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a new ibs solution
by Dr Mark Pimentel
A New IBS Solution explains how Dr Pimentel of Cedars-Sinai Medical Center has developed a new treatment for IBS sufferers, based on the theory of small intestinal bacterial overgrowth (SIBO). To put it simply, Dr Pimentel believes that many IBS patients are suffering from abnormally high levels of gas-producing bacteria within their small intestines. By testing for these bacteria using a breath test, and then eradicating them using antibiotics and diet therapy, the symptoms can be reduced or removed.
The digestion process produces various different types of gas, and of these, hydrogen and methane are detectable in the breath and can be measured. The levels of these gases are then used to estimate the numbers of bacteria present. The levels of gas may also correspond with the type of IBS present, as constipation sufferers tend to have higher levels of methane.
If you do not have bacteria in the small intestine, it will take around two hours before the lactulose reaches the bacteria in the colon which are present even in healthy people. Therefore, if the levels of gases rise after only a short time, and in high concentrations, it shows that bacteria are probably present in the small intestine.
an interview with dr mark pimentel
How did your interest in IBS begin, and when did you first formulate the SIBO theory?
I just could not accept that IBS was entirely a psychological problem and thought there had to be more to the story. The inspiration for my book was provided by my IBS patients. There is an unfortunate stigma attached to the diagnosis of IBS suggesting that symptoms are psychosomatic, or 'all in your head.' For almost two decades, patients have been told that they need to see a psychiatrist instead of a gastroenterologist. Some IBS patients have been given anti-depressant medications, which, in fact, do not address the root causes of this condition.
Recent studies now prove that, in most cases, IBS is not related to any psychological problem, not even stress. Even with this scientific data, however, it has proven to be very difficult to remove the long-standing stigma that has been associated with IBS. We now have a much better idea of what causes IBS. In my book, I take the reader through the history of IBS and how the new theories of IBS have changed the way we look at this condition.
How do people develop SIBO?
We believe that movement problems of the small intestine result in bacterial overgrowth in IBS. The concept that disordered small bowel motor function causes SIBO is not new. What is new is that it could be the culprit in IBS also.
In essence, often IBS patients describe that they had perfectly normal bowel habits until, for example, the case of food poisoning they had 10 years ago. This would be known as the heralding event for their IBS. The book describes how the association between IBS and the patient's heralding event was discovered and how it could lead to bacterial overgrowth, which causes chronic IBS symptoms.
Are there any specific symptoms for SIBO?
SIBO symptoms are bloating, abdominal cramping and alternating bowel habits. Essentially the symptoms are identical to IBS.
What percentage of IBS sufferers do you think could actually be suffering from SIBO, and do you think of IBS and SIBO as two separate conditions?
Based on all the research, it is likely that somewhere between 40 and 84% of IBS patients may actually have this problem.
There has been some criticism of the SIBO theory, and some studies have had difficulty in replicating your results. How do you respond to this criticism, and do you think that the SIBO theory is now generally accepted or is it still controversial?
Only one study has had difficulty replicating our results. The rest is just commentary. There are more than 10 papers that have replicated the results. It has been quite interesting this past year. Over the last 12 months there has been a growing use of rifaximin for IBS. Rifaximin has changed everything because in contrast to our previous antibiotic, neomycin, rifaximin is very effective. Now gastroenterologists are seeing dramatic improvements in IBS based on this drug.
I would estimate that compared to a handful of physicians using this concept to treat IBS two years ago, more than half of all gastroenterologists in the US are now considering bacterial overgrowth in the framework of IBS and treating it this way. Just remember that bacterial overgrowth can recur and the book outlines ways that may help prevent this from happening so as to avoid excessive antibiotic use.
Is there a list of hospitals or clinics in the US which administer the breath test for SIBO, and do you always need a doctor's referral?
Last I heard, nearly 60-70% of gastroenterologists in the US are trying or considering antibiotic-based approaches for IBS.
Is the breath test available in the UK or Australia?
Yes - both.
Would you ever advise a patient to try the SIBO treatment (antibiotics etc) without having a breath test first, if they did not have access to the test?
Many doctors do this but our operation is geared toward doing breath testing first.
I know you have used Zelnorm as part of the SIBO treatment. What was your view of circumstances surrounding the Zelnorm recall, and do you think it may return in the future?
I think that the FDA suspension of Zelnorm may be temporary. It seems unlikely that the small number of patients with pre-existing cardiovascular disease who get another event while on Zelnorm means anything. Zelnorm may have made patients feel well so they became more active and this is why they had more events.
What kind of diet advice would you give to IBS patients?
While I do not believe diet issues to be the cause of irritable bowel syndrome, diet has an important role. If bacterial overgrowth is a major causative factor in IBS, these bacteria cause trouble because they ferment, thus producing gas that will cause distention and bloating symptoms.
The best way to help bacteria is to give them carbohydrates. But not all carbohydrates are equal. The worst carbohydrates are those that humans cannot digest. What you cannot digest will go to the gut bacteria. The top carbohydrates I suggest avoiding on this basis are fiber, high fructose corn syrup, sorbitol and sucralose. By reducing these sugars, there will be less bloating.
Would you recommend probiotics as a general treatment for IBS, and if so is there any particular strain or product to look for?
Probiotics such as lactobacillus and bifidobacteria provide relief to the severity of IBS symptoms by stimulating the cleansing wave mechanism of the intestines. In a double-blind study involving 50 patients with IBS, test subjects received either the probiotics or a placebo powder for a period of 28 days. At the end of the study, 49% of the probiotic group showed improvements in the level of their abdominal pain, compared with 29% of the placebo group. While probiotics have not been found to eliminate IBS, the reduction of IBS symptoms is certainly a good outcome.
What are some of the reasons you recommend peppermint capsules?
Peppermint has been shown to be a calcium channel blocker of the muscle because of its ability to block calcium fluctuations in the muscle cells, thereby causing muscles to relax. When taking peppermint, the muscles of the stomach, small intestine, and colon are less likely to contract against gases, reducing the sensations of high pressure (or cramping) in the abdomen.
To achieve the above benefits, the peppermint needs to be enteric-coated to protect it from being broken down and digested prior to reaching the important areas of the gastrointestinal tract.
In your book, you discuss some of the advantages of taking digestive enzymes. What are some of those benefits?
The basis for using digestive enzymes in treating IBS is that I believe taking the enzymes will increase the speed of digestion. The faster the food is digested, the quicker it is absorbed. This leaves fewer available calories (or nutrients) for the bacteria of the gut. With this reduced number of calories, the bacteria will likely decrease in number. Typically, patients who take pancreatic enzymes report a 30% to 40% improvement in their symptoms.
Do you believe that stress plays a major role in contributing to IBS symptoms?
I do not believe that IBS symptoms are caused by stress. However, I do believe that stress can exacerbate the situation, making symptoms worse. There is data to suggest that stress may even increase bacterial levels in the gut. IBS patients often tell me that they feel worse when stressed, but are still symptomatic when not stressed.
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