Got excess intestinal gas, bloating and GI distress? Expand your knowledge on the topic of small intestinal bacterial overgrowth (SIBO) with our guest expert gastroenterologist, Dr. Mark Pimentel. Dr. Pimentel is a true maverick in the field of GI motility and the complexities of the small intestinal microbiome. His team has truly helped pave the way to our understandings of many complex GI conditions, including SIBO and irritable bowel syndrome (IBS). He shares insights from novel research happening in the Pimentel Lab, where he serves as the executive director of the esteemed Medically Associated Science and Technology (MAST) Program at Cedars-Sinai in Los Angeles, California. We kick off this episode debunking the myth that IBS is a woman's only disorder highlighting the importance of funding research for GI conditions which is essential for ALL.
Ever experience food poisoning? Learn how this may or may not have contributed to your current GI symptoms. We delve into the complexities of diagnosing SIBO with breath testing and examine its evolving credibility. We discuss how current state-of-the-art research is steering us toward more precise, microbiome-friendly treatments.
We conclude with a holistic perspective on managing gut health, with a scientific review of the impact of artificial sweeteners to the up-and-coming tailored approaches needed for conditions like SIBO. We address the critical importance of personalized treatment in the face of medical gatekeeping and underscore the necessity of balance in both diet and lifestyle.
Tune in for an insightful episode that promises to enrich your understanding of the delicate interplay with small intestinal microbes and our digestive system.
And... join our Gut Health Podcast Community! Subscribe and share – your gut will thank you!
This episode is sponsored by Ardelyx.
Reference:
Leite G, Morales W, Weitsman S, et al. The duodenal microbiome is altered in small intestinal bacterial overgrowth. PLoS One. 2020;15(7):e0234906. Published 2020 Jul 9. doi:10.1371/journal.pone.0234906
Learn more about Kate and Dr. Riehl:
Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast
Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.
The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kate Scarlata (00:00):
This podcast has been sponsored by Ardelyx.
Maintaining a healthy gut iskey for overall physical and
mental well-being.
Whether you're ahealth-conscious advocate, an
individual navigating thecomplexities of living with GI
issues, or a healthcare provider, you are in the right place.
(00:22):
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Hello, friends, and welcome toThe Gut Health Podcast, where we
talk about all things relatedto your gut and well-being.
(00:43):
We are your hosts.
I'm Kate Scarlata, a GIdietitian.
Megan Riehl (00:48):
And I am Dr Megan Riehl.
We have a very exciting podcastfor you today.
We are going to be talkingabout small intestinal bacterial
overgrowth, also known as SIBO,and we will be discussing the
small intestine microbiome.
And maybe you've suffered withSIBO, maybe you've never heard
of it, but either way, I'd saywe are going to be getting a
(01:12):
little heavy into the sciencetoday and I think you're going
to be fascinated.
Kate Scarlata (01:17):
Our guest today is a maverick.
He's really pushed the scienceand understanding SIBO for all
of us.
He is a world-renownedgastroenterologist and
researcher, Dr Mark Pimentel.
Dr Pimentel is the executivedirector of the Medically
Associated Science andTechnology, otherwise known as
(01:37):
MAST program at Cedars-Sinai inLos Angeles, California.
Pimentel's team researches IBSirritable bowel syndrome one of
the most prevalent GI conditions, impacting about 11% of the
population worldwide, as well asthe condition of small
intestinal bacterial overgrowthand intestinal methanogen
(01:58):
overgrowth.
Wow, I know that's a mouthful,but these two conditions are
often associated withsignificant GI symptoms.
Welcome to the Gut HealthPodcast, Dr Pimentel.
Mark Pimentel (02:10):
It's so good to be with you both and I'm excited
to talk about my favoritesubjects.
Megan Riehl (02:15):
Awesome.
Yeah, we're very excited tolearn from you and to share you
with our listeners.
So, as we dive in into theworld of gut health, we like to
bust myths and addressmisinformation, because right
now, there's a lot of stuff outthere that is not based in
science or coming from reputablesources like yourself.
(02:36):
We call it the snake oil.
So when it comes to SIBO, wehave literally one of the most
credible sources in the field ofgastroenterology.
Dr Pimentel, what is a commonmisconception about gut health
or GI disorders that you'd liketo dispel for our audience today
?
Mark Pimentel (02:56):
There's a lot of myths.
The biggest myth that I havespent my maverick years busting
is that IBS is a women's diseasequote unquote which is
ridiculous.
First of all, you do not blamea gender for a disease.
That's one aspect of it, andthat it's something to do with
(03:16):
hormones or something to do withwomen in general, or their
anxiety or their hysteria, asthey used to call it.
And that mythbusting that wasthe principal priority of my
work for many years is to saylook, it's a real thing and men
have it.
And it's not to validate menthat have it.
It's to validate that it isn'ta gender-specific condition,
(03:38):
albeit there are more women withit, but the condition was
dismissed and, as in a lot offemale predominant conditions,
there's less funding as well,which is also sad.
So biggest myth is stop blamingwomen for the disease and start
figuring it out, and I thinkwe've come a long way.
(03:59):
At least our lab has.
Megan Riehl (04:01):
Your lab has, and it really is again trailblazing,
because you're absolutely right, funding inequities and looking
at the variety of differentstrategies that we can use to
address these types of diagnosesis only going to change if our
mindset around diagnosis changes.
So thank you for leading theway.
(04:21):
We have some questions for younow, and we're going to start
with one.
What is small intestinalbacterial overgrowth?
What is the overlap with IBS?
Mark Pimentel (04:34):
The definition is changing because of science,
not because of opinion, unlikeRome criteria, which is more
from opinion than science.
Sorry, that was my little plugfor my pet peeve.
So what we realized in thebeginning, or what we thought in
the beginning, was that SIBOwas all these colon bacteria
(04:56):
moving into the small intestine,because maybe the motility was
bad, maybe there's a partialblockage or something else.
But it's not that.
It's not that at all.
It's much more interesting thanthat because in the latest
study which just came out thismonth, we show that SIBO, or
small intestinal bacterialovergrowth, is an accumulation
(05:18):
of two or three strains ofbacteria.
That's it.
Imagine that you look in a partof your body let's say an
infection in your skin you findpredominantly Staph aureus.
Well, it's a Staph aureus skininfection.
What we found in SIBO patientswho had greater than 10 to the 3
growing based on aspirates wefound E coli K12, almost
(05:41):
responsible for 50% of all theorganisms in the small bowel
just one strain of one species.
So it's really eye-opening evenfor us to see that specificity.
And so we can't call it aninfection, but it sounds like an
infection because it's only onecharacter and then maybe a
(06:02):
little bit of Klebsiellapneumonia thrown in there, which
is another species.
So it's really two charactersthat are dominating the whole
SIBO field.
Megan Riehl (06:12):
And what's the overlap with IBS?
Mark Pimentel (06:14):
The overlap with IBS is based on a lot of
different meta-analyses.
The most recent one is fromAyesha Shah from Australia,
where they show that there'sabsolutely more SIBO in IBS than
there is in healthy.
If you look at breath tests, ifyou look at culture studies,
it's the same thing and theoverlap appears to be based on
(06:35):
one study where they studied IBSand compared it to non-healthy
individuals.
The overlap is 60%.
So if you go back and look at Hpylori, H pylori causing ulcers
was about 60% to 80%, and nowwhen you do culture of the small
bowel of an IBS-D patient,you're seeing 60%.
So it isn't too dissimilar tothe H pylori story from the 80s
(06:59):
and 70s.
Megan Riehl (07:01):
Yeah, it's fascinating.
What are some of the keysymptoms with this condition?
What are patients presentingwith?
Mark Pimentel (07:10):
You know, what we see is bloating, of course,
because the bacteria produce gas.
And one of the things that wenoted in this recent study we
published in January was thatwhen you have this SIBO, when
you have these very uniquecharacters in the small bowel,
these patients are almost 63times more fermenting than
(07:31):
people who are normal.
Can you imagine that?
That your normal person's a onehorsepower engine for making
gas and you're a 63 horsepowerengine?
And then you wonder whypatients say well, I have 10
minutes after I eat, I'm gettingbloating and gas and then pain
because you get pain.
But what we've shown in a basicscience study so the two papers
(07:52):
in fact these two papers areprobably the most pivotal papers
we've ever written, alsopublished in January shows that
food poisoning starts the wholeprocess and we figured out which
toxin it was.
It's the CDTV toxin, was it'sthe CDTV toxin?
And when we gave the CDTV toxinto rats in their back, not in
their gut, they developed SIBO,they developed upregulation of
(08:14):
pathways, of visceralhypersensitivity in their gut.
They developed changes in theirpermeability, they developed
gut motility, serotonin pathwaychanges to suggest changes in
motility as well.
So it's food poisoning.
The CDTV toxin leads to allthese abnormal functions.
(08:34):
That leads to the bacterialovergrowth and they further
augment the hypersensitivity,because these bacteria produce
toxins and things that you don'twant and you get an
inflammatory response, albeitmild, not mild enough not to
cause symptoms.
Mild enough to cause symptoms.
Megan Riehl (08:52):
Right, and people are living with this, confused
because it sounds like they maybe picking up a food poisoning
that either they were aware ofor they had no idea, and kind of
just were living life, movingforward knowing something had
changed.
Mark Pimentel (09:07):
Exactly.
I mean, if you ask 100 peoplein their 20s if they ever had
food poisoning, you're going toget 100 yeses.
So it's a little tricky becausenot everybody who gets food
poisoning gets IBS and the MayoClinic showed that in their
meta-analysis that about 11% ofyou know.
If you go to a wedding and 100people get sick, only 11 out of
100 are going to progress to IBSbecause of their immune system
(09:28):
or whatever their reactivity isto this insult.
But yes, food poisoning.
They may not even remember thefood poisoning and they have
been on a trip and they had, youknow, a couple hours of
diarrhea and didn't even thinkabout it and then two months
later they're suffering with IBSfor the rest of their life.
So it's fascinating.
Megan Riehl (09:44):
Two months later, they're suffering with IBS for
the rest of their life.
So it's fascinating, yeah, Ithink.
When people are presentingfinally to a doctor with
symptoms, breath testing tendsto be one thing that may be
suggested, but it seems kind ofcontroversial.
So why is that?
What's the breath testingscenario?
Mark Pimentel (10:00):
So the breath testing has gone through stages
of development.
Let's put it that way Stages ofgone through stages of
development.
Let's put it that way Stages ofunderstanding and stages of
development.
I don't want to make this intoa long diatribe, but the
original gas was hydrogen, andhydrogen while if it's abnormal
you have symptoms, but it's notproportional.
So if your hydrogen is 30,which is abnormal at 90 minutes,
(10:22):
you have overgrowth, but ifit's 100, you don't have more
symptoms than somebody with 30.
And nobody can understand that.
And they say well, if it's SIBO, then why is this?
Why is that?
And then you have to do cultureand you have to prove that the
breath test correlates withculture and all that.
And that couldn't be done backin the 1980s when this was going
on.
So then they added methane.
Why did they add methane?
(10:44):
Nobody knows.
And there was no science to saymethane had any importance.
And I know we're going to getto methane.
And then we later learned itcauses constipation.
But there was a third gas,hydrogen sulfide, which we
couldn't measure.
So methane, the more it is, themore constipated you are.
Hydrogen was not a thermometer,but hydrogen sulfide is a
(11:05):
thermometer.
The more you have, the morediarrhea you have.
So it was a missing part of thebreath test to allow the
science to sort of come to itsfruition.
And I'll say one final thing Infact, the first validation of
breath testing, the truevalidation, was in 2022, in
December.
So we've been doing breathtesting for 40 years and in 2022
(11:28):
, we did the study where we tookdiarrhea, ibs patients,
constipation, ibs patients,breath testing with three gases
and the microbiome.
We showed that what you see onthe breath correlates with the
microbiome and correlates withthe symptoms.
And it's the first time thattriangle was completed in a full
(11:50):
, single study.
And so you could say breathtest was finally validated to be
accurate in 2022, which is asad testament, but we sort of
knew it was correct.
But you had to get the hard,hard data and that's what we
finally did.
Megan Riehl (12:06):
Okay.
So there is a lot of SIBO snakeoil out there.
You Google it, lots ofdifferent concoctions of
supplements and cleanses anddiets and all of that is out
there.
As a psychologist, this can beso anxiety-provoking for
patients, and weeding through itall and finding out what's the
(12:28):
short-term and the long-term ofthe treatment can be difficult
without again talking with areputable source.
So what advice do you give topatients and how do you counsel
your patients with treatment?
Mark Pimentel (12:41):
Well, even before SIBO, the industry, or the
cottage industry, of naturalproducts has always looked for a
niche or a wedge in order tosell a product and to provide
some healthcare benefit based onlimited data.
So you can always find onestudy that says one thing does,
maybe reduces one cytokine, andthen you say, oh, let's sell
(13:05):
that, but what does it do on aholistic basis to that person,
not just the single cytokine,and you're sort of putting that
as your anchor.
And a lot of these productsdon't go through randomized
control trials.
I'm going to go a little bitextreme peppermint.
Okay, they did one small studyand it was significant, using
(13:27):
modest framed endpoints, not theFDA endpoint.
You want to prove if somethingworks compared to a drug that's
FDA approved.
I want to see a thousandpatients, I want to see the FDA
endpoints, which are verydifficult, and then I believe it
.
Then it's toe-to-toe withwhat's drug approved.
But they can't spend that kindof money.
(13:48):
In fact, what we saw inpeppermint, for example, is we
did a meta analysis looking atthe size of the study, and you
both know this the bigger thestudy, the better the p-value
right, because you're gettingmore N.
What we saw with peppermint isthe bigger the study, the worse
the p-value got.
That's the wrong direction.
That means that it's sufferingfrom small study bias and you
(14:11):
get a positive small study andyou make a big big thing of it.
I'm not picking on peppermint,but probiotics is the same thing
.
Lactobacillus, lactobacillus,lactobacillus.
For 30, 40 years now we thinklactobacillus is a disruptor of
the small bowel, because nobodylooked in the small bowel.
They always looked in the colonand stool, and lactobacillus is
terrible for the small boweland you're going to see
(14:33):
something very, very interestingcome out in a paper that's
already in review and I can'ttell you what it is, but it's
going to cause people to curltheir hair a little bit and it's
lactobacillus being very, verybad, and we can talk more about
that another time.
Megan Riehl (14:49):
You have me on the edge of my seat.
Kate Scarlata (14:52):
Before I get sort of into my questions with you,
I did want you to talk a littlebit about the difference between
small intestinal bacterialovergrowth and intestinal
methanogen overgrowth, because Iknow these differ and a lot of
people haven't heard aboutintestinal methanogen overgrowth
.
Because I know these differ anda lot of people haven't heard
about intestinal methanogenovergrowth, so let's get into it
.
Mark Pimentel (15:10):
I'm happy to.
So, in contrast to what we'vediscussed with IBS-D and the
relationship to SIBO, which isthe E coli, klebsiella and then
the hydrogen sulfide productionwhich I just barely touched on.
That's all caused, we think,from food poisoning.
So that's the trajectory.
That's not the case for methane.
We don't know exactly whymethane accumulates more in some
(15:34):
individuals versus another,except to say that it clusters
in families, maybe sharing theenvironment.
You share your microbes, toilets, etc.
You know the usual way youshare your microbiome, which is
a little PG-13.
But it just happens you're inthe same environment and you
share your microbiome and so youaccumulate methane.
And the more methane youaccumulate beyond what is a
(15:57):
normal level, then you developconstipation and that's
intestinal methanogen overgrowth.
So it used to be lumped in SIBO.
But we realized that themethanogens are elevated in
stool and the small intestine.
And we do have a large abstractthat we're presenting at DDW
which describes everywheremethanogens grow, their
(16:18):
proportions and who they are.
But it all boils down mostly toone single organism
methanobrevibacter smithii.
So I want to pause therebecause you know, in all the 15
to 20 years of microbiomeresearch, do you both know of a
single name, of a singleorganism causing a disease in
(16:40):
all this 20 years of microbiomeresearch, because I don't, I
don't know a c diff, but thatpredates all of that.
But I've told you on this callthat E, coli, k12 and Klebsiella
pneumoniae are causing SIBO.
I'm telling you that we'vediscovered that
Methanobrevibacter smithii iscausing constipation and that
(17:01):
Fusobacterium andDecephalovibrio are causing the
diarrhea of hydrogen sulfide.
So our group has nailed downsingle organisms to single
disease in a number of areas,which is really exciting for the
patients and your listeners,because this gives us now the
nail for our hammer.
(17:22):
You can't just treat SIBOcoliforms, you have to treat the
nail and now that it's becomeso clear it's a specific nail,
we can figure out treatments forthe specific nail and we are
and we are already way into that, which is really exciting.
Megan Riehl (17:38):
You know, the reality is, even if I did know
it, I wouldn't be able topronounce it.
So thank goodness that you'reable to do that for us, because
even if I knew it, I wouldn't.
Mark Pimentel (17:49):
I didn't want to put you on the spot and wait for
an answer because there's somany wacky names.
Megan Riehl (17:55):
Well, thank you.
Mark Pimentel (17:58):
There hasn't been anything that's caught the
media's attention as a smokinggun, and now we have three
smoking guns.
So it's pretty exciting timesfor IBS-D, IBS-C, functional
disorders or DGBIs, becausewe're starting to sort out some
of these relationships betweenthe gut microbiome and how
they're going to.
Some of them produce serotonin,they affect the brain and sort
(18:21):
of unlocking the secrets of howthere's this mystery of how
everything worked.
The Pandora's box is opening.
Kate Scarlata (18:29):
It's really remarkable because I was
diagnosed with SIBO in 2003.
And it was like no one wastalking about it.
I mean, I had to educate mygastroenterologist to treat me
and just to see how this I meanreally your lab doing all of
this nitty gritty work into themicrobiome to you know, as you
(18:52):
say, find that nail so that wecan have targeted treatments,
instead of giving these fullspectrumspectrum antibiotics,
because we know the gutmicrobiome and the microbes
there for the most part arereally important and we're
really not treating.
You don't want to disseminatethese organisms, do we with
targeted treatments, or do wewant to just reduce them?
(19:13):
Like, what is the goal herewith treatment, when you're
thinking about treatments ahead?
Mark Pimentel (19:20):
Well, the program I run here is now determined
and far along that path, which Ican't tell you where we are
exactly, but we already havemolecules, let's put it that way
that are the hammers.
But our goal is to develop adrug for a bug, not a drug for
you a drug for that specific bug, and leave everything else
(19:40):
alone as much as possible.
And so our mission now is to bevery specific to the bug, but
it's not necessarily to kill it.
Not an antibiotic, just reduceit and get it back to the normal
level, because we really don'twant to wreck everything and we
don't want to use a wreckingball to treat the patient.
(20:01):
We want to use boutiquetherapies, and I think we've got
some and we just have to marchit along and get the right data
and make sure it's done properly.
Kate Scarlata (20:11):
Important.
So you've talked a little bitabout the microbes that are
there, a lot a bit about themicrobes that are there and
their impact on symptoms.
Are there certain microbes likejust to drill it down a little
bit more for our listeners thatcreate certain symptoms or
symptom severity?
Mark Pimentel (20:32):
I know methane is constipation but beyond, like
some of the other smallmicrobiome- In terms of what
we've been discussing methanethe higher it gets, the more
constipated a person is, and Ihave patients where you know
normally methane will beelevated, about 40 or 50, who
are 200 for methane and they'reabsolutely miserable people
(20:52):
because they're so bloated.
They talk about IBS-D being alow quality of life.
I can tell you it's much lower.
On the constipation side, Ifyou never have a bowel movement
properly, you never feel relief.
At least with the diarrheapatients, when they have the
purge they feel some relief fora period of time, but the
methane people never feel reliefand methane is more stubborn
(21:14):
and requires a better treatment.
The new kid on the block, thehydrogen sulfide as part of the
three gas breath test that'samazing what we're learning and
we're continuing to learn, andyou'll see at DDW some more data
and another couple of papersthat are coming out in the next
four or five months.
It's a direct line betweenhydrogen sulfide and diarrhea.
(21:35):
It's a direct line.
So the lower we can get that,the better.
The diarrhea IBS patients orthe diarrhea SIBO patients, if
you want to call them that, aregoing to be.
So it's pretty incredible nowthat we've unlocked these things
.
We didn't have three gasesbefore, so we couldn't see this.
I don't fault people forcriticizing breath testing.
I mean my task all these years.
(21:58):
In saying that breath testingwas important is because it
looked important.
We were seeing the signals, butwe were missing pieces, and
that was the frustration amongthe scientists and among myself.
So we had to answer thequestion, we had to move to the
next level, and now we're there,so we're starting to see the
right signals.
Kate Scarlata (22:18):
It's amazing.
This is a little off grid fromthe questions that I provided to
you, dr Pimentel, but you know,with the hydrogen sulfide gas
and sulfur in your diet, do youanticipate there'll be a
nutritional intervention withthat particular condition, the
hydrogen sulfide positive SIBO?
Mark Pimentel (22:40):
with that particular condition, the
hydrogen sulfide positive SIBO.
Well, wouldn't it make yourlife more interesting if I mean
as a clinician treating patientsyou know somebody who sees
patients like yourselves is to.
You'd have a diet for thehydrogen sulfide low sulfur diet
, a diet for the methane maybelow acid, low hydrogen sources,
and then a diet for SIBO maybeit's low FODMAP or low
(23:02):
fermentation, and so it isn't,you know, one big sledgehammer.
It's actually moresophisticated than that and
maybe better.
Those have not been developed,but it's not.
I mean, I can think about italready, what it might look like
, the construct might look like,and I think that will help
patients in the long run betterthan just one size fits all kind
(23:26):
of treatment.
Kate Scarlata (23:27):
Absolutely so.
Your group did an artificialsweetener study looking at its
impact on the small intestinalmicrobiome.
Can you share what you learned?
Mark Pimentel (23:40):
I can share it in sort of broad swaths.
But what we see is thatartificial sweetener ingestion
does change the microbiomemarkedly, especially the sugars
not aspartame I'll speak aboutaspartame in a minute.
But the artificial sugars, thesorbitol, the alcohol sugars,
(24:00):
sucralose and all of those had adramatic impact, as we would
have expected.
That because they're notabsorbed they're sugars the
bacteria can metabolize them andso you're selecting bacteria
that are not typically seen inhigher abundance because they
like to digest that sugar.
The question is how does thataffect health?
And our sample size wasn'tlarge enough to say, okay, well,
(24:22):
we have a thousand people onsucralose and they have a
detrimental health effect.
But now going to aspartame, itdidn't have that effect.
You didn't have a big change inthe microbiome.
But you know there was a studythat said there might be liver
toxicity from aspartame.
That came out recently.
We found that there was ahigher abundance of a liver
(24:45):
toxin that we saw in themetabolome.
We didn't see much changes inthe microbiome, but in the
metabolome we saw more of thisliver toxin.
So that needs furtherexploration.
So maybe that's why there issome toxicity.
So as much as I liked aspartameas a good sweetener, I have to
shake my head a little bit andsay, okay, am I doing the right
(25:06):
thing or not?
Now we have this data, we haveto rethink things.
What are we going to sweetenstuff with?
And so we all learn.
We have to learn and we have toadapt.
Kate Scarlata (25:16):
Well, I'm a big maple syrup sweetener queen over
here.
I think a little sugar is okay,a little sucrose.
IBS-C, or irritable bowelsyndrome with constipation, is a
common condition in whichpeople experience constipation
along with other belly symptomslike pain, bloating and
(25:36):
discomfort Sound familiar.
Many people with IBS-C arewilling to give up key parts of
their lives in exchange forsymptom relief.
And because the causes of IBS-Cmay differ for each person,
there is no one-size-fits-alltreatment approach.
If you're suffering from IBS-C,you may have to try a number of
(25:58):
different medications before youfind the right one for you.
So don't be okay with justfeeling okay.
If you have IBS symptoms thatcontinue to bother you, talk to
your healthcare provider to findout if your current medication
is right for you or if it's timeto try something different.
The more you know about IBS-C,the better prepared you will be
(26:20):
to speak with your doctor aboutthe right treatment option for
you.
So I wanted to talk a littlebit about medical gatekeeping or
just physicians in general thatjust don't believe in SIBO, and
how that might impact ourpatients.
Out there there's definitely acamp that just does not want to
(26:41):
see SIBO as a real diagnosis andunfortunately I've seen some of
those patients come to myoffice and really feel lost, and
I imagine you get a lot ofthese patients winding up at
your office.
So can you talk just about thatimpact on these patients out
there that are looking for care?
Mark Pimentel (27:02):
And there's various steps of physicians.
There are still physicians whowill see an IBS patient and say
look, you're not going to die,get over it, you're fine, you've
had it for 10 years.
Go do some yoga, relax.
There are still physicians whodo this or various combinations
and permutations of not takingthe patient seriously and saying
(27:24):
get on with your life, which Ithink is undereducated by an
extreme amount.
The next step are the skepticsof breath testing, because I
don't blame them for beingskeptical.
Until 2022, which I justdescribed to you we didn't have
the best validation of breathtesting.
We had a lot of data and a lotof signal and strong studies
(27:47):
that suggest it was important.
But if you're going to be askeptic in the minority, you
could say we didn't have thesequencing versus symptoms,
versus breath test validation,and we didn't have the three
gases.
We didn't have all that.
Well, we have all of that now,and so now it's a matter of
educating those I hope, minoritygroups of physicians who are
still stubbornly thinking thisis a fad rather than a fact.
(28:12):
But you know, sometimes withbreath testing and SIBO and you
see it because you see it onsocial media there is a tendency
to embellish it in a fadfashion Everything is SIBO,
everything is SIBO, everythingis SIBO.
I can tell you, in my officewhen I see a SIBO patient,
nothing is SIBO till I'm sure.
And I've undone that diagnosisin a number of patients where I
(28:35):
found some other explanation.
When they come to my office Isay I'm assuming you don't have
SIBO and I'm going to see what?
Because nothing, they haven'tresponded, they haven't done,
they haven't responded in thetypical way, and so I sort of
undo that diagnosis in someinstances.
So there's the doctors who arestubborn and maybe that's
(28:56):
undereducated.
And then there are doctors whoovercall SIBO, because they are
undereducated as well, becausethey just want to call
everything a nail, and so we getboth ends of that.
Kate Scarlata (29:07):
Yeah, I absolutely see that too.
You know it worries me whenpatients are just chronically
treated with antibiotics andreally not getting to maybe
something else going on.
We definitely see that.
Mark Pimentel (29:19):
I had a patient as an example where she was
treated with rifaximin, forexample, for four or five times,
no benefit.
We finally were able to do thethree gas breath test.
She had hydrogen sulfide.
We gave her rifaximin andbismuth.
The hydrogen sulfide went away,her diarrhea, which was like
eight times a day, totally goneand it hasn't come back.
It's been a year and a half.
(29:39):
But that's an example of a SIBOundereducated, under-evaluated,
because this is all new data.
And then there are otherexamples where it turns out to
be cancer or it turns out to bebe something else and the doctor
is barking up the wrong treebecause it's the simplest
explanation you know.
Kate Scarlata (29:56):
No, I love it.
I always tell people if plan Aisn't working, same for a low
FODMAP diet or you know,whatever treatment modality
they're doing like we need tocome up with plan B, C and D.
There's so many options and whyare we doing the same thing
that's not working?
Megan Riehl (30:16):
And oftentimes it's anxiety, it's the fear that,
well, maybe it is working.
You know, maybe I did get 10%relief from that antibiotic, so
I want to do it again because Ithink I may be and it really
takes the confidence of thephysician to, you know, say
let's look at other things,let's involve maybe some other
team members and we have otherstones that we can overturn here
(30:38):
.
Mark Pimentel (30:39):
But that's again education, and when a physician
or a health professional iseducated properly, they can take
command of the situation.
They don't have that confidenceas you described, Megan.
They can't confidently make thepatient feel confident that
they know what they're doing andtherefore they start exploring
the internet on their own tocome up with answers.
(31:01):
And so confidence comes.
Grow that education and thatsome of our listeners may change
some of their practices inmedicine, based on your
expertise and us having theopportunity to talk.
Kate Scarlata (31:25):
I know I agree with that.
I agree with that.
I just want to back up a littlebit because you did mention the
bismuth with the rifaximin.
Do you want to just talk alittle bit about what you have
found in your practice to beworking for some of these
hydrogen sulfide cases?
Mark Pimentel (31:40):
Yeah, so for hydrogen sulfide, we have a
randomized controlled trialwhich we haven't publicized yet.
It hasn't come out for some newproducts that we're working on,
but as it stands now andremember I talked about and said
things about peppermint andother products we need
controlled trials.
So what I'm going to tell youtoday is not a controlled study.
It's based on historical datathat suggests that bismuth
(32:02):
really reduces hydrogen sulfidein the gut, and so we have
adopted that based on studiesfrom the 90s, adding it to
rifaximin because you got to getrid of the hydrogen.
We know it works there forrifaximin and bismuth, reducing
the hydrogen sulfide, thengetting both of those together
because you need hydrogen tomake hydrogen sulfide, so that
your audience understands thatit seems to work very well in
(32:26):
our practice.
But this is not based on arandomized control trial yet,
but you'll see data coming,hopefully this year.
Kate Scarlata (32:34):
Awesome.
So let me review a few keypoints from today's episode, and
I'm definitely going to have DrPimentel weigh in, make sure I
got most of them.
So we understand that SIBOpresents very similarly to IBS,
often if it'sdiarrhea-predominant, like IBS-D
we often see that SIBOdiagnosis related to hydrogen
(32:55):
sulfide gas Intestinalmethanogen overgrowth appears to
be associated with constipation.
So you might see that in yourpatients or with yourself if you
experience IBS with aconstipation predominance
predominance.
(33:16):
We're beginning to understand alittle bit about the small
intestinal microbiome and who'sthere and what is really
impacting SIBO.
One of the things you said andI'm going to interject with you
now, Mark is the metabolome andI think you know when we talk
about the gut microbiomeinitially, when the science came
to sort of the front in theearly 2000s or so, we were all
talking about what microbes arethere and now we're really
(33:39):
shifting a little bit into thismetabolome and what they're
making and what they're doing.
So you mentioned is itaspartame?
It was really the metabolome.
Can you just talk a little bitabout the metabolome and how you
look at that in the researchsetting?
Mark Pimentel (33:53):
Well, I gave you sort of an example without using
the term metabolome, but we'reable to see in the metabolome of
SIBO, which is the topic oftoday, the immense upregulation
of the metabolic function tobreak down carbohydrates, and I
use the term 63-fold or63-horsepower engine.
And so by studying themetabolome we see that.
(34:16):
Wow, now that explains to mewhy my patients say 10 minutes
after I eat.
But there's a thing called theinteractome, which is the
metabolome, the composition ofyour microbiome, their products
and the host response to all ofthat milieu.
And so we've actually dug intothat as well.
(34:36):
Which is what we brushed acrossearlier.
Is that we actually see in thetissue that the chemistry for
gut hypersensitivity is there,the chemistry for cell-cell
interaction, to allow that quote, leakiness to the gut.
We see the serotonin signalingpathways altered, which we know
(34:57):
affects motility in a particularway.
So there's an interactionthat's occurring from a
consequence of the microbiomechanging the chemistry that they
produce and that chemistryaffecting you in that way, and
so we're able to really againtriangulating on cause and
effect pathways.
Kate Scarlata (35:17):
It's really amazing and I just you see these
stool tests just looking at youknow, really targeted to people
with IBS, with just the stoolmicrobes and it's just like such
a small window into themicrobiome and seemingly useless
when you see the complexity ofthis interaction that you just
described.
Mark Pimentel (35:37):
Well, and one other point, which is another
misunderstanding of themicrobiome.
When you think about themicrobiome of stool, the density
of microbes in stool is wayhigher than the small bowel.
But it's in a cylinder, rightfor the most part, and you only
see the outside of the cylinder.
The inside is just the microbesdoing their thing.
You don't see the metabolicstuff on the inside as much,
(35:59):
it's only what gets to theoutside.
So the surface area exposure ofthe microbiome and the colon is
quite small, even though thecontents are larger.
The small bowel is the size of atennis court, although I was
corrected on the social mediarecently but it's a large
surface area where, if you wereto, you know, put a thin layer
(36:21):
of bacterial pita butter on thatsurface which absorbs
everything or is meant to absorbthings, the impact on the human
is immense.
I mean, it's much more than thecolon.
And so we know now that thecolon microbiome is like a
different planet, it's like Marscompared to the earth, which is
(36:41):
the small bowel.
And so understanding the smallbowel is so vitally important,
because that's where things getabsorbed.
Kate Scarlata (36:48):
So important I want to just talk as sort of.
One of our main points is justthat SIBO can be anxiety
producing.
You know it's a tough diagnosis.
Having lived it myself and whata difference after being
treated.
You know like I could live mylife again.
Team, you know I think patientsare very confused about what
(37:11):
they should be eating and youknow I almost called it like
PTSD.
I'm no psychologist, megan, butwhen I had SIBO I was just like
the wary of it coming backbecause I was so sick.
I went into this like any gasbubble.
I felt like I'd be like oh,please don't be this again.
So getting a GI psychologistinvolved too, if that just
(37:33):
really escalates a little bit inthe wrong direction, I think
that team approach can be reallyhelpful for our patients.
Yeah, you're describinghypervigilance.
Megan Riehl (37:43):
You're describing GI-specific anxiety where a
gurgle sends signals up to thebrain to interpret what the heck
is going on down there and, aswe've learned with this
diagnosis, it can be like tryingto find a needle in a haystack.
So as soon as we kind of stepback and you are seated with a
practitioner, you know we'regoing to utilize different brain
(38:06):
, gut, behavioral therapies inconjunction with working with,
potentially, a dietician, agastroenterologist, a primary
care doctor, to really addressyour whole health and how this
has impacted how you eat, howyou behave, which all impacts
our gut microbiome.
But you're absolutely right,you may feel symptoms of
(38:28):
hypervigilance andhypersensitivity because of a
diagnosis like this, and we canaddress that?
Kate Scarlata (38:33):
Yeah, that's excellent.
I think too, you know we seethese food-related symptoms in
patients with bacterialovergrowth, as Dr Pimentel
mentioned.
Like 10 minutes after eating.
Well, you know, the food'sgetting into that small bowel
pretty quickly and if there's alot of different players in
there that have, to your point,upregulated ability to degrade
carbohydrates and ferment vastamounts of gas in that small
(38:56):
intestine, which is really notdesigned to accommodate all of
that gas, how uncomfortable thatwould lead you.
But on the flip side of that,getting rid of those microbes
and reducing them, thosefood-related symptoms can go
away, and so long-term dietstrategies may help prevent the
(39:18):
recurrent return of SIBO.
We don't really know that, butthere is hope that one doesn't
need to be really on this longstrict diet forever, and I think
people do get into that alittle bit.
Can you comment to that, drPimentel, about just the
necessity for everyone should beon a strict diet long-term?
Mark Pimentel (39:45):
Well, for example , in SIBO, as we've been
discussing, there are patientswhere you treat once and you
don't see them for years.
They're so mild, symptomaticenough to see the physician, but
the pathophysiology isn't thatdense that they relapse.
The motility isn't as affectedby the food poisoning.
And now going backwards in timeto what we talked about earlier
.
But there are patients where adiet which is a fairly
(40:07):
quote-unquote, benign way ofkeeping the patient from
relapsing meaning it's not adrug.
But you do get into thishypervigilance, as you both have
described.
I had a patient where she wouldhave incontinence from her
diarrhea.
She was an older woman.
We treated her SIBO.
She still wouldn't go to thegrocery store, even though
everything was normal.
(40:27):
But after some coaching andtime she was flying, she was
showing her dogs at dog shows,she was doing all the things
that she loved.
So it was amazing.
But it takes time to break thehypervigilance.
But the same thing happens withfood.
You get a fear of food and afear of things that made you
unwell before.
But I'll say one other thingwhich really gets in the weeds
(40:50):
for patients.
People think I've got bloating.
Therefore, what I ate an hourago is to blame, and in a
microbiology world.
That is not true.
The way it works is you atebeans three days ago, the beans
increase the amount of bacteriain your gut, so that today the
(41:13):
amount of bacteria in your gut,so that today the amount of
bacteria in your gut is wayhigher than it was three days
ago.
And you had pasta at the samerestaurant, which didn't bother
you last week, but today it didscratch that pasta off my list.
I can never eat it again.
And then you keep scratchingthings off the list, not
understanding how the microbiomeworks, and you scratch until
(41:40):
you're left with chicken andrice and hence ARFID or these
disorders of eating as a resultof IBS and SIBO.
If you don't have a healthpractitioner who can explain
those things to the patient,they end up restricting and
restricting and restricting.
It's not the pasta, it's themeal you ate two days ago that
made this meal bad.
That's just an example.
And so having a healthpractitioner who understands
(42:02):
diet and can counsel the patientso having a team I agree with
you both having a team isimportant.
Kate Scarlata (42:08):
Yeah, and I would just add you know bloating can
occur when there's a lot ofpsychological angst, when
someone is full of stool.
You know there are other reasonsand I think to your comment
that diet is a benignintervention, I agree it is not
a benign intervention because ofjust what you described and
that people can go down thisrabbit hole of restricting and
(42:36):
restricting, and we know thatsome of these very highly
restrictive eating disordersplace individuals at increased
mortality.
So we want to be careful withthat semantics, so to speak.
I mean, I know where you aregoing with, but diet has some
issues with it.
It can be very helpful I see ithelping patients all the time
(42:58):
but on that flip side, when youtake it to that next level, it
can be really problematic.
And I would say you know when Isay this to my patients, it's
like you need fuel for your gutmotility to work and for your
pelvic floor to workappropriately, so that efforts
to restrict the diet to help theSIBO are actually impacting gut
motility and function andthey're missing this very vital
(43:22):
point that is essential formaintaining a healthy gut.
Would you agree to that or youfeel free to disagree with me?
Mark Pimentel (43:30):
No, I mean, the extreme example of what you're
saying is anorexia.
Right, you have bloatingbecause, in part because the
muscles of the gut no longerhave any strength, so the
distension is more prominent,and then the body dysmorphism
can be more prominent, and thenyou want to restrict calories
more to see if you can get ridof that.
So that's just part of anorexia.
(43:52):
Anorexia is a much morecomplicated issue than I'm
simplifying.
The point is protein will buildthe muscle and the muscle
builds.
Then the gut works better.
It's a balance and I thinkpatients get too restricted.
But diet plays a very importantrole in all of these treatments.
But my main point was you haveto have a health professional
that understands how to do itcorrectly, to guide the patient,
(44:14):
rather than simply just anybodytelling you to do X, Y or Z
indiscriminately.
And you've seen this wheresomebody goes on a low FODMAP
diet and they've been on it fora year and a half because nobody
told them they should doanything different, and now they
have some nutritionaldeficiencies, and so you can't
just throw something at somebodyand then never see them back
(44:38):
and follow up and guide themfurther.
Kate Scarlata (44:40):
Absolutely.
I could not agree more.
You know, I see a lot of onlinesites recommending an placebo
protocol with a slurry ofsupplements and their special
diet, and we know that thiscondition really isn't one size
fits all right.
Mark Pimentel (44:57):
You mean, like with supplements, all mixed
together?
Kate Scarlata (45:00):
Yeah, if you just put SIBO protocol online, you
will be horrified with peopleout there with maybe had SIBO
themselves or have no medicalcredentials, and a lot of people
gravitate to this and they'rereally, you know, a probiotic, a
(45:20):
biofilm disruptor, specificdiets, you know, not discounting
.
I'm just not sure some of thisis science-based at this time.
Mark Pimentel (45:30):
I have to be careful because, as a scientist
and as you, from being amaverick in the beginning, I
don't discount anything.
I say there's no data.
Because there are things like,for example, berberine.
I wasn't altogether a fan ofberberine, I wasn't sure.
And then Johns Hopkins did astudy that said that a
combination of berberine.
(45:51):
I wasn't sure, and then JohnsHopkins did a study that said
that a combination of berberineand a couple of other herbal
products was as good asrifaximin.
So it's not good until youprove it and it's not bad until
you prove it.
So I think the problem is theclaims without data.
That's the problem.
So it's very important that youget data and if you want to
(46:12):
make money on it, you'll makemore money if you have data.
It's just evidence-based.
Kate Scarlata (46:18):
Finally, yeah, well, we're getting there and I
agree with you.
I totally agree with that.
There's a lot of informationout there that may prove to be
the best treatment ever for SIBO, but even with low FODMAP
there's no evidence that the lowFODMAP diet helps SIBO.
We find that it helps managesymptoms in patients clinically,
but I can't and will not evertell a patient that this is the
(46:41):
one-all, be-all diet protocolfor SIBO.
It's just symptoms overlap withIBS.
That's what we have, and it mayhelp to reduce FODMAPs, you
know?
Okay, Megan.
Megan Riehl (46:58):
So, outside of lighting up Cedars-Sinai and LA
with this microbiome gut healthdisrupting work that you're
doing you've cited so manypapers that I can't wait to sink
into and share the wealth ofinformation that comes with that
.
You've got to have time forself-care, I hope as well, and
so we like to ask all of ouresteemed guests what's something
(47:20):
that you do for your own healthand well-being, that's, you
know, sustainable over the longterm.
Mark Pimentel (47:28):
Well, you have to be a role model for your
patients in a lot of ways, and Ithink eating healthy I mean
these aren't hobbies.
Eating healthy, exercisingfrequently, which I do are not
hobbies but just lifestylechoices that I make.
But I play blues guitar.
Maybe it's something nobodyknows, or I try to.
Let's call it that it's amidlife crisis.
(47:48):
I didn't get a Ferrari, I got aguitar and I counsel everybody
who's out there get the Ferrariinstead of the guitar.
It's less worth it because it'sbeen a 10-year-plus journey of
trying to learn the guitar andit never ends what you can learn
and it never ends that you feelconfident in what you're doing.
But that's okay.
That's my life journey.
Megan Riehl (48:11):
It's lighting up a totally different side of your
brain.
So I love that for you and Ithink that it is inspiring to
kind of take something thatyou're clearly very good at what
you do in your profession.
So a little challenge by theguitar is probably a good thing
for you.
Mark Pimentel (48:28):
Yes, sometimes it overwhelms the brain because I
use the right side of my brainas a fatigue reliever and when I
fatigue both sides, I'm prettytired when I go to bed.
Megan Riehl (48:37):
Yeah, you'll sleep better.
You'll sleep better, exactly.
Kate Scarlata (48:40):
It's all positive , it's all positive.
Mark Pimentel (48:42):
It's all positive yeah.
Megan Riehl (48:43):
So we have worked with so many patients who have
been diagnosed with SIBO.
Typically, they're prescribedthe antibiotic and hope for the
best and onward they go.
And this is why this diagnosisreally highlights the importance
of remembering that everybody'sgut microbiome is different.
We have to tailor theirtreatment plan, individualizing
(49:06):
it for them, and it certainlygives a shout out to the dream
team approach of dietician and,you know, it certainly gives a
shout out to the dream teamapproach of dietitian,
psychologist and physician ormedical provider.
So we just want to say thankyou for the work that you're
doing, also for all thelisteners out there.
We do touch on SIBO in our bookMind Your Gut, so certainly
(49:28):
something to check out andconsider when you're thinking
about holistic ways to approachyour gut health.
So, Kate, what do we expect inour next ?
Kate Scarlata (49:37):
Yes so we are talking all about bloating with
Dr Brian Lacy.
He is a neurogastroenterologistat the Mayo Clinic in
Jacksonville, Florida.
He is the pastco-editor-in-chief of the
American Journal ofGastroenterology.
We're definitely in for a treatbecause he is a fantastic
provider and just a kind, gentlesoul, and it'll be really
(50:02):
interesting to hear his take onbloating.
He's one of the, I would say,world experts in this area.
Megan Riehl (50:08):
All right, we're lucky, we're excited for what's
to come, and you guys all knowthe drill at this point.
So make sure you subscribe,follow and like The Gut Health
Podcast.
Tell your friends, yourpatients, your loved ones, all
about us.
Know that gut health mattersfor everyone and your support
means the world.
Our friends have a great day,thanks again Mark.
Mark Pimentel (50:32):
Thank you, take care.
Megan Riehl (50:35):
Thank you for joining us as we grow this gut
health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media at T he Gut Health
Podcast, where we'd love for youto share your thoughts,
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Thanks for tuning in, friends.
This podcast has been sponsored by Ardelyx.
Maintaining a healthy gut iskey for overall physical and
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(00:22):
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Hello, friends, and welcome toThe Gut Health Podcast, where we
talk about all things relatedto your gut and well-being.
(00:43):
We are your hosts.
I'm Kate Scarlata, a GIdietitian.
Megan Riehl (00:48):
And I am Dr Megan Riehl.
We have a very exciting podcastfor you today.
We are going to be talkingabout small intestinal bacterial
overgrowth, also known as SIBO,and we will be discussing the
small intestine microbiome.
And maybe you've suffered withSIBO, maybe you've never heard
of it, but either way, I'd saywe are going to be getting a
(01:12):
little heavy into the sciencetoday and I think you're going
to be fascinated.
Kate Scarlata (01:17):
Our guest today is a maverick.
He's really pushed the scienceand understanding SIBO for all
of us.
He is a world-renownedgastroenterologist and
researcher, Dr Mark Pimentel.
Dr Pimentel is the executivedirector of the Medically
Associated Science andTechnology, otherwise known as
(01:37):
MAST program at Cedars-Sinai inLos Angeles, California.
Pimentel's team researches IBSirritable bowel syndrome one of
the most prevalent GI conditions, impacting about 11% of the
population worldwide, as well asthe condition of small
intestinal bacterial overgrowthand intestinal methanogen
(01:58):
overgrowth.
Wow, I know that's a mouthful,but these two conditions are
often associated withsignificant GI symptoms.
Welcome to the Gut HealthPodcast, Dr Pimentel.
Mark Pimentel (02:10):
It's so good to be with you both and I'm excited
to talk about my favoritesubjects.
Megan Riehl (02:15):
Awesome.
Yeah, we're very excited tolearn from you and to share you
with our listeners.
So, as we dive in into theworld of gut health, we like to
bust myths and addressmisinformation, because right
now, there's a lot of stuff outthere that is not based in
science or coming from reputablesources like yourself.
(02:36):
We call it the snake oil.
So when it comes to SIBO, wehave literally one of the most
credible sources in the field ofgastroenterology.
Dr Pimentel, what is a commonmisconception about gut health
or GI disorders that you'd liketo dispel for our audience today
?
Mark Pimentel (02:56):
There's a lot of myths.
The biggest myth that I havespent my maverick years busting
is that IBS is a women's diseasequote unquote which is
ridiculous.
First of all, you do not blamea gender for a disease.
That's one aspect of it, andthat it's something to do with
(03:16):
hormones or something to do withwomen in general, or their
anxiety or their hysteria, asthey used to call it.
And that mythbusting that wasthe principal priority of my
work for many years is to saylook, it's a real thing and men
have it.
And it's not to validate menthat have it.
It's to validate that it isn'ta gender-specific condition,
(03:38):
albeit there are more women withit, but the condition was
dismissed and, as in a lot offemale predominant conditions,
there's less funding as well,which is also sad.
So biggest myth is stop blamingwomen for the disease and start
figuring it out, and I thinkwe've come a long way.
(03:59):
At least our lab has.
Megan Riehl (04:01):
Your lab has, and it really is again trailblazing,
because you're absolutely right, funding inequities and looking
at the variety of differentstrategies that we can use to
address these types of diagnosesis only going to change if our
mindset around diagnosis changes.
So thank you for leading theway.
(04:21):
We have some questions for younow, and we're going to start
with one.
What is small intestinalbacterial overgrowth?
What is the overlap with IBS?
Mark Pimentel (04:34):
The definition is changing because of science,
not because of opinion, unlikeRome criteria, which is more
from opinion than science.
Sorry, that was my little plugfor my pet peeve.
So what we realized in thebeginning, or what we thought in
the beginning, was that SIBOwas all these colon bacteria
(04:56):
moving into the small intestine,because maybe the motility was
bad, maybe there's a partialblockage or something else.
But it's not that.
It's not that at all.
It's much more interesting thanthat because in the latest
study which just came out thismonth, we show that SIBO, or
small intestinal bacterialovergrowth, is an accumulation
(05:18):
of two or three strains ofbacteria.
That's it.
Imagine that you look in a partof your body let's say an
infection in your skin you findpredominantly Staph aureus.
Well, it's a Staph aureus skininfection.
What we found in SIBO patientswho had greater than 10 to the 3
growing based on aspirates wefound E coli K12, almost
(05:41):
responsible for 50% of all theorganisms in the small bowel
just one strain of one species.
So it's really eye-opening evenfor us to see that specificity.
And so we can't call it aninfection, but it sounds like an
infection because it's only onecharacter and then maybe a
(06:02):
little bit of Klebsiellapneumonia thrown in there, which
is another species.
So it's really two charactersthat are dominating the whole
SIBO field.
Megan Riehl (06:12):
And what's the overlap with IBS?
Mark Pimentel (06:14):
The overlap with IBS is based on a lot of
different meta-analyses.
The most recent one is fromAyesha Shah from Australia,
where they show that there'sabsolutely more SIBO in IBS than
there is in healthy.
If you look at breath tests, ifyou look at culture studies,
it's the same thing and theoverlap appears to be based on
(06:35):
one study where they studied IBSand compared it to non-healthy
individuals.
The overlap is 60%.
So if you go back and look at Hpylori, H pylori causing ulcers
was about 60% to 80%, and nowwhen you do culture of the small
bowel of an IBS-D patient,you're seeing 60%.
So it isn't too dissimilar tothe H pylori story from the 80s
(06:59):
and 70s.
Megan Riehl (07:01):
Yeah, it's fascinating.
What are some of the keysymptoms with this condition?
What are patients presentingwith?
Mark Pimentel (07:10):
You know, what we see is bloating, of course,
because the bacteria produce gas.
And one of the things that wenoted in this recent study we
published in January was thatwhen you have this SIBO, when
you have these very uniquecharacters in the small bowel,
these patients are almost 63times more fermenting than
(07:31):
people who are normal.
Can you imagine that?
That your normal person's a onehorsepower engine for making
gas and you're a 63 horsepowerengine?
And then you wonder whypatients say well, I have 10
minutes after I eat, I'm gettingbloating and gas and then pain
because you get pain.
But what we've shown in a basicscience study so the two papers
(07:52):
in fact these two papers areprobably the most pivotal papers
we've ever written, alsopublished in January shows that
food poisoning starts the wholeprocess and we figured out which
toxin it was.
It's the CDTV toxin, was it'sthe CDTV toxin?
And when we gave the CDTV toxinto rats in their back, not in
their gut, they developed SIBO,they developed upregulation of
(08:14):
pathways, of visceralhypersensitivity in their gut.
They developed changes in theirpermeability, they developed
gut motility, serotonin pathwaychanges to suggest changes in
motility as well.
So it's food poisoning.
The CDTV toxin leads to allthese abnormal functions.
(08:34):
That leads to the bacterialovergrowth and they further
augment the hypersensitivity,because these bacteria produce
toxins and things that you don'twant and you get an
inflammatory response, albeitmild, not mild enough not to
cause symptoms.
Mild enough to cause symptoms.
Megan Riehl (08:52):
Right, and people are living with this, confused
because it sounds like they maybe picking up a food poisoning
that either they were aware ofor they had no idea, and kind of
just were living life, movingforward knowing something had
changed.
Mark Pimentel (09:07):
Exactly.
I mean, if you ask 100 peoplein their 20s if they ever had
food poisoning, you're going toget 100 yeses.
So it's a little tricky becausenot everybody who gets food
poisoning gets IBS and the MayoClinic showed that in their
meta-analysis that about 11% ofyou know.
If you go to a wedding and 100people get sick, only 11 out of
100 are going to progress to IBSbecause of their immune system
(09:28):
or whatever their reactivity isto this insult.
But yes, food poisoning.
They may not even remember thefood poisoning and they have
been on a trip and they had, youknow, a couple hours of
diarrhea and didn't even thinkabout it and then two months
later they're suffering with IBSfor the rest of their life.
So it's fascinating.
Megan Riehl (09:44):
Two months later, they're suffering with IBS for
the rest of their life.
So it's fascinating, yeah, Ithink.
When people are presentingfinally to a doctor with
symptoms, breath testing tendsto be one thing that may be
suggested, but it seems kind ofcontroversial.
So why is that?
What's the breath testingscenario?
Mark Pimentel (10:00):
So the breath testing has gone through stages
of development.
Let's put it that way Stages ofgone through stages of
development.
Let's put it that way Stages ofunderstanding and stages of
development.
I don't want to make this intoa long diatribe, but the
original gas was hydrogen, andhydrogen while if it's abnormal
you have symptoms, but it's notproportional.
So if your hydrogen is 30,which is abnormal at 90 minutes,
(10:22):
you have overgrowth, but ifit's 100, you don't have more
symptoms than somebody with 30.
And nobody can understand that.
And they say well, if it's SIBO, then why is this?
Why is that?
And then you have to do cultureand you have to prove that the
breath test correlates withculture and all that.
And that couldn't be done backin the 1980s when this was going
on.
So then they added methane.
Why did they add methane?
(10:44):
Nobody knows.
And there was no science to saymethane had any importance.
And I know we're going to getto methane.
And then we later learned itcauses constipation.
But there was a third gas,hydrogen sulfide, which we
couldn't measure.
So methane, the more it is, themore constipated you are.
Hydrogen was not a thermometer,but hydrogen sulfide is a
(11:05):
thermometer.
The more you have, the morediarrhea you have.
So it was a missing part of thebreath test to allow the
science to sort of come to itsfruition.
And I'll say one final thing Infact, the first validation of
breath testing, the truevalidation, was in 2022, in
December.
So we've been doing breathtesting for 40 years and in 2022
(11:28):
, we did the study where we tookdiarrhea, ibs patients,
constipation, ibs patients,breath testing with three gases
and the microbiome.
We showed that what you see onthe breath correlates with the
microbiome and correlates withthe symptoms.
And it's the first time thattriangle was completed in a full
(11:50):
, single study.
And so you could say breathtest was finally validated to be
accurate in 2022, which is asad testament, but we sort of
knew it was correct.
But you had to get the hard,hard data and that's what we
finally did.
Megan Riehl (12:06):
Okay.
So there is a lot of SIBO snakeoil out there.
You Google it, lots ofdifferent concoctions of
supplements and cleanses anddiets and all of that is out
there.
As a psychologist, this can beso anxiety-provoking for
patients, and weeding through itall and finding out what's the
(12:28):
short-term and the long-term ofthe treatment can be difficult
without again talking with areputable source.
So what advice do you give topatients and how do you counsel
your patients with treatment?
Mark Pimentel (12:41):
Well, even before SIBO, the industry, or the
cottage industry, of naturalproducts has always looked for a
niche or a wedge in order tosell a product and to provide
some healthcare benefit based onlimited data.
So you can always find onestudy that says one thing does,
maybe reduces one cytokine, andthen you say, oh, let's sell
(13:05):
that, but what does it do on aholistic basis to that person,
not just the single cytokine,and you're sort of putting that
as your anchor.
And a lot of these productsdon't go through randomized
control trials.
I'm going to go a little bitextreme peppermint.
Okay, they did one small studyand it was significant, using
(13:27):
modest framed endpoints, not theFDA endpoint.
You want to prove if somethingworks compared to a drug that's
FDA approved.
I want to see a thousandpatients, I want to see the FDA
endpoints, which are verydifficult, and then I believe it
.
Then it's toe-to-toe withwhat's drug approved.
But they can't spend that kindof money.
(13:48):
In fact, what we saw inpeppermint, for example, is we
did a meta analysis looking atthe size of the study, and you
both know this the bigger thestudy, the better the p-value
right, because you're gettingmore N.
What we saw with peppermint isthe bigger the study, the worse
the p-value got.
That's the wrong direction.
That means that it's sufferingfrom small study bias and you
(14:11):
get a positive small study andyou make a big big thing of it.
I'm not picking on peppermint,but probiotics is the same thing
.
Lactobacillus, lactobacillus,lactobacillus.
For 30, 40 years now we thinklactobacillus is a disruptor of
the small bowel, because nobodylooked in the small bowel.
They always looked in the colonand stool, and lactobacillus is
terrible for the small boweland you're going to see
(14:33):
something very, very interestingcome out in a paper that's
already in review and I can'ttell you what it is, but it's
going to cause people to curltheir hair a little bit and it's
lactobacillus being very, verybad, and we can talk more about
that another time.
Megan Riehl (14:49):
You have me on the edge of my seat.
Kate Scarlata (14:52):
Before I get sort of into my questions with you,
I did want you to talk a littlebit about the difference between
small intestinal bacterialovergrowth and intestinal
methanogen overgrowth, because Iknow these differ and a lot of
people haven't heard aboutintestinal methanogen overgrowth
.
Because I know these differ anda lot of people haven't heard
about intestinal methanogenovergrowth, so let's get into it
.
Mark Pimentel (15:10):
I'm happy to.
So, in contrast to what we'vediscussed with IBS-D and the
relationship to SIBO, which isthe E coli, klebsiella and then
the hydrogen sulfide productionwhich I just barely touched on.
That's all caused, we think,from food poisoning.
So that's the trajectory.
That's not the case for methane.
We don't know exactly whymethane accumulates more in some
(15:34):
individuals versus another,except to say that it clusters
in families, maybe sharing theenvironment.
You share your microbes, toilets, etc.
You know the usual way youshare your microbiome, which is
a little PG-13.
But it just happens you're inthe same environment and you
share your microbiome and so youaccumulate methane.
And the more methane youaccumulate beyond what is a
(15:57):
normal level, then you developconstipation and that's
intestinal methanogen overgrowth.
So it used to be lumped in SIBO.
But we realized that themethanogens are elevated in
stool and the small intestine.
And we do have a large abstractthat we're presenting at DDW
which describes everywheremethanogens grow, their
(16:18):
proportions and who they are.
But it all boils down mostly toone single organism
methanobrevibacter smithii.
So I want to pause therebecause you know, in all the 15
to 20 years of microbiomeresearch, do you both know of a
single name, of a singleorganism causing a disease in
(16:40):
all this 20 years of microbiomeresearch, because I don't, I
don't know a c diff, but thatpredates all of that.
But I've told you on this callthat E, coli, k12 and Klebsiella
pneumoniae are causing SIBO.
I'm telling you that we'vediscovered that
Methanobrevibacter smithii iscausing constipation and that
(17:01):
Fusobacterium andDecephalovibrio are causing the
diarrhea of hydrogen sulfide.
So our group has nailed downsingle organisms to single
disease in a number of areas,which is really exciting for the
patients and your listeners,because this gives us now the
nail for our hammer.
(17:22):
You can't just treat SIBOcoliforms, you have to treat the
nail and now that it's becomeso clear it's a specific nail,
we can figure out treatments forthe specific nail and we are
and we are already way into that, which is really exciting.
Megan Riehl (17:38):
You know, the reality is, even if I did know
it, I wouldn't be able topronounce it.
So thank goodness that you'reable to do that for us, because
even if I knew it, I wouldn't.
Mark Pimentel (17:49):
I didn't want to put you on the spot and wait for
an answer because there's somany wacky names.
Megan Riehl (17:55):
Well, thank you.
Mark Pimentel (17:58):
There hasn't been anything that's caught the
media's attention as a smokinggun, and now we have three
smoking guns.
So it's pretty exciting timesfor IBS-D, IBS-C, functional
disorders or DGBIs, becausewe're starting to sort out some
of these relationships betweenthe gut microbiome and how
they're going to.
Some of them produce serotonin,they affect the brain and sort
(18:21):
of unlocking the secrets of howthere's this mystery of how
everything worked.
The Pandora's box is opening.
Kate Scarlata (18:29):
It's really remarkable because I was
diagnosed with SIBO in 2003.
And it was like no one wastalking about it.
I mean, I had to educate mygastroenterologist to treat me
and just to see how this I meanreally your lab doing all of
this nitty gritty work into themicrobiome to you know, as you
(18:52):
say, find that nail so that wecan have targeted treatments,
instead of giving these fullspectrumspectrum antibiotics,
because we know the gutmicrobiome and the microbes
there for the most part arereally important and we're
really not treating.
You don't want to disseminatethese organisms, do we with
targeted treatments, or do wewant to just reduce them?
(19:13):
Like, what is the goal herewith treatment, when you're
thinking about treatments ahead?
Mark Pimentel (19:20):
Well, the program I run here is now determined
and far along that path, which Ican't tell you where we are
exactly, but we already havemolecules, let's put it that way
that are the hammers.
But our goal is to develop adrug for a bug, not a drug for
you a drug for that specific bug, and leave everything else
(19:40):
alone as much as possible.
And so our mission now is to bevery specific to the bug, but
it's not necessarily to kill it.
Not an antibiotic, just reduceit and get it back to the normal
level, because we really don'twant to wreck everything and we
don't want to use a wreckingball to treat the patient.
(20:01):
We want to use boutiquetherapies, and I think we've got
some and we just have to marchit along and get the right data
and make sure it's done properly.
Kate Scarlata (20:11):
Important.
So you've talked a little bitabout the microbes that are
there, a lot a bit about themicrobes that are there and
their impact on symptoms.
Are there certain microbes likejust to drill it down a little
bit more for our listeners thatcreate certain symptoms or
symptom severity?
Mark Pimentel (20:32):
I know methane is constipation but beyond, like
some of the other smallmicrobiome- In terms of what
we've been discussing methanethe higher it gets, the more
constipated a person is, and Ihave patients where you know
normally methane will beelevated, about 40 or 50, who
are 200 for methane and they'reabsolutely miserable people
(20:52):
because they're so bloated.
They talk about IBS-D being alow quality of life.
I can tell you it's much lower.
On the constipation side, Ifyou never have a bowel movement
properly, you never feel relief.
At least with the diarrheapatients, when they have the
purge they feel some relief fora period of time, but the
methane people never feel reliefand methane is more stubborn
(21:14):
and requires a better treatment.
The new kid on the block, thehydrogen sulfide as part of the
three gas breath test that'samazing what we're learning and
we're continuing to learn, andyou'll see at DDW some more data
and another couple of papersthat are coming out in the next
four or five months.
It's a direct line betweenhydrogen sulfide and diarrhea.
(21:35):
It's a direct line.
So the lower we can get that,the better.
The diarrhea IBS patients orthe diarrhea SIBO patients, if
you want to call them that, aregoing to be.
So it's pretty incredible nowthat we've unlocked these things
.
We didn't have three gasesbefore, so we couldn't see this.
I don't fault people forcriticizing breath testing.
I mean my task all these years.
(21:58):
In saying that breath testingwas important is because it
looked important.
We were seeing the signals, butwe were missing pieces, and
that was the frustration amongthe scientists and among myself.
So we had to answer thequestion, we had to move to the
next level, and now we're there,so we're starting to see the
right signals.
Kate Scarlata (22:18):
It's amazing.
This is a little off grid fromthe questions that I provided to
you, dr Pimentel, but you know,with the hydrogen sulfide gas
and sulfur in your diet, do youanticipate there'll be a
nutritional intervention withthat particular condition, the
hydrogen sulfide positive SIBO?
Mark Pimentel (22:40):
with that particular condition, the
hydrogen sulfide positive SIBO.
Well, wouldn't it make yourlife more interesting if I mean
as a clinician treating patientsyou know somebody who sees
patients like yourselves is to.
You'd have a diet for thehydrogen sulfide low sulfur diet
, a diet for the methane maybelow acid, low hydrogen sources,
and then a diet for SIBO maybeit's low FODMAP or low
(23:02):
fermentation, and so it isn't,you know, one big sledgehammer.
It's actually moresophisticated than that and
maybe better.
Those have not been developed,but it's not.
I mean, I can think about italready, what it might look like
, the construct might look like,and I think that will help
patients in the long run betterthan just one size fits all kind
(23:26):
of treatment.
Kate Scarlata (23:27):
Absolutely so.
Your group did an artificialsweetener study looking at its
impact on the small intestinalmicrobiome.
Can you share what you learned?
Mark Pimentel (23:40):
I can share it in sort of broad swaths.
But what we see is thatartificial sweetener ingestion
does change the microbiomemarkedly, especially the sugars
not aspartame I'll speak aboutaspartame in a minute.
But the artificial sugars, thesorbitol, the alcohol sugars,
(24:00):
sucralose and all of those had adramatic impact, as we would
have expected.
That because they're notabsorbed they're sugars the
bacteria can metabolize them andso you're selecting bacteria
that are not typically seen inhigher abundance because they
like to digest that sugar.
The question is how does thataffect health?
And our sample size wasn'tlarge enough to say, okay, well,
(24:22):
we have a thousand people onsucralose and they have a
detrimental health effect.
But now going to aspartame, itdidn't have that effect.
You didn't have a big change inthe microbiome.
But you know there was a studythat said there might be liver
toxicity from aspartame.
That came out recently.
We found that there was ahigher abundance of a liver
(24:45):
toxin that we saw in themetabolome.
We didn't see much changes inthe microbiome, but in the
metabolome we saw more of thisliver toxin.
So that needs furtherexploration.
So maybe that's why there issome toxicity.
So as much as I liked aspartameas a good sweetener, I have to
shake my head a little bit andsay, okay, am I doing the right
(25:06):
thing or not?
Now we have this data, we haveto rethink things.
What are we going to sweetenstuff with?
And so we all learn.
We have to learn and we have toadapt.
Kate Scarlata (25:16):
Well, I'm a big maple syrup sweetener queen over
here.
I think a little sugar is okay,a little sucrose.
IBS-C, or irritable bowelsyndrome with constipation, is a
common condition in whichpeople experience constipation
along with other belly symptomslike pain, bloating and
(25:36):
discomfort Sound familiar.
Many people with IBS-C arewilling to give up key parts of
their lives in exchange forsymptom relief.
And because the causes of IBS-Cmay differ for each person,
there is no one-size-fits-alltreatment approach.
If you're suffering from IBS-C,you may have to try a number of
(25:58):
different medications before youfind the right one for you.
So don't be okay with justfeeling okay.
If you have IBS symptoms thatcontinue to bother you, talk to
your healthcare provider to findout if your current medication
is right for you or if it's timeto try something different.
The more you know about IBS-C,the better prepared you will be
(26:20):
to speak with your doctor aboutthe right treatment option for
you.
So I wanted to talk a littlebit about medical gatekeeping or
just physicians in general thatjust don't believe in SIBO, and
how that might impact ourpatients.
Out there there's definitely acamp that just does not want to
(26:41):
see SIBO as a real diagnosis andunfortunately I've seen some of
those patients come to myoffice and really feel lost, and
I imagine you get a lot ofthese patients winding up at
your office.
So can you talk just about thatimpact on these patients out
there that are looking for care?
Mark Pimentel (27:02):
And there's various steps of physicians.
There are still physicians whowill see an IBS patient and say
look, you're not going to die,get over it, you're fine, you've
had it for 10 years.
Go do some yoga, relax.
There are still physicians whodo this or various combinations
and permutations of not takingthe patient seriously and saying
(27:24):
get on with your life, which Ithink is undereducated by an
extreme amount.
The next step are the skepticsof breath testing, because I
don't blame them for beingskeptical.
Until 2022, which I justdescribed to you we didn't have
the best validation of breathtesting.
We had a lot of data and a lotof signal and strong studies
(27:47):
that suggest it was important.
But if you're going to be askeptic in the minority, you
could say we didn't have thesequencing versus symptoms,
versus breath test validation,and we didn't have the three
gases.
We didn't have all that.
Well, we have all of that now,and so now it's a matter of
educating those I hope, minoritygroups of physicians who are
still stubbornly thinking thisis a fad rather than a fact.
(28:12):
But you know, sometimes withbreath testing and SIBO and you
see it because you see it onsocial media there is a tendency
to embellish it in a fadfashion Everything is SIBO,
everything is SIBO, everythingis SIBO.
I can tell you, in my officewhen I see a SIBO patient,
nothing is SIBO till I'm sure.
And I've undone that diagnosisin a number of patients where I
(28:35):
found some other explanation.
When they come to my office Isay I'm assuming you don't have
SIBO and I'm going to see what?
Because nothing, they haven'tresponded, they haven't done,
they haven't responded in thetypical way, and so I sort of
undo that diagnosis in someinstances.
So there's the doctors who arestubborn and maybe that's
(28:56):
undereducated.
And then there are doctors whoovercall SIBO, because they are
undereducated as well, becausethey just want to call
everything a nail, and so we getboth ends of that.
Kate Scarlata (29:07):
Yeah, I absolutely see that too.
You know it worries me whenpatients are just chronically
treated with antibiotics andreally not getting to maybe
something else going on.
We definitely see that.
Mark Pimentel (29:19):
I had a patient as an example where she was
treated with rifaximin, forexample, for four or five times,
no benefit.
We finally were able to do thethree gas breath test.
She had hydrogen sulfide.
We gave her rifaximin andbismuth.
The hydrogen sulfide went away,her diarrhea, which was like
eight times a day, totally goneand it hasn't come back.
It's been a year and a half.
(29:39):
But that's an example of a SIBOundereducated, under-evaluated,
because this is all new data.
And then there are otherexamples where it turns out to
be cancer or it turns out to bebe something else and the doctor
is barking up the wrong treebecause it's the simplest
explanation you know.
Kate Scarlata (29:56):
No, I love it.
I always tell people if plan Aisn't working, same for a low
FODMAP diet or you know,whatever treatment modality
they're doing like we need tocome up with plan B, C and D.
There's so many options and whyare we doing the same thing
that's not working?
Megan Riehl (30:16):
And oftentimes it's anxiety, it's the fear that,
well, maybe it is working.
You know, maybe I did get 10%relief from that antibiotic, so
I want to do it again because Ithink I may be and it really
takes the confidence of thephysician to, you know, say
let's look at other things,let's involve maybe some other
team members and we have otherstones that we can overturn here
(30:38):
.
Mark Pimentel (30:39):
But that's again education, and when a physician
or a health professional iseducated properly, they can take
command of the situation.
They don't have that confidenceas you described, Megan.
They can't confidently make thepatient feel confident that
they know what they're doing andtherefore they start exploring
the internet on their own tocome up with answers.
(31:01):
And so confidence comes.
Grow that education and thatsome of our listeners may change
some of their practices inmedicine, based on your
expertise and us having theopportunity to talk.
Kate Scarlata (31:25):
I know I agree with that.
I agree with that.
I just want to back up a littlebit because you did mention the
bismuth with the rifaximin.
Do you want to just talk alittle bit about what you have
found in your practice to beworking for some of these
hydrogen sulfide cases?
Mark Pimentel (31:40):
Yeah, so for hydrogen sulfide, we have a
randomized controlled trialwhich we haven't publicized yet.
It hasn't come out for some newproducts that we're working on,
but as it stands now andremember I talked about and said
things about peppermint andother products we need
controlled trials.
So what I'm going to tell youtoday is not a controlled study.
It's based on historical datathat suggests that bismuth
(32:02):
really reduces hydrogen sulfidein the gut, and so we have
adopted that based on studiesfrom the 90s, adding it to
rifaximin because you got to getrid of the hydrogen.
We know it works there forrifaximin and bismuth, reducing
the hydrogen sulfide, thengetting both of those together
because you need hydrogen tomake hydrogen sulfide, so that
your audience understands thatit seems to work very well in
(32:26):
our practice.
But this is not based on arandomized control trial yet,
but you'll see data coming,hopefully this year.
Kate Scarlata (32:34):
Awesome.
So let me review a few keypoints from today's episode, and
I'm definitely going to have DrPimentel weigh in, make sure I
got most of them.
So we understand that SIBOpresents very similarly to IBS,
often if it'sdiarrhea-predominant, like IBS-D
we often see that SIBOdiagnosis related to hydrogen
(32:55):
sulfide gas Intestinalmethanogen overgrowth appears to
be associated with constipation.
So you might see that in yourpatients or with yourself if you
experience IBS with aconstipation predominance
predominance.
(33:16):
We're beginning to understand alittle bit about the small
intestinal microbiome and who'sthere and what is really
impacting SIBO.
One of the things you said andI'm going to interject with you
now, Mark is the metabolome andI think you know when we talk
about the gut microbiomeinitially, when the science came
to sort of the front in theearly 2000s or so, we were all
talking about what microbes arethere and now we're really
(33:39):
shifting a little bit into thismetabolome and what they're
making and what they're doing.
So you mentioned is itaspartame?
It was really the metabolome.
Can you just talk a little bitabout the metabolome and how you
look at that in the researchsetting?
Mark Pimentel (33:53):
Well, I gave you sort of an example without using
the term metabolome, but we'reable to see in the metabolome of
SIBO, which is the topic oftoday, the immense upregulation
of the metabolic function tobreak down carbohydrates, and I
use the term 63-fold or63-horsepower engine.
And so by studying themetabolome we see that.
(34:16):
Wow, now that explains to mewhy my patients say 10 minutes
after I eat.
But there's a thing called theinteractome, which is the
metabolome, the composition ofyour microbiome, their products
and the host response to all ofthat milieu.
And so we've actually dug intothat as well.
(34:36):
Which is what we brushed acrossearlier.
Is that we actually see in thetissue that the chemistry for
gut hypersensitivity is there,the chemistry for cell-cell
interaction, to allow that quote, leakiness to the gut.
We see the serotonin signalingpathways altered, which we know
(34:57):
affects motility in a particularway.
So there's an interactionthat's occurring from a
consequence of the microbiomechanging the chemistry that they
produce and that chemistryaffecting you in that way, and
so we're able to really againtriangulating on cause and
effect pathways.
Kate Scarlata (35:17):
It's really amazing and I just you see these
stool tests just looking at youknow, really targeted to people
with IBS, with just the stoolmicrobes and it's just like such
a small window into themicrobiome and seemingly useless
when you see the complexity ofthis interaction that you just
described.
Mark Pimentel (35:37):
Well, and one other point, which is another
misunderstanding of themicrobiome.
When you think about themicrobiome of stool, the density
of microbes in stool is wayhigher than the small bowel.
But it's in a cylinder, rightfor the most part, and you only
see the outside of the cylinder.
The inside is just the microbesdoing their thing.
You don't see the metabolicstuff on the inside as much,
(35:59):
it's only what gets to theoutside.
So the surface area exposure ofthe microbiome and the colon is
quite small, even though thecontents are larger.
The small bowel is the size of atennis court, although I was
corrected on the social mediarecently but it's a large
surface area where, if you wereto, you know, put a thin layer
(36:21):
of bacterial pita butter on thatsurface which absorbs
everything or is meant to absorbthings, the impact on the human
is immense.
I mean, it's much more than thecolon.
And so we know now that thecolon microbiome is like a
different planet, it's like Marscompared to the earth, which is
(36:41):
the small bowel.
And so understanding the smallbowel is so vitally important,
because that's where things getabsorbed.
Kate Scarlata (36:48):
So important I want to just talk as sort of.
One of our main points is justthat SIBO can be anxiety
producing.
You know it's a tough diagnosis.
Having lived it myself and whata difference after being
treated.
You know like I could live mylife again.
Team, you know I think patientsare very confused about what
(37:11):
they should be eating and youknow I almost called it like
PTSD.
I'm no psychologist, megan, butwhen I had SIBO I was just like
the wary of it coming backbecause I was so sick.
I went into this like any gasbubble.
I felt like I'd be like oh,please don't be this again.
So getting a GI psychologistinvolved too, if that just
(37:33):
really escalates a little bit inthe wrong direction, I think
that team approach can be reallyhelpful for our patients.
Yeah, you're describinghypervigilance.
Megan Riehl (37:43):
You're describing GI-specific anxiety where a
gurgle sends signals up to thebrain to interpret what the heck
is going on down there and, aswe've learned with this
diagnosis, it can be like tryingto find a needle in a haystack.
So as soon as we kind of stepback and you are seated with a
practitioner, you know we'regoing to utilize different brain
(38:06):
, gut, behavioral therapies inconjunction with working with,
potentially, a dietician, agastroenterologist, a primary
care doctor, to really addressyour whole health and how this
has impacted how you eat, howyou behave, which all impacts
our gut microbiome.
But you're absolutely right,you may feel symptoms of
(38:28):
hypervigilance andhypersensitivity because of a
diagnosis like this, and we canaddress that?
Kate Scarlata (38:33):
Yeah, that's excellent.
I think too, you know we seethese food-related symptoms in
patients with bacterialovergrowth, as Dr Pimentel
mentioned.
Like 10 minutes after eating.
Well, you know, the food'sgetting into that small bowel
pretty quickly and if there's alot of different players in
there that have, to your point,upregulated ability to degrade
carbohydrates and ferment vastamounts of gas in that small
(38:56):
intestine, which is really notdesigned to accommodate all of
that gas, how uncomfortable thatwould lead you.
But on the flip side of that,getting rid of those microbes
and reducing them, thosefood-related symptoms can go
away, and so long-term dietstrategies may help prevent the
(39:18):
recurrent return of SIBO.
We don't really know that, butthere is hope that one doesn't
need to be really on this longstrict diet forever, and I think
people do get into that alittle bit.
Can you comment to that, drPimentel, about just the
necessity for everyone should beon a strict diet long-term?
Mark Pimentel (39:45):
Well, for example , in SIBO, as we've been
discussing, there are patientswhere you treat once and you
don't see them for years.
They're so mild, symptomaticenough to see the physician, but
the pathophysiology isn't thatdense that they relapse.
The motility isn't as affectedby the food poisoning.
And now going backwards in timeto what we talked about earlier
.
But there are patients where adiet which is a fairly
(40:07):
quote-unquote, benign way ofkeeping the patient from
relapsing meaning it's not adrug.
But you do get into thishypervigilance, as you both have
described.
I had a patient where she wouldhave incontinence from her
diarrhea.
She was an older woman.
We treated her SIBO.
She still wouldn't go to thegrocery store, even though
everything was normal.
(40:27):
But after some coaching andtime she was flying, she was
showing her dogs at dog shows,she was doing all the things
that she loved.
So it was amazing.
But it takes time to break thehypervigilance.
But the same thing happens withfood.
You get a fear of food and afear of things that made you
unwell before.
But I'll say one other thingwhich really gets in the weeds
(40:50):
for patients.
People think I've got bloating.
Therefore, what I ate an hourago is to blame, and in a
microbiology world.
That is not true.
The way it works is you atebeans three days ago, the beans
increase the amount of bacteriain your gut, so that today the
(41:13):
amount of bacteria in your gut,so that today the amount of
bacteria in your gut is wayhigher than it was three days
ago.
And you had pasta at the samerestaurant, which didn't bother
you last week, but today it didscratch that pasta off my list.
I can never eat it again.
And then you keep scratchingthings off the list, not
understanding how the microbiomeworks, and you scratch until
(41:40):
you're left with chicken andrice and hence ARFID or these
disorders of eating as a resultof IBS and SIBO.
If you don't have a healthpractitioner who can explain
those things to the patient,they end up restricting and
restricting and restricting.
It's not the pasta, it's themeal you ate two days ago that
made this meal bad.
That's just an example.
And so having a healthpractitioner who understands
(42:02):
diet and can counsel the patientso having a team I agree with
you both having a team isimportant.
Kate Scarlata (42:08):
Yeah, and I would just add you know bloating can
occur when there's a lot ofpsychological angst, when
someone is full of stool.
You know there are other reasonsand I think to your comment
that diet is a benignintervention, I agree it is not
a benign intervention because ofjust what you described and
that people can go down thisrabbit hole of restricting and
(42:36):
restricting, and we know thatsome of these very highly
restrictive eating disordersplace individuals at increased
mortality.
So we want to be careful withthat semantics, so to speak.
I mean, I know where you aregoing with, but diet has some
issues with it.
It can be very helpful I see ithelping patients all the time
(42:58):
but on that flip side, when youtake it to that next level, it
can be really problematic.
And I would say you know when Isay this to my patients, it's
like you need fuel for your gutmotility to work and for your
pelvic floor to workappropriately, so that efforts
to restrict the diet to help theSIBO are actually impacting gut
motility and function andthey're missing this very vital
(43:22):
point that is essential formaintaining a healthy gut.
Would you agree to that or youfeel free to disagree with me?
Mark Pimentel (43:30):
No, I mean, the extreme example of what you're
saying is anorexia.
Right, you have bloatingbecause, in part because the
muscles of the gut no longerhave any strength, so the
distension is more prominent,and then the body dysmorphism
can be more prominent, and thenyou want to restrict calories
more to see if you can get ridof that.
So that's just part of anorexia.
(43:52):
Anorexia is a much morecomplicated issue than I'm
simplifying.
The point is protein will buildthe muscle and the muscle
builds.
Then the gut works better.
It's a balance and I thinkpatients get too restricted.
But diet plays a very importantrole in all of these treatments.
But my main point was you haveto have a health professional
that understands how to do itcorrectly, to guide the patient,
(44:14):
rather than simply just anybodytelling you to do X, Y or Z
indiscriminately.
And you've seen this wheresomebody goes on a low FODMAP
diet and they've been on it fora year and a half because nobody
told them they should doanything different, and now they
have some nutritionaldeficiencies, and so you can't
just throw something at somebodyand then never see them back
(44:38):
and follow up and guide themfurther.
Kate Scarlata (44:40):
Absolutely.
I could not agree more.
You know, I see a lot of onlinesites recommending an placebo
protocol with a slurry ofsupplements and their special
diet, and we know that thiscondition really isn't one size
fits all right.
Mark Pimentel (44:57):
You mean, like with supplements, all mixed
together?
Kate Scarlata (45:00):
Yeah, if you just put SIBO protocol online, you
will be horrified with peopleout there with maybe had SIBO
themselves or have no medicalcredentials, and a lot of people
gravitate to this and they'rereally, you know, a probiotic, a
(45:20):
biofilm disruptor, specificdiets, you know, not discounting
.
I'm just not sure some of thisis science-based at this time.
Mark Pimentel (45:30):
I have to be careful because, as a scientist
and as you, from being amaverick in the beginning, I
don't discount anything.
I say there's no data.
Because there are things like,for example, berberine.
I wasn't altogether a fan ofberberine, I wasn't sure.
And then Johns Hopkins did astudy that said that a
combination of berberine.
(45:51):
I wasn't sure, and then JohnsHopkins did a study that said
that a combination of berberineand a couple of other herbal
products was as good asrifaximin.
So it's not good until youprove it and it's not bad until
you prove it.
So I think the problem is theclaims without data.
That's the problem.
So it's very important that youget data and if you want to
(46:12):
make money on it, you'll makemore money if you have data.
It's just evidence-based.
Kate Scarlata (46:18):
Finally, yeah, well, we're getting there and I
agree with you.
I totally agree with that.
There's a lot of informationout there that may prove to be
the best treatment ever for SIBO, but even with low FODMAP
there's no evidence that the lowFODMAP diet helps SIBO.
We find that it helps managesymptoms in patients clinically,
but I can't and will not evertell a patient that this is the
(46:41):
one-all, be-all diet protocolfor SIBO.
It's just symptoms overlap withIBS.
That's what we have, and it mayhelp to reduce FODMAPs, you
know?
Okay, Megan.
Megan Riehl (46:58):
So, outside of lighting up Cedars-Sinai and LA
with this microbiome gut healthdisrupting work that you're
doing you've cited so manypapers that I can't wait to sink
into and share the wealth ofinformation that comes with that
.
You've got to have time forself-care, I hope as well, and
so we like to ask all of ouresteemed guests what's something
(47:20):
that you do for your own healthand well-being, that's, you
know, sustainable over the longterm.
Mark Pimentel (47:28):
Well, you have to be a role model for your
patients in a lot of ways, and Ithink eating healthy I mean
these aren't hobbies.
Eating healthy, exercisingfrequently, which I do are not
hobbies but just lifestylechoices that I make.
But I play blues guitar.
Maybe it's something nobodyknows, or I try to.
Let's call it that it's amidlife crisis.
(47:48):
I didn't get a Ferrari, I got aguitar and I counsel everybody
who's out there get the Ferrariinstead of the guitar.
It's less worth it because it'sbeen a 10-year-plus journey of
trying to learn the guitar andit never ends what you can learn
and it never ends that you feelconfident in what you're doing.
But that's okay.
That's my life journey.
Megan Riehl (48:11):
It's lighting up a totally different side of your
brain.
So I love that for you and Ithink that it is inspiring to
kind of take something thatyou're clearly very good at what
you do in your profession.
So a little challenge by theguitar is probably a good thing
for you.
Mark Pimentel (48:28):
Yes, sometimes it overwhelms the brain because I
use the right side of my brainas a fatigue reliever and when I
fatigue both sides, I'm prettytired when I go to bed.
Megan Riehl (48:37):
Yeah, you'll sleep better.
You'll sleep better, exactly.
Kate Scarlata (48:40):
It's all positive , it's all positive.
Mark Pimentel (48:42):
It's all positive yeah.
Megan Riehl (48:43):
So we have worked with so many patients who have
been diagnosed with SIBO.
Typically, they're prescribedthe antibiotic and hope for the
best and onward they go.
And this is why this diagnosisreally highlights the importance
of remembering that everybody'sgut microbiome is different.
We have to tailor theirtreatment plan, individualizing
(49:06):
it for them, and it certainlygives a shout out to the dream
team approach of dietician and,you know, it certainly gives a
shout out to the dream teamapproach of dietitian,
psychologist and physician ormedical provider.
So we just want to say thankyou for the work that you're
doing, also for all thelisteners out there.
We do touch on SIBO in our bookMind Your Gut, so certainly
(49:28):
something to check out andconsider when you're thinking
about holistic ways to approachyour gut health.
So, Kate, what do we expect inour next ?
Kate Scarlata (49:37):
Yes so we are talking all about bloating with
Dr Brian Lacy.
He is a neurogastroenterologistat the Mayo Clinic in
Jacksonville, Florida.
He is the pastco-editor-in-chief of the
American Journal ofGastroenterology.
We're definitely in for a treatbecause he is a fantastic
provider and just a kind, gentlesoul, and it'll be really
(50:02):
interesting to hear his take onbloating.
He's one of the, I would say,world experts in this area.
Megan Riehl (50:08):
All right, we're lucky, we're excited for what's
to come, and you guys all knowthe drill at this point.
So make sure you subscribe,follow and like The Gut Health
Podcast.
Tell your friends, yourpatients, your loved ones, all
about us.
Know that gut health mattersfor everyone and your support
means the world.
Our friends have a great day,thanks again Mark.
Mark Pimentel (50:32):
Thank you, take care.
Megan Riehl (50:35):
Thank you for joining us as we grow this gut
health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media at T he Gut Health
Podcast, where we'd love for youto share your thoughts,
questions and experiences.
Thanks for tuning in, friends.
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