Dr. Sandeep Gupta is joined by integrative gastroenterologist Dr. Farshid Sam Rahbar, to discuss the relationship between SIBO, leaky gut and and Mold Illness/Chronic Inflammatory Response Syndrome (CIRS).
0:00:00 – INTRODUCTION
0:03:46 – Dr. Sandeep Gutpa
0:05:37 – Dr. Farshid Rahbar
0:08:30 – What is Chronic Inflammatory Response Syndrome (CIRS)
0:11:30 – What is SIBO & Leaky Gut?
:21:45 – SIBO & Leaky Gut – Symptoms & Conditions
0:24:30 – SIBO & Leaky Gut – Testing
0:33:02 – SIBO & Leaky Gut – Why so common in CIRS?
0:43:35 – SIBO & Leaky Gut – Nasal Infection Connection (MARCoNS)
0:46:28 – SIBO – Treatments
0:53:50 – Leaky Gut – Treatments
1:01:21 – SIBO & Leaky Gut – More Treatments
1:04:00 – Mold Illness Made Simple
——————Q&A———————
1:09:00 – How to diagnose food allergies/sensitivities (IgE/IgG/IgG4)
1:11:08 – Cholestyramine and the gut
1:12:06 – Motility/Neti pot for MARCoNS
1:13:13 – Long term binder use and the gut
1:13:44 – Heavy meals, SIBO, Leaky gut and CIRS
1:14:33 – Why BEG spray has been replaced by EDTA/silver
1:16:26 – Closing
TESTING
REFERENCES
Introduction
Dr. Gupta
Welcome everyone to this webinar on SIBO, Leaky Gut, and mold illness. I’m very excited to have Dr. Farshid Rahbar here, who is an integrative gastroenterologist from Los Angeles, joining me on this call. How are you today, Dr. Rahbar?
Dr. Rahbar
Feeling nearly perfect, thank you very much.
Dr. Gupta
Awesome. I’m actually really excited about talking about this subject with you and just really tap into some of the specialized knowledge you have on this subject. It seems to be such a fascinating field that’s evolving all the time, this area of leaky gut and SIBO and inflammatory illnesses. Do you find that this is such an interesting area overall?
Dr. Rahbar
I find it quite fascinating as far as understanding the commonality of the illness, understanding the mechanisms behind it, and the association with a lot of other unexplained inflammatory conditions that we never thought about it this way. I feel that I’ve relearned medicine again in the last ten years. It’s like going back to medical school, trying to pick everything again from the beginning.
Dr. Gupta
That’s right. And we were never taught any of this in medical school, it’s really seems to be coming out in the more recent research. For someone like myself who has been dealing with hundreds of patients who have got chronic inflammatory response syndrome (CIRS) due to water damaged buildings, or due to tick bites or other illnesses, I’ve often found that gut complaints can be a really big part of their illness and it can be a very inconvenient part of their illness as well because the symptoms are very debilitating. It can affect every part of their life. It’s really good to know that there are some new solutions and new treatments available that may be able to help these patients.
Dr. Rahbar
Absolutely. I think it’s really a good place to start. Patients are probably more receptive to that concept, and in our practise at LA Gastroenterology, many patients do come with GI problems primarily. The manifestations are primarily GI, and then I had to go back and think about mold and tick borne illnesses and stealth infections and so forth. We have to think about it, they don’t always come with CIRS.
Dr. Gupta
Have you found some patients where, it’s almost just gut-related and a manifestation of exposure to water-damaged buildings, for instance?
Dr. Rahbar
No, I wouldn’t say, just gut. When we do a review of systems generally, there are other system involvements, and it really points toward which direction we need to go with the evaluation.
Dr. Gupta
Well, let’s jump into this a bit further, and I really look forward to the different bits of information and new insights that are going to come out. Thank you.
To get the most out of this webinar, we really recommend giving your full attention if you can, and so if it’s possible, please be with us totally here and close any other browser windows and if you would like to please get some notepaper out and make some notes, because there may be some different treatments you may like to explore or some different avenues of thinking that you may like to explore further in the future. Thank you.
0:03:46 – Dr. Sandeep Gupta
Okay, so most of you probably know me really well already, but just a very quick introduction. I’m a physician in Australia. I graduated from the University of Queensland, which is in the northeast part of Australia. My initial background was working in intensive care units for around about five years. I had a brush with illness myself in around 2005, 2006, and that led me to start exploring this totally new and amazing world of integrated medicine, that led me to switch my career into holistic medicine. Now I have a private holistic practice on the Sunshine Coast in Australia and I also practise in Sydney.
I got interested in mold-related illnesses around 2012 when my then-partner was suffering, after our house flooded on the sunshine coast, and I could not understand what the reason was that she was suffering from this multi-system illness when she’s only been exposed to seemingly innocuous mold. However, I was able to seek out Dr. Ritchie Shoemaker and his colleagues, and do the physician training, and came to understand that there is actually a well-documented, scientifically documented, physiology, whereby water-damaged buildings can really affect a person, and turn them from someone who was relatively well to someone who is very unwell.
I was lucky enough to be part of the physician’s consensus statement with doctors Ackerley, Berndtson, Rapaport, McMahon, and Dr. Shoemaker himself. There’s my website there at the bottom of this slide if you’d like to check me out and sign up to the newsletter.
0:05:37 – Dr. Farshid Rahbar
Dr. Rahbar, would you like to introduce yourself a little bit and your background, and how you got into this integrative view of gastroenterology?
Dr. Rahbar
I’ve practised since 1986, originally with a more traditional model of gastroenterology. Like many other functional practitioners, there was some sort of incident that caused one to think about why we would need to go into integrative or functional model. I had my beloved suffering from orthostatic hypertension and some other nutrition deficiencies that they were unexplained. I could not find a simple answer in the traditional model and we started to explore. After that, I felt I was becoming a conference junkie, going from one place to another, and felt that it was probably best to see if we can integrate the models from the east and the west because I can’t give up what I learned for many years. We now have more tools in our hands when dealing with different levels of illness with the patients.
Dr. Gupta
Great, and it’s interesting to see that you’re actually a board member and educational committee member for ILADS. For those who don’t know, ILADS is the International Lyme and Associated Diseases Society, and they have a real interest in Lyme-like illnesses and co-infections. Has that been quite a big part of your practice as well, Dr. Rahbar, for the last few years?
Dr. Rahbar
Yes, I just want to make one correction. I was on the board until November of 2017, so my period is finished. I have other roles now. I just wanted to make that clear.
But we fortuitously got into understanding tick-borne illness or vector-borne illness. I don’t want you to use just tick because it’s not just one infection. Many patients with susceptible HLA [genes found in CIRS] background, they harbour multiple infections. That opened up a completely new area of understanding for us. It gave another level of chronic inflammatory response syndrome, if you will, that it may be mitigated by infections, not just biological toxins that one may encounter from the mold. We also realize that the two actually quite commonly co-exist, and one may trigger another one. We can talk about that more as we go through it.
0:08:30 – What is Chronic Inflammatory Response Syndrome (CIRS)
Dr. Gupta
Okay, great. So we’re just going to spend a moment revising chronic inflammatory response syndrome, if that’s okay with you, Dr. Rahbar, just really get it straight in people’s head. What is C-I-R-S, or CIRS, and how does it actually lead to this multi-system condition, which we call CIRS. As for Dr. Shoemaker’s research and understanding, really what he described is that certain genetically-susceptible individuals, there may be around 25% of the population, when exposed to biotoxins and inflammagens from water-damaged buildings or tick bites or other sources or stealth infections or even infected bodies of water or infected reef fish, which is fairly rare. What happens is instead of creating a proper immune response or a proper antibody response, they develop a chronic and inefficient inflammatory response. That leads to gene dysregulation and brain changes. So, Dr. Ackerley likes to call it the brain on fire, which I think is an excellent term, and really the body is on fire, the whole body is on fire, not just the brain. What that means is that there’s a silent fire going on in the body of inflammation.
Inflammation means that certain compounds that are elevated are causing damage to different tissues of the body, and therefor one feels unwell. When one has CIRS, you generally don’t just feel unwell in one department. For instance, as you said, Dr. Rahbar, you don’t just get abdominal pains or bloating – even though the patient may come in just saying, “My problem is abdominal pains and bloating.” If you go deeper, you’ll probably find that they’ve actually got anxiety. They’ve got headaches. They’ve got fatigue. They’ve got insomnia. They’ve got muscle pains. So, it’s actually not a localized syndrome, it’s the whole body.
Sometimes this syndrome can even continue when the exposure to the original trigger, such as a water-damaged building, has been removed. That inflammatory response can still be there and it needs specific treatments to bring that inflammatory response back to normal.
0:11:30 – What is SIBO & Leaky Gut?
Now jumping more to your area, it seems like just over the last maybe 10 years, the interest in SIBO, which stands for small intestinal bacterial overgrowth, and leaky gut, which is this concept of an inflamed gut – that is letting in foreign proteins into the bloodstream – has become more and more studied and there’s been a lot more interest in it. Could you talk a little bit about those conditions, and also small intestinal fungal overgrowth (SIFO) and what you understand them to mean and why you think they are a big problem?
Dr. Rahbar
Well, let’s just start with a very basic concept that the small intestine, it’s really sterile. The load of bacteria in the proximal small bowel is very low, perhaps one to the power of three, and that’s basically a thousand. However, studies now show that if that number goes higher, then this number of bacteria in the proximal small bowel will interfere with the proper gut function and it will add to symptoms that may sound like malabsorption and micro-nutrient deficiencies and so forth.
Now, as we learned that this alteration of the small bowel microbiome – in simple words you can call it dysbiosis. It may be bacterial, it may be fungal, it may be both. There’s no reason to just believe that only one may exist and physicians should be on the lookout, or watch, for other manifestations as well. Traditionally SIBO is attributed to a post infectious type of phenomenon where, after a component of food poisoning, a person may develop the antibodies to vinculin and to CdtB (cytotoxin distending antibody B). This was well described by Mark Pimentel’s research and published at CS not too long ago. And there’s commercially available tests now, which test for anti-vinculin antibody and anti-CdtB antibody.
However, a number of patients do not necessarily have these antibodies. They still have SIBO, and they may or may not have a fungal element in addition to that. I’d like to talk about that, because it’s not so easy to make an assessment of fungal overgrowth in the small bowel. One may be able to look at organic acids in the urine, look for fungal growth in the stool, but eventually it comes to understanding the clinical fixture and the response to the therapeutic trial that take place. I think the mindset to be that these things could co-exist, with or without presence of parasites, if there was a constant exposure to contaminated food or water sources. There are so many factors that can modify, this cleanliness, or the sterility of the small bowel.
Dr. Gupta In other words, sometimes it’s more of a classic presentation of SIBO and sometimes it’s not so classic. The classic ones would generally have the anti-vinculin antibodies, is that correct?
Dr. Rahbar
That is right. To elaborate a little bit more on the SIBO. Obviously we have hydrogen predominant, and methane predominant, and then the combination of both.
The term leaky gut, was something that was not previously regularly used by physicians. I’m seeing it more and more, even in the classical journals, and I don’t think that one should think is taboo.
It really is a simple way of saying increased intestinal permeability. Permeability measurements at the level of the science and physiologic testing is done by highly sophisticated instruments on the tissue level where they measure the TEER, which stands for trans epithelial electrical resistance. However, that test is not readily available, so we use a variety of indirect, or crude, ways to measure leaky gut.
It is not something that we can easily see at the microscopic level, so we need to look at the functionality. Traditionally the lactulose/mannitol (urine) test has been used, and if it’s abnormal, it generally suggests that there’s a major leak going on. You can have a normal lactulose/mannitol test and then still have a general concept of the leaky gut that’s going on for a person. Many of these patients present with food sensitivities, and a variety of those symptoms that they’ll describe in CIRS – a classical presentation. Many patients they may come with a skin sensitivity, a rash that is unexplained. Part of our practice has now become sometimes seeing patients with chronic inflamed skin problems that they don’t really have a name and not clear on what to do with it.
In these type of patients, gut dysbiosis, is very common. It contributes to the damage to the surface lining of the gut, what we call “leaky gut”. But to be able to understand this a bit better and the mechanisms behind it, we need to know what happens.
It generally has been described as a problem with transport through the cells, the enterocytes, are the cells that the gut is covered in. As you know the intestines are just covered by one layer of cells, it’s not like the skin, which has hundreds of layers to protect it. The gut inside is extremely vulnerable; there’s only one layer protecting us from the outside world.
Another possibility would be that the junction between the cells could be affected and those proteins that they hold tight, they may be affected by the infection next to it, or some other mechanism, heavy metal, or toxicity of other types. Another one, which actually was presented just a few years ago in GI literature, that promises to be very fascinating by the group from Canada; they did microscopic studies using an endoscope and they counted the number of holes in the gut. This is what they call extrusion or drop out of the cells. The reality is that intestinal cells are constantly in a stage of turnover, probably every 15 to 20 minutes, they get replaced (in animal models). So, the human surface of the gut may be replaced maybe every five to seven days. One needs an extreme number of stem cells to be able to constantly be able to recreate these cells when they get to the surface and repair the surface.
If that repair process is slowed down for any reason; inflammation, malnutrition, then we will have more holes in the gut, not just issues with the tight junctions, but we’ll have more holes. Those substances (that get past the holes) are detected by the immune system, and you’re going to have a variety of inflammatory conditions detected. I think the TGF-beta, which is pictured in one of the upcoming slides very nicely, basically modulates the inflammation behind the surface of the gut.
Dr. Gupta To summarise, would you say a simple way of understanding leaky gut for just a layperson, might be to say: the concept is that the gut is not keeping away the foreign invaders that It should, or not keeping out the foreign proteins that it should.
Dr. Rahbar Yeah, that’s a simple way, or we can say that it has lost its ability to pick and choose.
Dr. Gupta Oh, that’s good. I like that.
Dr. Rahbar I want to bring this one in, but you got to stay outside. The selection process has been affected in leaky gut. What we understand is a dropout, tight junctions, or damage to the enterocyte itself, may be positive.
Dr. Gupta Just to reiterate on SIBO, you could really simply understand that as being too many bacteria where they shouldn’t be.
Dr. Rahbar That’s right.
Dr. Gupta In a sense, most bacteria should be in the large bowel. It’s not normal to have a lot of bacteria at the end of the small bowel and therefor, part of the problem if I understand correctly, is that the motility of the intestines, meaning the contraction of the intestines, may be part of the problem. Is that correct?
Dr. Rahbar
Right, and I think that maybe one of the mechanisms. Just for the audience, in the upper intestines the number of bacteria is 103 but as you get to the colon, it’s 1013. So there is an exponential increase, but this is step-wise. As we go further down into the gut, the number goes up and obviously, if there’s a backup of that system, one will have SIBO by definition.
0:21:45 – SIBO & Leaky Gut – Symptoms & Conditions
Dr. Gupta
Talking a little bit more now about the risk factors and some of the symptoms that go along with these conditions, would you like to talk about those areas a little bit, Dr. Rahbar?
Dr. Rahbar
What we see commonly in the practice, and I think your slide demonstrates common symptoms and how they may be related to the SIBO. Without trying to go to that extent, generally, patients come with abdominal pain, cramping, altered bowel habits and particularly bloating and flatulence. Generally speaking, it’s a sign of fermentation and it’s very, very important to be able to recognise that flatulence and bloating, is not normal, and it’s an excessive amount of bacterial fungi present dealing or interacting with food substrates and producing this phenomenon. I think the take home message should be those particular symptoms should not be taken lightly.
Dr. Gupta
So in a sense, these gases are being produced by the bacteria or the fungi, fermenting, mainly carbohydrates. Is that correct?
Dr. Rahbar Carbohydrates would be the prime target, yes.
Dr. Gupta
And that causes gas, and a lot of the symptoms seem to be caused by the fact that the gas then distends the intestines. Is that right?
Dr. Rahbar
The symptoms, maybe be caused by distention or by the immune provocation as a consequence of leaky gut and so-forth. You asked about motility, just to make a quick comment. One of the causes of this SIBO is basically loss of what they call, “ICC cells,” or Interstitial Cells of Cajal, and pathologists would describe this from over 100-years-ago. These cells are part of our physiological and anatomical presence, if you will.
During this autoimmune response, they get damaged and we lose these ICC cells. It’s not completely clear if they actually come back, but the more of those we lose, the more issues we have with intestine motility and keeping the gut clean.
0:24:30 – SIBO & Leaky Gut – Testing
Dr. Gupta
You’ve talked a little bit already about some of the testing modalities for SIBO and leaky gut. Would you mind just elaborating a little bit about the breath testing in particular, and how that can be beneficial in diagnosing SIBO?
Dr. Rahbar
Well, breath testing for SIBO uses the concept of the fermentation using a substrate, in this case sugar. The majority of the times, physicians use lactulose because it has the ability to reach lower-down into the small intestine and colon, and be able to pick up the fermentation process further down.
If the test is negative, and generally I would say if there’s SIBO, the test has a sensitivity of about 80-90%, sometimes physicians use glucose as a substrate. Glucose because it gets absorbed, it is mainly good for looking at SIBO in the upper parts of the intestines. So if I suspect the SIBO may be more proximal and I might have missed it by doing a lactulose test, glucose could be an alternative.
We have tried that for some patients. I have not found it to be very helpful as an extra measure but again, the tool is available. Some people even go further to do a fructose test because some bacteria may be more prone to using fructose as a fermentation substrate.
Dr. Gupta So in the majority of people, you just recommend doing the lactulose breath test, then?
Dr. Rahbar
Yes, lactulose should be really, the first step to do it. It’s not absorbable, and will have less chance of challenging the patient, as well. Glucose, if the patient has a fungal element, I would be concerned that it could set off fungus-related symptoms by just doing the test. So, if we highly suspect that, I definitely would not use a glucose test.
Dr. Gupta
Great. Thank you for that tip. In general, you’re saying it has a sensitivity of around 80% so if someone still feels that they may have SIBO, for instance, they’re getting a lot of gas and bloating in someone but their lactulose test is not clearly positive, what would you suggest they do in those cases if further investigation seems warranted?
Dr. Rahbar
I will say 80% to 90% going by the literature. It may vary on that, but when you look at the breath test results, either the test is clearly normal or is clearly abnormal. Then you have these patients who fall between, and in our previous presentation at one of the conferences, we put guidelines on how one may be able to still doing interpretation when it doesn’t meet classical criteria.
And when I say, “Classical criteria,” I’m referring to the criteria that was established by the Consensus Conference back in 2016 . Again, this was the experience of people from all over the world giving their opinion and I can assure you, in the back room I knew that there’s were some differences in opinion if you talk to each physician separately.
So, one has to use some clinical judgement in this scenario. If I highly suspect it, I may want to treat it. If I see growth of yeast in the stool, then I would speculate maybe the yeast is a player. If the organic acids test shows some yeast products in the urine, again, I may speculate that their yeast may be a player, or I may change my treatment protocol.
Dr. Gupta Moving onto the testing for leaky gut or intestinal hyperpermeability, I think you mentioned that the lactulose/mannitol urine test is still considered to be the gold standard. Would you like to just maybe take us through how that test works?
Dr. Rahbar
Lactulose is built to go mainly in-between the gut cells, and the mannitol goes more through the cells, so if you find an imbalance there, you can make an interpretation. For example, if mannitol is not going through the cells, there may be a problem with the enterocytes.
If the lactulose goes heavily in-between the cells and you find a high amount in the urine, then you have a ratio that would be consistent with leaky gut.
The example that you have here: You can see the lactulose recovery is high and the mannitol recovery is low. So, the ratio looks terribly abnormal, and then after the treatment, you can see that the lactulose is reduced and the mannitol is improved, but the ratio is corrected into the normal range.
Dr. Gupta
Would you say it’s not normal for lactulose to appear in the urine? Is that correct because it shouldn’t really be absorbed at all while it is normal to have a lot of mannitol in the urine. What’s happened in this case is the person has absorbed a lot of lactulose where they shouldn’t, and they haven’t absorbed a lot of mannitol when they should. So, it’s showing the fact that the gut is not doing the right thing.
Dr. Rahbar
Exactly. That simply means there’s a problem with the cells (enterocytes) and the (tight) junctions, both of them.
Dr. Gupta
Great. Thank you for explaining that. Do you find that testing, such as antibody panels and zonulin or occludin, helpful in these conditions, in general?
Dr. Rahbar
I do. Again, when we talked about indirect way of measuring it as opposed to doing a TEER, we use the Cyrex Array 2, which is an antibody to occlude the zonulin and the LPS, lipopolysaccharides. I use it as an indirect way to say that the pores are open, if you will. I think it may be reasonable to do it because it’s much easier than trying to do it a lactulose/mannitol mouth or urine test.
Dr. Gupta
I think that may not be available to overseas patients at this point. It may just be available to United States as far as I’m aware. But in other countries, for instance, there could be tests such as secretory IgA and food intolerance panels, IgG Panels, and so on. Do you find that they can be of some benefit?
Dr. Rahbar 100%. Absolutely. We use this cell-mediated reaction, we use the IgG model, which is generally not covered in US by many of the carriers, but I still find it very valuable to give us an overall idea if we’re dealing with increased intestinal permeability.
Dr. Gupta There is a range of indirect tests, then, that can indicate leaky gut rather than just using the intestinal permeability test it sounds like. That’s really-really important information for our viewers.
0:33:02 – SIBO & Leaky Gut – Why so common in CIRS?
Just changing gears a little bit now. You and I have both seen patients who have mold or Lyme related CIRS who have a lot of gut problems. It’s interesting to reflect on why SIBO and leaky gut and related conditions are so common in CIRS. Would you mind talking a little bit about that and sharing your thoughts?
Dr. Rahbar
Absolutely. I will share our observation and then we can relate to these slides as well so we can correlate it because this type of discussion, obviously, is in none of the classical textbooks.
First of all, we have seen high level of association with an abnormal nasal microbiome. Even as a GI physician, we have started to culture the nose and we have seen a variety of bacteria, and sometime fungi, that I don’t believe it should be in the nasal microbiome. For example, why would Enterococcus or E.coli be seen in nasal cultures if those belong to the gut environment? That generally suggests exposure to an environment that these type of bacteria may be polarised in the air or the nasal cavity might have lost some of its ability to keep the environment clean and perhaps there’s abnormal mucus that may be promoting this type of phenomenon.
Among those patients, we saw a good number of patients having the MARCoNS. I’m sure that the audience is familiar with this term, multiple antibiotic resistant coagulase negative Staph, and from the little knowledge that I have and I’ve learned through our colleagues, the markers are commonly associated with reduced MSH, melanocyte stimulating hormone. Somehow the bugs communicate with the brain and this MSH drops. This particular hormone has significant effect in immune system balancing of the gut. So, hypothetically, that may be a mechanism by which the gut doesn’t have the integrity that it should have to keep itself clean or to reduce the inflammatory response to the antigens, so they permeate through the gut.
I think it, beyond that, if you have a leaky gut, then you have high TGF-beta, that may be dysregulated and now you have created the cascade of an inflammatory process. In our practice to be able to help patients, we feel that the nose microbiome has to be changed. Is there an anatomical abnormality? Sinus deviation? That generally requires a formal ENT consultation, particularly for symptomatic patients. Even though the symptoms could be subtle, I wouldn’t ignore some post-nasal discharge, “my nose runs a little bit; I’m generally congested.” Patients with that type of symptom generally have abnormal cultures that need to be addressed.
Dr. Gupta
That’s really interesting that you’ve zoned in on the nasal microbiome. I know, Dr. Dale Bredesen on one of our previous webinars was also talking about that he feels that the nasal microbiome is probably a really important area of future research, and it sounds like there is a correlation from what you’re saying between abnormalities of the nasal microbiome and then the GI microbiome.
Dr. Rahbar
100%. Again, we’re going to learn this fortuitously, by remaining quite humble, noticing that some patients with SIBO that were not adequately responding to treatment where they get better and they get recurrent SIBO. Some of the patients had negative vinculin and CDT antibodies. So, I couldn’t explain that they were getting the recurrent infection based on a motility issue. Then, when we cultured the nose, we realised that they have had definitely some stuff going on in that area.
Dr. Gupta
Great. You mentioned that some of the inflammatory markers, which are often abnormal in CIRS, such as MSH, melanocyte stimulating hormone, and also TGF-beta 1 may also be part of the picture here. It really seems that MSH, perhaps, has an effect on the tight junctions themselves and may actually, physically, contribute to the gut becoming leakier. Is that a simple way for people to maybe understand how this inflammatory response of CIRS then results in this leaky gut condition?
Dr. Rahbar
To put it in simple terms, I think considering that association is something that I keep in mind. If you ask me to present a lot of literature behind it, I probably need to do a lot of digging, but that’s the concept that we currently operate from. Hopefully we will evolve and learn more about that as we go on.
Dr. Gupta
It also seems that there is a two-way correlation between the gut and TGF-beta levels. So, one thing is that it appears that when one starts to get abnormal gut flora, that can also increase TGF-beta, and if one already has elevated TGF-beta levels, that could also have an inflaming effect on the gut. So, that’s interesting how it almost seems to be a two-way communication, if you like, between inflammation and the gut. Is that a reasonable way of putting it?
Dr. Rahbar
100%. I always say, “Is there a point of no return that we have entered into a vicious cycle in a phenomenon?”
Dr. Gupta
A lot of chronic health problems seem to involve vicious cycles where the body seems to just be going round and round and one thing is perpetuating another and another thing is perpetuating another. Sometimes for people who are suffering with these syndromes, they can start feeling like it’s impossible to break out of that vicious cycle. Do you have anything that you could say to that kind of conundrum?
Dr. Rahbar
Well, I definitely would like to go forward with an attitude that we can break the cycle, it is not completely out of control. But you’ve got to start from somewhere. In the case of the mycotoxins for example, and the CIRS; do we start with the binders? Do we start to reduce the load or shall we start with the gut microbiome or correction of the micronutrients, or maybe some basic hormonal balance? Or maybe I could take care of the nose.
In my practice as I’ve kind of evolved into this, if I feel the person has an abnormal nasal microbiome, I almost go after that first or I do it concurrently with the gut itself. Again, in instances where we’re involved with dealing with mold-related illness, taking the patient out of the environment is crucial. But, I personally would not initiate a binder immediately unless I feel that the absorption issues and detox pathways are somewhat supported, and it would reduce the chances of die off or some other burden, if you would or you wish to call it.
Dr. Gupta
That’s a really interesting point. Could you talk a little bit more about that and how you might support someone to detoxify better as part of this process of eliminating mold toxins, or whichever biotoxins, they may have been exposed to?
Dr. Rahbar
Assuming that the burden has been reduced, that we’re not constantly exposed to it, for example, in reviewing the materials that you have provided, everywhere you go and live is a target that is suspected and I even tell the patients sometimes, “You need to think about your automobile”. The automobiles may have air conditioner. At home the new air conditioner systems, when you turn it off it goes for another five minutes to dry up the ducts. The car when you turn it (the aircon) off the moisture remains in the channels. In one instance, a few years ago, I had to take my own car, nice brand, but when I went back to the shop they took the ducts out and it was full of mildew.
Assuming that the burden was reduced, the next step is if there is evidence of malabsorption, we usually do comprehensive nutrition analysis to replace and see how we can target the nutrient replacement, maybe putting some stomach acids, some enzymes, correcting the infections. Then, occasionally we use additional herbs to stimulate the Nrf2, in the liver, and see if we can actually support the liver’s natural detox pathways.
Some patients may require oral glutathione or glycolic acid or NAC or by injection. And so a variety of these things we use to support the detox first.
0:43:35 – SIBO & Leaky Gut – Nasal Infection Connection (MARCoNS)
Dr. Gupta
Right, thank you so much. Let’s shift gears a little bit and talk a little bit more about MARCoNS, particularly, but also maybe nasal fungus and other abnormal species in the nasal microbiome. Would you like to talk a little bit about some of the treatments that you might use when people have an altered nasal microbiome?
Dr. Rahbar
First let me make an announcement. I’m not an ENT specialist. I do act in a capacity that I find it straightforward, easy and not complicated.
In cases that I feel there’s anatomical problem where patient has a lot of symptoms, I do refer. In those cases that we refer to specialised ENT who understand this concept, we found significant amount of pathology that needed to be concurrently fixed.
But let’s say somebody has little (nasal) symptoms. In those cases, I don’t necessarily jump into giving nasal antibiotics or antifungals. We found out that proper irrigation is very helpful. If you do a good irrigation once or twice a day, and also use a biofilm buster for the nose, that may do the job. If we just remove the heavy mucus, their body may get a chance to do its own repair process.
So for some of our patients we have used mucus breakers. I looked at the stuff that was used by different physicians, EDTA, NAC, and these are easy and safe to use, and even XyliFos, which is made from xylitol was recommended by some of the pharmacists that they were using it as excipient. I asked them not to put any drug as an ingredient and just to use the filler as a biofilm buster so the patient opens this, mixes it with saline and they use nasal irrigation only with the biofilm breakers.
To go one a step higher, we sometimes add silver wash to this. Again that may suffice in some of the simpler cases if you will. If the patient does not get better it would require some form of ENT evaluation.
Dr. Gupta
Thank you so much. It’s worth also noting that it’s part of the Shoemaker Protocol now, the BEG nasal spray has been replaced with the colloidal silver and EDTA nasal spray for treatment of nasal MARCoNS. And xylitol is certainly something that seems to also be helpful so thank you for that
0:46:28 – SIBO – Treatments
So jumping ahead now onto SIBO. So let’s say someone has got those symptoms that you described such as abdominal pain, and bloating and flatulence and they have come up positive on a breath test, could you talk a little bit about the treatment that you may want to give to these patients and what might help them to recover their small intestinal biome.
Dr. Rahbar
Absolutely. So the first thing is, after we have a breath test, we’re going to ask, is this hydrogen producer or is it methane producer or both? And are we dealing with a possible background of fungus as well. Many of patients do not have a fungal issue, I don’t want to make that a big deal. But at times, it’s something we do need to entertain concurrently.
If the patient is a hydrogen producer, I generally give them the classical treatment. That is my rule to inform the patient the facts, for example rifaximin has about an 80% success rate if you treat SIBO with primarily hydrogen.
If there’s methane, one may consider adding neomycin, or metronidazole or tinidazole. Tinidazole in the US would be expensive so sometimes we have to use metronidazole. Classically neomycin is the one, which has been used and is the one with the most research and been adopted. Dr. Pimentel has presented data on it.
The interesting part with rifaximin, it actually protects the other antibiotics from becoming resistant, because the bugs are smart and they pass their genetic code to their classmates. Rifaximin basically blocks this plasmid transmission of antibiotic resistance genes. So if you use rifaximin with neomycin, neomycin will continue to be a good antibiotic if you have to re-treat. If you use neomycin by itself, the chance of resistance for the next round of treatment would be high.
With neomycin alone, we have about 30% chance of eradicating SIBO, and if we use rifaximin alone, and with methane, we have about 20% chance. You do both of them together, the response rate may go up to about 80%.
In those patients who are recurrent, I would think about a motility issue, a lifestyle problem, stress, alcohol, or a bad nasal microbiome.
Now if I highly suspect that fungus is a player, again this is not based on textbooks, but what I usually do is I take an herbal approach. Herbs don’t seem to be so specific about which bugs they go after. Maybe that’s a safer way of dealing with it. So I use a combination of herbs. Some of these have been published by Dr. Mullins, but we add to that, and I like to use four herbs to be able to capture both the fungi and the bacteria and reduce the load of the excess bacteria in the small bowel.
Dr. Gupta
For some people it can be a little confusing, to think about the idea of treating the gut with antibiotics, because in many people’s minds antibiotics are bad for the gut. Could you just speak to that idea and why this is a little different, in this case?
Dr. Rahbar
Well, there is always concern, but there are a few things to consider. It is very rare that, at least in our practice and I think for a lot of other GI physicians, that they use traditional antibiotics for the treatment of SIBO. I don’t remember having used ciprofloxacin or levofloxacin for SIBO alone, although we used to do so over ten years ago. Rifaximin is different. Rifaximin seems to target the small bowel but it does not seem to change the microbiome in the colon. Apparently it crystallises or changes composition by the time it gets to the colon so there’s much less concern about it changing the microbiome when you’re using rifaximin alone.
If you add neomycin or metronidazole, then of course, there’s more concern. But, like anything else in medicine, you’re balancing the benefits with the risks, and then looking at the patient’s symptoms, and then making a mutual or informed decision after the discussion with the patient.
Dr. Gupta
That’s a very good answer, thank you. Would you like to talk a little about natural treatments as well and what place you think they may have in treatment of SIBO?
Dr. Rahbar
Originally we used herbal products as a rescue measure. If rifaximin or neomycin failed, I would do a trial of the herbs. I don’t use singular herbs. Most of the stuff that we use are proprietary blends and the products, they have multiple components into them, beyond the discussion of this presentation. Berberine could be one of them. I don’t use berberine alone, unless I’m using it as a maintenance, just to kind of keep things under control, or if I feel there’s issue with insulin sensitivity, obesity, something of that nature that I want to get some cardiovascular benefits from. But the combination of four herbs, one of them is Allicin, the other one is ADP, which is the oil of oregano, we use in a tablet form. Other products that we have used from Biotics Research is Dysbiocide and FC-Cidal, these are the ones that we have used in combination, either three or four of them, to be able to get the maximal benefit.
Especially if there’s a fungal component, I like this, because with some of these herbs, they capture the fungus as well. You can hit two birds with one stone, if you will.
Dr. Gupta
So in a sense, sometimes the herbal treatment, which you say is a little bit broader, but not as strong in a sense.
Dr. Rahbar
I think that’s a good way to put it. I would have less concern about permanent changes in the microbiome.
0:53:50 – Leaky Gut – Treatments
Dr. Gupta
Shifting gears onto leaky gut. We’ve talked about the treatment quite a bit. This is actually really exciting to me, because a lot of this is new for me- could you talk a bit about these treatments that you use for leaky gut and which you find to be particularly helpful?
Dr. Rahbar
Well I brought up some of these discussions because I think that people should know that these are out there and we kind of use them here and there. For example, lubriprostone (Amitiza) is a medication available in US (and UK but not in Australia), and it is used in very minute amounts. Patients may use as little as 8 micrograms once or twice a day. The drug was originally released in the US for IBS symptoms and constipation. It works on the chloride channel. When you look at the animal data it actually has effects on tight junctions, and now they even have it in the brochure that comes with the drug. So, if I have somebody with constipation and bloating, and I also suspect they have a leaky gut, I don’t mind using lubriprostone as a product. It doesn’t absorb. It’s a minute amount of peptide. So I’m not so concerned with the use of this, and I think it would be a good choice to consider for the patients.
Dr. Gupta And have you had good results with using Lubriprostone?
Dr. Rahbar
Overall, yes, especially if there’s a constipation, or IBS type symptoms. It has been an additional component. I cannot say that by itself it’s enough to fix to the leaky gut problem, because the leaky gut may have different mechanisms, but it could be something in the armamentarium to use.
Dr. Gupta Now tell us a little about BPC 157. That seems to be a fascinating new treatment.
Dr. Rahbar
Right. BPC 157 is a peptide which is actually created or generated in the stomach juice, and the credit goes to Doctor Sikiric from Croatia whom I had the opportunity to visit this past September. I was so fascinated by his research I made a trip to Zagreb and I met with him. He took me to his lab, and looked at the research behind it. He has many articles with different benefits that come from this little molecule. In simple words, it seems to have a healing effect on surfaces. Even though many physicians or patients have used this for orthopaedic problems, we feel that this is generated in the stomach juice, and it has an effect on intestinal lining. Why not just use it orally? So we asked our pharmacy to compound this and prepare this in an oral format in very small amounts. It seems to be very effective from the feedback that our patients have given us.
Dr. Gupta Would you ever use that together with the lubriprostone?
Dr. Rahbar
Yes. I don’t see a problem. If necessary, I may use more than one element in the armamentarium. Again, Lubriprostrone would be valuable if the bloating does not go away, if there is constipation and I need some improved defecatory effect by stimulating the chloride channels, producing more water in the colon.
Dr. Gupta
Could you just touch on natural treatments as well for leaky gut. As you know, Restore is a new product which has been heavily marketed for leaky gut, and there’s a number of other things. Would you mind speaking about those.
Dr. Rahbar
Restore, again, from what I understand, has special forms of carbon molecules that work as a binder. This was based probably, from what I understand, on glyphosate being a product that is getting in our food chain and is causing damage to our tight junctions and creating food sensitivity and so forth. Nowadays we have resorted to actually measuring glyphosate in organic acids panels. There’s one lab in the US, the Great Plains lab that provides that. Again, if you find a high level of glyphosate obviously you need make sure patient is not getting food with Roundup in it, but you can use Restore to maybe bind some of this product and improve the tight junctions. Overall, it’s helpful and can be another element in your arsenal. If you didn’t measure it, then you can probably treat the patient empirically and see if you saw clinical benefits.
Glutamine obviously is an amino acid that is most commonly used at the level of intestines. So we usually incorporate that. One caution: if the patient has ADHD or some of the autism spectrum disorders, one has to be careful because they may convert this into glutamate and they may become more agitated. So if you suspect it, just go slower on that. Zinc Carnosine has some data that helps to activate the white cells and it maybe helps with clearing infections at the liver or the gut so it is commonly used as part of the armamentarium. We frequently use amino acids particularly, when we feel that it’s malabsorption and malnutrition, when patients have gone through long periods of time with poor nutritional intake, it is very likely that they don’t have adequate amount of amino acids and if you don’t have enough amino acids the gastric lining, pancreatic juices, everything gets affected, including the stem cells. Remember the repair process needs amino acids to refuel these nutrients. And again, vitamins that we try to go orally, maybe more so in powder format for better absorption, so we use capsules but for highly malnourished patients, we use I.V infusions.
Omega-3s from what I understand and CLA they seem to help with the process of leaky gut repair. Perhaps, by balancing it with Omega-6 and creating a better balance in the Omega-6, Omega-3 ratio.
Dr. Gupta
It’s good to see you that there is a growing arsenal for leaky gut because that does seem to be a big problem.
1:01:21 – SIBO & Leaky Gut – More Treatments
Dr. Rahbar
I’ll say the lifestyle is very, very important, people can do the wrong thing, go beyond their stress, ignore their feelings or have bad sleep patterns. We generally tell people, do not eat or drink before you go to bed, it’s a no man’s land. No water, no tea, no supplements. And stress management is, very, very important and reduction or elimination of alcohol is crucial. If a patient drinks wine they’ll end up with more acid reflux if they end up on an acid reducer, then we’re back into vicious cycle again.
Dr. Gupta
Great, thank you. And as we know there’s a bunch of other pro-kinetic agents that can also be used in SIBO, such as Motilium and metoclopramide, etc. Maybe we could just very briefly talk about diets as well.
Dr. Rahbar
Most of the patients, by the time they come to us they have experimented with a variety of diets. I think the diet issue has to individualised, if their food allergies are something that turns up the inflammatory process, obviously the major ones need to be taken out and they should take less of the other ones and try to be on a rotation diet. If SIBO is an issue, then after the treatment, not necessarily before, the fermentation process should be reduced.
So eating foods that would have less capability to get fermented would be important, and they’re different protocols. when you see a sign of low fermentation diet (e.g low FODMAP) but the discussion of diet becomes so individualised that I really think once we have some of the results and response with treatments, as a maintenance they really need to work with an educated or knowledgeable, nutrition consultant to be able to customise the diet to be most appropriate for that person.
1:04:00 – Mold Illness Made Simple
Dr. Gupta
Now if you don’t mind me spending a minute or two just speaking about the Mold Illness Made Simple Course. Right now, just wanted to explain why people who are suffering with CIRS, or a related illness may find that this course could be of benefit, and I guess really the biggest reason is just to get a clear path forward. The reason that, essentially I created this course, was that I realised there was a lot of overwhelm and confusion around the subject of CIRS and recovery from CIRS and that the information that was already available was not necessarily that clear and understandable.
It’s already a huge anxiety, provoking thing for a patient to find out that their house may be making them sick, and therefore I considered it was very important to have very clear and simple information that helps to bring clarity and calm into the picture. I actually believe that’s a really important part of getting better from this illness as well, is just getting into a state of clarity and calm and feeling like I’ve got this.
Therefore, I believe this course is a useful option if you want to try and get a clear path forward and not get too much confusion. Currently a lot of other, information sources out there are somewhat confusing. So, look, this course isn’t for everyone. It’s not really an instant gratification kind of thing. It’s for people who are willing to put in at least 1-2 hours a week for around eight weeks and to invest the time in learning about this illness.
It will mean learning about the alphabet soup that exists, which is things like C4a and TGF Beta 1 and MMP-9 and MSH and that can a little bit tricky if you’ve got a foggy brain but basically as far as we can see, there’s no way around it, you’ve just got to invest that little bit of time to understand the science behind this illness. Once you’ve got that, you actually should feel a lot more clarity, and you should feel a lot more confidence that you can get better from this illness.
So, what we have in this course is, eight weeks and that consists of eighteen chapters. Now each has a video lecture and slides, which you can download. There’s also a workbook, which you can download as a PDF for each chapter. So, on the right-hand side of this diagram you see what the PDF workbook looks like and on the left-hand side, the example of the slides. Then there are weekly quizzes to make sure you’ve understood the information properly and sometimes they can just point to the need for going back and revising some information.
There’s also a private Facebook group once you reach around week five, that you can join in the discussion and start asking questions for anything that you are not clear on and myself and also Caleb Rudd has been my collaborator on the course, are regularly on that group and can assist with answering questions.
I think Dr. Rahbar, you’ve had an opportunity to have a look at the course, is that right? Did you have any feedback that you wanted to share about it?
Dr. Rahbar
I love it, I love it. It’s a great course, I didn’t want to stop, just wanted to keep going.
Dr. Gupta
Thanks so much for saying that. So, as usual, as usual with these webinars we really do want to help people to get access to the course if you are suffering with this illness and so we are offering a 25% off and so if you use this code: BEATSIBO then it is 25% to $149.25 US dollars and there will be a link that you can click on. You should be able to see that now and if you click on that link you can enter in the coupon code and get instant access. So, basically to summarise, the Mold Illness Made Simple Course just gives you a clear path forward to understanding this illness and charting the path to recovery, if that’s what you are looking for.
Do you have a few minutes for a few questions Dr. Rahbar?
QUESTIONS & ANSWERS
1:09:00 – How to diagnose food allergies/sensitivities (IgE/IgG/IgG4)
So the first one. How do you accurately diagnose food sensitivities or allergies? Do you find that elimination is more helpful or IgG testing and if so, by which lab?
Dr. Rahbar
The elimination concept is generally done by allergists. We do not to this in the practice. For food IgE, which is more immediate reactions, we always use basic labs. If you see something with IgE, which is more immediate reaction, obviously they would need to eliminate that or significantly reduce it, depending upon what the level of the reaction is. The IgG test is not quite accepted by the more classical, centres if you will, and sometimes it is a challenge to getting it approved but as I said overall I find it helpful. I cannot tell you one lab is better than another, I find them for this particular basic test, they’re almost equal, whichever lab does it, I can look at the data. However, there’s another form of IgG called IgG4, which may have a little bit more relevance in the clinical practice because IgG4, for example traditionally is used to diagnose autoimmune pancreatitis, that’s a condition that when the IgG4 level goes up.
If I have access to labs, for example, Genova in US does IgG4 testing for variety of foods. If the patient has the resources I usually use that one instead of a regular IgG testing.
1:11:08 – Cholestyramine and the gut
Dr. Gupta
Okay, great, thank you for that answer. Since CSM or cholestyramine is a widely used binder for eliminating mold toxins and also has impacts on the gut. What do you recommend for those wanting to take cholestyramine but also have SIBO and motility issues?
Dr. Rahbar
Well, my feeling is that if there’s constipation and one has to address that and the SIBO first as much as possible before adding cholestyramine. I also want to make sure that it’s taken away from the nutrients so it doesn’t interfere with their absorption. So the key would be, how do I get any constipation resolved and elimination corrected before I add the cholestyramine as a binder?
Dr. Gupta
That makes sense. So, treating the SIBO first and addressing the constipation and then going on to the CSM.
1:12:06 – Motility/Neti pot for MARCoNS
Do you recommend using a Neti Pot during or after MARCoNS treatment or is this unnecessary? Also, does motility improve after MARCoNS treatment and/or progress with mold toxin detox?
Dr. Rahbar
Scientifically speaking, I don’t know the answer to that question, because I don’t have any research saying the motility has improved. It’s not so easy to measure motility. If you’re talking about constipation, yes, many patients should treat the gut dysbiosis, constipation gets better, but the word motility often implies too, gastric motility, small bowel motility and I don’t have enough data to answer that question.
Dr. Gupta Okay great and neti pot, the answer with regard to the neti pot was a yes?
Dr. Rahbar
Yeah, I mean we do recommend ongoing nasal irrigation for a while, sometimes even once a day or few times a week, to continue to reduce the mucus flow.
Dr. Gupta
Okay great, and then one question is: Do you have any data on whether long term binder use helps or harms the gut flora, for instance, charcoal, microsilica, clay, cholestyramine, Welchol, etc?
Dr. Rahbar
I don’t have a scientific answer to that but I can tell you that we don’t use it on a long term basis, usually 1-3 months is the time that we use it for. At least intermittently.
Dr. Gupta
Can you explain how you feel heavy metals influence the process of SIBO, leaky gut and CIRS?
Dr. Rahbar
I think they add to the problem. It becomes a huge allostatic load and we do a screen for heavy metals. It doesn’t make sense if I’m treating gut dysbiosis and somebody continue to eat sushi and tuna. It doesn’t make sense, most of the patients they have detox issues and their system is overwhelmed already and if you add the heavy metals, it’s just going to interfere with the cellular function at the level of the gut and it’s going to become very difficult, particularly to get rid of the fungus.
1:14:33 – Why BEG spray been replaced by EDTA/silver
A couple more: So can you please explain why BEG nasal spray is no longer the preferred treatment for MARCoNS. My doctor has prescribed BEA spray for me. Should I avoid using this and ask him about colloidal silver and EDTA instead?
Dr. Rahbar I must defer that answer to you.
Dr. Gupta
I think the answer is that Dr. Shoemaker and other colleagues were concerned about bacterial resistance in MARCoNS which seems to be increasing, and he did present a paper at the CIRS Irvine, California conference, or an abstract, suggesting that he’s seeing an increased amount of Gentamicin and Vancomycin resistance and that had actually been put down somewhat to anti-fungal use. So, the BEA spray would have Amphotericin in it and the BEG spray has Gentamicin in it. So it would seem logical that giving Gentamicin might contribute to more Gentamicin resistance.
More and more we’re moving to the idea that it’s more of a biofilm problem in MARCoNS and we don’t necessarily need heavy duty antimicrobials. Therefore something like EDTA, which is an anti-biofilm agent just added to a fairly weak antimicrobial, which the (colloidal) silver is, seems to be quite effective. I think it’s a good development and will help to prevent more multi-resistant MARCoNS.
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Dr. Rahbar
One comment, if I may: occasionally if the patient swallow the Gentamicin or other antibiotics, it may bring on some fungal related symptoms.
1:16:26 – Closing
Dr. Gupta
I’m going to suggest we wind up at this point because we’re probably both going to move on and I’ve got a patient in around ten minutes. I just wanted to give a big thank you to Dr. Rashid Rahbar for joining us today and sharing his knowledge on integrative gastroenterology, SIBO and leaky gut. Thank you so much. I really appreciate the time you’ve given us and hope to be in touch further with future webinars and so on.
Dr. Rahbar
Thank you for this invitation
Dr. Gupta
And also big thank you to Caleb Rudd for the content and technical support. Have a great rest of the day everyone and I hope you’ve enjoyed this webinar, got something out of it and we look forward to talking to you soon. Thanks very much
Dr. Rahbar
Thank you.
TESTING
USA
- Cyrex labs – Expanded gliadin/gluten/wheat screen, zonulin, occulin, LPS and more
- Genova – SIBO lactulose breath test, stool tests for dysbiosis, stool and serum zonulin, IgA, IgE, IgG, IgG4 food antibody panels and more
- US Biotek – IgA, IgE, IgE food antibody panels
- Doctor’s Data – stool tests for dysbiosis, celiac/gluten screen, serum zonulin
- SIBObreathtest.com – Lactulose, glucose and fructost breath tests
- Research Nutrition – Agents for Doctor’s Data and US Biotek
- NutriPATH – Agents for Genova, also have own secretory IgA saliva test and intestinal permeability test
REFERENCES
- Bauché et al. (2017). Transforming growth factor β: a master regulator of the gut microbiota and immune cell interactions. Clin Transl Immunology. 7;6(4):e136. doi: 10.1038/cti.2017.9 PMID 28523126
- Enck et al. (2014). Irritable bowel syndrome. Nature reviews: Disease primers (24);2:16014. doi: 10.1038/nrdp.2016.14.PMID 27159638
- Ghoshal, U.C. (2011). How to interpret hydrogen breath tests. J Neurogastroenterol Motil. 2011 Jul;17(3):312-7. doi: 10.5056/jnm.2011.17.3.312 PMID 21860825