Living with persistent digestive issues that disrupt your daily life? Whether it's chronic diarrhea, bloating, constipation, or abdominal pain, getting to the root cause shouldn't feel like solving a mystery.
Watch world-renowned gastroenterologist Dr. Mark Pimentel during this webinar replay as he shares his expertise on helping you understand what's really going on with your gut, and what to do about it.
In This Video You'll Learn:
✅ Why your digestive symptoms might not be "just IBS" - and what else could be causing them
✅ The crucial differences between SIBO, IMO, and ISO - conditions that often masquerade as IBS
✅ How to know which diagnostic test to take first (and why the order matters)
✅ At-home testing options that could provide the answers you've been seeking
✅ Practical strategies for managing symptoms while pursuing a diagnosis
✅ The latest research-backed treatment approaches
Read the Full Webinar Transcript
Paige:
It is my pleasure to introduce Dr. Pimentel, a world-renowned gastroenterologist and expert in SIBO, IMO, ISO, and IBS. He will be speaking about the challenges many face in finding the right path to healing. I'll hand it over to you, Dr. Pimentel. Thank you so much.
Dr. Mark Pimentel:
Thank you so much, Paige. Oh, it's such a pleasure to talk to people and patients. Usually, I talk to doctors on these webinars and explain the science and try to broaden their understanding of how to treat patients, but it's more rewarding for me to talk to patients as I do in the clinic.
And I know I can't see any of you, but I hope you get some benefit out of this. I have a philosophy in science and in talking to people that, my patients at least, I don't dumb things down. I tell them the science as it is and that's what I'm going to do here today. I'm going to explain the science to you, so you understand why you feel the way you do. I'm going to try to explain how we got to these tests and why they're so important and how they can help you and your physician make you better.
And then hopefully, as I get to near the end, I'll be able to take some of the questions that were sent in advance. I don't know how many I'll get through, but I'll do my best to try to answer them. I can't provide direct medical advice because I don't know you one-on-one.
And sometimes people think they have a condition, but they actually have something more serious. So, you have to work with your physicians, but I'm happy to at least address some of the questions that seem relevant to the conversation today. And so, I'll go ahead and get started.
I run a program called the MAST Program at Cedars-Sinai, which is called Medically Associated Science and Technology. And this was a brainchild of mine of about 15 years ago, and it took about 10 years to convince Cedars to do this.
But we just felt like the pharmaceutical industry was going in the wrong direction in the context of irritable bowel syndrome and all these common conditions, that the way IBS was is that it was designed symptom wise to push pharmaceutical companies to create more laxatives or more antidiarrheals, and not necessarily give us the roadway or the pathway to develop drugs that treat the condition, find the causes.
And so that's what I was heading towards. I want to try and find the cause of IBS or the cause of the problem and treat that because that's when patients will really get better. And we've had a lot of success in that now, and we wrapped a program around that so that we can get some better resources and be able to really help patients, and we're doing really well.
Thankfully, we're getting some foundation funding and because the other thing that I want... Not a plug, but I just want to say is the NIH never gives money for IBS research. They just don't. I was sad because how I'd like to start is to say IBS affects 40,000,000 to 60,000,000 people in the United States and about $1 billion worldwide. So, we're not talking about a small disease, and yet there's no money, no resources, and no really strong attempts to find out what's going on. And so, I'm glad that I have this opportunity and that I've had all the opportunities in my career to be able to help people with this condition, especially given the obstacles that I've mentioned.
But let me talk about your obstacles because this is where it started in 1996 when I started my career. When I started my career, this is what IBS was thought of -- It was early life trauma, anxiety, depression. IBS was a female disease. Look at the quote at the bottom, "IBS is a disease of hysterical women."
Now, as a physician, I'm embarrassed by that comment, but I'm even more embarrassed that the last time I heard somebody say this was only 2018. So older physicians or physicians that are still practicing like it's 1996 still say stupid things like this, and that's shameful because women are not a disease, and IBS is not a women's disease. And so, this is not correct statements.
And then the other thing that we have, and I'm not trying to raise your ire too much, but anytime in medicine that you think a condition is unknown, you don't understand it, you don't know what's going on, you blame stress, anxiety, depression. I'll give you an example. 1970s, early 1970s, person has a heart attack. They enter the ER.
They keep them in the hospital for a month and they say, "You need to quit your job. You're CEO of a company. It's too much stress. It's killing your heart. It's too much stress." Well, it wasn't the stress of the job. It was the eating at the steakhouse, the smoking, the drinking and all the other things CEOs were doing at the time, and then genetics, but we didn't know that in 1970. So, the same thing with IBS. That's how I see it.
Now, look at the middle. The middle is how do we diagnose irritable bowel syndrome? Well, we have criteria. So, the criteria, you have to have pain, and you have to have constipation or diarrhea or both, and that's it. So, your disease or condition, I should say, is defined by symptoms. So, if you define a disease, let me give you an example. Crohn's disease, if you see on TV, you see all these new drugs for Crohn's disease.
Every few months there's a new drug approved for Crohn's disease. Why? Because it's defined by inflammatory cells in the gut. It's defined by the cause that causes all these inflammatory cells in the gut. So, then you get tons of drugs because you're treating the cause. All we get is treating symptoms because the disease is defined by symptoms.
And so, you get psychological therapy because people think it's stress. You get antidepressants for the same reason, and then at the bottom, antidiarrheals and laxatives. And that's the way it's been all along. And so that's why I don't like this landscape. I don't like the way IBS has been going and we've taken a different path.
But the other amazing thing which you probably don't know because you're not in the politics of IBS, is that the irritable bowel syndrome criteria that are created say you have to have abdominal pain, you must. And then you have to have either diarrhea or constipation. And then when you meet those criteria, if you then take 1,000 IBS people who meet those criteria, pain, and change in bowel habits, and you ask them, "What's your most bothersome symptom?" They tell you, "Bloating," and you're scratching your head and you're saying, "Well, bloating's not one of the symptoms of IBS by the criteria developed by those experts." So, the patients say, "It's bloating."
The experts say, "No, no, no, it's pain and diarrhea and constipation." Well, we're not listening. You got to listen to your patients because it is bloating. And so, the Rome Foundation on the right here studied 55,000 people and said, "Yeah, bloating's really super important in IBS."
Another study on the left, super big study, 88,000 people again saying, "Bloating's really important in IBS." Well, Rome is the one who comes up with the criteria for IBS. So, I've been pushing them for almost a decade. Bloating needs to be part of the criteria, but this is the stubbornness that we deal with and why patients are somewhat dismissed.
Now, the other thing I will say is can you imagine being called irritable? And you can imagine because many of you suffer with this, being called irritable, that it's your bowel and that you're a syndrome, not even a disease. So, you're dismissed.
And so, these are the things that are very frustrating when I treat patients with IBS because I think we've gone a little bit in the wrong direction. This really is a disease, and bloating is really part of it, and I'm going to explain all of that to you now.
But the Rome folks have come up with some understanding of what we should do in a sense, and they say if you have bloating, you really should do breath testing, whether it's for bacterial overgrowth, which is the bottom, SIBO breath testing, if you want to call it that, or malabsorption testing to look for malabsorption of these sugars.
And these are the things that Gemelli Biotech offers, all five of these tests. And so, they do recommend that you look for these things. So, if you're really a novice to this program, SIBO stands for small intestinal bacterial overgrowth. And I'll explain what that is in a lot of detail, maybe more than you want, but a lot of detail.
So, I've said the term IBS, irritable bowel syndrome, and I said the term SIBO, small intestinal bacterial overgrowth. And patients are like, "Well, do I have SIBO, or do I have IBS or is SIBO IBS?" And by the end of this, you're going to understand that SIBO is IBS, at least some of it. So let me give you how this comes together.
If you have symptoms that nobody understands, that you meet the Rome criteria for IBS, it means that you're in a bucket of patients where we don't know how to define you except by symptoms. So, if you take that bucket of people, of which there's about 60,000,000 in the United States, and you look for SIBO, you're going to find it in about 60%. And this is work that we've done over 27 years. So, we can explain about 60% of the bucket, which is fantastic considering we explained none of it in 1996. So, I'm going to talk about that group and how this comes about and how people get SIBO. And then it's called irritable bowel syndrome, but they're one and the same.
But I'll say one more thing about SIBO before I move on. Anything that slows your small intestine down, if you had a tubal ligation and you ended up with adhesions in the bowel that are slowing the gut down, you can get SIBO. That's not IBS. If you've had surgery on your bowel and there's scar tissue and that's causing the gut not to flow, you can get SIBO. That's not IBS, but it is SIBO. If you are on narcotics for pain control because you have a bad back, the narcotics will slow your gut down and you'll get SIBO. So not all SIBO is IBS, but 60% of IBS is SIBO. So, I hope that makes sense.
This is the spoiler slide. It's really complicated, but it's not really complicated, and that is food poisoning starts this whole thing. So, you go to a wedding and the chicken on the tray in the buffet has campylobacter food poisoning in it. It was bad chicken and 100 people get food poisoning. Out of that 100, I'm going to tell you how many develop IBS, and they develop IBS because of a toxin. This toxin here, CDTB. And because you get exposed to this toxin, you form antibodies to a protein called vinculin. And this protein vinculin is really important to the nerves of your gut to keep the nerves connected like the wires to a light switch on your wall. And when it's not connected, the gut doesn't flow correctly.
And I've already told you, if the gut doesn't flow correctly, you have to build up of bacteria and that's bacterial overgrowth and that's IBS, and that's why IBS responds to antibiotics, and I'm going to take you through pieces of this. To get you through this whole story with all the detailed science would take about three hours. We're going to do it in a very short period of time, but you will understand.
So how does food poisoning cause IBS? There's been a ton of research on this. This is 25 publications summarized into one by the Mayo Clinic here. And if you went to the wedding, 100 people got food poisoning, 11, one in nine would develop irritable bowel syndrome because of that exposure and they would develop it for an indefinite period of time. So, we know that food poisoning causes IBS. We know absolutely truthfully that it does, and it probably causes IBS in 60%.
I'm going to say 60% many times during this presentation, but you can get IBS from Shigella, which is a type of food poisoning from salmonella. You've probably heard of the term salmonella. You may not have heard of campylobacter as often, but it is the most common cause of food poisoning in the United States.
And you've all heard about E. coli outbreaks and broccoli and sprouts and other things that you hear on TV, but they all have one toxin in common even though they may look very different, and that's the cytolethal distending toxin, that's CDT toxin. So that's what's causing IBS, but we actually proved this.
So, what we did was we said, "We did food poisoning studies in rats. They get IBS." That's interesting, but we already knew that in humans. What we did was we took the toxin, just that toxin that I've been talking about and put it in rats, but we didn't put it in their gut. We just injected it like a vaccine under their skin and they got bacterial overgrowth.
Let me show you first. They develop antibodies to the toxin. They didn't have them before. They do now, and their wet weight of their stool goes up statistically. And the higher the antibodies in the blood, the higher the stool wet weight in the rats were. This was just published this year.
This is a complicated slide, but what the dots represent, focus on the left-hand side. What the dots represent is the gut bacteria in the small intestine. Okay? The orange dots are healthy rats who never got food poisoning, never got the toxin. The green rats are the people, or rats, who went to the wedding, got the toxin, but they're fine. They didn't get IBS, but the blue and purple rats are the ones who went to the wedding and now they have IBS.
But what we see in the rats is they get two different kinds of IBS, potentially. One with too much of this type of bacteria, E. Coli, or they get one with this kind of bacteria. Too much of this, Desulfovibrio. This bacteria produces hydrogen and this bacteria produces hydrogen sulfide. This is going to be really important because as we get to the end, you're going to see that the new three-gas breath test measures hydrogen, and now measures hydrogen sulfide, which is super important because that's what we see in the rats and that's what we see in humans after food poisoning.
But before I get to the bacterial overgrowth part of this lecture, this toxin makes you form antibodies to it and it makes you form antibodies to that really special protein that keeps the wires connected in your gut, and those are now measurable in IBS patients. We can measure using the IBS smart blood test, which Gemelli offers. Anti-CDTB or anti-vinculin, and if you compare the levels to Crohn's disease or ulcerative colitis or any other cause of diarrhea, it's way higher in IBS, and it's so high that you can actually diagnose irritable bowel syndrome.
So why is that important for a patient? It's important for a doctor, but why is it important for a patient? Because it tells you you have IBS. Okay, that's interesting, but no, it's telling you you have a disease, not a syndrome. IBS is irritable bowel syndrome, but it's a syndrome because there's no marker. There's nothing that tells you, "Oh, you have it. Oh, your blood is off, you have a disease. Oh, your kidneys are bad, you have kidney disease." This tells you and converts IBS from a syndrome to a disease. That's number one.
Number two, it tells the doctor and you, "Food poisoning did this to you." Number three, you better not get food poisoning again because if you do, these antibodies are going to go higher. And if they do in my practice, if you get food poisoning again, you come back to my practice, the blood test is higher, I have a harder time making you better because the nerve damage, at least that's what we think, the nerve damage is worse. And so, things don't work as well. It's just a worse illness. So, knowing you have the antibody makes you much more diligent when you eat, when you travel, when you are more careful with your food choices because you can't get food poisoning again.
And so this test is so important. It doesn't tell us how to treat you, but it tells you why you have what you have and how to behave so you don't get worse over time. So, it's very important. It can now be done at home and you just put this on your skin, you press the red button, the blood comes in the tube right on your shoulder, easy-peasy. You close it up, send it to the lab. So, you don't even need to go to a lab to get a puncture to draw this. It's a capillary blood draw. Really, really easy.
Now we're going to move to breath testing, and this is so important because this is small intestinal bacterial overgrowth, but it's not SIBO anymore. It's three different things. It's SIBO, IMO and ISO. Don't worry. I promise, I'll take you through it and help you to understand it more clearly. This is an important study because this summarizes 25 papers that look at breath testing in irritable bowel syndrome.
Remember, I told you about the 60% rule? You're going to hear that more again, but breath testing is, if you look at the summary diamond at the bottom, one is no different. Breath test between healthy and IBS. No, it's way over here. So absolutely, people with IBS have more positive breath tests. The problem with breath testing, for 50 years we've been doing breath testing, but we've only been using hydrogen up until the late 1990s. Then they added methane. They didn't know why methane was added. There was no science to say, "Oh, methane is going to show you some interesting results." But we now know methane causes constipation.
So, this is what's explaining the constipation IBS, but we still couldn't explain the diarrhea because hydrogen wasn't correlating with diarrhea until we got hydrogen sulfide. Hydrogen sulfide correlates with diarrhea. So the only three-gas breath test that's available is the Trio-Smart breath test, and I'm going to show you all the exciting data we have so far and there's so much more that's already done that hasn't been published that really puts a nail in the coffin of this, that hydrogen sulfide is so important.
But before I do that, I want to show you some really cool stuff that we've done in our lab. So, the circle on the left is IBS patients with SIBO, and the different colors represent different bacteria, but we used to think bacterial overgrowth, or too much bacteria in the small intestine was, "Oh, those colon bacteria are coming up into the small intestine and overgrowing there."
But what we showed, and this is the first time in the history of the world that we've sequenced the entire microbiome of the small bowel of SIBO to show who are the actual bad actors. And what was amazing even to us, and a surprise even to us, is that SIBO is really only two bugs, Klebsiella pneumoniae and E. Coli. So, it's almost an infection that half...
Normally, the normal microbiome contains 1,000 different bugs. Beautiful. It's like Los Angeles. Right? You have doctors, plumbers, lawyers, nurses, sanitation workers in the right numbers, in the right proportions. So, the city can function nice and normally, and imagine, you took half the city and made most of it lawyers and plumbers. It doesn't function. That's what's happening here.
It's two bugs, Klebsiella pneumoniae and E. Coli, but it may be only one strain of one bug. We've shown that K12 at the bottom is the most correlated with symptoms. So, we're still trying to work through this data, try and figure out could it be possible that one bug is responsible? But it's really replacing the city, half the city with lawyers or lawyers and plumbers. And so that's not a normal city.
I like to point this out and hear me out with this because I think it's going to resonate with you. Patients come to their doctors, and I get doctors complaining, saying, "Oh, this can't be true, this can't be true." The patient says, "I ate and literally five, 10 minutes later, I'm starting to get bloated." And the doctor says, "That's not possible." Look at the first number there, 63. Because you have all these E. Coli in your gut. They're not regular bacteria. That's not a regular bug. That's a super fermenter. 63 represents the fold change versus normal. What does that mean? That means the normal person produces gas at one horsepower. A SIBO patient produces gas at 63 horsepower.
So, you're 63 times faster at producing gas, and you know what that means? 10 minutes is enough, and you start to produce gas, especially if you have it all the way up to the…
So, I like to say, listen to your patients. They're telling you what they're feeling and experiencing, and they actually are right that they are getting, not everybody, but there are many patients who literally do get gas formation that quickly, and this is a good explanation of all of that.
I'm going to talk a little bit about methane now because methane is really important. This is intestinal methanogen overgrowth. Methane slows your gut down. And if you look at this, this is an animal study, but anytime you put methane gas into the intestine, the gut slows down by about 60%. So, you're getting 60% slowing. And then you say, "Well, okay, because it's paralyzing the gut."
So, this is not food poisoning. Methane is a different animal altogether. Look what happens to the gut when you put methane in. It's spasming, it's not slowing. It's slowing by spasming. It's not like the muscles are shutting down. They're going too hard and holding back the fecal material.
So, methane slows your gut down and we've now known that for a number of years, but hydrogen sulfide is the new kid on the block and that's associated with diarrhea. This is a really cool study because for the first time in history, I know we've had breath tests for 50 years, but this is the first time in history that a breath test has been done in an IBS group, both diarrhea and constipation, and the microbiome has been looked at by sequencing.
And this is a study we published now in 2021. This is your IBS diarrhea patient. This is your IBS constipated patient with methane, and this is what the methane looks like. But look at the diarrhea patients. No methane. They don't have methane. Diarrhea patients don't have methane, just the constipated patients.
This is the breath test of an average IBS diarrhea patient. The average IBS diarrhea patient meets the criteria for SIBO because it's over 20 at 90 minutes. SIBO is part of IBS, and this is the hydrogen sulfide. Every time point is higher in the diarrhea patient. So, we actually now define IBS into micro types.
So, I want you to focus just on the purple and the blue for a minute. I showed you in rats that when they got food poisoning, they broke down into two types, hydrogen producers with E. Coli and hydrogen sulfide producers with the Desulfovibrio for rats. They don't have fuso. So, we get the same thing in humans. This is the human study. This is the result of human data. Same two subgroups on the diarrhea side. On the constipation side, it's here, it's methane, it's this organism…,. We now know at the end of 2024, exactly the organisms that are contributing to IBS-D and IBS-C in that 60% of the group that I talked about from the beginning.
So how are we treating IBS? Well, rifaximin is a drug. It's an antibiotic that was approved by the FDA and I was heavily involved with rifaximin development. It took a lot of work to get a drug approved for a cause of IBS, meaning a microbial cause, because it's a new, 14-day treatment, patients got better, but then they stayed better.
So, you didn't have to stay on the drug. You just took 14 days, and you stayed better. And the FDA approved the drug understanding that there was a microbial contribution or bacterial contribution to irritable bowel syndrome. But at the time, whether it was SIBO or not, still remained undetermined.
But as I've shown you, now we know it's SIBO. But if you did a breath test in those big rifaximin studies, if you did nothing, if you just blindly took rifaximin, 44% of people would get better. But if you knew you had SIBO by breath test, 56% of those patients. So that's the 60% thing again.
But of these patients, the ones whose breath tests became negative, 76% of those patients met the endpoint by the FDA which is very difficult. So, the breath test was already telling us who should get the antibiotics.
For methane or intestinal methanogen overgrowth, as we call it, it's different. We only have one study that's ever been done. It's a double-blind study. So, it's the right kind of study, and neomycin and rifaximin made constipation less, more than just neomycin alone. So, this is where we head and how we treat it in our group.
Now, we don't know what to do with hydrogen sulfide exactly yet, but we are using bismuth because bismuth has been shown in previous studies as early as 1998 that it will reduce hydrogen sulfide. Those bugs don't like bismuth. And so, we can get some pretty good benefits from that.
So how do I do this in my practice? If somebody comes in with chronic diarrhea or mixed diarrhea and constipation, they all get antibody measurements, they get the IBS-Smart test because for me, I need to know why they have the symptoms, and this gives me the why. And for the patient, they need to know why they have the symptoms because we have to take precautions so as not to let them get food poisoning again. This is really important because this is the cause.
So, if we had a drug to get rid of these antibodies, we wouldn't need anything else. We'd be done. We're not there yet. We're working towards that. I have a meeting tomorrow. We've identified the antibodies; we've identified the B cells that produce the antibodies and we're working toward a treatment for the antibodies.
So, stay tuned on that. Not ready for that yet, but we do them because we understand their importance as the root cause of all of this. But in the meantime, these antibodies are having their effect and you're getting these abnormal breath tests. So, we do the three-gas breath tests. And if it's hydrogen, I give rifaximin. If it's hydrogen sulfide, I give rifaximin and bismuth in my practice.
And then I'd be careful with travel, especially if these antibodies are positive and I give counseling to my patients. If a patient is constipated, the antibodies are less important or relevant. So, I only do it if I get a clear history that food poisoning was there. You don't need a history of food poisoning to have these antibodies because you don't remember the first day of diarrhea if you have diarrhea today. So, it could have been food poisoning. So, I do the antibodies for the dire rule.
But anyways, back to constipation. We do the three-gas breath test. If it's methane positive, I give in my practice rifaximin and neomycin from the study I showed you. But for people who are worried about neomycin, I do recommend substituting metronidazole and it seems to work quite as well as neomycin, but we don't have a study published on it.
So, before I conclude, we started in 1996 with this dogma about IBS being related to stress. It's a female disease, a disease of hysterical women. The criteria were developed that IBS is a symptom disease or a syndrome, I should say.
We're now at the point where we can call this a disease and move away from just symptom approaches, but I want to contrast this picture to now what we know in the microbiome, and I haven't been able to explain all of what I'm going to show you on the next slide, but we know a lot, and a lot more than I've shown you today because we just don't have time. But it's amazing what we know and what's actually going on in that 60% of IBS.
But putting it all together, this is how it works and this is why we measure these antibodies because this toxin from food poisoning in animal and human studies leads to these antibodies in the bloodstream, and these antibodies damage your nerves of the gut and that damage leads to the gut not moving correctly. And a lack of cleaning waves of the gut, which I'm showing here, I didn't show you the data earlier. And so, as a result, you get a buildup of bacteria in rats. You get two groups, hydrogen, and hydrogen sulfide.
In humans, you get two groups, hydrogen, and hydrogen sulfide. And so, we then look at everything that the human is doing in response to these terrible bacteria build-ups. And we see a lot of bad things. We see the gut being pain sensitized, serotonin and motility is screwed up. The barrier of the gut gets leaky, or it gets dysfunctional. Of course, you're fermenting like crazy because you have these super fermenters. Your circadian rhythm is off, histamine is abnormal as well.
And so, we then see normalization once you get the bacteria down, but we're still not treating the root cause yet, which is the antibody. So, it comes down to IBS breaking down like this. You have ISO, intestinal sulfide overproduction. We know the bacteria that are causing this in the small bowel and the colon, and now we're attacking them. And we have a new drug that we're going into clinical trials in February, we hope. We're putting in the paperwork in December, as I've suggested on social media. We've got SIBO, which is the conventional E. Coli and Klebsiella, two bugs, the lawyers and the plumbers, too many.
And then in IMO, which is the methanobrevibacter, we have a new product that we're working with that blocks methane production. Now that we know the players, new drugs are coming. It's going to be like Crohn's disease. It's going to be like you see on TV where there's going to be drugs, I hope, every few years as this unpackages and people start to get on this and drug companies start to get on this.
But what I wanted to do, I have a list of things that I did want to cover, and I printed it here, and there are a few things that I want to cover now that you know the science. So, you understand there's three groups here. So, the three-gas breath test measures all three of these gases and gives your physician a chance to understand which one you have and to treat it. And so that's offered by Gemelli. The second is that there's also malabsorption testing.
So, if you are concerned about sucrose or fructose or lactose, you can do those breath tests with Gemelli as well. And they do measure the three gases, but hydrogen is the only one that's validated for those malabsorptions. So, you can also do the breath test through telehealth. So, they have a provider online that can help order the test for you if you wish, but at some point, you need to get a doctor involved, your doctor in order to be able to get the test done.
So with that, what I'm going to try to do here is go through some of your questions so that I can give you some feedback on those questions because I got a long list of questions and I want to be able to at least address a few of them.
So, there's a comment that IMO is not associated with food poisoning and that is correct, and I think I mentioned that to you as we were going through this. There are some comments on diet.
So, while I focused a lot on treating with antibiotics to get the bacteria down or the combination of neomycin rifaximin for IMO as to how I do it, there are a couple of other ways to help. There's now an elemental diet that's very effective.
We discovered using elemental formula to treat all of these in about 2003 using a product that was on the market, but it tastes awful. And so, we kept doing it, but now, we helped the company develop a product that tastes absolutely great. It tastes like tropical vanilla, they call it. And you take it for two weeks. It's a liquid diet, it's expensive, but it has about a 75% chance of making the methane disappear, and nearly 100% chance of making the hydrogen disappear. And so that's been very effective. The problem is it can come back in time just as these all do.
Another question that comes up is, "Okay, so you get rid of it, but you haven't gotten rid of the antibodies, so this could come back."
So, the way I see it in my clinic is if 100 people have one of these three conditions and we successfully treat them, I would say about 10% to 20%, I don't see them. I see them at the mall, and they say, "Oh, since you treated me two years ago, I'm fine." 10% or 20%. About 10 or 20%, "It's frustrating. We're having a difficult time getting rid of it.
IMO is particularly hard for some people, and we have a hard time getting rid of it and we struggle, and then we have to go to things that are not antibiotics, even herbals sometimes, and to try to get this down." But in the middle, about 40% to 50%, 60% we're getting great success, but it keeps coming back, maybe every six months, maybe every three months. And in those patients in the middle, we do use something to make the motility better. Prokinetic for example.
And so, what we do is I mentioned that when the antibodies are elevated, some of the wires are not connected. So, think about it like this. You have a house, and somebody took half the light bulbs out. So that's with the antibody. Your half the wires aren't connected properly, the flow isn't good. In the case of the house, it's dim at night. So, you don't have light bulbs, so you can't replace the light bulbs.
So, what can you do to get more light? Well, you can turn the energy up on the electricity in the house, which makes the light bulbs that you do have brighter. And that's what the prokinetic does, is it makes the motility work stronger with what is connected. And so, I do sometimes in patients give them that and there's a lot of questions about diet.
And so, I don't, myself, personally like the low-FODMAP diet. I know low-FODMAP is very popular, but I don't like it because it's too restrictive, very difficult. My entire career, I've spent talking to patients trying to get an IBS patient normal. Normal is not just normal bowel movements. Normal is you go to a restaurant and there's six people at the table and the waiter spends 10 minutes with you and 30 seconds with each of the other people at the table because you have too many questions about what's in the diet? What's in the food?
Low-FODMAP is very difficult. There are too many things restricted, and I don't think you need to restrict all of those. So, we came up with a diet plan called the low fermentation diet, which if you went to almost any restaurant in the country, you'd find one thing that you don't really have to ask a lot of questions about. And so, it makes your life more normal, and that's what I try to do for my patients. So that's really important.
Another question, "My naturopath doesn't test for which type of SIBO. Is this okay?"
Anything you do has a cost. So rifaximin is extremely expensive. I get questions about this all the time. I don't control what drug companies do. I know it's really expensive and insurance companies are denying these kinds of things. They don't charge you for the breath test. They charge your insurance first, and what if the insurance pays almost all of it?
The leftover is a small amount, yes, you might have to pay that leftover, but they don't charge you. So that's good, but there is sometimes a cost to these things. And so it may be that your naturopath doesn't want to incur that cost with you, but personally, if you don't know the gas you're treating, the chance of you getting it right is pretty awful.
For example, IMO, a lot of my men don't have a lot of constipation. Women tend to get more constipated than men. So, I might have a male patient come in who's got more back and forth, diarrhea, constipation, but they're IMO because men don't get that kind of constipation. And so, I might've missed IMO if I just did a hydrogen breath test, or I just assumed that they had hydrogen and not IMO.
And then sulfate, intestinal sulfate overproduction, if you have that, if you give rifaximin with bismuth, in my experience, now having done this for a couple of years, if you get rid of the hydrogen sulfide, in fact these patients stay better. I've had a couple of patients now I've seen recently where they've been a year, no relapse. I was shocked and they had bad diarrhea.
And when I say ISO is associated with severe diarrhea, I mean really severe diarrhea. These patients are the sickest of the group. And so, knowing that they have ISO and knowing to give the right cocktail of different things is important.
So let me just see what else I've got here. I've got a number of questions. I've circled some that are relevant to the talk. So, there's one comment about SIBO for decades or SIBO recently. It doesn't matter how long you've had it. I had a woman come to my office who was skeptical. So, she said, "Okay, I've had this for 30 years." She's now 65 years old. Can you imagine having something for 35 years?
And then I gave her rifaximin after knowing she had the hydrogen SIBO, and she came back 14 days later and she brought in a paper bag literally with 13, 14, 15 different pill bottles and she literally dumped them on the table in front of me. She says, "I've been getting all of this kind of stuff over a number of years, and you made me better in two weeks. And 35 years, I haven't gotten better with all these different drugs." So, it doesn't matter how long you've had it, but the sad part is 35 years of suffering that this person had, and then something so simple works so well.
And so, I'm not saying it's like that for every single patient. So please don't take that as an extreme example, but it works quite well for most patients. In fact, it's been working so well that even in my practice, we don't see as many diarrhea patients now. We see mostly IMO because IMO was the new kid on the block a few years ago, and so doctors haven't figured out how to do IMO well yet. So, most of our patients are IMO now, but because of our education around SIBO, there's less... We're now seeing the ISO and the IMO actually.
"Do you have any book recommendations to learn more about SIBO?"
I'm not pushing my book, but we do have a book out there and it's called The Microbiome Connection. Almost everything I've shown you here is in there, but the newest stuff isn't because it's already a year old and things change quite quickly.
So, this one is interesting. "My daughter had a campylobacter infection, exactly what we talked about that went undiagnosed for months. She now has SIBO and can't get it under control. Should she try another round of rifaximin? She's been doing low-FODMAP on her own with mixed results."
So, I can't give advice on what to do and I don't know the whole story from this, but I point that question out because it really is the story I told you today. If the campylobacter lasted a long time, that's a problem. If the campylobacter led to extremely high anti-vinculin.
So, in a patient like this, I would 100% get an IBS-Smart blood test because if the vinculin is over three, it's really hard to get rid of the overgrowth because the neuropathy is really bad. So that would help me understand why the response or the rifaximin is not working or you're not getting a complete response.
And then I would want to know if there's a hydrogen sulfide because if there is, maybe bismuth with rifaximin as I do in my practice would help get the patient further along in an improved state. So, this sort of explains the whole thing for us here that the way this patient is responding. So, I appreciate the question, and I wish you good luck with your daughter because I know how tough that can be.
"I have gastroparesis, should I use glucose or lactulose when doing a breath test?"
Well, this opens up a couple of things to talk about. I'll say that gastroparesis slows the stomach down so the lactulose won't get out, the glucose won't get out. So, it's really tough if the gastroparesis is bad. The other thing is the GLP-I inhibitors that are being used for weight loss are really making breath tests squirrely. So, if you're on a GLP-I, it might make the breath test falsely negative because the stuff never gets out of your stomach. So just keep that in mind as well.
Now, I think I've exceeded my time limit. I know that the folks on the phone from Gemelli do want to have a chance to talk to you about how do you get the tests? How do you order telehealth and other factors? So, I'll stop talking now. It was my pleasure to speak to patients and I know I see 297 on here. So, I'm really honored to have had that opportunity, and I hope this was helpful to you and gives you some understanding of how this really works. And I wish I could talk more, but I'll let it go for now. And thank you again.
Paige:
Thank you, Dr. Pimentel. I really appreciate you speaking with us tonight, and I hope that everyone found this webinar valuable, informative. Before we go, I just wanted to do a short recap of the tests that Dr. Pimentel spoke about tonight.
We have the Trio-Smart breath test and the IBS-Smart blood test. They're both at-home kits that you can do in the comfort of your own home, mail them in and receive your results either through your provider or through your email if you go through our telehealth service online.
The Trio-Smart test, that is the breath test that tests for all three of the gases, hydrogen, methane, and now hydrogen sulfide. It is also the only breath that can give you that complete picture of your gut health with those three fermented gases. And we're trusted by over 100,000 patients. We have sensitive equipment. We're CLIA-certified, and we are again, the only three-gas breath test on the market.
I just want to say thank you very much, and I hope that you have a great night.