Presenter: Dr Nirala Jacobi ND

1. SIBO Update 2016
The latest in research and
treatment
Dr Nirala Jacobi, ND
Medical Director, SIBOTest
14 July 2016

2. Outline
 News and Review – what’s new in 2015/2016
 2016 SIBO Symposium USA Highlights
 Update in SIBO treatment
The New Biphasic Diet
Antimicrobials:
“New” herbal antimicrobials for SIBO and SIFO
Rifaximin update
 Noteworthy Research in 2016
 Q + A

3. News and Review of 2015/2016

4. We’ve been busy at SIBOtest.com
 New website– brand new practitioner section which features handouts and
educational videos
 SIBO News section – blog.sibotest.com
SIBO Doctor Podcast – interviews with experts. Launching August/September 2016
SIBO Practitioner in the spotlight videos
SIBO Diet and Nutrition section
SIBO Research
 SIBO MasterClass- 3 x 2 hour sessions working through basic to advanced case
management as well as special topics. Next class starts in September

6. In case you get lost…..
 The purpose of this annual update is to build on our existing SIBO knowledge
 If you are new to the field of SIBO and get lost: Please review
the Foundations of SIBO Assessment and Treatment
This 90 minute video is available for free in the Practitioner Resource section at
www.SIBOtest.com

7. SIBO
suspected
Lactulose and/or
Glucose Breath test
Herbal
Antimicrobials,
Bi-Phasic Diet
Elemental Diet
Antibiotics,
Bi-Phasic
Diet
Partial
improvement
90%
improvement
Retest
Consider other Dx
change herbal
antimicrobials, repeat
rifaximin, consider
elemental diet
Prokinetic, Biphasic
Diet, Prevention
Test negativeTest positive

8. Consider SIBO in chronic illness
 Leaky Gut
 Release of zonulin occurs in:
Acute Gastroenteritis
Gluten sensitivity
SIBO
 LPS and other bacterial endotoxins
Most potent trigger of inflammation
 SIBO also associated with increased inflammatory cytokines eg IL6

9. Lactulose Breath Test
 if negative, consider follow up with glucose breath test if SIBO is suspected
 Why? Each substrate can be fermented by different bacteria
 Substrates: Lactulose, glucose, fructose etc
 Lactulose/Glucose combination test most accurate across a wider field of
bacterial species

10. Methane
 Methanobrevibacter smithii – methanogen, highly associated with SIBO-C
 Patients feel best when methane <3ppm – interpret test results 6ppm
(BreathTracker is accurate within +/- 3ppm)
 Poorly absorbed from LI
 Not produced with Lactulose– instead it produces methane from hydrogen
secreted by hydrogen producing bacteria
 New Spot Methane
Used if patient had high baseline which stayed high during initial breath testing
Convenient single vial
Monitor if treatment is working

11. Methane cont’d
 High Baseline which stays high
Possibly more of an indicator of LI dysbiosis
 Rise of methane over baseline - SIBO

12. SIBO Symposium Highlights
 Underlying causes of SIBO
 SIBO treatments in pregnancy and lactation
 Biofilms
 Prevalence of SIBO in Lyme patients
 Intersection of IBD and SIBO

13. Underlying causes of SIBO
Normal protection against SIBO: MMC, HCL, Bile, Enzymes, Immune system,
ICV
1. Damage to the migrating motor complex (MMC) -- Bacteria not cleared/swept
out of the SI
2. Altered Anatomy/structure - Bacterial clearance blocked
3. Altered Physiology/function – Bacteria not killed in stomach or SI

14. Damage to the migrating motor complex
(MMC) -- Bacteria not cleared/swept out of
the SI
 Post infectious SIBO caused by 4 strains of gram – bacteria: C. jejuni, salmonella, E.coli,
Shigella
Release CDT– damages ICC cells in MMC -- Ab formed to CDT– damage vinculin protein on nerve
cells
 Lyme
 C.difficile
 IBD
 Scleroderma
 Diabetes
 Ehlers– Danlos
 Hypothyroid
 Drugs: Opiates, recurrent antibiotics,
 Surgery/injury: muscle/nerve damage
 ANS dysfunction: Sympathetic Dominance

15. The MMC- Video
Video: http://wzw.tum.de/humanbiology/index.php?id=41&L=1

16. Altered Anatomy/structure - Bacterial
clearance blocked or retrograde migration
 Adhesions
 Partial obstructions (adhesion, stricture, tumor, compression, twist)
 IBD stricture
 ICV removal (common in bowel resection for IBD)
 Volvulus – congenital obstruction caused by twisting of the stomach or
intestines
 Cancer
 Superior mesenteric artery syndrome- duodenum compressed between the
abdominal aorta and SMA
 Non draining pockets:
Blind Loop – post surgery
SI Diverticula

17. Adhesions, strictures, obstructions
Consider these common surgical histories
 laparoscopy or laparotomy
 C-section or episiotomy
 appendectomy
 bowel obstruction repair
 cholecystectomy
 back or hip surgery
 hysterectomy
 gastric bypass

18. Altered Physiology/function – Bacteria not
killed in stomach or SI
 Hypochlorhydria
 Altered bile flow and enzymes
 PPIs
 Frank immunodeficiency
 Leaky gut – microvilli damage

19. Important considerations when
considering SIBO
 SIBO is associated with chronic relapse. The more the practitioner
understands and treats the cause, the more relapse is minimised.
Hx of abdominal surgery or Endometriosis: refer to adhesion specialist
Hypothyroid: improve digestive function with HCL and motility agents
Hx of gastroenteritis and sxs since: may have to stay on prokinetic indefinitely
Hx of PPI use – high incidence of relapse (Scarpignato)
 Not all underlying conditions can be cured
eg genetic conditions, advanced scleroderma, surgical damage to nerves. in
these cases, the patient should be advised that the condition can be managed

20. SIBO Tx in Pregnancy, Lactation,
Pediatrics (Dr. Allison Siebecker)
Pregnancy
 Safe for pregnancy: Allicin, Low Dose Naltrexone (LDN), Iberogast, Ginger (up to 2,000mg) ›
 Not recommended (per label): Berberine, Oregano, Neem, Cinnamon, Motil Pro
 Category B: Metronidazole,Prucalopride, Erythromycin- at Antibiotic Dose (a 15x higher dose
vs Prokinetic Dose) “Animal reproduction studies have failed to demonstrate a risk to the
fetus and there are no adequate and well controlled studies in pregnant women.”
 Category C: Rifaximin “Animal reproduction studies have shown an adverse effect on the
fetus and there are no adequate and well-controlled studies in humans, but potential
benefits may warrant use of the drug in pregnant women despite potential risks.”)
 Category D: Neomycin “There is positive evidence of human fetal risk based on adverse
reaction data from investigational or marketing experience or studies in humans, but
potential benefits may warrant use of the drug in pregnant women despite potential risks.”

21. SIBO Tx in Pregnancy, Lactation,
Pediatrics (Dr. Allison Siebecker) cont’d
Lactation
 Safest antimicrobials: Allicin, Rifaximin, Neomycin
 Safest Prokinetics: LDN, Iberogast, Ginger ( NJ: I’ve used bitters at 6+ months
lactation safely)
 Safe: Allicin, Iberogast, Ginger (AS used Berberine & Oregano at 8+ months
lactation safely) ›
 Not Recommended (per label): Berberine, Oregano, Neem, Cinnamon, Motil Pro ›
 Low Secretion in Milk: Rifaximin, Neomycin (clinically insignificant/ very low),
Erythromycin
 Unknown: Prucalopride (no anticipated effects, lack of human data)
 Secreted In Milk: Metronidazole

22. SIBO Tx in Pregnancy, Lactation,
Pediatrics (Dr. Allison Siebecker) cont’d
Pediatric
 Rifaximin: 10-30mg/kg x 7-14 days (30mg showed better results), or 200mg 3xday
 Neomycin: ½ adult dose- 250mg 2xd x14 days, or 50mg/kg 3xd
 Metronidazole: 30 to 50 mg/kg/day orally in 3 divided doses, Maximum dose: 2.25
g/day (AS hasn’t used it)
 Herbs- Allicin, Berberine, (NJ: Oregon Grape, Pomegranate, Burr Marigold) : ½
adult dose (or ¼ dose if very young/low weight)
 Prucalopride: 0.01mg/kg, if > 50kg use adult dose of 0.5mg/night
 Low Dose Erythromycin: 1-3mg/kg body weight, typically 25mg/night
 Iberogast: 10-30 drops/night
 Safety Unknown: Oregano, Neem Powder (Neem Oil is unsafe), Cinnamon, Motil
Pro (AS has used at ¼-½ Neem Powder capsules adult dose in 7+yo safely)

23. SIBO and Biofilms
(Dr. Michael Ruscio, DC)
 Biofilms are extracellular polymeric substance (EPS) matrix, comprised of
primarily polysaccharide material, also fiber/fibrin, protein,
mucopolysacharides, heavy metals/minerals
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2732559/
 “Biofilm formation is a crucial step in the pathogenesis of many subacute and
chronic bacterial infections...”
 Antimicrobial agents can become trapped within the biofilm and then
inactivated by enzymes
 Can spread antimicrobial resistance by promoting horizontal gene transfer
and increased expression of resistant genes (aka efflux pumps)
 Biofilm bacteria can decrease their growth rate making antimicrobials less
effective

24. SIBO and Biofilms
(Dr. Michael Ruscio, DC)
 Much research evidence that IBD has biofilm as a component. Going so far as
to say “IBD can be viewed as a polymicrobial infection that is characterized
by [...]complex bacterial biofilms on the epithelial surface.” Mucosal flora in
Crohn's disease and ulcerative colitis - an overview.
 Most organisms can create a biofilm including candida and SIBO bacteria -
Biofilms may be present in more than 65% of all bacterial infections
 Archaea: it appears that Methanobrevibacter smithii can form biofilms

25. SIBO and Biofilms
(Dr. Michael Ruscio, DC)
Treatment:
 NAC- evidence of efficacy as pre-treatment for H.pylori
 Nato, lumbro and Serapeptase (NJ has used successfully )
 Proteolytic enzymes
 chelators for metals/minerals
 A number of well-controlled studies indicate that probiotics, particularly
lactobacilli, suppress Candida growth and biofilm development in vitro.
 Timing of dosing (with or without the antimicrobial) does not appear to
matter
NOTE previous SIBO webinars reported that many practitioners have not found
any clinical benefit with biofilm treatment

26. The Prevalence of SIBO and Lyme disease
(Dr. Farshid S. Rabar, MD- Gastroenterologist)
 Bloating/Gas 76%
 Tire easy/weakness65%
 Anxiety 50%
 Abdominal Pain 48%
 Sleeplessness 44%
 Constipation 42%
 Food Intolerance 42%
 Irregular BowelMovements 37%
 Weight Loss / WeightGain 36%
 Joint Pain 34%
Top 10 Sxs of Tick Borne Disease (TBD) infection

27. The Prevalence of SIBO and Lyme disease
(Dr. Farshid S. Rabar, MD)
 Patients with Lyme and TBD’s may present primarily with GI manifestations.
These patients may have complex or persistent GI symptoms involving upper,
mid, or lower GI tract
 65% of patients newly diagnosed with Lyme dz also tested positive with SIBO
Lyme commonly affects the ANS and ENS
 Autonomic Nervous system:
Sympathetic
Parasympathetic
 Enteric Nervous System (ENS)

28. The Prevalence of SIBO and Lyme disease
(Dr. Farshid S. Rabar, MD)
The Enteric Nervous System: The enteric division is a self contained nervous
system that surrounds the GI tract and receives sympathetic and
parasympathetic input.
Central Nervous
System
Peripheral ganglion Target cell
Preganglionic neuron Postganglionic neuron

29. The Vagus nerve innervates
all aspects of the GI tract,
except the rectum, which
Is directly innervated by the
Parasympathetic NS

30. The Prevalence of SIBO and Lyme disease
(Dr. Farshid S. Rabar, MD)
 Lyme commonly affects the ANS and ENS and is a cause of small fiber
neuropathy.
 Small fiber peripheral neuropathy is a type of peripheral neuropathy that
occurs from damage to the small unmyelinated peripheral nerve fibers.
 These fibers, categorized as C fibers, are present in skin, peripheral nerves,
and organs.
 Mechanism of Injury to the Nerve: In neuro-borreliosis
Direct bacterial invasion
Cytokine mediated
Autoimmune mediated

31. The Prevalence of SIBO and Lyme disease
(Dr. Farshid S. Rabar, MD)
Symptoms of Autonomic Dysfunction
• Excessive fatigue
• Lightheadedness
• Blood pressure fluctuations
• Distension of the abdomen
• Gastroparesis
• Constipation
• Sweating Issues
• And more... Dry mouth, rapid heart rate, blurry vision, sexual problems etc.

32. Tx resistant GORD and small fiber neuropathy
 Loss of Gastric Accommodation in fundus

33. SIBO and IBD (Drs Weiner and Gurevich)
 SIBO appears to be the “IBS within the IBD” – contributes to mucosal inflammation
 Incidence of SIBO in IBD much increased
 Risk factors which contribute to SIBO in IBD:
Scarred, inflamed and ulcerated ileocecal valve
The most important function of this valve is to limit the reflux of colonic contents into the ileum of
the small bowel
80% of patients diagnosed with Crohn’s have small bowel involvement of the terminal ileum
Transmural thickening impairs MMC
Adhesions, strictures
OCTT impaired in UC
 Consider testing for SIBO as part of your routine workup
Glucose breath test and Crohn's disease: Diagnosis of small intestinal bacterial overgrowth and evaluation of
therapeutic response. Scand J Gastroenterol. 2015;50(11):1376-81. doi: 10.3109/00365521.2015.1050691. Epub 2015 May 19. Greco
A, et al
Small intestinal bacterial overgrowth and orocecal transit time in patients of inflammatory bowel disease. Dig Dis
Sci. 2013 Sep;58(9):2594-8. doi: 10.1007/s10620-013-2694-x. Epub 2013 May 7. Rana SV, et al

34. Update in SIBO treatment
 The New Bi-Phasic Diet
 Beyond Berberine- new herbal considerations for SIBO and SIFO
 Update on Rifaxmin

35.  Available for download in the practitioner section of SIBOtest.com
 General SIBO diet plans can be confusing and highly variable
 Patients often need customized approaches
 Leaky gut, digestive deficits
 Other intolerances: histamine, salicylates, oxalates etc
 Malnutrition

36. The Bi-phasic diet allows for a sequential
treatment approach
Phase 1: “Reduce and Repair” (4-6 weeks)
 Reduce: fermentable starches and fibers and therefore bacterial fermentation
 Repair: intestinal inflammation, brush border enzymes, other digestive
support
 Starts out with very restricted food plan, patients move into “semi-
restricted” as soon as symptoms improve
Phase 2: Remove and Restore (4-6 weeks)
 Removing bacteria (and fungi) with antimicrobials
 Restore Motility

43. Food reactions
 Common in chronic SIBO cases
 Commonly seen with leaky gut (intestinal hyperpermeability)
 Most common reactions seen in my clinic:
Histamine
Salicylates
Oxalates
 Special mention and suggestions are made on the Bi-phasic handout

44. Histamine
 Biogenic amine, is naturally high in certain foods, especially aged foods.
 Symptoms of histamine intolerance include headaches, bloating, cramping,
insomnia, itching, allergies.
 Histamine is found in a number of foods but is particularly high in: spinach,
aged meats, bone broth which has been cooked for hours, tinned fish or
meats.
 Microvili and brush border degradation leads to reduction of DAO – primary
enzyme responsible for the degradation of food-borne histamine

45. Salicylates
 Natural plant substances which help the plant defend itself against bacteria,
fungi and other pests. Salicylates are toxic to everyone in very high doses, but
with a salicylate sensitivity the threshold is much lower before a reaction
occurs.
 Symptoms of salicylate sensitivity include: itching, stomach pain/nausea,
headaches, puffy or burning eyes, sinus congestion.
 The range of salicylate content of foods varies, in the bi-phasic diet it is
highest in: nightshade vegetables - tomato, eggplant, capsicum, chili, as well
as radish, zucchini, berries, avocado, coconut and olive oils

46. Oxalates
 Natural molecules abundant in green leafy vegetables and certain other plant
based foods. Well known in their role in kidney stones, oxalates can also
cause gut reactions by irritating the mucosal lining. They usually are not
problematic in a healthy digestive tract.
 Symptoms of oxalate sensitivity include: joint pain, kidney stones, vulvar
pain.
 The ranges of oxalate content varies but high oxalate foods on the Bi-Phasic
Diet are: almonds, spinach, silver beet, beet root greens, rhubarb, quinoa,
cacao.

47. Caution with the SIBO Bi-Phasic Diet
 A word about Orthorexia
“Pavlovian” responses to foods
 Timeframe of treatment – low FODMAP diet long term is NOT a healthy diet
 Supporting the microbiome while on the diet

48. SIBO Phyto-medicines: Herbal
antimicrobials

49. Antibiotics for SIBO– out of the frying
pan and into the fire?
Long term damage to the microbiome with repeated antibiotic courses
“The fecal microbiome was severely affected by most antibiotics: for
months, health-associated butyrate-producing species became strongly
underrepresented. Additionally, there was an enrichment of genes
associated with antibiotic resistance. Clearly, even a single antibiotic
treatment in healthy individuals contributes to the risk of resistance
development and leads to long-lasting detrimental shifts in the gut
microbiome.”
Same Exposure but Two Radically Different Responses to Antibiotics: Resilience of the Salivary Microbiome versus Long-Term Microbial Shifts in Feces
Egija Zaura,a Bernd W. Brandt,a M. et al. Mbio November/December 2015 Volume 6 Issue 6 e01693-15

50. The Culprits
Predominant SIBO bacteria isolated on duodenal aspirate (Pimentel, 2015):
 gram positive:
Enterococcus spp (other studies also identified Streptococcus and Staphylococcus)
 gram negative:
Proteus mirabilis
E.coli
Klebsiella pneumoniae
 Methanobrevibacter smithii (methane)
Co-morbid SIFO – up to 63% of SIBO patients
candida and other fungal spp
The prevalence of overgrowth by aerobic bacteria in the small intestine by small bowel culture: relationship with irritable
bowel syndrome. Pyleris E, Giamerellos-Bourboulis EJ, Pimentel M, et al. Dig Dis Sci 2012 May;57(5):1321-9. doi: 10.1007/s10620-
012-2033-7. Epub 2012 Jan 20.

51. Herbal Antimicrobials
 Dr Mullin Research at Johns Hopkins University showed herbal antimicrobials
as effective as Rifaximin for the treatment of SIBO
 His research used herbal products from 1 US based company
 None were specifically formulated for SIBO
Mullin et al Global Advances in Health and Medicine May, 2014

52. Mullin et al Global Advances in Health and Medicine May, 2014

53. Herbal Antimicrobials
Berberine containing herbs are clinically well established for reducing
hydrogen
Phellodendron, Mahonia aquafolium, Coptis chinensis, Berberis vulgaris, Hydrastis
canadensis
 effective against: E.coli, Streptococcus, Klebsiella p., and candida spp
 poorly absorbed from GI thus ideal for local infections
 Mucous membrane “tonifying” effect
Allicin/Alliin (Garlic) – clinically proven to lower methane
Essential oils of Oregano, Cinnamon, Thyme – both methane and hydrogen

54. Berberine and hydrogen reduction

55. Garlic extract and methane reduction

56. Other phyto-medicines to
consider….

57. Punica granatum (Pomegranate)
 Juice, rind and seed used
 Active constituents: ellagic acid glycosides and ellagitannins, other tannins,
flavonoids
 Gram –positive bacteria : Staphylococcus aureus, Streptococcus, spp, and
Bacillus spp
 Gram-negative bacteria: E.coli, Campylobacter jejuni, Salmonella spp,
Shigella spp, Vibrio spp, Klebsiella pneumonia, Pseudomonas aeruginosa,
Yersinia enterocolitica, H.pylori
 Fungal: candida spp
 Parasitic infections: Giardia spp, Blastocystis spp, Entamoeba h.,
Cryptosporidium parvum, and more..

58. Punica granatum (Pomegranate)
 “Significantly enhances growth of Lactobacillus spp, Bifidobacterium
breve and Bifidobacterium infantis while inhibiting the growth of pathogenic
clostridia and Staphylococcus aureus”
 Therapeutic Dose: 40-80ml/week ( 10ml daily) of a 1:2 tincture
Evaluation of antimicrobial activity of Punica granatum peel against enteric pathogens: an in vitro study. Pai V, et al Asian Journal of
Plant Science and Research 1(2), 57-62
The Pomegranate: Effects on Bacteria and Viruses That Influence Human Health. Howel A, D’Souza D. Evid Based Complement
Alternat Med. 2013; 2013: 606212.
The effect of pomegranate (Punica granatum L.) byproducts and ellagitannins on the growth of human gut bacteria. Bialonska D,
Kasimsetty SG, Schrader KK, Ferreira DJ Agric Food Chem. 2009 Sep 23; 57(18):8344-9.

59. Artemisia annua (Qing Hao)
 Active constituents: essential oils and sesquiterpenoids
(artemisinins)
 Classically used for parasites, malaria
 Antimicrobial activity against
Gram –positive bacteria : Staphylococcus aureus, Streptococcus, spp, and Bacillus spp
Gram-negative bacteria: E.coli,, Salmonella spp, Klebsiella pneumonia, Pseudomonas
aeruginosa, Proteus spp
 Antiparasitic against: Toxoplasma gondii, Schistosoma (blood fluke), Fasciola
hepatica (liver fluke), Plasmodium f.

60. Artemisia annua (Qing Hao)
 Immunomodulation- inhibits NO, iNO and NF-kB
 Therapeutic Dose: 20-50ml/week 1:2 extract
Artemisinin Attenuates Lipopolysaccharide-Stimulated Proinflammatory Responses by Inhibiting NF-κB Pathway in Microglia
Cells.Cansheng Zhu, et al. PLoS One. 2012; 7(4): e35125.Published online 2012 Ap13. doi:
Essential Oil of Artemisia annua L.: An Extraordinary Component with Numerous Antimicrobial Properties. Bilia AR, et al. Evid Based
Complement Alternat Med. 2014; 2014: 159819.
Antibacterial Activity of Essential Oils and Plant Extracts of Artemisia (Artemisia annua L.) In Vitro. Massiha A, et al. Zahedan Journal
of research in Medical Sciences, 15(6), 14-18

61. Usnea spp (Old Man’s Beard)
 Over 600 Usnea spp
 Primary active constituent: usnic acid
 Primarily active against gram positive bacteria:
Bacillus spp, Clostridium spp, Enterococcus spp, Listeria monocytogenes,
Staphylococcus spp, Streptococcus spp, etc
 Some gram negatives: H.pylori, E. coli, Yersinia enterocolitica, Proteus
mirabilis
 Antiparasitic
 Candida spp,

62. Usnea spp (Old Man’s Beard)
 Anti-inflammatory- in one study as or more effective as NSAID and
hydrocortisone
 Anti-oxidant: activates superoxide dismutase (SOD) and glutathione s-
transferase (GST) enzymes, protects against damage in mucosal cells
 Therapeutic Dose 10-15ml daily 1:2 extract
Buhner, SH (2012) Herbal Antibiotics: Natural Alternatives for treating Drug-Resistant Bacteria, 2nd ed, Massachusetts, USA : Storey
Publishing, p.197
Contributions to the complex study of some lichens-Usnea genus. Pharmacological studies on Usnea barbata and Usnea hirta species.
Dobrescu D, et al. Rom J Physiol. 1993 Jan-Jun;30(1-2):101-7
Effects of water extract of Usnea longissima on antioxidant enzyme activity and mucosal damage caused by indomethacin in rats.
Halici, M, et al. Phytomedicine 2005 Sep;12(9):656-62.

63. Bidens tripartita (Bur Marigold)
 Annual weed
 Primary active constituents: tannins, flavinoids, volatile oils (eugenol,
ocimene, cosmene) coumarins, etc
 Affinity for mucous membranes, Anti-ulcer, antiinflammatory
“One of the great antibacterial herbs…a mucous membrane tonic and astringent,
powerfully anti-inflammatory, and strongly antibacterial, it is specific for a
number of troublesome diseases caused by resistant pathogens” SH Buhner

64. Bidens tripartita (Bur Marigold)
 Gram + Staphyloccocus spp, Enterococcus faecalis, Streptococcus spp,
 Gram – E.coli, P.aeruganosa, Salmonella spp, K. pneumoniae
 Fungal: candida albicans, candida parapsilosis
 Dose: 40-80ml/week 1:2 liquid extract
Composition of the essential oil of Bidens tripartita L. roots and its antibacterial and antifungal activities. Tomczykowa M, et al. J
Med Food 2011 Apr;14(4):428-33. doi: 10.1089/jmf.2010.0066. Epub 2011 Mar 3.
(Shoutai Z (1989) Treatment of 500 cases of dysentery with Bidens tripartita. Shandong Journal of Traditional Chinese Medicine.
8,11–12)

65. Benefits of herbal antimicrobial therapy
 Individualizing the medicine to the patient
Antibacterial
Antifungal – horopito, pau d’arco
Nervines – lavender, kava, passionflower,
Digestive support- bitters: gentian, oregon grape, dandelion,etc
Circulation – cayenne, ginkgo
Antiinflammatory/Antioxidants – turmeric, green tea, maritime pine
 can add minerals and homeopathics to tinctures
 Less damage to the microbiome

66. Thoughts
 There is no “one size fits all” to SIBO treatment
 Use herbs before microbiome-disrupting antibiotics.
 Refer to someone who has experience with herbal medicines if you don’t
 Only use herbal medicines from reputable manufacturers who test batches
frequently
 Rotate antimicrobial herbs maintain effectiveness
 Do not use the low FODMAP diet or Bi-phasic diet indefinitely

67. Rifaximin Update
(Dr Carmelo Scarpignato, MD – Gastroenterologist)
 Retest 10-14 days after discontinuing Rifaximin
 Cyclical Treatment for chronic relapsers?
 Rifaximin Attenuates Chemokine and Cytokine Generation Caused by LTR4
Activation by LPS (anti-inflammatory effect)
Rifaximin is gut-specific ligand for the human nuclear receptor pregnane-X receptor (PXR), a
master gene critical for maintenance of intestinal integrity
[Mencarelli et al., Eur J Pharmacol 2011; 668: 317-324]

68. Noteworthy Research 2016
 PPI use
increases incidence of SIBO from both faecal and oropharyngeal type of microbes
High rate of SIBO relapse with hx of PPI use
Causes immediate changes in bowel flora even with short term use
(Dr. Scarpignato, SIBO Symposium, research awaiting publication
L. paracasei F19 Supplementation Prevents Bowel Symptom Onset in Patients on Long-
term PPI Therapy [Compare et al., Dig Liver Dis 2015; 47: 273-279]

69. Use of Lovastatin to reduce Methane
 Review article: inhibition of methanogenic archaea by
statins as a targeted management strategy for constipation
and related disorders Aliment Pharmacol Ther. 2016 Jan; 43(2): 197–212.
Gottlieb, Wacher, Sliman, Pimentel
 Prevents production of methane gas
 Red Yeast Rice?

70. Metabolic improvements in pre-diabetics
by lowering methane
 Metabolic effects of eradicating breath methane using antibiotics in
prediabetic subjects with obesity.
Obesity (Silver Spring). 2016 Mar;24(3):576-82. doi: 10.1002/oby.21385. Epub 2016 Feb 1.Mathur
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71. Thank You!
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