, and it's very effective. It’s only a one pill a day dosage. Nystatin, it’s a short-acting drug, so you have to take it two to three times a day. So fluconazole is a long-acting drug. I would think it's safe, so they should be able to get it and try it.

Shivan Sarna: Yeah, it's a terrible feeling to feel like you're afraid to take the things that could be helping.

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She took oral nystatin for two weeks and got a bad yeast outbreak at the end of her treatment course. Have you heard of that before, where people actually get worse yeast outbreaks from a yeast killer?

Dr. Satish Rao: Yes, I have heard of that. I've not seen it, but yes, it has also been reported in our medical literature. Some people say there is a reaction called the Herxheimer reaction. It is like a hypersensitive reaction where you are releasing some of the compounds from these bugs that are dying that causes a generalized flare or a hypersensitivity reaction and so on. It can happen. It's been well-described. And yes, it can cause it that way, yes.

Shivan Sarna: We call it die-off, right?

Dr. Satish Rao: Correct, we can call it die-off.

Shivan Sarna: Right! Okay, I’m going to move on from this area. But the question is—and there's several that are sort of adjacent to this—about treating Candida and parasites at the same time, and SIBO at the same time. What do you treat first?

I've heard some people say they treat the biggest thing first. I've heard people say they treat it all at the same time. What is your usual approach once you have a diagnosis?

Dr. Satish Rao: Okay. So, principles first… I'm assuming that we have some solid ground for this. In other words, we’ve identified an individual who has a high bacterial load, a high fungal load, and the presence of parasites in their body. The treatments are very different for each one of these conditions.

So, if you're treating—and again, it depends on what kind of parasites we're talking about. Are we really talking about amoeba and giardia kinds of parasites? Are we really talking about a pinworm, tinea, a tapeworm kind of parasite?

[35:17]

Dr. Satish Rao: If it is that kind of parasite, their treatment is just two days of treatment. Mebendazole, thiabendazole, a couple of pills twice a day… and nothing for 14 days. And then, repeat another two days of treatment because that's when some of the spores may not have hatched. They may still be lurking around, so you want to kill it.

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So, that's a fairly easy treatment. That can be done along with treatment of SIBO.

So, you can start antibiotics, let's say you want to give somebody rifaximin or you want to give somebody some amoxicillin because they have SIBO. You can start that alongside the anti-parasite treatment. There's no harm with that. So, you can do both.

Now, the antifungal treatment… I usually do not start antifungal treatment the same day as I'm starting antibiotics. Why? Because the antibiotics that I'm giving may actually cause fungal infection too.

So, what I do is I give a two-week course of SIBO. But starting with the second week of antibiotic, I start the antifungal. So that is the time when the antibiotic-induced fungus infection is going to set in.

There is a fine balance between bacteria and fungus in the gut. When the bacterial count goes down, the fungus flares up. So normally, the fungus is kept in check by the bacteria. So when you have not only gotten rid of the nasty bacteria, but there are also good bacteria in the body. The good bacteria is keeping a check on the fungus. But with the antibiotic, that is very nonspecific. The antibiotic is not going to differentiate between the good bacteria and the bad bacteria.

Of course, it's going to hit the bad bacteria harder because there is a larger amount of the bacteria. But it's also going to affect the good bacteria which is trying to keep the fungus in check. Now, when you kill the good bacteria, then the fungus is going to flare up now.

So, that is why I give antibiotics for a week, starting from the second week. While I'm continuing with the antibiotic for one more week, I start the antifungal. And then, after that, the second week, now you're done with the antibiotic, but you carry on with the fungal for two more weeks.

So, in that way, you really treated both the SIBO and the SIFO most effectively. That's the regime that I use.

Shivan Sarna: Very nice! Okay, let's see…

“What herbs do you turn to for treating SIBO and SIFO?”

Dr. Satish Rao: I think the ones that I've mostly used are the oregano oil, berberine. The combination that I've preferred is something called ParaBiotic Plus. I think that's one of the ones

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that we use. It has thyme. It's got all of those ones that have both bacteriostatic and fungistatic mix. That's the one we’ve used.

The other one that we've used is—hmmm, I'm forgetting the name. It's actually made locally here in South Carolina somewhere.

Shivan Sarna: CandiBactin?

Dr. Satish Rao: That’s it! That's it, Candibactin. That’s it, that’s it.

Shivan Sarna: AR and BR?

Dr. Satish Rao: Good, that’s correct.

Shivan Sarna: Okay, that's the one that was studied by Gerard Mullin and all that?

Dr. Satish Rao: Correct.

Shivan Sarna: Yeah, okay.

Let’s see, here we go. So, from David: “Can fungal cultures from endoscopic aspirates produce false negatives? There's fungal overgrowth in there, but your aspirate just didn't pick it up?”

Dr. Satish Rao: Yes! Absolutely yes.

Shivan Sarna: Okay!

Dr. Satish Rao: I think the answer is yes. And we're actually just looking at our data because, in selective cases, we use a longer instrument. So, a traditional upper endoscope goes for about, let's say, 1 ½ ft. in the small bowel—that’s as far as we go—the scope that I was sharing with you in the picture. Now, we can use another one that will take us up to 5 ft. or 6 ft. into the smaller bowel called an enteroscope and so on.

So, we are now comparing the yield of that kind of a scope versus the traditional upper endoscope to see whether we are picking up more bacteria. But we're still limited because, as I’ve said, it’s 19 ft.

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Now, have instruments that will take us through the entire 19 ft. of small bowel. But it's a very prolonged test. It takes about two to three hours to do. And it's not easily done. Routinely, it's not a test that we do. We do it only in a few centers. And you need expertise skill and so on.

[40:19]

Dr. Satish Rao: So, I think, ultimately, the test that will give us is this capsule test that we talked about. Once that comes into work, I think we'll have a much better chance of picking it up.

So, the answer to the question is you’re absolutely right. We can have false negative because of sampling issues that we have in our current technology and limitations.

Shivan Sarna: I guess the other question—and Karen’s already addressed it because she put your contact information in the chat for everyone. But let's say someone wants to come see you, do they need to get a referral? Does it depend on their insurance?

Dr. Satish Rao: So, I think these are good questions. So ideally, I would encourage them to either contact my schedulers at Augusta University Medical Center directly, the medicine schedulers. And they will be able to find and help collect all the information, whatever their insurance and referral note, et cetera, and send it to me.

They can also write to me. And then, I will pass it on back to my schedulers and so on and so forth. And I would encourage them to send me a copy of their medical records.

I don't necessarily will need a referral from the doctor, although I would prefer that because then I can communicate effectively with their physician. But it's not a must. As long as they can send me the medical records, then I think we can schedule them.

Many times, if their medical records are insufficient in terms of giving me a clear understanding of their symptoms, then I will send out a questionnaire that I use. It's about a five-page questionnaire that details their symptoms. And then, I use that as a way for me to better understand their symptoms so that, if they're especially coming from out of state, then we can maximize their time with our testing and my ability to visit with them and come up with a treatment plan.

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Shivan Sarna: I think a couple of people I know have come to Augusta and basically spent a week there to see you for SIBO, SIFO, fructan or fructose testing. Is it like one a day?

Dr. Satish Rao: That's right. So typically, that's what we do. We see between two to four out-of-state patients a week. They come and they spend the whole week with us. They go through a series of tests, motility testing. We're looking at SIBO, SIFO endoscopy and so on.

And then, at the end of the week, I sit down with them. And mostly, I have answers for 70% of the tests; 30% are pending because they've gone off to different labs. Someone is brain foggy, for example, the urine and so on we collect, that goes to Mayo Clinic. If we're looking at enzyme levels, then that goes to the University of Buffalo.

So, cultures takes about five days from my microbiology lab. So we're waiting for some of those results to come back. And then, we have another conversation with them on the phone (or if they’re able to come back, we’ll chat with them again).

Shivan Sarna: Very good. Very good. And are there good hotels—or not good, but are there decent hotels in the area?

Dr. Satish Rao: Well, remember, Augusta is the master place. The masters comes here once a year. So there are decent hotels. Yeah… good, I would say reasonable. I wouldn't say fantastic, but they’re reasonably good.

Shivan Sarna: And when is the Masters Tournament because I would say nobody go during that week?

Dr. Satish Rao: No, that is the first full week in April. Just avoid that like the plague. You do not want to come to Augusta at that time.

Shivan Sarna: Yeah! Unless you're into golf. There you go. Okay!

“Can someone have SIBO on a breath test, have it be positive, and still be asymptomatic?”

Dr. Satish Rao: Yes, they can have SIBO on a breath test and be asymptomatic.

Now, particularly, I think this may apply to both tests—the lactulose and glucose. I think it's more likely the lactulose breath test because, as I’ve said, what's happening in those individuals,

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they may have gotten rid of their SIBO, but the test is still going to be positive because the lactulose is now getting into the colon and it's going to give positive.

Now, we used to say, “Well, if the rise is happening before 90 minutes and before 100 minutes,” or whatever, “it signifies SIBO. But if it’s happening after 100 minutes, then it’s lactulose getting into the colon.” That is not as clear cut as it is because different people move lactulose at different speeds through their body.

I'm one example. I don't SIBO. But if I drink lactulose, my lactulose rises within 40 minutes. So by definition, I have SIBO, but I'm asymptomatic. So, I'm the exact answer to your question.

[45:12]

Dr. Satish Rao: So, that I think is a false positive lactulose breath test. But I'm negative for glucose, so I know I don't have proximal SIBO.

Shivan Sarna: Okay. Okay, that's fascinating.

Dorothy: “I was positive for Candida in an OAT test,” which is that organic acids test I was talking about, which is very functional and probably not mainstream, “and treated with nystatin for three months. I then tested in the organic acids test, and now it was negative for Candida, but another fungus came up. It’s called tartaric…” Have you heard of that?

Dr. Satish Rao: No…

Shivan Sarna: It was positive. “But arabinose was now negative.” Maybe tartaric was an organic acid.

Dr. Satish Rao: Oh, tartaric… tartaric acid is an organic acid, yes.

Shivan Sarna: Okay. So that was positive. “But the arabinose was now negative. What should I do now?”

If this isn't your wheelhouse, that's fine.

Dr. Satish Rao: I really don't know. I don't know about that OAT test. Can you describe that to me?

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Shivan Sarna: It’s an organic acids test. It's a urine test. And it's quite interesting. I know Dr. Siebecker really likes it. She doesn't use it to diagnose SIBO. I know that part for sure. She loves the test, but she doesn't use it to diagnose SIBO.

But Dorothy…

Dr. Satish Rao: Is it gut-related or…?

Shivan Sarna: Everything.

Dr. Satish Rao: So, it may be telling us fungal maybe in the urinary track, for example, or somewhere else. That may be what I'm really suspecting. So, sure! Sure…

Shivan Sarna: Okay. So here, have a bite to eat, Dr. Rao, because I'm going to tell everybody something here.

Okay. Here's the thing, you guys. We got 200 questions for this class. And part of it was because we cancelled because of the hurricane, so everybody had extra time. And also because Dr. Rao is such a very special practitioner, and I know a lot of you had very specific questions—which is fantastic.

Then we also gave it as a bonus for the docuseries. So we had even more people have access—which is fantastic.

Here's the deal. If I don't get to your pre-submitted question today, we are doing another class with Dr. Lisa Shaver, November 1st. And that is on SIBO and gluten and the gut. She’s just an incredible practitioner as well and very knowledgeable. And that's November 1st. And if you bought the Speaker Series, you have access to that.

But for free, included, we are doing a Facebook Live with Dr. Steven Sandberg-Lewis. This is also another November 1st at 3 p.m. Eastern time. And I will try to get the rest of your questions answered there.

So, Dorothy, I'm going to try to do that for you in one of those two sessions. So that's my aside.

So, don't be upset if I can't get to your pre-submitted question today. I will work really hard to get it to you by that first week of November.

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Dr. Satish Rao: But how are we doing overall with the questions? Are we doing okay? Or do we need to do it a little faster? How are we doing?

Shivan Sarna: A little faster would probably be best.

Dr. Satish Rao: Okay, we’ll move on.

Shivan Sarna: Yeah, a little faster. No pressure! I’m feeling pressure, you don’t have to. But a little bit faster would be great or we’ll never get through them.

Okay! From Kelly: “Can you explain ileocecal valve syndrome and how it might be a root cause or an effect of IBS, SIBO and gut issues?”

Dr. Satish Rao: So, I think as I explained very quickly, there is this gatekeeper valve that allows food and digested particles to go from the ileum (or the end of the small bowel) into the cecum (which is the beginning of the large bowel). So this gatekeepers checks the flow. It literally stops backflow. It stops the material, the poop and the bacteria from the colon backing up into the small bowel, contaminating the small bowel, and thereby facilitating SIBO.

But if this valve is defective, the valve is inflamed, the valve has been removed by surgery or what-have-you, and you now have an anastomosis or a connection between the small bowel and the large bowel, then there is just no more gatekeeper—free flow between the small bowel and the large bowel. Then I think you can get an infection. You’re easily contaminating the small bowel.

That's what we showed in that paper that we just published.

Shivan Sarna: Okay. Alright! I'm going to continue on here.

Donna: “My ALT and my AST liver enzymes have been rising ever since I began my treatment for SIBO. Any connection between SIBO and elevated liver enzymes?”

[50:05]

Dr. Satish Rao: No, but it may be the treatment. The antibiotic or antifungal or what-have-you may be causing a mild level of hepatitis. And that is what we’re checking.

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One issue is that there is a group of individuals in whom SIBO/SIFO can cause abnormal liver function tests. These are individuals in whom the bile ducts have been opened up, having had some pancreatic or bile duct surgery where you now have a big hole at the end of the bile duct. And therefore, bacteria from the small bowel are now going up into the bile ducts, causing cholangitis, and also migrating all the way to the liver causing a mild degree of hepatitis.

And the other group are people who have had obesity surgery. They can get liver abnormalities for various reasons including bacterial overgrowth.

Shivan Sarna: Okay!

KJ: “My gallbladder is not working properly, and I have adhesions from abdominal surgery. I'm scheduled to get my gallbladder removed. Is this likely to help my SIBO? And how? And then, would removing the adhesions help too?”

So, that's a lot of questions. So the gallbladder is not working. He has adhesions from abdominal surgery. He’s scheduled to get the gallbladder removed. Can that help SIBO?

Dr. Satish Rao: I think the gallbladder removal will not help the SIBO. But the adhesions, yes, it will. The adhesions are loops of bowel that are stuck to each other. And they are interfering with the motility. And so that will help the SIBO issue.

Shivan Sarna: So, let's talk about that because adhesions can also be from abdominal surgery or like the loopy colon and all of that. But I have heard that if you have adhesions surgery, it can create more adhesions.

I've also heard from Dr. Pimentel that he felt it was an adhesion, they went and they did the surgery—it was a very specific kind, almost a hammock. They cut that. And it totally solved the problem. So it wasn't like your typical scar-like adhesion. What is your opinion about all that?

Dr. Satish Rao: Absolutely! I think adhesions, every time you have surgery, you’re going to form adhesions. And the next surgery will double; and the one after that will triple the adhesions.

So, although we are getting rid of adhesions, the surgery itself will create new adhesions. So this is an ongoing problem. Some people have greater predisposition than others to form adhesions. So yes, it's a temporary relief. But it can still lead to long-term problems.

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So, you only want to remove adhesions when those adhesions are causing medical obstruction, really clinical obstruction symptoms and so on, or major dysmotility. And so you don't take it lightly, doing the so-called surgery of adhesiolysis. So, you want to weigh that very carefully.

If the gallbladder on the other hand has gallstones and is not functioning and causing mischief, that will also have to be removed.

But I would also caution against removing a gallbladder that’s normal, that do not have gallstone disease. There is a tendency, unfortunately—and I don't know if this particular patient. But there is a tendency to remove normal gallbladders using a test called the HIDA test. The HIDA test is an ejection fraction test of the gallbladder. Unfortunately, it is very deceiving test.

Many times, it gives a false positive abnormality. In other words, it says, “Oh, the ejection fraction is only 20%.” That is not true. Somehow, this test is not the best test.

So, if that is the basis for removing the gallbladder, I would caution against gallbladder removal because it creates another set of problems that we call bile gastritis. And there's a paper that we will be publishing in the next few months showing a very large series of patients having that problem.

Shivan Sarna: Okay. I had a gallbladder stone, a little baby stone, stuck in the—what is it? Not the vent, but the…

Dr. Satish Rao: The bile duct, yeah. The bile duct…

Shivan Sarna: …the duct. And I was not at home. I was in another town, another state. They wanted to take it out. I did the HIDA and everything. And I was just like, “Just let me go home and see my doctor.”

And then, I go home and the doctor is like, “You’re fine!”

They wanted to yank it out, you know? Obviously, everybody’s different. But I'm like, “What do you mean I'm fine? I just got scared to death.” Anyway…

[55:00]

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Shivan Sarna: From Gwen: “Can SIBO mimic bile acid malabsorption, and actually you don't have bile acid malabsorption, and therefore can stop medication?”

Never stop medication from one of these webinars. Always speak to your doctor. But her question really is: “Can SIBO mimic bile acid malabsorption?”

Dr. Satish Rao: Yes, it can cause symptoms similar to bile acid malabsorption, primarily causing gas, bloating, and diarrhea. The answer is yes.

Shivan Sarna: Okay. How could you tell? Maybe do a SIBO test?

Dr. Satish Rao: Unfortunately, we don't have a test for bile acid malabsorption in this country. So SIBO test is the way to go with it, or SIBO treatment is the way to go with it.

Shivan Sarna: Okay. Lois: “I tested positive for SIBO. But the treatment didn't help me. I still have lots of abdominal and body pain, body aches, headache and constipation. My naturopath said that the test was probably a false positive. But why do I still have the symptoms of SIBO? I've had FM (fibromyalgia) for 25 years.”

So Lois—and there are a couple of other great questions here—I feel like the answers were covered in the content of the class. So if that's the case, I'm just going to continue on. But would you say…

Okay! So, this happens all the time. Positive for SIBO test, treatment didn't help. Could it be that they need to retest and do another round because it only dropped your breath levels from 80 ppm to 60 ppm?

Dr. Satish Rao: So, I think there are several possibilities. Number one, the first one I would say is inadequate treatment. That’s probably what I would suspect as the first thing. Let's say you have a positive test, you were given rifaximin—I have nothing against rifaximin or any drug. I'm just giving an analogy here. The patient has a partial response, you give another course, no response and so on. It is possible that the bacteria that that individual has is not sensitive to rifaximin. So that is not going to be effective. So, the option is now to switch to another antibiotic. So that, I think, is one approach that we should be taking.

It is also possible that the patient has now got a new infection. A new set of bacteria have come onboard. So again, we may need a different antibiotic.

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So, both those scenarios are possible.

Now, the third scenario is that it's a false positive test… depending on the kind of test. If it is a glucose breath test, there’s almost a zero probability of a false positive breath test. But with a lactulose breath test, there is a high probability of a false positive test.

So, we should then set aside the notion of SIBO, but explore other causes for bloating. As I mentioned in my talk that I think people have gone through, they will know that we're looking at other causes of sugar or food intolerance and so on.

And lastly, again, the visceral hypersensitivity story.

So, those are the three biggies—SIBO/SIFO false positive tests, likelihood of carbohydrate intolerance, or hypersensitivity.

Shivan Sarna: Okay. Let’s see here…

Benjamin: “Two years ago, I had food poisoning. I recently took the Xifaxan and was on a low FODMAP diet. I took a SIBO test.”

“I don't like reading test results because they're very hard to comprehend without the visual. At 90 minutes, my hydrogen was at 3 ppm; at 105, it was at 20; at 120, it was at 31 ppm for hydrogen; and at 135, it was at 47 ppm. The lab said that I am SIBO-free since, at 90 minutes, I was under 20.”

Does that make sense?

Dr. Satish Rao: Make sense!

Shivan Sarna: “They are assuming the hydrogen was in the large intestine after 90 minutes. Can I rely on that? At 105 to 120 minutes, it still could have been in the small intestine?”

Dr. Satish Rao: Yes possible too. But that's what I said… the lactulose is…

That is the clinical conundrum with the lactulose breath test. You never see that with the glucose test. It's either positive or negative. You never have this gray zone—which is a problem with the lactulose breath test.

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So, it looks like, based on the test, the patient was ruled out as not having SIBO. But the patient is still symptomatic. So the question is: “Does this individual still have SIBO? Or there is another cause for their symptoms?”

I think both of those have to be explored further either with the glucose breath test, duodenal aspirates and/or the sugar test.

[01:00:07]

Shivan Sarna: So, with these SIBO breath test, you have a test tube that you blow into. And this Benjamin must have taken a test that was not a QuinTron-provided test kit or Aerodiagnostic Labs because he said: “I also found it strange that the way they performed the test was that I blew air into a straw which then went into an uncovered test tube.” Quinton and Aerodiagnostic have the covered test tubes. “Then the medical assistant immediately covered the test tube. Do you think that's reliable?”

Dr. Satish Rao: You know, I didn't even know there was a test like this until very recently. We are now engaged in a clinical trial where this is the first time in my career I've been exposed to this test.

Shivan Sarna: …with no lid? No lid?

Dr. Satish Rao: No! This patient describes it accurately. It's like a little test tube with a cap. You open up the cap. They say you blow into this. You close up the cap. And they say that you are still trapping enough air from your breath. That gives them a positive or a negative test.

Honestly, I'm very suspicious of this test methodology, very suspicious. I've called the lab. I've talked to them. They say, “Well, we do thousands of samples. We’ve validated it.” I don't know how it is validated, they're claiming it. But we are part of this trial.

What we are doing is we are actually validating it ourselves. We are sending the samples, but we are doing our own control. We'll see what the test results come in our sample size. So I'll keep you posted on that.

Shivan Sarna: So Benjamin, reach out to my advice, QuinTron or Aerodiagnostics Lab.

Dr. Satish Rao: I would support that. I would definitely support that.

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Shivan Sarna: Okay, good. They are… you know…

Dr. Satish Rao: No, that methodology is foolproof. I tested that. But this other one, I'm a little unsure.

Dr. Satish Rao: Okay.

Merly: “My MD says that the breath test for SIBO is inaccurate because the speed of your food transit varies per person. Is that correct?”

Dr. Satish Rao: Speed? That is correct.

Shivan Sarna: Okay.

Dr. Satish Rao: But I don't know why the breath test is…

Well again, I think I know what the person is alluding to. It is the same test that you just described, the lactulose breath test where we're using this 90-minute cut-off threshold. And I think this individual is actually right. It is possible that the small bowel transit in a particular individual maybe four hours before it's going to get to the cecum. And as I’ve said, in my case, it is 60 minutes. So it can be anything between 60 minutes to four hours. So how are we going to interpret the lactulose breath test?

So, that is the conundrum with the lactulose breath test. But with the GBT and aspirates, you don't have that problem. When we pick up a SIBO, I am a hundred percent sure it is SIBO. There is no if in that diagnosis.

Shivan Sarna: …unless there was a problem with the—what did you call it, the sterility.

Dr. Satish Rao: Contamination?

Shivan Sarna: Contamination…

Dr. Satish Rao: Yeah, I think the likelihood is there. But we're doing all the precautions as much as we can take. There’s a small contamination when the scope is going down through the mouth and maybe introducing it into the bacteria into this small bowel. But the likelihood of that is small.

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We are using a sterile tube. We’re using sterile precautions. And we leave the scope, and then we push this tube a good four inches beyond an area that I have not yet contaminated with the scope. So, in other words, I have not gone down and come back up, and then putting the tube in that area. So, I have not touched that area of the small bowel yet, but I'm pushing my probe further downstream by three or four inches that remains untouched… and that's where I'm sampling one.

So, we have minimized as best as we can with our current methodology for clinical purposes. But it's a very strict methodology. And that's what you will see in that video that, unfortunate, didn’t play. But that's what the methodology is.

Shivan Sarna: …that we’ll try to put in the portal, but give me a week.

Dr. Satish Rao: …that you will try and put in the portal.

Shivan Sarna: Yeah!

Alexa: “On my breath test, I had an unusual methane result. Despite the fact that my starting point was 64 after half an hour, it dropped to 40 before going back up into the 60’s on the next one. The only theory I have is that the bacteria are happy feeding on my gut lining, so they didn't care that I didn't feed them. No explanation for the drop though other than the drink provided a change in food source and activity. What's your take on this?” Does that make sense?

Dr. Satish Rao: I think the breath levels will fluctuate. No, I think the point that I should have made in the beginning is that the breath test is a very indirect test of measurement. It is not perfect. It is not perfect. But at the same token, the argument that it is not standardized and it's useless is totally wrong. That, I don't believe at all. It is not a perfect test, but it is very useful as we have shown in the study that had just been published.

[01:05:26]

Dr. Satish Rao: So, the issue is we are looking at gas that has been produced in the gut. Now, what's happened to this gas? A proportion of the gas is being flushed downstream. And a proportion of that is getting into contact with the lining, getting absorbed into the bloodstream, and then being expired through air through the mouth. So, not the entire gas that is being produced is being sampled in the breath. It is a tiny fraction of that gas.

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And plus, the bacteria are not uniformly present throughout the small bowel. There are pockets where there is a higher density of bacteria. And there are pockets where there is a lower density of bacteria. And as the sugar solution profuses through this area of higher density of bacteria, you're going to produce more hydrogen and methane; lower density, less hydrogen method. So there will be this natural fluctuation of up and down levels. So, it's very hard to read.

Although generally the trend will always be up, up, up, up, up… and then it'll be down. But it is not uncommon that you will see an up and down if the density and the flow and the absorption kinetics are all taken into consideration.

Shivan Sarna: Okay! Here we go with another breath test.

Jana: “Hello! After one round of SIBO treatment with low fat diet and herbs, it dramatically decreased my initial hydrogen levels from 77 to 18, but did nothing with my CH4…”

Dr. Satish Rao: Methane…

Shivan Sarna: Methane…

“My glucose test results after first treatment, H2 was decreasing during the test from 18 to 14 in the 90 minutes; and then, with the methane, it went from 0 to 14 in 90 minutes. Can you please help me with my diagnosis? Is it methane dominant SIBO as I supposed? I do not have constipation. I suffer from bloating, abdominal pain, reflux, sometimes diarrhea. Helicobacter was negative.”

Dr. Satish Rao: I think the 0 to 14 methane was after treatment. And there was another higher value before treatment. Is that how you read it?

Shivan Sarna: Yes, “My glucose test result after first treatment was the H2 was decreasing during the test from 18 to 14 in 90 minutes. The methane went from 0 to 14 in 90 minutes.” And this was after…

Dr. Satish Rao: It’s not a positive test though, so I'm not sure where the diagnosis came from.

So, with that test, yes, this individual has methanogenic flora. It may be in the colon, it may be in the small bowel. The only way we know it is in the small bowel is when the methane level goes up with the glucose breath test.

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Let's say it's 0 to 14, it went up to 25 and 35. Then clearly, it's gone up by more than 15 ppm from baseline value.

Let's assume the baseline value of methane was 14. And the peak that you found was 35. That's an abnormal methane breath test. And there, the methane organisms are actually sitting in the small bowel. But otherwise, methane may be sitting quietly in the colon. And it will not change. It will remain the same value.

Shivan Sarna: Okay. From Mary Lou—and this sounds very much familiar—“I had a lactulose breath test and the result was 49.” But was it for hydrogen, I'm not sure, or methane.

“Results say positive 20 points higher than baseline. The gastro doctor called me and said he will prescribe rifaximin to take for two weeks. Will this get rid of my SIBO right away? He only tested me because I asked for it after seeing the docuseries. I also wanted to be tested for leaky gut, but he said that was hard to test for. What tests do you do for leaky gut? And where can you get one?” She this person, Mary Lou, can get one.

So, can you explain how the antibiotics don't necessarily in one two-week period fix SIBO?

Dr. Satish Rao: Yes, I think as we’ve discussed earlier on, it can be the wrong bacteria and the wrong antibiotic for the bacteria. That was one reason why one course of antibiotics may not fix it. Although, typically, if you really dose it correctly and give it correctly, most people (two-thirds) should respond to one course of antibiotic; but a third will not respond. So that's the first thing.

[01:10:07]

Dr. Satish Rao: Here, I think this individual is very likely—based on the single value, I'm just making the presumption that the baseline values were 0 to 10 and went up to 49 which was positive. But the lack of response means another antibiotic is what I would do first before another test. If not, we should look at other reasons for gas and bloating.

Specifically, as far as the leaky gut is concerned, there is no viable/valid test in most laboratories including our laboratory for this. Mayo Clinic and one other clinic, they do have a permeability test that they have validated—very limited use. It’s a little cumbersome test, but it can be done to identify permeability dysfunction there.

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Again, it is not commercially available or widely available. And that’s why we and others have not really used it much in clinical practice. So there is no good test for permeability.

Shivan Sarna: Okay, alright.

What do you think about having a prebiotic with GOS in it?

Dr. Satish Rao: Which is oligosaccharides?

Shivan Sarna: Yes, I'm quite sure.

Dr. Satish Rao: Well, oligosaccharides, I assume glucooligosaccharidases. So, probiotic…

Shivan Sarna: Prebiotic.

Dr. Satish Rao: Prebiotic with oligosaccharides…

So, what you do with prebiotic—I mean, fructans is one example; fiber is another example. What you're doing is you have food that you're using or fuel that you’re using to feed the probiotics that are dependent on this for their growth and survival. So, potentially, if you already have SIBO, If you're going to give prebiotics, you’re going to enrich the SIBO, and you make them worse.

If you do not have SIBO, but you have dysfunctional flora in your colon, and you want to really try and rebuild a healthy flora, then I think it makes a lot of sense to take prebiotics, preferably even more than probiotics… or a combination of prebiotic with probiotic with the hope that you're going to enrich normal, healthy flora, restoring digestive health.

So, it's the decent thing to do. But really, you gotta be careful. If you have SIBO, it may make things worse.

Shivan Sarna: Yeah, definitely. I've seen that a lot with people.

Okay! Let’s see…

Jean/Jeannie: “I have been diagnosed with both fibromyalgia and chronic fatigue syndrome, also leading to the GI issues of IBS, microscopic colitis. And I have SIBO several times in my life.”

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“I also have had Candida infections and urinary tract infections that continue to be recurring. Besides seeing GI doctors, being placed on medication for the SIBO and the UTI medication, followed the low FODMAP diet, stayed away from naughty products, I’m still having problems. I even tried Keto.”

“What about the elemental diet for SIFO?”

Dr. Satish Rao: I think the elemental diet is good. It is challenging to take and to adhere to it. But a three-week trial of the elemental diet for an individual like this is is certainly worthwhile. You need to be careful. Make sure you're doing it not by yourself but under a nutritionist’s supervision and a physician’s supervision. And the right elemental diet is important for that.

I mean one of the ones that we use (although it’s a little expensive) is the Physician’s Elemental Diet or PED, which is non-gluten, non-fructose and all-vegan. It can be very helpful. There are lots of elemental diets and one needs to be careful in figuring out what exactly is the right elemental diet for it. Most elemental diets are not very palatable.

So, under caution, yes, this would be a good way to clean the slate, so to say, and then start fresh and see if that restores health and balance.

Shivan Sarna: What was the kind of elemental diet you were just saying?

Dr. Satish Rao: PED, Physicians Elemental Diet.

Shivan Sarna: Oh, PED. Okay, right. From Integrative Therapeutics.

Dr. Satish Rao: Correct, Integrative Therapeutics.

Shivan Sarna: So Jeannie is thinking that she's heard that people have gained weight with the elemental diet. My understanding is that, if you're doing enough calories, your weight will probably not change that much.

Dr. Satish Rao: I really doubt anybody is going to gain weight from the elemental diet. I mean the amount of calories there are very little. So I doubt it.

But the only reason you may gain weight is because you had weight loss to begin with. The bacteria or whatever was the problem that you were not absorbing your normal nutrients previously, either because of an infection or because of some other reason, causing

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malabsorption. And now, you are taking products that are easily observable, so you are restoring your weight back.

[01:15:29]

Dr. Satish Rao: But it is unlikely that a two- or three-week of the elemental diet, you will gain enormous amounts of weight. I mean that's not what elemental diets are designed for. They will not do it. It shouldn't happen.

And the amount of fat content is not much in most elemental diet to give you weight gain. It is more than restoring your nutritional balance.

Shivan Sarna: What about the people that have been told, “You’re constipated, take some fiber.”

Dr. Satish Rao: And?

Shivan Sarna: And they have SIBO, but it makes them so much worse.

Dr. Satish Rao: Yes, absolutely, it will. A lot of constipated folks have coexisting SIBO because if your colon has had a backlog, buildup for months to years, your ileocecal valve is going to be dysfunctional, allowing bacteria to crawl back up into the small bowel.

So, the bloating there is a mix of stool overload, gas overload, and SIBO. So now, if you give fiber on top of it—which is like a prebiotic—you are going to feed the small bowel bacterial overgrowth. And yes, some of it may spill and help the colon to soften stools and push it down. But meanwhile you're suffering with bloating or worsening of the bloating.

So, I would be cautious about fiber supplementation. It's much better to take a laxative such as milk of magnesia or magnesium compound rather than a fiber supplement. Try and move the stool out. Treat the constipation issue. And if the bloating is still not better, then really think of SIBO treatment as a second time.

Shivan Sarna: Okay, this is interesting. Well, they’re all interesting. Where did you go, Jean?

What about inflammation, systemic inflammation, with these gut issues? Do you see that all the time?

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Dr. Satish Rao: You know, I do believe there is a strong connection between the gut and various non-gut illnesses, including fibromyalgia; and I also believe various arthritic problems, particularly rheumatoid arthritis and so on and so forth.

So, there is a connection, largely because the gut epithelium or the gut intestinal epithelial barrier, if you like, has been compromised and weakened somehow which is allowing permeability to happen, allowing bacteria, bacterial toxins, or certain toxin products, to leak into the body stream, and thereby set up inflammation in different parts of the body. I sincerely believe in that.

But the challenge for us—me as a scientist-physician and others—has been to truly identify this, describe this, characterize this, have a test that can help us with it. That entire body of science is not there yet. So we are handicapped by that.

In principle, I believe in it. But it has been hard to prove at this stage. Perhaps with better improvements in our techniques tomorrow, we might be able to prove that. Until such time, the science is not there to establish this. But I believe in the concept, yes.

Shivan Sarna: Okay, let’s talk about diet, change it up a little bit. Best diet for SIFO?

Dr. Satish Rao: That is going to be the challenge. But I think fermented foods that are more likely to have fungal organisms—I mean I'm not talking about cheese and things like that—they may have a higher likelihood of giving SIFO. So lying low with those products is probably the best advice that I can give, in addition to speeding up motility or going on low sugar compounds as well because sugar will feed everything (it can lead to more fermentation and so on and so forth).

So, I don't believe that this should be followed for life. I think this should be a temporizing effect. Maybe we're talking about six weeks, that’s it. That's as long as it should take to restore the balance. I'm not really a firm believer that such a dietary change has to be life-long.

[01:20:04]

Dr. Satish Rao: What I think is important is that there is a co-existing problem in many of these people. They have had SIFO, but they may also have fructose intolerance. So you've treated the SIFO. They’re gone! You're fructose intolerant, unfortunately, and that has not been diagnosed. And therefore, when you take your orange juice or when you drink your Coca-Cola or you take a

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high fructose corn syrup product, you're going to get bloated. You're going to blame it on the SIFO or the SIBO, whereas in fact, it is not the cause. It is the sugar intolerance that is the cause. That will have to be addressed. Likewise, lactose or fructan intolerance.

Shivan Sarna: I think that that and parasites are some of the most underrated, confusing factors for SIBO patients. Everybody gets the SIBO breath test; they aren't getting these sugar tests.

Dr. Satish Rao: Absolutely, I agree. And I think that if there's one important message for our audience today, I think it is to knock on your doctors and see if they can help you with those tests.

I mean, people have become very chummy in ordering the breath test for SIBO, but they're not doing the other tests. Again, the labs can help with establishing them. Or they will send out tests that can be done by QuinTron and others, Commonwealth, et cetera. You can actually do it from home and get this diagnosis done… and treat appropriately.

Shivan Sarna: Aerodiagnostics has them as well. You don't need a prescription…

Dr. Satish Rao: Aerodiagnostics, yeah.

Shivan Sarna: Yeah, you don't need a prescription either. So I did a fructose test. And it was the highest level possible… it was a hundred.

Dr. Satish Rao: Oh, wow! Wow…

Shivan Sarna: He’s like, “I've never seen that before.” He said, “Oh, wow!” I’m like, “I need to do that one again.” If you've never seen it that high… really? So yeah, that's very interesting.

Okay, more about you guys here. For structural problem—okay, I want to say, Heather, the questions that you’ve asked are answered in many different portions of this class. So I just wanted to let you know I have seen your question.

Danny, I need to look for yours.

Let’s see...

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“Of these treatments, Candida using caprylic acid, oregano oil, Diflucan, nystatin, et cetera, do you find one to be less damaging to the microbiome than others?”

Dr. Satish Rao: It's very hard to say “damaging to the microbiome” because these antifungal will not affect the microbiome. They would probably affect the fungal part of this microbiome. They will not affect the bacteria part of the microbiome because they are highly selective. They're only going to work on the fungal organisms only. So it should not affect the bacterial microbiome.

Shivan Sarna: Okay. Back to the idea of—Nikki, this is for you—the elemental diet feeding SIFO. Have you seen it feed SIFO?

Dr. Satish Rao: Feeding… I doubt it. I don't know how it will feed SIFO. It should not. I don't think so.

Shivan Sarna: I think some people get that thrushy type of coating on the tongue. But that could be from something else, right?

Dr. Satish Rao: It could be from something else. It could be from various factors including—I think the thrush, me they may have thrush, or they may have something else, other deficiencies. But I doubt it that the elemental diet is actually causing that.

Shivan Sarna: But also, you know, we were talking about die-off. Couldn't having that die-off almost create like a thrushy thing in the mouth?

Dr. Satish Rao: You could. I mean, that may be the oral…

I mean, the mouth is sometimes a nice window of what is happening in the gut. So, if there is a strong reaction happening in the gut, maybe the mouth is a little window of that problem. And it may reflect that. And I think that's what—

We see that in people with severe gastroenteritis. We do see changes in the mouth. So, I think it may be reflecting something that's ongoing.

But most of the time, mouth, what we see, is totally independent of what's happening in the gut. You may see lots of things in the mouth, but the gut may be very quiet and unconnected with that

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also. But if you have GI symptoms, and you're seeing something in the mouth, then I think you now have to use that as a window of what may be happening in the gut.

Shivan Sarna: Okay, LIBO, large intestine bacterial overgrowth… are you a fan? Do you think about it? Do you diagnose this LIBO?

[01:25:02]

Dr. Satish Rao: I don't diagnose it. I really don't know how to diagnose it because it is very challenging. I mean, you have a trillion bacteria sitting there.

And I think the challenge for me and for many of us is really improved understanding of what is normal. What is normal colonic flora? We don't have a good clue. There are hundreds of articles, each one claims differently because I think they’re all different human beings in terms of where we live, what we drink, what we eat, what is our genetic makeup, what is our cultural background and so on. So, there are just too many factors that make up who we are; and our bacteria reflects that, and our colonic microbiome reflects that.

So, the challenge for us is knowing what is the normal baseline for an individual. And when that individual develops a GI problem, what has happened to that normal? Then only I think we are truly understanding the change which is highly specific to that individual.

But taking that change is what we're looking at now. We’re taking an individual who has got GI symptoms and an altered flora. And then, we’re making a leap of faith judgment that it is a symptom of constipation, it is a symptom of LIBO. That’s where I’m challenged with because we don't have the normal base for that individual… or even for the population! So we are very, very challenged at this stage.

The final thing in the LIBO story is what we find in the poop, in the stool, to what is actually residing in the colon are very different. When people do sampling and washings from the colon, culture them with their most sophisticated techniques, and then the same individual that collects stool, they examine, there is a big difference in the bacterial population.

So, in the same individual, there is such variability because, for some reason, some of these bugs are stuck to the lining. They're playing some role in the colonic lining. But they’re not being excreted in the same amount in the colon poop.

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So, there are just too many unknowns at this stage for me to truly accept LIBO as a clinical entity to diagnose, how to diagnose it, and how to treat it. So I am not there yet.

Shivan Sarna: Okay… not there yet. You know who is a huge fan of that? If you guys want to talk to Nirala Jacobi, she’ll talk to you about that. She’s a big fan.

So, okay, let's see…

Elizabeth: “My symptoms are bloating, belching, excess gas, including loud, persistent noise in the gut. It seems to work on a cyclical basis, often about one or two weeks of low level symptoms followed by one to three days of much longer-lasting and intense symptoms.”

Have you heard of this before? Do you think it might be hormonally related of a root cause you can think of? She’s had several SIBO breath tests, but no idea what caused it.

But Elizabeth, you didn't tell me if you have a positive or a negative result, my friend. So close, so close.

Dr. Satish Rao: Yes, and we also don't know how old Elizabeth is. Assuming that Elizabeth is in the menstrual cycle age individual, then yes, fluctuations in hormones may be much more likely to explain the fluctuations in symptoms and effects on gut. If it is post-menopausal, it is a little challenging because there may not be that much of a fluctuation. But some people do even the post-menopausal age. At least of the first 10 years, the hormonal fluctuations do happen. But after 10 years post-menopause, it is unlikely that this is a hormonal related issue.

The question really is: “Is this an IBS variant?” IBS, we know, waxes and wanes. And there could be other reasons that's happening. But most important could be inadequate treatment or incomplete treatment of the underlying problem. It may be worth addressing it. And also, some dietary component…

The one thing that is never constant is diet. We never eat the same things repeatedly all the time. And one thing we always do, we all indulge in various dietary indiscretions intermittently—not necessarily every day. But once a week, we go out, and we may eat something in a different restaurant. We like to taste. We go to places. So, that indiscretion in the diet—if I can use the word indiscretion—or really a new diet adventure (let’s put it that way rather than indiscretion), that may lead to this fluctuation in symptoms. So, we need to look into that.

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[01:30:26]

Dr. Satish Rao: I would recommend that she keeps a close diary of those periods when there are symptoms happening, what food she's eating, what medications she may have eaten. And then, either consult a physician and/or a dietitian to help identify any food triggers for that.

The hormonal issues, we've already addressed.

Shivan Sarna: Okay.

I've got one for you here, FMT, fecal microbiota transplant… what are your thoughts?

Dr. Satish Rao: So, I think two things. I would encourage everybody to go—and I'm going to do a little plug and advertisement here, not for myself, but actually for my daughter who has a podcast. She is an executive producer for one of the NPR stations produced by the UNC, University of North Carolina. This program is called The State of Things. And I think this show was made into a podcast somewhere in August 22nd or something like that. And her series is called Embodiment. And she did a very nice podcast for about an hour on fecal transplantation and the gut microbiome. And I think, Shivan, you should also go and listen to that.

Shivan Sarna: I can't wait, I’m going to.

Dr. Satish Rao: So, in that, they talked quite a bit about FMT. They had four people on that show, including a good friend of mine, a gastroenterologist; and another local infectious disease person, a lab; and really, a wonderful lady from Leeds in England.

But anyway, coming up to the question for this lady about FMT… so FMT, as per FDA mandate today, we can only use it in patients with C. diff infection in the United States. It is very strictly controlled. We cannot use FMT for any other conditions legally, ethically and so on. I know FMT has been used for treatment of SIBO. FMT has been used for the treatment of large bowel dysbiosis, if you like, and so on and so forth. Currently, that is all illegal in the United States of America. And we do not have proper trials.

There have been regulated states that have been done in inflammatory bowel disease, Crohn's disease and ulcerative colitis. The results have not been favorable. Most recently, there have been three trials in IBS. Again, it's a mixed response so far. One trial showed a positive benefit. At least two trials that represent our national meeting earlier this year, they were both negative.

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So, the jury's still out as far as FMT for GI intestinal dysbiosis.

But clearly, for C. diff infection, I do that routinely. It is phenomenally beneficial. Over 90% of patient symptoms magically disappear. It's a great treatment.

Shivan Sarna: Okay. I'm going to go a little bit faster. We have 30 minutes.

Okay, Pam: “Does he not agree with Dr. Pimentel and the MAST program? At DDW ’19, studies showing that the small bowel microbiome does not change from PPI use.” Are you familiar with this study?

Dr. Satish Rao: I disagree with Mark on that. Yes, that's the answer. There’s just too much evidence in favor of that PPIs cause it as opposed to what he presented.

Shivan Sarna: Okay. I’m going to keep going here.

Anne: “Has there been an observed connection between the Sphincter of Oddi dysfunction following a gallbladder removal and recurrent SIBO? I have two ERCP’s for the SOD symptoms and developed SIBO after the last one.” I don't know what those letters mean, by the way.

Dr. Satish Rao: I know what they mean. And I think this lady, this person, is really on to something very important. And I agree that the problem may not be SOD. The problem all along was SIBO.

Shivan Sarna: What’s SOD? Tell us what SOD is.

Dr. Satish Rao: I'll explain that. I'll explain that. But I think it has been mis-characterized or mis-diagnosed as SOD. And I've seen this happen in many patients, and I've treated them successfully for SIBO… but SIBO was not identified and diagnosed.

So, the Sphincter of Oddi is a valve that is located at the end of the bile duct where it opens into the duodenum of the small bowel. This valve allows juice from the pancreas gland and the bile to empty into the small bowel. That opening or that sphincter is called the Sphincter of Oddi.

[01:35:19]

Dr. Satish Rao: So, in people in whom the gallbladder has been removed, sometimes there is stagnation of juice and materials or the valve become spastic. It causes pain. It causes liver

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enzymes. And it causes cholangitis. And this has been called as Sphincter of Oddi dysfunction. And there are three types that have been described and so on and so forth.

I do believe that, in a vast majority of the Sphincter of Oddi dysfunction, the cause is SIBO but has been mis-diagnosed as a muscle valve dysfunction… then it is not the case.

Shivan Sarna: Fascinating! And isn't there like a migrating motor complex up there?

Dr. Satish Rao: Not inside the Sphincter of Oddi. But the sphincter itself has a valvular mechanical activity that may not be working properly in some people, yes.

Shivan Sarna: Somebody told me that cortisol manages valve opening and closing.

Dr. Satish Rao: I'm not aware of it.

Shivan Sarna: Okay, yeah.

I think this is Carlene: “My MD prefers to use the Crook's Candida Questionnaire. And according to it, I probably have Candida overgrowth. I've never had thrush or vaginitis and do not crave sugar, bread or alcohol. What are some physical/mental symptoms that I could look for to distinguish it from gut dysbiosis, which I do know I have?”

Dr. Satish Rao: This person has gut dysbiosis, but she’s trying to find out whether there are any specific symptoms of SIFO.

Shivan Sarna: Yes… yes…

Dr. Satish Rao: And the answer is there aren't any specific symptoms of SIFO. My slides clearly show that. The SIFO negative, SIFO positive, SIBO positive and SIFO positive, they all have very similar symptoms.

Shivan Sarna: Yeah, okay.

Carol: “Any possible relationship between low bone density and high SIBO or SIFO?

Dr. Satish Rao: I honestly don't know. Great question! I really don't know.

I can say that now that the person has posed it, I'm thinking fast in my little computer, it’s telling me that there is a likelihood because SIBO interferes with absorption of gut nutrients, chemicals,

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calcium, vitamin D, and so on and so forth. So, if you are now depriving your body of essential trace elements and vitamin D, then you can get osteoporosis. Your bone density will go down. And therefore, if you can now treat the SIBO and/or SIFO, you’ve gotten rid of the bacteria that's eating up your food and vitamins, you are now absorbing normal levels of these calcium and vitamins, then I think that will help to treat osteoporosis or calcium deficiency or vitamin D deficiency.

So yes, there can be connection. But I've not seen anybody draw that connection so clear cut as this patient describes.

Shivan Sarna: Christina, she has a lot of histamine levels and a lot of nausea. Do you have any suggestions for nausea?

Dr. Satish Rao: So, I think this particular individual may have either mast cell activation syndrome, as we call it, and/or high histamine levels being produced because there’s some level of allergy/immune dysfunction inside the gut most likely.

So, I think taking foods that are low in histamine can be very beneficial. Taking medications perhaps, such as mast cell stabilizing agents and anti-histamines, both H1 like Benadryl-kind of compounds, H2 blockers such as cimetidine or famotidine, those kinds of compounds, they may help to mask the gut mast cell activation, and thereby lower the histamine levels of the body.

Shivan Sarna: For mast cell activation, guys, that is such an exciting area. And it answers so many questions. If you don't know what it is, please, please go to the Facebook group and look up that recent Facebook Live I did with Dr. Leonard Weinstock because it's a good primer on all of that if you don't know what it is and you have systemic inflammation.

Okay! What about hydrogen sulfide? Do you have a special treatment that you do for hydrogen sulfide SIBO?

Dr. Satish Rao: So, I don't even have a method yet. I know Mark has done some very nice work in that area. He's the only one who has the ability to detect it because they are developing this commercial instrument for measuring hydrogen sulfide.

[01:40:11]

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Dr. Satish Rao: And yes, I do believe hydrogen sulfide—as I’ve said, there are people in whom you get a flat hydrogen, flat methane level, yet they're symptomatic. Currently, I would probably call them maybe hypersensitive. But maybe they are producing hydrogen sulfide. We don't have a good method of detecting it.

If that methodology can confirm that, then we can use that as a way of identifying hydrogen sulfide-producing SIBO and use that as a way of diagnosing and treating it. We don't have that ability right now.

Shivan Sarna: Okay. Danny, I want to make sure I got you. I did answer one question of you, Danny. I just see one question submitted.

Ah, more gallstone fun! “I have IBC-C and had a breath test showing methane.” She took treatment, it didn't make any difference. “I've now discovered I have gallstones. Could this be the reason I feel much worse with bloating and pressure after a bowel movement?” from Angela.

Dr. Satish Rao: I think so. I mean, this would be the classic situation where you have gallstones, and you have those symptoms that Angela is describing, and I would probably consider strongly talking to a physician and having gallbladder removal. And that may lead to the resolution of all of those symptoms.

Shivan Sarna: have girlfriends who’ve had their gallbladder removed, and it leads to diarrhea? Is that just like a pro/con thing?

Dr. Satish Rao: Twenty-five to thirty percent of patients who have their gallbladder removed will get bile acid malabsorption diarrhea. And the reason why it happens is, normally, the liver is continuously producing bile, and all of that bile is stored in the gallbladder. When you no longer have this reservoir, this bladder, to store bile, bile is continuously pouring into the small bowel.

And then, normally, less than 5%—95% of this bile is reabsorbed in the last six inches of the small bowel. Less than 5% spills into the colon. But if you have lost your gallbladder, more bile is pouring into the small bowel, it is likely that, intermittently, more bile will spill into the colon.

When more bile spills into the colon, there is no laxative that is stronger than your own bile. Your bile becomes your laxative and you get diarrhea from it. That is called bile acid diarrhea or bile acid malabsorption.

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And that is not an uncommon problem. It can be treated very easily with bile-binding resins— cholestyramine, colestipol, colesevelam. There are several of these drugs that are available. And your doctor should be able to diagnose it.

Unfortunately, we don't have a test in this country for diagnosing bile acid diarrhea accurately and commercially available throughout the country. Outside this country, yes; in Canada, UK, everywhere you go, you have a test.

Shivan Sarna: Hmmm… that’s interesting.

UT: “I was my stomach does not produce enough acid. The advice was to preferably eat vegetables, which I did. But I want to understand why. The logic in my eyes would be meat, for example, and of course avoid meat and eat vegetables when you already produce too much acid.” He’s not a native English speaker.

Dr. Satish Rao: So, the challenge really is it’s a very rare condition where you don't produce much acid. Pernicious anemia is one of those conditions and so on—most of the time, people produce a lot of acid—or if I had some surgery in the stomach (we cut off your nerves for the stomach that produces acid, so on so forth). So, it’s very rare you have no acid production.

So, most people who have not had surgery, that don't have pernicious anemia, it's unlikely that they will not be producing enough acid.

So, I think in the absence of those conditions, you should be able to eat everything. You should be able to digest most things normally, including vegetables.

Shivan Sarna: Okay. Two questions about drinking water. One is what happens when you feel like you have a rock in your stomach after drinking water; and the other is, when people bloat after fasting, and then just drinking water.

Dr. Satish Rao: I have never come across those two issues. So, a rock in your stomach after drinking water… I honestly don’t know what is it.

Shivan Sarna: Okay. Joan, we’ll…

Dr. Satish Rao: We have to pass on that.

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Shivan Sarna: Yeah, we're going to pass on that. Okay, let's see.

Raul: “I have severe stomach cramps and chronic diarrhea after I eat. How can I relieve my stomach and gut cramps?” He has had the gallbladder removed and has tried an elimination diet. Could that be from having the gallbladder removed, that 25%?

[01:45:14]

Dr. Satish Rao: I think so. This individual clearly has what we just described, bile acid diarrhea. And I think, talk to your doctor. Say that you were on this show, use my name. It doesn't matter. They would probably recognize and say that we’ve discussed this possibility.

You don’t diagnose the problem. But tell your doctor, “This is what was discussed. Is it a possibility that I have this condition?” And if so, can they treat you for that?

There is no harm with this treatment. It's a very safe treatment. And you can go on a trial a few weeks to see whether this medications that I mentioned can help.

Shivan Sarna: Okay. Great! Alright, I got it right here. I just had it, about somebody daddy, a 91-year old…

Okay! Dave: “My 91-year old dad has constant chronic gut pain below the navel radiating up his side. His regular doctor has done all the usual treatments for constipation—fiber, laxatives, probiotics. And he has had all the scopes and imaging which show nothing. The doctor says IBS. Is there a naturopathic doctor in our neck of the woods?”

So, this is this is a referral question. Actually, I'm going to handle this one separately. But how can you test for adhesions is the other part of my question?

Dr. Satish Rao: There's no test for adhesions.

Shivan Sarna: Ah, ok, alright.

Dr. Satish Rao: …unless the gut becomes obstructed. And in a patient with a history of bowel surgery, and we can see evidence that the gut is twisted up to a point where there is no movement of barium or what-have-you, then we know that it's obstructed. Most likely, that twist or lack of

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movement or blockage is from adhesions. That's how it’s diagnosed. But there's no test for adhesions. It’s an indirect test.

Shivan Sarna: Okay.

Liliana: “Which medication—laxative, stool softener—would work better to address the dyssynergic…”

Dr. Satish Rao: …dyssynergic defecation...

Shivan Sarna: Yeah!

Dr. Satish Rao: I just got that condition, so I should know better than anyone. I gave it such a terrible name, but I think I coined the term.

But really, there was no other way of describing it because, in simple words, the act of pooping or defecation is uncoordinated. It’s not coordinated properly. And the only medical term for incoordination is dyssynergia. And here, the muscles are uncoordinated or dyssynergic.

There is no medical treatment for this. No medication is going to cure it. No laxative on earth will solve the problem. You really need biofeedback treatment. That is the only way to solve it. It's a behavioral treatment.

The art of pooping is learned, miraculously, between the ages of two to five by all of us (or the majority of us). In some, this art was never learned properly. That seems to be the problem in a third of patients with dyssynergic defecation.

In two-thirds, they had a normal art, but something happened to them that they had a painful defecation. They had a fissure. They had, unfortunately, abuse. Or they had surgery. Or they had pelvic floor dysfunction of some kind… something that led to a change in their behavior, and now they've acquired a new way of pooping which is the dyssynergic way or the coordinated way, leading to long-standing constipation.

The only way to treat it is biofeedback.

Shivan Sarna: That is fascinating! So, how do you find a biofeedback therapist that specializes in this?

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Dr. Satish Rao: So, I think there are two ways. One is you can go to the ANMS website, American NeuroGastroenterology & Motility Society website. And they have a patient information portal there. They have providers of various motility testing in different parts of the country—state by state, city by city. You can look for one to see if someone close to you has it. Or go to your gastroenterologist locally. They might know where to send it.

Or the third option is that physical therapists do this. And I don't mean any disrespect to my physical therapy colleagues. Generally, I find my physical therapy colleagues are outstanding for biofeedback treatment for stool leakage, fecal incontinence or urinary leakage, urinary incontinence. But they are less equipped and less well-trained for treatment of dyssynergic constipation problem.

But nonetheless, these are the resources available today.

Shivan Sarna: I can't even say that word, dys…

Dr. Satish Rao: Dyssynergia…

Shivan Sarna: Dyssynergia…

Dr. Satish Rao: Got it!

Shivan Sarna: There, I got it. Thank you.

So, when I think of a prokinetic, I think of like a symphony and a synergy and synchronicity. This is different.

Dr. Satish Rao: Right! This is the opposite. Dyssynchrony, dyssynergia, dys-symphony, that’s what it is.

[01:50:16]

Shivan Sarna: So would a prokinetic help it?

Dr. Satish Rao: No… because the prokinetic will restore normal kinesis in gut movement. But this movement is all controlled by the brain and the body. Otherwise, prokinetics will give

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everybody diarrhea. Whether you're sleeping or walking or whatever, you'll be pooping automatically. And that doesn't happen.

The exit ultimately is under voluntary control. This voluntary control mechanism has gone wrong. And we need to correct that.

And for that, we need to understand the problem. We need to learn breathing, pushing, relaxation techniques. It’s just a physical therapy program. But we have to educate them, show them. Over a period of six sessions, 80% of my patients are cured.

Shivan Sarna: Fantastic! That is fantastic.

Let’s see…

Oh, Alaine, this is for you. What do you think about colonics?

Dr. Satish Rao: I have not been a big fan, to be honest, about colonics. I mean colonics are useful perhaps for short periods of time in people with really difficult colonic problems. But at the same token, they also make the gut lazy because the body has got a built-in rhythm, a bio -rhythm. It is supposed to form stools, move stools and evacuate stools. If that is not being achieved, and you’re artificially extracting stool, the body quickly learns that. It says, “Aha, I don't need to do any work. Someone else is doing my work for you. So I'm happy to become more and more lazy.” It only perpetuates the problem. It never cures. It's a band-aid, but not a cure.

What we need to find out is why is that individual constipated? The majority of them, trust me, have the dyssynergic defecation that has not been diagnosed.

Identify the problem. Go to a gastroenterologist, go to a motility doctor. They will run the test. They will treat you. And they will cure you from this problem in the long-term.

Shivan Sarna: Nice! I love the word cure.

Okay, let's see here… oh, hold on. Lot of diet questions! I'm going to have the diet questions I think answered by somebody else because I have a lot more that are like hospital-type questions here for you, Dr. Rao.

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Okay! So, Liliana had a second part to her question. She said about the dys…

Dr. Satish Rao: …dyssynergia?

Shivan Sarna: Yeah, dyssynergia constipation. Her background is that she's taking linaclotide.

Dr. Satish Rao: Linaclotide…

Shivan Sarna: Yeah, and receiving pelvic floor dysfunction therapy with biofeedback. Very good!

Dr. Satish Rao: Okay…

Shivan Sarna: …diagnosed with this and internal hemorrhoids and IBS-C and methane SIBO and parasites and dysbiosis. So, how long have you been doing the biofeedback because you said…?

Dr. Satish Rao: You need at least six sessions of treatment. That I think is what we found. We have published several studies now. They’ve all shown that six sessions is effective in about 80% of patients. Some people need longer time. Some people need a longer time to connect.

We're also trying to develop a home biofeedback. Unfortunately, it's not yet commercially available. We did this in a randomized study published in The Lancet last year. It showed that home biofeedback is just as good as office biofeedback. But there is no commercial tool yet.

Shivan Sarna: Okay.

Sylvia: “When I get a serious bruise as in a fall, a rash develops within a few days on the bruise. It's raised and very itchy. And if I scratch it, it spreads. Have you heard of this as a symptom of Candida, mold, or MCAS? It reminds me very much of poison ivy but with no weeping.”

Dr. Satish Rao: So, I think I'm not so sure about Candida. But I think it can be a problem of MCAS, yes. But again, you really need to go talk to a skin doctor first. Have them do a skin biopsy to look for this mast cell activation syndrome or a benign level of mastocytosis as we call it. And then, you can be treated appropriately.

[01:55:07]

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Shivan Sarna: Guys, remember, there's a Facebook Live with Dr. Leonard Weinstock who discusses a lot of this. It’s a rabbit hole. It's a great rabbit hole if you have what you have which is fibromyalgia and all that. So, please find out more through that resource at SIBO SOS Community on Facebook.

Let's see… how can you tell if your bloating is air or food? Good one, Amanda!

Dr. Satish Rao: So, we all have a little bit of bloating and a little bit of distension after we eat. That’s normal. Now, the air bloating and air distension is abnormal. It often happens very quickly, over a period of time. And it persists for a long period of time.

Food-related bloating usually decreases within an hour to two hours. But if something is persisting longer than that, then most likely it is air. And continued production of air or entrapment of air, that is what is causing it. So, food-related usually settles.

Most important, I think food-related will happen immediately after we eat food. It should never be painful for prolonged periods of time with food. Food normally satiates, we feel comfortable and happy.But sometimes, we feel really full because we've overeaten it. And if you have not overeaten it, and you're feeling full, then that could be of gastroparesis—which is another problem altogether. That is called postprandial fullness. That has to be detected. And that may also sometimes masquerade as SIBO, so we need to test you for that.

Shivan Sarna: What about T4 for daily medication? Do you see that impacting the gut?

Dr. Satish Rao: T4 you said? What is that?

Shivan Sarna: T4… is it the levothyroxine?

Dr. Satish Rao: Oh, levothyroxine, okay. Yeah, the l-thyroxine. Yeah, what about T4?

Shivan Sarna: Just whether T4 daily medication for life gets in the way of preventing relapses?

Dr. Satish Rao: …relapsing SIBO?

Shivan Sarna: I would say so, yes.

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Dr. Satish Rao: No, I mean you’re taking your thyroxine first thing in the morning. And I don't think that should any way interfere.

But I know the other way around. In other words, SIBO can interfere with thyroxine levels. I think that may be what the person is alluding to. In other words, if you have SIBO which has not been treated or partially treated, and you're taking thyroxine, thyroxine is not going to get absorbed because of SIBO interfering with thyroxine absorption. It will interfere with other drugs’ absorption. It will interfere with food absorption and everything else as it is fermenting away the food.

So, it can cause fluctuation of your thyroxine levels if you have SIBO. So yes, it is important to diagnose and treat it to ensure that you have proper absorption of thyroxine levels. Yes, that is the connection.

Shivan Sarna: Can a liver biopsy cause an adhesion?

Dr. Satish Rao: No…

Shivan Sarna: Okay. Let’s see…

Can you test for zonulin to help with determining whether or not you have leaky gut?

Dr. Satish Rao: That has been proposed as a method of diagnosing leaky gut. I'm not sure the data is credible and strong enough for that.

Shivan Sarna: Okay.

Annette: “Can you recommend a diet or supplements to help with flaring of microscopic colitis, specifically, collagenous colitis?”

Dr. Satish Rao: …collagenous colitis. You know, I feel this microscopic colitis and collagenous colitis is another medical conundrum. It is a true problem. It is definitely a form of inflammatory disease in the colon. Why people get it, how to treat it, has remained challenging.

But in terms of diet, which is the question, I would strongly recommend two things. Number one, try first going on a lactose-free diet, completely lactose-free. If that is not cutting it, I would go

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on a gluten-free diet. Those are the only two diets that we have tried with some measure of success in treating these people with collagenous colitis.

Shivan Sarna: Interesting. Okay. So, what about the relationship between SIBO and Celiac?

Dr. Satish Rao: So, they can co-exist. They can make each other’s condition worse. I’ve diagnosed a lot of Celiac disease patients with SIBO. But mostly, they are untreated or before the diagnosis of Celiac disease. One Celiac disease has been treated, and their SIBO has been treated, they rarely have recurrence of the problem as long as they're compliant with their diet. So they can co-exist.

And also, we know that Celiac disease patients can have gut dysmotility. And so, once the gluten is withdrawn, the motility is restored.

[02:00:12]

Dr. Satish Rao: Many people also have lactose intolerance. And that lactose intolerance also improves with correction of the enteropathy that is part and parcel of Celiac disease.

Shivan Sarna: Judy, I think your question has been answered already.

Leonard: “What should be done to help the microbiome recover as soon as possible after a routine and unremarkable colonoscopy?”

Dr. Satish Rao: You know, you really don't need to do anything. I mean I know the colonoscopy washes out the gut. But when you take antibiotics, for example, or you get gastroenteritis, you probably have even more stronger cleansing of your gut, if you like, and more aggressive cramps and so on than you would get with colonoscopy.

So, I don't think you need to do anything. Your normal diet should restore your colonic flora very, very quickly.

I've had colonoscopies myself. I've had three of them. And yeah, the first maybe three or four days, there is a little change in bowel habit. But within three or four days, it becomes normal.

Shivan Sarna: Okay. Okay… I'm just making a few notes to make sure I get everybody covered here.

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Pam: “What should the next step in investigating the root cause of upper left pain”— I'm assuming abdominal—“bloating and constipation be after H. pylori stool test was negative?”

Can you test for H. pylori from a stool test?

Dr. Satish Rao: Yes, yeah.

Shivan Sarna: Okay. “Pancreatic enzyme testing was okay. Negative SIBO breath test. And all other tests were normal. I have no gallbladder and do have various issues with certain high FODMAPS and sugars. But things like enzymes and HCl all cause diarrhea.”

Dr. Satish Rao: So, I think again two possibilities. Still, SIBO is a possibility (I would undergo duodenal aspirate and culture). SIFO is a possibility (again, duodenal aspirate and culture). If they are negative, iw ld go for further breath testing with fructose, lactose and fructan. Those, I think, can cause diarrhea and persistent symptoms. And I would look for them and have them treated.

Shivan Sarna: Okay. Do you know who Dr. John Chia is and his findings of enteroviral infections?

Dr. Satish Rao: A little bit. I think maybe this is an individual who is actually in Los Angeles I suspect. Go ahead anyway.

Shivan Sarna: No, if you don't know who he is, it's not going to work. Okay.

And do you know Dr. Skip Pridgen’s studies?

Dr. Satish Rao: No.

Shivan Sarna: Okay.

Dr. Satish Rao: I know about the enteroviral infections. But that’s mostly causing duodenal issues and dyspepsia symptoms and so on. It causes duodenal eosinophilia and stuff like that. So that may be where that context is. So that's why I was…

Shivan Sarna: No, Dr. John Chia has found via endoscopy biopsies that 80% of his chronic fatigue syndrome patients with chronic abdominal complaints have this enteroviral infection.

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Dr. Satish Rao: Correct. It’s not been replicated by others. But yes, that's been observed.

Shivan Sarna: Okay, alrightee…

Okay, let’s talk diverticulitis. “I’m just coming off a round of antibiotics for diverticulitis. Years of gut problems. And I'm now convinced of SIBO. I'm very excited to begin an elemental diet now that all my bacteria is killed… good and bad. What's the best form of vitamins and minerals to add to my drink? I’m making my own because I'm allergic and sensitive to so much. Even Thorne rolls through me in about 10 to 20 minutes. This is my hardest challenge.” So, you are doing the elemental diet…

Dr. Satish Rao: So, I think most elemental diets have a very good balance of vitamins and minerals and nutrients. You don't need any more supplements. You really don't need any more supplements. Especially the PED that we talked about earlier on, it’s very balanced. It's got everything. So you don't need any supplements. Just stick to the diet. You have to get enough calories, maybe 1600 to 2000 calories. And that should be enough. You should have all the elements there.

Shivan Sarna: Okay. What's the best approach to help a six-year old with yeast overgrowth that has been causing bloody mucousy stools for 3 ½ years. His livers been burdened with die-off from it during coconut grapefruit seed extract protocols. High fever, hives, and vomiting on two occasions. Your advice is appreciated.” Yikes!

Dr. Satish Rao: A six-year old, he said?

Shivan Sarna: Yeah…

Dr. Satish Rao: You know, I really don't know. I don't practice pediatric. So I would rather not comment on this child.

[02:05:10]

Shivan Sarna: Do you have a couple of people you know of that do practice pediatric?

Dr. Satish Rao: Yes! I think there are a lot of people who I know practice pediatric medicine. I don't know where this particular family is from. But clearly, the best doctors are in Columbus Hospital, Ohio—you know, Dr. Carlo de Lorenzo and their group, one of the largest groups of

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pediatric GI. The second largest group is in since Cincinnati; then the University of Wisconsin at the Medical College of Wisconsin.

Milwaukee has a very nice group of pediatric GI people. And of course, up in the Boston area, the Beth Israel and Mass General; and finally, the Cedar-Sinai. So, these are some of the big groups—and the Michigan group also. So they can really go see them.

Shivan Sarna: Have you ever heard of neomycin?

Dr. Satish Rao: Yes.

Shivan Sarna: Well, of course you have. Of course you’ve heard of neomycin. But the hearing loss…?

Dr. Satish Rao: Yes. So, the challenge really is it is well-described, but the neomycin dose that has been used that caused this usually is much higher levels.

We used to use a gram of neomycin four times a day. That is 4g a day. We would do that standard for gastroenteritis, and particularly for liver failure patients. We used to do that for years. We’ve done that. That is the kind of scenario where we observed it.

If you're going to give a lower dose of neomycin, 500 mg. three times a day or four times a day—which is what we’re now using for methane SIBO and so on—I think the likelihood is small. We need to be cognizant. If they're getting any symptoms, then we should just stop it. But I think, at a smaller dose, it is less likely to cause this problem.

Shivan Sarna: Okay! Guys, we are out of time. And one of the things I really need to do is always honor these doctors’ times, especially on a Saturday afternoon. My gosh, Dr. Rao, thank you so much.

Please put some love into the Q&A box and the chat box, anywhere you want, for Dr. Rao. What were your aha moments? We love sharing that with our speakers.

Thank you very much, sir. We really appreciate you. And I wanted to really honor the time. So thank you. You're brilliant. Amazing! Thank you for your good services. And I think anybody who gets a chance to have you as their practitioner is going to be a lucky duck.

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So, make that luck happen, you guys. See if you can get to Augusta, Georgia.

Dr. Satish Rao: Well, thank you, Shivan. That was wonderful! I didn't even know. The time passed so quickly. I had so much fun talking to you. Your questions were very poignant. Your audience is fantastic. They're very knowledgeable. I was touched by their questions.

I hope I provided convincing answers for many of them.

Shivan Sarna: Beautiful, beautiful.

Dr. Satish Rao: And hopefully, it should lead to either better diagnosis and treatment for all of them. If some of them choose to come and see me, I think we would love to have them. Please be patient. I think there are many people out there with similar issues, but we'll try and do our best to get your problem answered to the best of our ability.

And it was truly a pleasure. I look forward to your future sessions and to following your masterclasses. They are superb indeed. So thank you.

Shivan Sarna: Oh, thank you so much. We'll talk to you soon, Dr. Rao. Thank you.

Dr. Satish Rao: Take care, Shivan.

Shivan Sarna: Take care. Bye bye.

Dr. Satish Rao: Bye.

Shivan Sarna: Bye bye.

[02:09:50]

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