This in-depth webinar, free for all health professionals, examines some of the latest advances in the treatment and management of small intestine bacterial overgrowth, or SIBO. SIBO is now understood as a prime cause of leaky gut, IBS and many autoimmune diseases. Presented by Dr Nirala Jacobi ND, CMO, SIBOTest following the SIBO Symposium at the SIBO Center in Portland, Oregon, June 2015. Key Learning Objectives: Updated SIBO assessment and treatment New information on the autoimmune link to SIBO Key herbal and conventional strategies Adhesions and restrictions; often a key element in the development of SIBO..

1. By Dr Nirala Jacobi, BHSc, ND (USA)
CMO, SIBOtest.com
Advances in the Treatment
and Management of SIBO:
2015

2. Exponential increase in SIBO
interest over last few years
2015 SIBO Symposium
Increase in online interest: Blogs, summits,
podcasts, support groups
SIBO FB support group in Victoria has over 1300
members
Your IBS patients are actively researching SIBO!

3. SIBOtest Mission
• To provide highest quality Breath Testing
• To educate practitioners
• Practitioner resource Section
Handouts: Diet, protocols, referral brochure
• “Find a SIBO treating practitioner” section
• Individual Practitioner pages
Position yourself as a natural SIBO treating expert!

4. 2015 SIBO Symposium
Main Presenters
• Drs Allison Siebecker, Steven Sandberg-Lewis-
SIBO Centre, Portland, Dr Melanie Keller
• Dr Mark Pimentel, Motility clinic Cedars-Sinai
Dr Lenny Weinstock, Dr Gary Mullin, Johns
Hopkins University School of Medicine

5. Topics covered in this Presentation
Underlying Causes of SIBO
Advances in Testing
Advances in Treatment
• Antimicrobials
• Elemental Diet
• Prokinetics
Dr Jacobi’s Clinical tips

6. The Basics of SIBO
• Bacterial overgrowth of normal colonic bacteria into
the small intestines
• Cause damage to the brush border and therefore
absorptive pathways
• Often a consequence of gastroenteritis (food
poisoning)
• 60% of IBS is considered to be SIBO
• A very specific condition which requires proper
assessment and treatment
• Please refer to the 2014 webinar for more
information (available at www.sibotest.com)

7. SIBO/IBS
• SIBO-D = diarrhoea dominant
• SIBO-M = mixed diarrhoea and constipation
• SIBO-C = constipation dominant (methane
mostly)
• NOTE: if excessive watery stools (in excess of
6-7 daily) it is unlikely to be SIBO. Typically
SIBO has some mixed bowel patterns

8. Underlying causes of SIBO
• SIBO does have a CAUSE and if this cause is not
addressed, relapse after treatment is common
• The main causes are either:
The impairment of the migrating motor complex
(MMC) and the enteric nervous system
or
Anatomical issues causing the normal loops of
small intestines to be affected (kinks in a garden
hose)

9. Underlying causes of SIBO
• Post infectious
• Diabetic enteropathy
• Adhesions: abdominal surgery- appendix,
endometriosis, cesarean, cholecystectomy
• Blind loops (gastric bypass patients)
• Pseudo-obstruction: mechanical obstruction without
evidence of anatomical obstruction
• Medications: narcotics (morphine, codeine, illicit
drugs), proton pump inhibitors
• Stress :
HCL output
Motility of the SI

10. Underlying causes of SIBO
• Large and small intestinal diverticulosis
• Alcoholism
• Other diseases: celiac disease, NASH,
pancreatic exocrine insufficiency

11. Post Infectious SIBO
• Military study looked at the likelihood of
developing IBS after stressful events or
gastroenteritis
• Stressful events included: shooting a gun in
combat, shooting another human, active
combat, and being injured in combat
• Only gastroenteritis was associated with the
development of IBS
Porter CK, et al. Dig Dis Sci 2013

12. Risk of Post infectious IBS
• Risk of PI-IBS increases 7 fold after infectious
gastroenteritis
• 4 main infectious organisms causing acute
gastroenteritis (food poisoning):
• Campylobacter jejuni
• E.coli
• Salmonella
• Shigella

13. CdtB toxin
• These 4 organisms secrete a similar toxin:
cytolethal distending toxin B (CdtB)
• Anti-CdtB secreted as a response to the
infection.
• Anti CdtB – similar to vinculin, an important
component of the MMC and enteric nervous
system
• Mistaken identity: anti-vinculin antibodies
made instead of anti-CdtB attack the enteric
nervous system

14. Food
poisoning
• C. Jejuni
• E. Coli
• Shigella
• Salmonella
Bacterial toxin
CdtB
• AUTOIMMUNIT
Y
• Anti vinculin
antibodies
• Anti CdtB AB
Gut nerve
damage
• Reduced ICC
• Reduced
migrating
motor complex
(MMC)
SIBO
Common IBS/SIBO
pathophysiology

15. Ileal Interstitial cells of Cajal
(ICC) in normal controls

17. Inflammation
• Nerve inflammation is driving the
autoimmunity
• Inflammation without autoimmunity: ICC cells
able to repair within 3 weeks of resolution of
inflammation

18. In patients with history of
food poisoning and IBS
• 5 times more likely to get another episode of
food poisoning due to the slowed MMC
• Takes fewer and fewer bacteria in each episode
to cause food poisoning
• Each episode increases the likelihood of
developing SIBO due to further decreased
motility

19. The big Question
In SIBO cases caused by post infectious
gastroenteritis:
should our main goal be the resetting and repair
of the MMC rather than primarily focusing on
antimicrobials?

20. Clinical Pearl
• Prevention of food poisoning is important in our
SIBO patients to prevent further damage to the
MMC
My travel recommendation:
Herbal bitters/Iberogast
Antimicrobial containing berberine
Saccharomyces boulardii

21. Adhesions
• Another cause for the development of SIBO
besides post infectious causes.
• Post surgical: adhesions are a healing
mechanism. Appendectomy, cholecystectomy,
hysterectomy, Laparoscopy, bowel resections
etc.
• Can often be palpated in an abdominal exam.
Movability of organs, areas of restriction

22. Treatment of adhesions
• Clear Passage: US based PT centre specialising in
the non-surgical tx of adhesions
www.clearpassage.com
• 20 hours of Tx over 5 days
Other options
Visceral release therapy?
Acupuncture?
I don’t think Castor oil packs are enough

23. Testing for SIBO
• New Blood test for IBS – does NOT replace the
breath test
• Lactulose/ Glucose breath tests
• Hydrogen
• Methane- new spot test may be on the horizon
• Other tests to consider for your SIBO patient

24. New IBS Blood Test (just
released)
• Measures anti CdtB and anti vinculin
• >60% accurate to diagnose IBS
• Intended to prevent extensive work up
(colonoscopies, endoscopies)
• Best suited for GPs as an initial workup: IBS vs
IBD
• Does NOT replace lactulose breath test for
SIBO
Establishes IBS as an autoimmune condition

25. Drawbacks of the blood
test
if negative, can still have SIBO but means it is
less likely to be caused by autoimmune reaction.
Follow up with breath test to confirm
Not yet offered by labs in Australia. 48 hour
turn-around time to get blood to the lab in the
USA

26. Lactulose Breath Test
(LBT)
• Still considered to be the primary test for SIBO
• SIBOtest uses same testing guidelines and reference
ranges as the SIBO center in Portland.
• 3 hour breath test-
• first 2 hours are considered SI time
• Last hour could be slow transit or LI
SIBOtest – only lab in Australia to offer LBT for SIBO

27. Why test?
• To understand the levels of hydrogen and
methane
• Gives you a guideline as to how many cycles of
antimicrobials you may need
• Re-test to ensure bacteria are eradicated

28. First Test June 2014

29. 2nd test Nov 2014

30. 3rd Test May 2015

31. Methane
• Methanobrevibacter smithii – methanogen
• Unknown if beneficial benefit but assoc. with
higher calorie extraction
• Highly associated with SIBO-C
• Patients feel best when methane <3ppm
• Poorly absorbed from LI
• Not produced with substrate lactulose
• New “spot re-test” is coming…stay tuned

32. So the LBT is negative….
• No test is perfect
• If your patient has all the classic symptoms of
SIBO: consider Glucose breath testing as a back
up

33. Other tests for the SIBO
patient (not diagnostic for
SIBO)
• Celiac/Gluten intolerance: sxs often same as
SIBO
• CDSA – calprotectin, elastase, fat in stool
• Food sensitivities
• MTHFR and other methylation tests – Histamine
sensitivity, B12/FA
• Lyme disease: similar GI sxs

34. Alarm s/sxs in IBS-- require more
extensive evaluation (e.g., imaging
studies and/or colonoscopy
• Fever
• weight loss
• blood in stools
• nocturnal symptoms
• progressive abdominal pain
• laboratory abnormalities
• abnormal physical findings
• family history of inflammatory bowel disease (IBD)
or colorectal cancer (CRC)

35. Advances in Treatment
Antimicrobials
o Rifaximin
o Herbal antimicrobials
o Elemental Diet
Prokinetics
o Conventional: low dose erythromycin, LDN, and
Resolor
o Herbal: Iberogast, Motilpro, Ginger

36. Maintenance
Prokinetics Maintenance diet
Re-test 6-8 weeks
(+)Repeat above (-) move to below
Positive Breath test
Antimicrobials SIBO diet

37. Antimicrobials
• Rifaximin and other antibiotics (great resource
for proper dosing www.siboinfo.com)
• Herbal antimicrobials
• Elemental Diet

38. Rifaximin
• Only just approved by the FDA for the
treatment of IBS
• Rifaximin (Xifaxan) – high Hydrogen
• Rifaximin and Neomycin – high methane
• Does not cause dysbiosis as it is bile soluble not
water soluble
• Does not cause antibiotic resistance
• Other antibiotics taken with Rifaximin seem to
also be less likely to cause bacterial resistance

39. Rifaximin
• Dose is 550mg 3x daily
• Compounded Xifaxan. Uncertain from where
this is sourced. There is quite a bit of
grumbling about Rifaximin sourced from
outside the US– questions about efficacy and
systemic absorption (vs just staying in the
intestinal lumen)
• I have had patients get Rx a handful of times in
tough cases

40. Herbal Antimicrobials
• Dr Mullin Research at Johns Hopkins University
showed herbal antimicrobials as effective as
Rifaximin
• 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

42. Tried and Proven Herbal
Antimicrobials
Hydrogen
• Berberine
• Neem
• Oil of oregano
Methane
• Allimax (Biomedica)
• Oil of oregano
• Neem

43. Potential new
antimicrobials
• Manuka herb
• Pomegranate seed
• Horopito
Clinic based research coming in 2015/2016

44. SIFO- small intestinal
fungal overgrowth
• Fungal overgrowth often accompanies SIBO
• The diet and the antimicrobials usually treat this
as well but consider
• Additional antifungals
• Probiotics (immune regulation)
• Biofilm disruptors – seem more successful with
fungal infections

45. Elemental Diet (ED)
• Very effective in reducing bacteria
• Can decrease severe gas levels in one course (2
weeks) – reductions of 148ppm have been
documented
• Vivonex formula – Dr Pimentel.
• Homemade ED – Dr Siebecker- not formally
tested
Pimentel, M. A 14 day elemental diet is highly
effective in normalizing lactulose breath test.
2004

46. Elemental Diet (ED)
• Recipe: Siboinfo.com; Resources; Handouts
• Protein= amino acids, CHO= honey (fructose &
glucose)/glucose (dextrose), Fat= oil,
Micronutrients= multi-vitamin, salt
(electrolytes)
• 2versions: 1. Matches Vivonex (High CHO) 2.
Low CHO/High Fat

47. Commercial vs Homemade
Vivonex
Expensive
Studied
Contains corn, soy,
maltodextrin, preservatives
Premixed packets
Higher carb, lower fat
Homemade
Less expensive
Not studied
Cleaner ingredients
Separate ingredients which
have to be mixed together

48. Elemental diet
• Both Vivonex and Homemade are excellent for
hydrogen and methane
• Challenges:
Bad taste
Emotionally difficult
Die off
Weight loss
Can aggravate yeast

49. Ingredients
• Amino Acid Blend - 24g protein per serve
• Dextrose (glucose)- 106g CHO per serve. This
can be adjusted
• Oil (coconut ,MCT, olive, Macadamia, cod liver)
– 4.6g fat per serve
Based on a 2000cal diet/day
3 serves daily
Add Mulivitamin, Salt

50. Elemental Diet: Clinical
Notes (Dr Siebecker)
• Recommend family/friends give encouragement during
• Expect bowel changes-odd colors, diarrhea, constipation
• Often takes 1-2 weeks for stool to normalized after, or longer
• Die off can be very bad and last the whole time
• Flu-like feeling
• Fatigue
• Headache
• Aggravation of existing or past symptoms
• New GI symptoms

51. Important points about ED
• Standard commercial “detox” formulas and
protein powders are NOT the Elemental
formula and will NOT work for this purpose
• Wait about 10 days after completing the ED
before re-testing

52. Prokinetics
New Guideline: Typically started AFTER
completion of antimicrobials and re-test is clear
Aims to reset the MMC (vs just laxatives)
Failure to use effective prokinetic is most
common cause of relapse

53. Prokinetics
Conventional
Resolor (Prucalopride)
Low dose Erythromycin (LDE)
Low dose Naltrexone (LDN)
Natural
Iberogast
Ginger
Motilpro

54. Conventional Prokinetics
• Prucalopride: 5HT4 agonist, works on stomach,
SI, and colon. Limited data, difficult to get in
the US but Preferred prokinetic of Dr Pimentel.
Dose: 0.5-2mg before bed
• Low dose Erythromycin (LDE) – Motilin agonist,
works on stomach and SI, mild effect on colon.
In vitro- no effects on microbiome. Dose: 50mg
before bed
• LDN- in limited use and practitioners report
mixed results

55. Herbal Prokinetics: Iberogast
• 9 Herb European Combo= Dyspepsia & IBS
• Iberis Amara, Angelica, Chamomile, Caraway, St. Mary’s
Thistle, Lemon Balm, Peppermint, Celandine, Licorice
• 40+ years clinical use: nausea, GERD, bloating,
cramping/pain, constipation, diarrhea
• 47+ articles (5 Rev/4 MA/6 RC/5 Ret/1 NI –including
pediatric)
• Dyspepsia, IBS, GERD, Ulcer, Rebound Acidity, Gastroparesis,
Visceral Hypersensitivity, Colon Cancer, Colitis,
Inflammation, Radiation, Sepsis
• No SIBO Studies

56. Iberogast studies
• Proven Prokinetic Effects
• More effective for Dyspepsia than some conventional prokinetcs
• MoA: 1.Partial 5HT4 agonist 2.5HT3 antagonist 3.selective M3 inhibition
(muscarinic) 4. Opioid inhibition
• Adaptogenic: treats both constipation & diarrhea & upper & lower sx
• IBS adults: 65-80% sx improvement, Good or Very Good results in 80%
• IBS children: 76% sx improvement, Good or Very Good results in 89%
• Based on 1 mo of use 3xd. Results were better with shorter IBS/sx
duration
• Low side effects: 0.04%, Safe for long term use/Pregnancy/children.
• Dose: 20 drops 3 x daily before meals and before bed
Note: nightly dose is standard for prokinetic SIBO prevention
Ottillinger ’13,Simmen’06, Raedsch’07, Rosch’02

57. Ginger (Zingiber
officinale)
• Bioactive compounds within the rhizome of ginger,
particularly Gingerol and Shogaol class of compounds
• The major chemical constituents of ginger are [6]-
gingerol, [8]-gingerol,[10]-gingerol, and [6]-shogaol
• Promotes gastric emptying rate and motility
(gastroduodenal)
• Modulates serotonin signaling by 5-HTP4 stimulation
• Binds Type 3 (5-HTP3) receptors in enteric nervous
system and brain stem
• NOTE: Ginger may be contraindicated with blood
thinning medications.

58. Ginger and Motility
•The effect of a ginger rhizome extract (2 x
100 mg) was studied on fasting and
postprandial gastroduodenal motility with
stationary manometry in 12 healthy
volunteers.
•The results showed that: the interdigestive
antral motility was significantly increased by
ginger during phase III of the migrating motor
complex
•Oral ginger improves gastroduodenal motility
in the fasting state and after a standard test
meal
Int J Clin Pharmacol Ther. 1999 Jul;37(7):341-6. Effects of ginger on gastroduodenal motility.
Micklefield GH1, Redeker Y, Meister V, Jung O, Greving I, May B.

59. MotilPro
• Pyridoxal 5 Phosphate 10mg- Cofactor to
decarboxylate 5-HTP to Serotonin
• Ginger 1000mg
• Acetyl L-carnitine 500mg- synthesis of
acetylcholine
• 5HTP 50mg – serotonin production, 5-HTP also
stimulates enteric neurons through activation
of 5HT4 receptors.
• Ascorbyl Palmitate (Corn dextrose and palm
oil) 30mg

60. Prokinetics – thoughts
• Need to stay on it for a minimum of 6 months
even if sxs have resolved
• Suggested to re-test after stopping the
prokinetic to ensure MMC is working
• In case of debilitating adhesions or more
severe disease, may have to stay on it
indefinitely

61. *

62. SIBO patients are often
very sensitive!
Microvilli and Brush border disrupted.
• Histamine intolerance (low DAO)
• Salycilates
• Sulfites

63. Histamine intolerance
Flushing
Rapid heart rate
Profuse sweating
Headache
Migraine
Food allergies
Seasonal allergies
Prickly heat
Swollen mozzie bites
Runny nose
Bloody nose
Car sick
Seasick
Motion sick
Itchy
Irritable
Nausea
Vomiting
Higher libido
Asthma
Exercise induced
asthma
Stomach ache
Menstrual cramps
Chest tightness
Loose stools
Skin rashes (eczema,
psoriasis, etc)
insomnia

64. Foods high in Histamine
• any fermented food: e.g. sauerkraut, yogurt, vinegar, cheese
• tinned fish products and any fish that isn’t fresh
• tinned foods in general
• alcohol
• Left overs in general
• vegetables: spinach, eggplant, tomato, avocado
• all legumes: beans and lentils, this includes soybean products like tofu,
tempeh
• fruit: strawberries, banana, raspberries, pineapple, kiwi, pears, papaya
• nuts: peanut, walnut, cashews, sunflower seeds
• condiments: anything containing yeast extract or preservatives, stock
powders, sauces,
• soy sauce, fish sauce, spices like chill, curry, mustard
• sweets: chocolate, cacao

65. Products to consider for
your sensitive client
• Generally:
L-Glutamine
Digestive enzymes including brush border enzymes
Probiotics (no prebiotics)
• Histamine sensitivity
DAO- HistDAO
Vit C- not containing sweeteners
B6/copper
• Salycilate sensitivity
Glycine 2-5g daily (Dr Vera’s)
• Sulfite sensitivity
Molybdenum

66. Constipation
• Methanogens- successful treatment: <3ppm on
test
• SIBO diet is typically constipating as well
• Long standing constipation can result in large
intestinal ‘inertia’
• Constipation/Bowel retraining page at
SIBOtest.com
• Gets patient involved

67. Retraining a sluggish colon
• Oral: Magnesium, Herbal laxative:
Cascara/Kawakawa (OptimalRX)
• NOTE: prune based laxatives contain Sorbitol
• I usually adjust the diet to contain some insoluble
fibre (brown rice, rice bran, increase dark leafy)
• Exercising/Breathing- stimulating diaphragmatic
movement
Walking
Nadya Andreeva’s belly exercises - TED talk- 5 min
Dr Datis Kharrazian’s Vagal nerve exercises (gargling,
gagging) YouTube 59mins
Coffee enemas

68. Retraining a sluggish colon
• Stress reduction
Breathing exercises
HeartMath- Inner Balance Device
Meditation- Examples: HeadSpace, Chopra
• Position – Squatting Stool

69. SIBOtest
• To educate practitioners
• Practitioner resource Section
Handouts: Diet, protocols, referral brochure
• “Find a SIBO treating practitioner” section
• Individual Practitioner pages
Position yourself as a natural SIBO treating
expert!

72. SIBO MasterClass
• Web based- conference call via Go2Meeting
• Case review and Management with Dr. Jacobi
• Meets fortnightly for 6 weeks
• Small class size – 12 practitioners max
• Sign up at SIBOtest.com

73. Thank you!
Coming up in 2015/2016
• Pimentel: study of new drug stopping the
production of methane
• SIBOtest trial of new antimicrobials
• Anti-Methanogen diet?
• Need more research of herbal prokinetics