IBS Might Be Connected To Your SIBO (Small Intestinal Bacterial Overgrowth) | Podcast #257

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Between 3 percent and 20 percent of Americans experience irritable bowel syndrome (IBS) symptoms. The condition affects more women than men. People are most likely to get the condition in their late teens to early 40s. IBS is a mix of belly discomfort or pain and trouble with bowel habits: either going more or less often than normal (diarrhea or constipation) or having a different kind of stool (thin, hard, or soft and liquid).

Today’s podcast is all about IBS, a common disorder that affects the large intestine. We are going to dive in deeper on how is SIBO connected to IBS, symptoms, the root cause and a lot more. Read up more about Dr. Justin’s podcast with Evan Brand.

Dr. Justin Marchegiani

Dr. Justin Marchegiani

In this episode, we cover:

1:12 What is IBS

9:47 Fodmap diet, histamine IBS connection

24:01 Hydro Colon Therapy

31:09 Antibiotics

33:56 Biofilms


Dr. Justin Marchegiani: And we are live. It's Dr. J here in the house. Hope everyone is doing phenomenal. today's podcast is going to be on the SIBO IBS connection we're going to dive in to IBS and is it connected to SIBO lot of symptoms there will try to look upstream inside out and get to the root cause of this. Evan, how are you doing today, man?

Evan Brand: I'm doing wonderful. I was diagnosed with IBS. And can you remember what year it was several years ago by a conventional doctor who did nothing but look at me and palpate my stomach and prescribed me an acid blocking medication and then said, Yep, you've got IBS and that was it. So it's just crazy. How many people get diagnosed with IBS? I should try to pull up some numbers on this and see, but I would say most people are undiagnosed because they're suffering, right? They're having diarrhea or constipation or bloating or gas and they just don't go to the doctor, they just take an over the counter this or that and move on with themselves.

Dr. Justin Marchegiani: Exactly, exactly. And IBS is a, a disease a diagnosis of exclusion, meaning you rule out a lot of the more Inflammatory Bowel issues, Crohn's, ulcerative colitis, a lot of those symptoms being like extreme weight loss. you rule out all of the inflammation markers, like high amounts of calprotectin blood in the stool, whether it's from inflammation in your colon, small intestine, or ulcerations in the stomach, right. So you're ruling out all of the big, big, big, big issues, okay, rectal bleeding, extreme weight loss, extreme vomiting, extreme abdominal pain, those kind of things are going to be the big things that we're going to be ruling out. And then of course, we have you know, more of the in between symptoms where we have Yeah, we have constipation. We have some loose stool and diarrhea. We have some nausea, but there's not a lot of inflammation present. There's not a lot of us no calprotectin we may run like a colonoscopy or sigmoidoscopy, we're looking at the end of the colon and seeing no real signs of inflammation, or bleeding, a run a CT or an X scan an X ray scan and see what's going on there. But we're ruling out like the strong pathological issues, but we still may have a lot of symptoms that I mentioned earlier. And so once we've done that, then you kind of fit the criteria of IBS. Now, the question is, what's the root cause? And I've seen many, many times we have one study right here, saying that IBS, is connected to seabone can be caused by SIBO between one and 40% of the time. This isn't a study by the journal gutten liver in March 2017. We'll put the link below on that. So we know there's a strong association up to 40%. And so we know there's a strong association when we have IBS. There's two major kinds of IBS. Keep it bluntly, we have IBS D which is diarrhea, IBS. IBS C which is going to be IBS for this digestive issues. But there's more on the constipation the slow motility side. And the faster high motility side.

Evan Brand: Here's the interesting thing, the route of, I guess the diagnosis of exclusion, you mentioned, a lot of people don't even get to go that route because the doctor throws them the drug and sends them on their way. I mean, you talked about the optimal scenario where you get all the proper scans, you get your calprotectin looked at, you can measure your Secretory IgA and look at your gut barrier. But that often doesn't get done. Often. It takes multiple complaints, it takes multiple visits. Sometimes, emergency room visits are required because people are in they have to be in so much pain and misery for the conventional doctor to listen enough to then give them the proper referral. So I just want to point out what you said is that all these things are great, but a lot of times it doesn't happen that way in the conventional we always do that in the functional world. Looking into the testing but that's not the first step for most people. And that's just the sad truth. And I don't know if it's a cost saving measure. I don't know if it's the insurance companies don't want to go straight to send you over to a gastro doc for deeper analysis. I don't know why. But I never got referred over until I had major complaints. And even when I got referred over the gastro doc didn't even do a full workup. It was just a quick seven minute visit.

Dr. Justin Marchegiani: Exactly. So when they're looking at these things, they're just trying to rule out the more serious Irritable Bowel Disease type of symptoms. Right. Once that's been ruled out, you can still have a whole bunch of nausea and spasms and diarrhea and constipation, then obviously, headaches and fatigue and mood issues can resolve, especially if you're not digesting and absorbing a lot of your nutrition. You may have a lot more symptoms, and you're going to be typically left with just a few medication choices. So the big ones are going to be things that help with the diarrhea, various anti diarrheal or antispasmodic medications, okay, and then you'll have laxatives to help with the constipation to slowly side of the stool moving. That could be various laxatives that could be Metamucil or fiber supplements. And then of course with some of the diarrhea things antispasmodic medications tend to be used and then also a lot of times, antidepressants because we know serotonin plays a huge role in the gut on motility. So conventional medicines using a lot of antidepressants, whether they're tricep like antidepressants, the older ones from the 80s or SSRIs are also use. And then of course, there's the pain, right? It could be a pain in the intestine, then pains are going to be used, whether it's like gabapentin or something else like that. They're giving medications on the pain side. So these are the big ones that are going to be used. It's kind of cookbook, right? It's okay fast tools, slow stools, pain, right? pain medications, and then sometimes they'll give pro kinetics for you know, your food setting in there so long. And then of course, the antidepressants. Those are the big for families and medication. So walk me through how does any of that fix the root cause it doesn't, right, the mindset is we're going to just manage the symptoms and hope that things don't get worse over time. And we know that with entropy and inertia, things always tend to go downhill over time. Not better if we don't get to the root cause if we ignore the root cause.

Evan Brand: Did you mention acid blocking drugs? Those are often thrown a lot.

Dr. Justin Marchegiani: Yeah. Yeah, I mean, if that's symptoms present, I mean, those are typical symptoms for IBS in general, but if we have IBS, and GERD combined, yeah, acid blockers would definitely be used. Pro kinetics, along with that to pro kinetics are just things that help with the motility and the migrating motor complex to keep food moving through the intestine. So yeah, you may see that as well. Yeah, there's a lot of different scenarios where other let's say diagnoses or symptom presentations could overlap for sure.

Evan Brand: Okay, so I just want to briefly dive into some of the other symptoms or things that could be happening outside of the gut. So like the mood issues that can happen we've done stuff on this before and we'll continue to talk about the gut bacteria and the the the mindset so anxiety issues, depression issues, insomnia, irritability, there's a lot of other emotional things that people may not even recognize are from the gut. I mean, and this is coming from somebody who I suffered with depression for a long time of my life. And once I cleared up my gut, it was if the clouds over my head lifted, so I just want to point that out that, hey, if you're suffering, emotionally, it may also be your gut. So you have to start in my opinion, you have to start they're going to the mental health counselor may be necessary to but for me, the game changer was getting my gut cleared out my energy, my mood just went insanely, insanely good after that.

Dr. Justin Marchegiani: Exactly. And then what's happening there physiologically or biochemically what's happening is when we have unresolved emotional stress, and it could be subconscious stuff where we may need to use techniques that help address things subconsciously, it could be just conscious stress, what we need to just have kind of write out the big issues and and create some kind of an action plan that we could execute to get to the problem on it. Whatever it is, if it's work or relationship or financial stuff, whatever it is, that's going to activate our fight or flight and sympathetic nervous system and the sympathetic nervous system interplays with the adrenal and that makes stress hormones to help us deal with that stress, whether it's adrenaline or cortisol, and cortisol and adrenaline long term is very catabolic, so it's going to help, it's going to actually break down our neurotransmitters so we'll have less neurotransmitters that can then affect motility. We know that antidepressants are used for motility. So we know if we actually deplete our own natural antidepressants that we make naturally serotonin don't mean we may have less of it to help with motility number one, the more fight or flight we get into the more we can actually break down our gut barrier. High levels of cortisol can break down IGA. I did a video that's out this morning, you can take a look at it on histamine intolerance, and in that study, there was an article talking about cortisol impacting IGA and the immune response and can cause more histamine when you're stressed. So you could have high amounts of histamine, which a lot of histamine symptoms overlap with IBS. So it could be skin stuff. It could be headaches, it could be fatigue, brain fog stuff, you know, and a lot of the histamine issues overlap because when you have inflammation in the gut, and you have a lot of cortisol stress, you may be making more histamine and the gut bacteria has a huge impact on the kind of histamine you have. And we know that dysbiotic bacteria and or SIBO, which is bad bacteria from the colon migrating up into the small intestine can have a major impact on histamine. And on all the other symptoms. We just talked about mood, nausea, depression, anxiety, and then of course, your typical IBS symptoms, constipation, diarrhea, stomach pain, etc.

Evan Brand: Yeah, well said. So you may come in with the diet, right? We may use the diet as a modifying tool, you know, something like a low fodmap diet may help, right because you're trying to reduce the things that are fermenting in the gut, and possibly feeding the bad guys, but that's where a lot of people stop is they end up with some diet protocol like a SIBO diet or an IBS diet. And and that's it and they don't go any further. So they may be able to manage it. But that's still not the full root cause what would you say about the diet piece? And the involvement?

Dr. Justin Marchegiani: Yeah, so a lot of people they come in, they may already be on a standard American diet, and then they're like, oh, okay, I'm going to make some diet changes. And they may still have issues and and the problem is a lot of fodmaps are fermentable carbohydrates or healthy foods. So why do people start scratching their head because they're like, wait a minute, I'm already cutting a lot of crap out but I still don't feel good. Or hey, like, I'm following this Weston a price thing where they're telling me to eat lots of fermented foods. Why do I feel worse, and this can happen because a lot of those foods are very fermentable. So the bacteria in your gut feeds on a lot of the carbohydrates in those foods. Those carbohydrates being from fructose oligo, die in moto and poly, all these different kinds of carbohydrates or sugars that are naturally in these foods, healthy foods, but the bacteria will feed off of them.

Evan Brand: Let's talk fugit just so people like okay, what is he talking about? like apples, pears, those are common fruits that are five.

Dr. Justin Marchegiani: Yes, right. Yeah, yeah, those will have. So there's a really good handout that you can look at, I'll post my handout underneath. But these are different carbohydrates. So frictions are going to be high and fruits only go and die in mono and poly sat and poly, poly alcohol. These are going to be in different types of vegetables and foods. Now there's an app that you can get on your phone called fodmap, A to Z and it will tell you exactly which one of those fo de ma ma p ma PS in there, the different types of carbohydrates are in each food. I have a generalized handout that I'll put below that has all the different ones in there. And so you know, but the big thing is you just want to cut them out. And the goal is that you're starving out some of these critters by not giving them the fermentable fertilizer so they can grow. You can starve them out. And that can be a good first step that makes sense.

Evan Brand: Yeah, kombucha has an issue too I remember I had a woman who she had extremely high levels of [inaudible] her organic acids test indicating she had a ton of Candida overgrowth, she had toenail fungus. She had even fungus on her on her skin like a fungal infection on the skin. This lady was drinking five kombuchas a day. Now, granted, that's an extreme case, most of you listening are probably not drinking five kombuchas a day. But that just goes to show you can have too much of a good thing in the fermentable food category. And some people get crazy with it. They're eating sauerkraut every day, I just don't think that's necessary.

Dr. Justin Marchegiani: Exactly. So a little bit goes a long way. But if we if we have what I call probiotic intolerance, meaning foods that have good natural probiotics, and it caused problems, there's probably SIBO going on, and there may even be an overlap with histamine issues. Because fermentable foods also have a high amount of histamine. So so many different conditions overlap, and it's really, really confusing because you have to have a root cause perspective, because when you go to the root cause and you're up here, lots of things emanate down below various symptoms, various others diagnoses and all a diagnosis is it's just a way of taking a whole bunch of symptoms and throwing them in one bucket. The problem is different buckets have overlap as well total, whether you have like a mass cell issue, that's one bucket, but then that may overlap with IBS. And then a lot of IBS symptoms, of course, overlap with Crohn's or ulcerative colitis or microscopic lattice, but they don't quite have as many of the inflammation signs. So there's a lot of different characteristics and you have to, if you can go upstream is only a few root causes up here. So you get much less overwhelmed when you go up, right? You go essentially inside out, above, below, above, below, inside out. So you always go in to fix the outward manifestations and symptoms.

Evan Brand: Yeah, well said about the histamine IBS connection. I don't think most people pick up on that they, they go on like a low histamine diet, but they're doing it for what they think are histamine problems, but really, that's the same thing as IBS problems. So the diarrhea could be a histamine thing. It could be a SIBO thing. So you really have to tease apart all these things. So how do you how do you tease this apart? You know, how do you approach these different buckets and then go up to the top what's at the top.

Dr. Justin Marchegiani: You need a good functional medicine provider that can help guide you because it's really confusing. And unless you've walked that path before, it's easy to get to glom onto one thing, and then get overwhelmed. That's number one, and it happens all the time. And then number two, you can go down the path where you're kind of stuck on a whole bunch of medications that are managing issues, but then you're like, you know, you're just trying to like, you're crumbling and you're trying to hold everything up with duct tape, and it's, it's stressful. So the first thing is you got to get the diet component under control. So we have to look at cutting out fodmaps maybe cutting out autoimmune foods, we have to really pre digest and cook everything very well so we can digest it better. Right? Think of cooking as pre digestion. So kind of wrap your head Okay, cooking is precious, and a lot of people will think oh raw, so good. While raw may be okay for some people that have great digestion, but if you don't have good digestion, so a lot of fiber in there that could be hard on your gut, it could be a lot more fermentable fiber in there. Also, the fact that you just tell me has to work harder and if you have less hydrochloric acid less enzymes, which we know according to many studies show that SIBO patients have less acid. They're [inaudible] low stomach acid. We know stomach acids, an important trigger to make enzymes as well. So if we have low stomach acid, we have low enzyme issues. And then of course, if we're eating when we're stressed, or we're not chewing our food up well enough, we're just going to not break those foods down. And then those foods are sitting in our guts, and it's a stress to break it down. So number one is choose good foods. But number two is pre digest them with really good cooking methods and in mastication just chewing it up.

Evan Brand: Well, yeah, when I had gut bugs, I was trying to eat salad and it was a waste of time. I was not digesting leafy greens at all. So I just gave up on eating salad and that's why a lot of people end up going with a more meat based diet and I've seen so many people, there's a lot of like famous YouTubers and other people who were raw vegans. And they end up getting off of that because they're just like, hey, it destroyed me. I couldn't digest anything. I was malnourished.

Dr. Justin Marchegiani: And some people they go to the extreme of going full carnivore, which is definitely low fodmap to, which does great, but some don't have to go to that extreme. And some people they actually feel worse too, because protein and fats are also hard to digest as well. So sometimes there's less anti nutrients and there's less fiber, there's less fermentation, and that's enough to allow them to feel better and heal others they can handle some of those foods, they just have to be more autoimmune or moral low fodmap. And they really have to be working on the cooking methods and of course, the next step is going to be supplementation. So we may work on adding natural prokinetics, things to help with motility. We may add in hydrochloric acid and enzymes, you may add an anti inflammatory support for the gut lining, whether it's dgl or like in my line, we use gi restore which is a healing nutrient for the gut lining. You have different things as well and your line as well. But we may we may come up with a plan based on how the person is presenting and things that have already helped or haven't helped.

Evan Brand: Yeah, so it could be some herbal antihistamines to you kind of hit on the IBS histamine connection. So part of what we do is teasing apart when to do what? So if we're trying to get someone's got dialed in, they may be so miserable that we first have to use herbal antihistamines to try to calm things down. Let's use the example of somebody who every single food they eat, they have a food reaction there. They say I have food sensitivities, and we say to what they say to everything, and we say, okay, and that's where we can come in with maybe herbal antihistamines that you can take during the day to try to help regulate that massell reaction. You can look at the acid and enzymes, possibly possibly probiotics, but usually that's like phase two. Usually phase one is more of us trying to manage the symptoms, get the proper information via the lab testing that we could talk about, and then make the game plan and usually the game plan is going to have to involve some combination of anti parasitic antifungal and or antimicrobial herbs and often we combine those together.

Dr. Justin Marchegiani: Exactly and then pre digesting the food by cooking it well is going to be helpful. We can do a crock pot, which is great for pre digesting foods and making more soup and stew like foods. The only problem with the crockpot is foods can accumulate more histamine there so if you're not feeling good with crock pot foods, we may need to progress more to an Insta pot or pressure cooker. And a pressure cooker is great because it cooks the food faster so there's less time for histamine to develop and of course an Insta pots even better because that's going to be a hybrid pressure cooker and a crockpot combined. You just have to make sure with a with a crock pot with an Insta pot you're very present when you cook it so you have to make sure you release that steam valve before you open it up and you'll have an explosion so I always recommend like you put it way away from the shelf. Make sure kids don't touch it. Make sure everyone knows like you do not touch it. Have one person deal with it. Someone comes in and wants to grab a snack bite of something, you're going to have an explosion. So just make sure you're very aware of that. And you have one person managing it, put it away, make sure the kids are out of the room and make sure that the vent is vented and that little little kitaen in the middle drops all the way down. So you know that that thing is cool when you're when you're opening it up. And I even recommend get like a fireproof blanket, put it over it and then turn it. Those things are-

Evan Brand: Yeah, they're insanely hot. Good point about the-

Dr. Justin Marchegiani: Just gotta be careful because some women or even myself and I'm in the kitchen, you're just like you're doing 10 things at once and you may just go right to it and not think so you just really got to be very present when you're using an Instapot. Okay, this is how you gotta do it. And you got to be very, very careful.

Evan Brand: Yeah, they're incredibly hot and powerful for sure. I'm so glad you brought up the the histamine issue with the crock pot because you know bone broth is all the rage everybody's drinking bone broth. We measure their gut barrier, guess what their gut barrier still toast drinking a gallon of bone broth a day did nothing for you and a lot of these people if they're missing making their own bone broth because they don't want to pay the price of somebody else to make it for them. People are saying that they're letting it in the crock pot for 12 hours or 15 or 20 or 25 hours. That is a ton of time for histamine to build up. So I'm not saying stop doing bone broth, but I'm kinda saying that because I've had people that were actually having histamine reactions. They didn't know it was linked to the bone broth. They get these weird rashes on their face or on their skin. They get a headache. They have no clue why. And I'd say well, when you get a headache Oh, it's always in the morning. Oh, well, what do you do for breakfast? Oh, I drink a cup of bone broth in the morning. Ah, take out the bone broth, no more headache.

Dr. Justin Marchegiani: And again, my rep my opinion on this is bone broth for most people will probably be fine. So if you have negative symptoms, after taking it, like Evan said, then you probably want to pull it out for a period of time and really look at getting the histamine out just for a period of time and just I just call it being histamine conscious, right? Look at the high histamine food list and really pull out all the ones that you are consuming the most and just kind of watch and wait, but if you're consuming has to mean are you you're consuming bone broth and you feel relatively good with it. Continue doing it. I have no problem with that.

Evan Brand: Yeah, sorry, I'm not trying to, to label a small population as the whole population, because you're right. That's not that's not everyone. But there are some super sensitive people listening that may hear that little nugget and apply and be like, Oh, yeah, I wasn't so different. I didn't know it. But hopefully you're not in that category. Hopefully, you're in, you can do as much bone broth as you want.

Dr. Justin Marchegiani: And this is the hard part because there's so many caveats, right? There's so many exceptions, you know, if and, but, and that's why you really need a good provider to work with that can help you navigate because there's so many exceptions to the rule, and we can't be absolute in our generalizations here. So take everything with a grain of salt for sure. And if you're working with someone that's individualizing approach, there may be an exception to it. So that's really good to note. So outside of that, I think the food components really big I mean, I've have my six our approach, which you kind of follow something similar as well, where we're removing the bad foods or replacing the enzymes second or repairing the gut lining under the hormones. The hormones are the X Factor. People forget about this. I already highlighted how cortisol and stress and the sympathetic nervous system can affect digestion, but it also affects histamine. It affects the gut barrier. It affects the immune response. So the hormones are a big component. People come in there. There's a lot of, let's say, guts, functional medicine, doctors online, and they're so myopic to the gut. They just everything else blows away and I can't tell you how many people I've seen that they're menopausal women that have ridiculously low hormones that are affecting their gut as well. They have low thyroid, which are that affects their motility, hey, that's a sign of SIBO and IBS, right. Also people that have poor adrenal function, they don't have enough cortisol to deal with the inflammation in their gut either. So you got to look at the hormones that gets overlooked all the time. And then I've personally then of course, removing the infections which there can be different kinds of infections and you you got to know that it may not just be SIBO, your SIBO they also have an H pylori connection which may also have a fungal overgrowth. SIBO and SIFO, there may be like you said, everyone we had I think that the three amigos, right, I think we had blasto giardi and H. pylori. So it was a-

Evan Brand: Crypto always you always mix up the blasto in crypto currency.

Dr. Justin Marchegiani: So, so crypto giardi and H pylori.

Evan Brand: Equal equally terrible.

Dr. Justin Marchegiani: Yeah, crypto grd. which is which is worse? I mean, crypto is probably worse than x file, then blasto.

Evan Brand: Yeah, my gut was a mess. I was not I was not healthy man. I was malnourished for sure.

Dr. Justin Marchegiani: Hundred percent, one hundred percent, or anything else you want to add to that list?

Evan Brand: The testing aspect, you kind of hit upon what we're doing, but not in too much detail. So we'll just kind of briefly cover that is primarily stool testing is going to give us a lot of the answers, of course, but as you mentioned here, you've got to get the other puzzle pieces. So you may need to run that cortisol panel, you may need to run that thyroid panel. So we may have to send you out to blood to get blood work because, as you mentioned, you could have someone with a gut motility problem that is not gut related. And how crazy is that? That it could be a thyroid problem causing your gut problem. Most people find that connection.

Dr. Justin Marchegiani: It can it definitely can for sure. And I have a couple of questions that popped in in regards to doing hydro colon therapy is that helpful? My opinion about hydro colon therapy, it's an extreme way to move the bowels. So if there's an extreme constipation, that may be a good way to start to kind of get things moving. But in general is a lot of things that happen in the colon, where we reabsorb electrolytes and things like that. So I don't really want to disrupt a lot of that day in day out. So I much rather use natural things to kind of move the bowels if we have to do colon hydrotherapy acutely fine, but long term, we want more natural strategies that fix it and of course, fixing the bacterial or the infection stressor that could be screwing up motility is obviously root cause so there's a lot of natural things that I consider to be non root cause like that, not root cause, but it's palliative, and it may support it may be better than a lot of the medications or surgeries but we still have to have our eye towards the root cause and more sustainable everyday Things that are less invasive.

Evan Brand: Yep. Well said if I may mention the whole vitamin D connection we wanted to hit on this a bit.

Dr. Justin Marchegiani: Oh, yes.

Evan Brand: So there is a paper that had come out. Just a couple of weeks ago, October 2019, which was a study on ultraviolet B UVB light, which you get from sunlight exposure, and you could buy like UVB lamps, I'm sure. And the paper looked at the implications of low vitamin D. And at the end of it here, it just talks about how seasonal fluctuations in the composition of the gut microbiome are found and this is due to the different levels of UVB light. So basically summertime, a lot of people say they feel better during summertime. Part of the reason is if you're getting more sunlight, you're actually helping to regulate your gut bacteria and they found that the IBD flare ups were super common and linked to vitamin D deficiency. It says here, due to the gut dysbiosis associated with low vitamin D they go on and on. But that's the sparknotes is that low vitamin D equals gut dysbiosis equals irritable bowel.

Dr. Justin Marchegiani: Yep vitamin D can have a big implication I think also vitamin D has a big connection with the serotonin receptor sites and we know serotonin has a big connection with what motility so I think it's all connected right i think vitamin D then connects to serotonin. serotonin connects to motility. And if we're not moving our bowels adequately, then you know you can start to have bacteria accumulating right because low and slow motility can definitely cause bacterial overgrowth, right that food sitting in your gut fermenting longer. So, when we look at SIBO, we primarily have hydrogen dominancy about or methane dominant SIBO, and those symptoms tend to correlate methane, constipation, hydrogen diarrhea, and sometimes we can have a combination of two. That's the general correlation. So, the testing that we would do with that as a lactulose breath test, and that's going to look more at small intestine overgrowth. We also have glucose breath test which you can look more at the upper stomach, there's the urea blood, the urea breath, which is more of a newer test kind of an experimental phases. But essentially you're blowing into a tube baseline, slamming down a 50, to 75 gram thing of lactulose, which is a large sugar molecule that does not get digested and absorbed, but gets fed to the bacteria. And when the bacteria starts to eat it, it starts spitting off gases. And the sooner in that three hours, so you get baseline below, slam down some lactulose below every 20 minutes for three hours. So the rule of thumb is, it should take the lactulose about two hours to get into the colon. So typically, at two hours, you'll see this double peak accumulate. And that's a sign that that the lactulose is hit the bacteria in the colon. So the mindset is, if we start seeing spikes in gases, right, methane greater than three are definitely great of intense concern hydrogen greater than 15 combined greater than 20 definitely concern, we start seeing spikes in these methane and hydrogen gases, then we know the bacteria, especially if it happens before two hours. We know the bacteria are gobbling it up. And there's more bacteria because more bacteria equals more gases. So lower gases, lower bacteria, more bacteria, more gases, of course, hydrogen based bacteria, more hydrogen, but no bacteria, more methane. And on the GI map, we can actually they're testing now various methane bacteria, so you can see some of that on the GI map.

Evan Brand: I like that. Yeah, I was gonna ask you now that that's on there. How do you how do you correlate that? Or do you do a breath test and you're going to run stool? Is it just in certain situations, or can you infer from the stool Now that may cause you not to run the the breath?

Dr. Justin Marchegiani: So we know a lot of the bacteria that we test on the GI map? We know if it's connected to SIBO. So, we already know like things like Pseudomonas and klebsiella and citrobacter Prevotella and Morgenella are already connected to SIBO. Now, do we know without a doubt that this bacteria is in your small intestine? No, I mean, it's like, it's like you have a toothpaste tube. And then you have a little bit of toothpaste in the middle, and then you squeeze it all out and then you try to infer after you squeeze it all out where in the toothpaste thing it was, it's hard to know that right? You need a biopsy where you go in there and you either grab it in that part of the testing, or you do the breath test where you can infer based on the time where it's at. Outside of that. I just say that you're you're making a diagnosis, a functional assessment of, hey, you have a general dysbiosis. And based on the research, we know that this the bacteria that's high in your test is associated with SIBO. And then we can also try cutting out some foods and seeing what happens. Number two is a strong history or a lot of symptoms. We may run a breath test alongside of it, it just depends. I typically don't recommend a ton of testing. If we can do functional assessments and we see improvements and we see functional assessments approving it, then that gives us enough ammo to say this is an issue. The patient is already getting better. That's the most important thing.

Evan Brand: Yeah. Well said Because see, a lot of people get caught up on that, like, What? Where are the bacteria? What's the location? Do I have SIBO or not? And it's like, well, you've got Pseudomonas Aeruginosa over growing. It's probably in your small intestine based on your symptoms. let's address the Pseudomonas. And if your symptoms get better, it was probably in the small intestine. That's kind of how I approach it. I don't often run breath testing.

Dr. Justin Marchegiani: And you can also make some diet changes, too. And so yeah, cutting out the fodmaps, like I mentioned, or those kind of things, they can give you a pretty good window into it.

Evan Brand: Yep. So So yeah, we try to only do things that we see are going to help us create a clinical outcome. And in a lot of cases, my opinion, you tell me if yours is different, my opinion, the SIBO breath test doesn't add too much more to the picture. If we get a really, really good stool analysis.

Dr. Justin Marchegiani: If we get a good soil analysis, and we already make changes on the diet and the lifestyle and supplement side and we already see things that they give us a clinical indication of what direction we're heading in for sure I hundred percent agree with that. Yeah. Okay.

Evan Brand: Well, I think that's all I needed to say that I don't have anything else on this topic at the time, but I hope it's been helpful for people.

Dr. Justin Marchegiani: I think it's been really, really good and of course, antibiotics can be helpful, but more specific ones that are using the SIBO are going to be the Neomycin and or the Rifaximin or Sifaxon, those are antibiotics tend to stay more in the gut and don't go systemic. Of course, our natural bias is towards the antimicrobials. There have been studies that compared the effectiveness of the antibiotics with antimicrobials and the the natural ademma chrome os have come up better in some situations. That being said, Every now and then someone does better with antibiotics, but clinically, I found most people do very good with herbs. And they tend to do really well because of the E flux pumps, the natural antimicrobials inhibit the flux pumps, which is essentially let's just say you're you're in a canoe and what you start taking on water okay, the flux pumps are essentially you in the canoe bailing the water back into the into the lake, right? That's the flux pumps. So think about it. If we have a bacteria we want to kill, we want that water to accumulate in that canoe and sink the person or sink the bacteria. So the flux pumps prevent that canoe from sinking. So the herbs tenant act like someone coming in and taking away that person's bucket and then they can't bail out the water and then the canoe or the bacteria takes on water faster and sinks. So you have some really good benefits with the herbals with the flux pumps and then also the biofilms are another component so the biofilms are like protective shields that the bacteria use from being killed so things like ginger or silver and or graphics or systemic enzymes can be very helpful for essentially taking away that the Spartans shield so to speak and making them more vulnerable to the herbals.

Evan Brand: Yeah, Serapeptidase did a wonder for me as soon as I started on that I had a massive massive sinus drainage and I wasn't even someone who felt like I had any sinus issues at all, but once I started doing that, and combining with antimicrobial antifungal herbs, I mean it was literally me achieve he was literally me peeling back the onion and hitting a new layer of infections, which is why sometimes on the retest, we'll see new bugs show up and people say well, why wasn't this on the first test? We did? Well, probably because it was hiding and we pulled it out of hiding.

Dr. Justin Marchegiani: Exactly any patients that are listening you know, they always see my ginger tea recipe or me talking about using ginger tea. Why? Well wonder ginger tea helps with inflammation. It helps with motility but also it helps with biofilms. So I like to use things that have multifactorial benefit and it's cheap right helps them the digestive side helps in the motility side and helps on the biofilm side beautiful in reducing inflammation too.

Evan Brand: Beautiful. We could do a whole show on biofilm, I think but yeah, it's definitely definitely part of this puzzle.

Dr. Justin Marchegiani: 100% I did a video on biofilms. We'll put that we'll put that in the reference below that a few years back, so that'll be a good reference for y'all. Silver is also a great biofilm Buster as well. So my line, we use GI Clear three, which is a nano silver. And then of course, we just make the homemade ginger tea. And I have a video on that too well, so we got a lot of stuff with the references. And if you want to add anything for your video, and we'll add stuff there too. That's perfect. Cool. All right. Any other questions from the listeners feel free to chime in? Again, we're one of the only podcasts out there where we try to really talk about real life experience with patients. You know, we've had experiences over the last decade with thousands of patients. And then we take questions live because we don't need to prep for this stuff where this is things that we do every day. So you don't prep for the for the book that you read to your kid at night because because you you know the language so well. We know the functional medicine language and we're happy to be able to engage with y'all on that. Let me see what we have for questions here. All right. How do you treat patients from a distance so we have labs that we can order anywhere in the country. Or even the world. And then number two, we can always engage face to face via FaceTime or Skype or zoom. And then of course, we can make diet changes. We have a lot of handouts and video support, we just engage via phone or Skype or video works great. IBS constipation and frequent urination and a tingling sensation to my testicles and anus and the doctor didn't know what it was any ideas, hard to say. I mean, there could be some aggravation of your your lower single nerves if you're knowing that pudendal area is irritated, there could be a disc issue potentially that could be a sciatic potential issue with that s one s two s three nerve root could be affected. So it's hard to say what's going on there. I mean, people that ride bikes or things like that that area can be a compressed people that have sciatic issues or sit too much could be compressed. So I need to have a little bit more info but of course, if there's digestion issues, fixing that would also be helpful using all the things we talked about today. Evan?

Evan Brand: Gosh that was great. I have nothing else to say except, you know, you could run some testing but that doesn't sound like a parasitic type issue. I agree with you. It sounds more nerve related.

Dr. Justin Marchegiani: Exactly. And how to get rid of colon pain that's caused by chia seeds. Well, first thing if you're having a lot of colon or digestive pain, let's cut out the chia seeds. Let's cut it out for a period of time, see how we do. Excellent. And then another question here that's on topic is the SIBO always come with pain. No. And this is weird. A lot of times SIBO may not even come with digestive issues. It may come with brain fog, it may come with fatigue, it may come with depression. And they come with symptoms not associated with digestion. And this is the hard part where people that go to their conventional medical doctor, or even a lot of functional med doctors there, hey, if you don't have these gut symptoms, we're not going to run these gut tests, right? People become very symptom oriented in regards to what testing they're recommending. And that can be a big mistake, and people can fall through the cracks.

Evan Brand: Oh, yeah. Well said anxiety too I've had a lot of people with anxiety, and they don't have gut symptoms, and then we get their stool test back. I'm like, are you sure you don't have any gut symptoms? Like how do you have this many infections and you have no gut symptoms. It's always amazing. I don't know if it's just a disconnect. If it's a, they're used to it. They don't know what their gut should feel like, you know, they're used to their stomach being bloated all the time. And then we do a protocol and it's flat and like, Oh, I guess I was bloated. I didn't know that. Yeah, that's a great point.

Dr. Justin Marchegiani: Yeah. And then a patient writes in what if you have gas when you're taking sulfur based amino acid. So if you're having a lot of gas, when you're taking sulfur based amino acids, you just back off the dose and just gently taper it up. And I'd probably take it with food. So it mixes in with the sulfur amino acids of my animal products, animal products, and just kind of taper it up from there and go slow and get to a level where you feel comfortable. It's great that we had all the major questions here so far. Anything else you want to add, Evan?

Evan Brand: No I'm glad we have some questions, it's helpful to dive into the real life experience. So if people have questions ahead of time or in the future, you know, feel free to reach out to us on our websites, you know Justin Health Wellness Clinic on Facebook, Instagram as well, you know, look us up, follow us connect with us that way too because a lot of what we do is kind of a thankless job you know, we're connecting with, you know, hundreds of thousands of people per year but rarely do we have people actually reach out and give us an actual like, hey, I want you to cover this or this or this topic, y'all kind of just sit there and wait which is fine, but we would like the interaction to so feel free to reach out and ask us questions will answer them.

Dr. Justin Marchegiani: We appreciate it. Also, someone wrote in Yeah, our intestines are our essentially our GI tract is our first brain for sure. there's what's called the enteric nervous system and there's just as many nerves in our in our gut and our GI tract as there are in our brain, right and our brain is essentially our central nervous system that's brain the spinal cord. Peripheral nervous system is the spinal cord out to the extremities. And then of course, we have the enteric nervous system, just as many neurons in the gut, as in the spine and brain, so that's really important. So of course, having digestive issues can affect your mood just as having issues in your brain can affect your mood. Your second brain, which is your gut, is so important. And of course, that's where all the building blocks from your gut go to your brain anyway, so all the nutrients and amino acids that make your brain chemicals come from your gut so of course, you have your own enteric nervous system there but you have all the building blocks that come from there too. So really, really important.

Evan Brand: Yeah, just treating your brain is not the answer.

Dr. Justin Marchegiani: It could be part of it and some people it may be all of it but most people it's going to be a combination of the two. Yeah, yeah. And this is where you need that skilled experience so feel free and you want to reach out to Evan, EvanBrand.com, Evan works with thousands of patients all over the world and then myself at JustInHealth.com and we appreciate you guys clicking below and write us a review as well as go into iTunes. Justinhealth.com/iTunes, Evanbrand.com/iTunes. Appreciate it y'all. You guys have a phenomenal day. Take care.

Evan Brand: Take care. Bye bye

Dr. Justin Marchegiani: Bye.



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