The Bi-Phasic SIBO Protocol Module 1 Diagnosing SIBO

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1 Dr Nirala Jacobi, BHSc, ND Author, SIBO Bi-Phasic Treatment Protocol and the SIBO Bi-Phasic Diet Medical Director, SIBOTest.com and host of TheSIBODoctor.com The Bi-Phasic SIBO Protocol Module 1 Diagnosing SIBO

2 Module Module Summary Module 1 Diagnosing SIBO Which breath tests to order Review of SIBO breath test results Additional Lab tests to consider Module 2 Reduce and Repair The SIBO Terrain - Considering Causes Phase 1 of the Protocol Healing inflammation and digestion Module 3 Remove and Restore Phase 2 of the Protocol Herbal prescriptions in SIBO and SIFO Conventional Antibiotics and Prokinetics Module 4 Pre and Probiotics Pre and Probiotics SIBO-C retraining the sluggish colon Biofilm treatments Module 5 Food Intolerances Management of Histamine, salicylate, oxalate and sulfur sensitivities Management Phase: How to transition out of the Bi-Phasic Diet Module 6 The Histamine Bi-Phasic Diet BONUS Webinar

3 Objectives of the Course 1. Increase your confidence in the assessment and treatment of SIBO 2. When to consider other lab testing 3. Understand the nuances of individualized treatment 4. Use herbs effectively for various SIBO symptoms SIBOTest Professional Education

4 New to SIBO? The Bi-Phasic Treatment Protocol Course for Practitioners assumes basic knowledge of SIBO If you are new or would like to review the pathophysiology of SIBO, please see Fundamentals of SIBO course on

5 The typical SIBO patient BLOATING especially after meals Constipation, diarrhea, or alternating Fatigue Increasing food reactions often come in with a self restricted diet Gluten intolerance but not feeling much better off gluten Mucosal issues: abdominal pain, bladder issues. Often anxious and stressed SIBOTest Professional Education

6 Don t forget to consider SIBO Acne rosacea Fibromyalgia Non alcoholic steatohepatosis (fatty liver) Gallstones Diabetes Restless leg syndrome Hypothyroid Interstitial Cystitis SIBOTest Professional Education

7 Diagnosis Lactulose or Glucose breath test SI aspirate can request when patient is doing endoscopy but requires special handling and culture media Not great for distal SIBO Good aid in SIFO diagnosis

8 Breath testing is a useful, inexpensive, simple and safe diagnostic test in the evaluation of common Gastroenterology problems

9 Testing Stool test NOT accurate to diagnose SIBO Breath test: assess bacterial fermentation over minutes measures Methane and Hydrogen gas (not produced by humans) hydrogen sulfide testing coming soon. SIBO-D = diarrhea dominant: E coli, Klebsiella, Proteus, Aeromonas (most common) Produce hydrogen gas (H 2 ) - SIBO-C = constipation dominant Methanobrevibacter smithii produce methane gas (CH4)

10 What is breath testing? Ingestion of substrate: Lactulose Glucose Fructose D-Xylose Exhalation of hydrogen, Methane. Captured in breath sample collection Fermentation of substrate by SI bacteria into Hydrogen, Methane. These are absorbed into Circulation and carried to the lungs

11 Labs how to be a discerning practitioner Important questions to ask Prep diet- how restrictive? open or closed sample collection system testing for hydrogen, methane, and CO2 grams of test sugars 10g Lactulose 75g Glucose (1g/kg) 25g Fructose Sample timing (eg 20 min vs 30 min intervals) and length of test (2h vs 3h) SIBOTest Professional Education

12 Prep Guidelines- what to avoid 1 month prior to testing: Colonoscopy Antibiotics (unless re-testing- immediately after) 1 week prior: probiotics including fermented foods Herbal antimicrobials (unless re-testing) 1 day prior: Laxatives Digestive aids: HCL, enzymes NOTE: PPIs are no longer to be discontinued

13 Prep Diet 12 hours before overnight fast, then test next day If constipation dominant: 2 days of prepping prior to test Very low FODMAP (pt doesn t have to consume all of these): Basmati or Jasmine rice Chicken or Turkey Eggs Parmesan cheese Coconut or Olive oil Salt and pepper Patient Prep Guidelines available at

14 What test to order? The primary test for SIBO is a lactulose breath test Not every bacteria ferments lactulose equally so sometimes SIBO test is negative with lactulose Some practitioners opt for testing with both lactulose and glucose (one after the other) Glucose is an excellent test substrate but gets absorbed in the first part of the SI, thus sometimes missing distal SIBO

15 Fructose Used for Fructose malabsorption test and as another substrate for SIBO Many practitioners do the Triad of Lactulose/Glucose/Fructose for maximum accuracy If not using fructose as a substrate for SIBO testing, it is recommended to treat SIBO first before testing for true fructose malabsorption

16 Interpreting the Results Testing window is min from baseline min- transition zone into the large intestine After that, a rise in gases is likely due to large intestinal contribution Tests can be positive for Hydrogen (H2) Methane (CH4) Combined H2, CH4 Lactulose and Glucose have different parameters for testing positive

17 Interpreting the Results Hydrogen positive with a rise of 20parts per million (ppm) over lowest preceding level by minutes for LACTULOSE 12ppm for GLUCOSE Methane positive with a rise 12ppm over lowest preceding level by minutes (for both Lactulose and Glucose) Note: some researchers use a 3 hour test for methane Combined Hydrogen/Methane levels LACTULOSE 15ppm GLUCOSE 12ppm

18 Lactulose Test Results- positive Classic SIBO positive if in min - H 2 rise of 20ppm - CH 4 rise of 12 - Combined rise of 15ppm SIBOTest Professional Education

19 Lactulose and Glucose Breath Test Positive

20 Lactulose negative, Glucose positive

21 Methane (CH4) Positive Classic SIBO positive if by min - CH 4 rise of 12ppm

22 Methane conundrum High methane throughout breath testing is likely to be large intestinal overgrowth (or Bloom) of Methanobrevibacter smithii. Methane will be produced wherever hydrogen producing bacteria are located. Methanogens require hydrogen to produce methane. Presence of hydrogen producing bacteria in the SI is SIBO, but hydrogen producers are also common in the LI. 1-2 hours for H2 to be produced, a further 1-2 hours for CH4 to be produced from H2. Total 2-4hours? (Pimentel) SIBOTest Professional Education

23 Methane conundrum Until further data is available, we suggest that a level of 10 p.p.m. be considered positive for methane on a breath test (previously 3ppm) An early rise in H2 production significantly decreases when methane is produced in excess SIBOtest reports Methane rise of 12ppm by 100 min as positive for SIBO, presence of 10ppm as positive for methane SIBOTest Professional Education

24 Methane positive IBS-C but negative for SIBO Methane that starts high and stays high No rise of 12ppm noted throughout the test Positive for IBS-C methane positive if patient is constipated If patient is not constipated, may not need treatment

25 Methane positive, negative SIBO

26 High methane followed by high hydrogen on re-test. Frequently seen- no need for alarm! Reduced methane by almost 70 ppm in 7 weeks!

27 Fructose Positive

28 Fructose- timing matters! Most labs sample for hydrogen every hour Ideally: samples every 20 minutes

29 High Baseline Possible bad prep diet, ask your patient!

30 Bad sampling For proper collection watch the sample collection video CO2 is the control gas to ensure all samples are viable

31 Flat lining Zeros or single digits which don t go up or down by more than 1-2ppm throughout the entire test It is thought this might be due to the presence of hydrogen sulfide producing bacteria Lactulose non-fermenters?

32 Normal rise in the large intestine

33 Factors influencing methane test results H.pylori + - can falsely elevate methane 1 PPI use - lowers methane output Bifidobacterium infantis 2 weeks of B. infantis (Align) supplementation affects LBT assessment for SIBO by significantly increasing methane, but not hydrogen 2 1.Helicobacter pylori infection is associated with high methane production during lactulose breath test. Del Zompo F et al. Eur Rev Med Pharmacol Sci Aug;20(16): Effect of Bifidobacterium infantis (Align) on the Lactulose Breath Test for Small Intestinal Bacterial Overgrowth. Kumar K, Saadi M, et al. Dig Dis Sci Apr;63(4):

34 Re-testing SIBO suspected Lactulose and/or Glucose Breath test Elemental Diet Herbal Antimicrobials, Bi-Phasic Diet Antibiotics, Bi-Phasic Diet 90% improvement Partial improvement Prokinetic, Biphasic Diet, Prevention Change herbal antimicrobials, repeat rifaximin, consider elemental diet Retest SIBOTest Professional Education Consider other Dx Credit to Drs Allison Siebecker and Steven Sandberg-Lewis

35 Treatment how long? Once you ve started Antimicrobials, typically methane gas will reduce by 20-30ppm with each 2 week course of antibiotics and 4-6 week course of herbal antimicrobials. Hydrogen gas is less predictable. So if someone has high levels of methane and/or hydrogen you can expect them to be on herbal antimicrobials for a good 2-3 months. Often, antibiotics have to be repeated (ie one course is often not enough) SIBOTest Professional Education

36 If Lactulose breath test is negative but you think it is SIBO Some bacteria (E.coli, some strep) don t ferment lactulose well so test can be negative. When in doubt, confirm with Glucose breath test.

37 Example of insufficient reporting Lactulose dose too high (diarrhea!) 30 min time intervals No CO2 measured SIBOTest Professional Education

38 Summary of Breath Testing Breath testing is an excellent tool to assess and manage SIBO There are differences in labs, in terms of prep recommendations, testing parameters, length of test, and collection devices If you get a negative lactulose test result, consider following up with another substrate to confirm if the patient has classic SIBO symptoms

39 Other testing to consider (NOT diagnostic for SIBO) Organic Acids Test Blood tests Complete Digestive Stool Analysis (CDSA) Microbiome assessment via PCR Protozoan and other parasitic infections (PCR) Gastric emptying study SIBOTest Professional Education

40 Patient Name: Niehowa Burton Date of Collection: 4/4/2017 Patient Age: 55 Time of Collection: 00:00 AM Patient Sex: F Print Date: 04/14/2017 Organic acids testing Metabolic Markers in Urine Intestinal Microbial Overgrowth Reference Range (mmol/mol creatinine) Patient Value Reference Population - Females Age 13 and Over Yeast and Fungal Markers 1 Citramalic Hydroxymethyl-2-furoic 14 H Oxoglutaric Furan-2,5-dicarboxylic 16 H Furancarbonylglycine 1.9 H Tartaric Arabinose 29 H Carboxycitric Tricarballylic Bacterial Markers 10 Hippuric Not diagnostic for SIBO Very helpful for - SIFO - Clostridia - Mitochondrial deficits - Nutrient deficiencies 11 2-Hydroxyphenylacetic Hydroxybenzoic Hydroxyhippuric DHPPA (Beneficial Bacteria) Clostridia Bacterial Markers 15 4-Hydroxyphenylacetic 19 (C. difficile, C. stricklandii, C. lituseburense & others) H HPHPA 208 (C. sporogenes, C. caloritolerans, C. botulinum & others)

41 Useful OAT Markers

42 OAT bacterial markers (NOT diagnostic for SIBO)

43 OAT - Oxalates

44 Blood tests e/lft: chloride below 100 could indicate hypochlorhydria. Folate often high in SIBO due to increased bacterial production B12 often low in SIBO due to bacterial destruction

45 Stool testing (NOT diagnostic for SIBO) CDSA: siga feacal fat Short chain fatty acids (SCFA) Zonulin Microbiome PCR SIBOTest Professional Education

46 siga The only non-inflammatory Immunoglobulin we produce Essential to mucosal immunity and microflora Reduced with stress, inflammation, chronic infections, frustration (decrease siga 50%) Adequate siga = 67% increase in beneficial microbial adherence Prevents candida and other opportunistic infections SIBOTest Professional Education

47 Increasing siga Saccharomyces boulardi: Anti-inflammatory (decreases IL6, IL8, TNFa, NFKb) Improves brush border enzyme functions Reduces leaky gut Stress reduction! Sarsaparilla (Smilax), Pelargonium Zinc, Vitamin A SIBOTest Professional Education

48 Faecal Fat on CDSA Faecal fat is an important marker for bile acid deconjugation only when pancreatic elastase is in normal range It indicates the presence of fat even though pancreatic lipase production/release may be intact If SIBO bacteria are destroying bile acids, they are unable to emulsify fats thus the presence of faecal fat Could also be due to rapid transit SIBOTest Professional Education

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50 SCFA Short chain fatty acids are a product of bacterial fermentation. Elevated SCFA on a CDSA could be an indication of SIBO LOW SCFA especially butyrate could be assoc. with constipation/slow transit SIBOTest Professional Education

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52 Microbiome PCR assessment Methanogens Sulfur reducing bacteria Butyrate producers Bacteroidetes Lactobacillus, Bifidobacteria

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54 Summary of Other Tests Consider stool testing with microbiome PCR with High hydrogen after 120minutes on a lactulose breath test High methane throughout patient is not improving with SIBO treatment and negative on retest Consider OAT with SIFO, chronic fatigue, food intolerances

55 Thank You Module 1 Quiz link and reminder will be ed to you Module 2 topic next week: Strategic approaches to treating SIBO causes Phase 1 of the Protocol The SIBO Doctor Podcast SIBOTest Professional Education