An exclusive interview with Dr. Mark Pimentel of Cedars-Sinai Hospital.

Part II

Mark Pimentel is an associate professor of medicine at Cedars-Sinai Medical Center in Los Angeles. His medical training includes a fellowship in gastroenterology at the UCLA Affiliated Training Program. He has been very active in research and has served as a principal investigator or co-investigator for numerous basic sciences, translational and clinical studies in areas like irritable bowel syndrome (IBS) and the relationship between gut flora composition and human disease. Dr. Pimentel is widely known and sought out for major scientific developments that he has pioneered, including the discovery that IBS is a condition of altered intestinal microbial balance and the recognition that antibiotics improve IBS. This officially legitimized IBS because before these discoveries, IBS was often considered to be a psychosomatic condition.

Friedbauer: Let’s talk about antibiotic treatment options for someone who comes up positive for SIBO, IBS caused by food poisoning? What is the gold standard for hydrogen-dominant SIBO (small intestinal bacterial overgrowth) versus methane dominant SIBO (now called IMO)?

Pimentel: [The antibiotic] rifaximin is FDA approved for irritable bowel syndrome (IBS) on the basis that IBS is a microbiome condition and rifaximin has been shown in a study just a year-and-a-half ago that if your breath test is positive in IBS and you get rifaximin you’re more likely to respond to it, so that’s the one for hydrogen. For methane we lean on one double blind study, a randomized control trial where [two antibiotics] rifaximin plus neomycin are required to have a greater benefit on methane. In fact, almost 80% of people who take rifaximin plus neomycin for methane in the case of constipation, their constipation improves. Where we are still learning is, because *hydrogen sulfide is new, how to treat hydrogen sulfide, and again here we lean on some papers from the 1990s, where bismuth products (Pepto-Bismol) are very good at reducing hydrogen sulfide, so we add rifaximin to bismuth like Pepto-Bismol. That’s how we treat the hydrogen sulfide, and again we are seeing good successes with that strategy for all three gasses.*

*Please note the newest SIBO breath test (Trio Smart) now includes testing for hydrogen sulfide in addition to hydrogen and methane gasses.

If you have a patient who cannot take or tolerate one or all the antibiotic options, what does the research show on the use of botanicals such as oregano, garlic or neem, among others?

Pimentel: The Hopkins group has shown that berberine dominant cocktail of herbs has been almost as successful, if not as successful, as rifaximin for treating routine hydrogen SIBO. In the case of the methanogens, we know that allicin, which is a component of garlic (there are various products that sell purified allicin), does reduce methane production and so can be effective. Unfortunately, what I see in my practice is it’s effective short term, maybe for a month, six weeks there is benefit and then it starts to wane; the bugs are smart and they figure it out and then they don’t respond as well. If you want to stick to the antibiotics route and you can’t tolerate neomycin, even though it’s not published yet, [the antibiotic] metronidazole is a good substitute for neomycin, and works as well in my opinion.

So now that we understand the options for treatment and management of the bacteria and archaea, we know there is also a problem with decreased gut motility. If the person is suffering from IBS/SIBO caused by food poisoning, what treatments do you recommend for addressing the decreased gut motility?

Pimentel: You can’t give antibiotics over and over again every two months, so we use prokinetics at night, when your cleaning waves occur. Cleaning waves only occur when you are not eating. So, part of our strategy is to give a prokinetic at night because you can have as many cleaning waves induced by the medication as possible. The other strategy that we apply is to the diet structure, the low fermentation eating diet: It’s a compositional diet, but it also tells you how to eat, meaning you have to have spaces between meals; let those cleaning waves come. If you are eating all day, your gut is constantly working and never cleaning, so there’s a couple of strategies that we do to optimize cleaning wave production.

*A prokinetic agent is a type of drug or natural supplement that enhances gastrointestinal motility by increasing the frequency or strength of contractions, but without disrupting their rhythm. It helps induce cleaning waves.

What are your thoughts on other treatments to address decreased motility such as acupuncture, manual therapies such as visceral manipulation, and stress management?

Pimentel: Let’s talk about stress and anxiety. There is a huge study looking at military deployment. The folks who went to Iraq and Afghanistan in the last two decades, they came back with IBS, many of the troops, and they tried to figure out what it was. It wasn’t the extreme stressful events that they experienced, it was whether they got food poisoning there. But that doesn’t mean stress doesn’t affect your gut; absolutely stress and anxiety will make your IBS worse or your SIBO worse. If you are stressed, you do have fewer cleaning waves. That’s known; if you are stressed you will have more and worse symptoms. It’s not quite that simple, but of course stress management is important.

Acupuncture is sort of a mixed bag as to whether it works or not in this situation; acupuncture is great for nausea—it’s absolutely proven for nausea. It’s a little bit more foggy for this, but if patients do it and they respond, then that’s absolutely fantastic, but I don’t routinely order it because I don’t routinely get a good response.

Visceral manipulation is something that’s done more if you are confirmed to have adhesions. I will say that I have had some very good responses in patients with mild adhesions, but it’s like anything else; adhesions are formed by tears inside the gut, so if you tear the scar with a manipulation or even surgery, does that mean it forms more scar or not? And that’s the part I don’t quite know yet because I know if I do surgery or someone does surgery again, that you could have more or the potential for more scarring, but if you tear the scar with visceral manipulation, could you also form more scar?

How about the exercise? As a physical therapist myself, I always wonder, could exercise, which can activate the gut, do something for SIBO?

Pimentel: You are absolutely right. Exercise helps in a lot of ways. For example, keeping a tight core is important because it prevents the distension—it actually helps to push the gut further down—in other words, keeping things moving in the right direction. The other thing is, exercise in and of itself makes gut motility better, makes colon contractions better to make bowel movements more often, as long as it’s within moderation. We do see patients who are inexperienced training for marathons, and they have all sorts of bowel problems because they’re training so hard. They get lack of blood flow to the gut as all the blood is going to the muscles and they can even have bleeding from their colon if they overtrain. Like everything else, it’s a matter of moderation, especially if you have a condition, but exercise is very beneficial.

Let’s talk about dietary approaches, which is a pretty hot topic. I hear we are starting to move away from the low-FODMAP diet [a diet low in certain sugars that may cause intestinal distress] and moving toward the SIBO diet. Can you talk about this approach and why it helps with treatment?

Pimentel: We came up with this idea of low-fermentation eating, and it stemmed from the fact that a lot of these SIBO patients were coming in and eating almost nothing: chicken, rice, that kind of thing. First, that is not nutritionally sound, and second of all, their life was miserable; they couldn’t go to a restaurant with friends, needing that limited of a menu. Then the low FODMAP [diet] came along and it’s much more restrictive. You can hardly have any vegetables; you can’t have onions—onions and garlic are probably the most difficult things to remove from the diet because everything has onions and garlic! You can’t go to a restaurant because it’s the flavor they add to everything.

That made low-FODMAP really difficult for patients; it worked because it was even more restrictive, but it was difficult for three reasons: one, patients had a hard time with it because they couldn’t live a normal life; two, it actually causes nutritional deficiencies; and three, it reduces your microbial diversity because it’s so restrictive and that’s also considered unhealthy. So, low-FODMAP regrouped and said, OK we need to reintroduce some foods after a month; it’s not a long-term plan. Low-FODMAP is great for a month or two, but then what? So our low-fermentation eating is more, I don’t want to say liberal, but based on what I know about the microbiome and what foods would be best and not best.

Where can individuals learn more about what is considered the SIBO diet?

Pimentel: Well, we have a book coming out on April 12 that will be a good place to start, and there are various places on the internet where you can see our low-fermentation diet. I think your best source will be the book called The Microbiome Connection. A couple of our colleagues are putting out a cookbook in partnership with that book, that also looks at low-fermentation eating.

When should individuals start the diet? During antibiotic treatment or after?

Pimentel: I generally say, “Look, I’m not talking about the diet until we’re done with the antibiotics,” but as soon as we’ve done the antibiotics, we do the diet and frankly, the diet is meant to be a long-term thing.

Since cases of SIBO and IMO can reoccur, what is the protocol for these cases?

Pimentel: It depends on the reoccurrence. One patient may not even be taking the prokinetic anymore and be symptom-free and feel fine after two years, and another can relapse two months after treatment; that’s the patient that you have to ask, “Are you really following the diet?” and then you are going to give the prokinetic and you manage them that way. If they keep reoccurring, even though they’re responding to the antibiotics, I start looking for adhesions; I start looking for other things, because if there is an adhesion, treating it could be the cure for them; maybe they don’t need any of this—prokinetic and diet things—if the adhesion is gone, then their bowel will be freed up and back to normal. We take different approaches depending on how quickly things reoccur.

So it really can be quite the investigative process of figuring out what is going on.

Pimentel: That’s why the blood test *(IBS Smart) and constant thinking is important in this process. I’ve always had the philosophy: Don’t treat the symptoms, treat the cause; you treat the cause, the patient gets better.

*IBS Smart is a blood test developed by Pimentel that measures two antibodies that can definitively diagnose IBS caused by food poisoning.

To hear the complete interview, please listen to the author’s new podcast “Heal Your Gut, Heal Your Soul” on Spotify.

Jill Friedbauer has been working in the field of health and wellness for 20 years. She is a national board certified health and wellness coach, licensed physical therapist, author of the book “Heal Your Soul, Heal Your Gut,” and has a podcast, “Heal Your Gut, Heal Your Soul” on Spotify. Friedbauer is available for one-on-one health coaching, family health coaching, group coaching and speaking engagements. She can be reached via email at: [email protected], or to book a consultation, visit her website at: www.jillfriedbauer.com .