IBS Awareness Month Q&A w/ Dr. Mark Pimentel | Cedars-Sinai

Good morning, welcome this is Facebook
live I’m going to be talking to you about IBS, bacterial overgrowth, and
answering some of your questions. Remember this is IBS Awareness Month so
we’re doing a number of outreaches in different capacities to try and inform
the public and give the people an opportunity to ask me questions directly.
I know it’s hard to come to our office and see us so we’re trying to do these
kind of outreaches and also world IBS day is coming up on the 19th so a lot of
IBS excitement this month but remember every day is IBS day for people who have
IBS so it doesn’t end on April 30th. So I’m gonna go ahead and see what kind of
questions we have coming in so far and then let me answer those questions right
away. First question is how do people know if they have IBS. This is tricky so
what used to be used or has often been used as the Rome criteria. The Rome
criteria say you have pain and you have change in bowel function, essentially, but
so does Crohn’s patients so do patients with celiac disease so it’s really not
specific for IBS. We’ve been very lucky because we have developed a test that
measures anti cdtv and anti vinculin antibodies and we can actually make a
confident diagnosis of IBS. If both markers are positive there’s a 98%
chance you have IBS and not IBD meaning Crohn’s or ulcerative colitis. That’s
pretty cool so we’re very thrilled about this next generation test called IBS
Smart. What is the best diet for someone with IBS? So I don’t know how many of you know but we recently published with a
colleague of mine a review article on diet and IBS. So the question is what do
we eat with IBS and in that paper we described a number of techniques of
eating but also different food additives or food spices that that can actually
inhibit bacteria but but specifically what we use is we
use the low fermentation diet. The low fermentation diet we sort of developed
it in year 2000-2001 and it basically restricts a number of foods that ferment.
Now it’s not as restrictive as the Low Fodmap diet as you know the Low Fodmap
diet is very popular these days the couple of problems with the low fodmap
diet is that it and within any diet for the most part is that it’s hard to do.
It’s hard to do the Low Fodmap because it’s very restrictive. The other problems
that have been keen encounter with the Low Fodmap diet is that the Low Fodmap
diet is so restrictive that after three months you get nutritional deficiencies
that are measurable but also they change the microbiome and make the microbiome
less diverse: less diverse, bad. And so we think that the Low Fodmap diet cannot be
sustained. The Low Fermentation diet which is what we developed can be
sustained indefinitely, we think, because we don’t see those nutritional
deficiencies and anyways we could provide more details on the low
fermentation diet if requested. So somebody was asking if Creon helps Creon
is a trade name for pancreatic enzymes. So the whole philosophy about bacterial
overgrowth is and remember bacterial overgrowth is the largest part of IBS we
think about 70 percent of irritable bowel syndrome patients it’s bacterial
overgrowth especially the diarrhea type so the diet that we just talked about
allows food to get absorbed higher up so there’s less food for the bacteria left
behind. So the more fiber you eat all that sort of stuff you’re feeding the
bacteria and we want you to restrict those things so that you don’t feed the
bacteria just feed you. Pancreatic enzymes will help digest food a little
more quickly and higher up at least that’s the that’s sort of the theory and
therefore maybe less for bacteria. To be honest I use that usually when other
therapies have been unsuccessful so if you have failed any
i otic sore of you you have failed other therapies then we tried the pancreatic
enzyme approach for a lot of reasons it’s expensive, especially the
prescription type, now people do over-the-counter as well and that’s less
expensive. So the hydrogen sulfide breath test is a very exciting development and
what I can tell you is that when hydrogen sulfide is elevated that
predicts diarrhea when methane is elevated that predicts constipation so
it’s going to be key to have all three gases hydrogen methane and hydrogen
sulfide and what I can tell you is that it’s not many months away it’s more like
weeks away at least that’s what we were hoping but stay tuned we’re there’ll be
an announcement when it comes close. So, thanks for that question. So it’s interesting because of this new
biomarker for example the new anti CDT be an anti being keulen let me explain
those for a second so that you understand. We think that overgrowth /
IBS develops from food poisoning. So you get sick, you ate some bad food somewhere,
on or during your travels, you had bad diarrhea, that sort of settles down, and
then you end up having this IBS or then erythromycin SIBO. There’s a toxin in
bacterial gastroenteritis or bacterial food poisoning in those include
salmonella, Campylobacter, Shigella, and e-coli. When you get those, the toxin
causes an antibody to form in your blood but it also causes you to form an
antibody to you to the nerves of the gut and that impairs the flow and then when
the flow of the gut is impaired or slowed down it’s sort of like a slow
drain then you get bacterial build-up. That’s what we think is happening but
well some people are suggesting maybe if we provide immunoglobulins maybe you can
dilute out these antibodies or have some impact on these antibodies and to be
honest that really hasn’t been tested so we don’t really know if that’s going to
be effective so at this point I can’t give you a good answer on that question.
What are the most common symptoms of IBS. So the most common symptoms of IBS is
the next question. So, it really varies but let me say it in a different way
than just listing the symptoms. So if you look at patients with Crohn’s disease
when they’re in a flare generally speaking they’re having 10 bowel
movements a day and it’s miserable 10:00 today but 10 tomorrow 10 the next day
and the 10 the next day and I and I say that at this at all my talks because at
least it’s predictable so you know you’re gonna have 10 you roughly know
when but IBS is totally different. You could wake up in the morning have
nothing, you go to work still nothing, you’re in the middle of a meeting
suddenly you’re doubled over and have abdominal pain and you go to the
bathroom and you have diarrhea for half an hour
or you’re on the opposite spectrum or you don’t have a bowel movement for days
at a time and you never know what it’s gonna you coming you’re hoping hoping
and this still doesn’t come and you’re bloated and distended. So I know I’ve
sort of listed them it’s diarrhea bloating and constipation
but listing them really doesn’t Express the the difficulty of the patients. So
imagine you’re going on a date and suddenly you have to have a bowel movement
and you’re gone for half an hour and the unpredictability of the symptoms is
really the tragedy for these patients because they really don’t know when it’s
going to strike and that’s difficult imagine getting on an airplane and then
you have to put your seatbelt on and now it strikes. So this is the misery that
these patients so just listing the symptoms doesn’t really capture the
essence of this really difficult disease. So as I said there’s the low
fermentation diet so the question is are there foods that you should avoid. Our
low fermentation diet is quite expansive in its explanation but there’s absolute
noes and the absolute noes are in general no beans.
So no legumes because they ferment everybody knows beans cause gas and so
those will feed the bacteria the most. The second would be to try to restrict
non absorbed sugars. So things like sucralose which is a sweetener, sorbitol
a sweetener, and there’s many different varieties of these
alcohol sugars maltitol, lactitol, and those should be
avoided as much as you can because if you’re gonna blow you’re gonna blow from
those things and then there’s sort of minor criteria after that so try to
avoid lactose because that’s harder to digest and high levels of fructose such
as in sweetened drinks with fructose. So that’s sort of the starting point of the
diet. So visceral hypersensitivity is the question. What are treatment approaches
for visceral hypersensitivity. So why are you getting visceral
hypersensitivity? So for those of you don’t understand the question visceral
hyper sensitivity means when you have something going on IBS they used to
believe that you put a balloon in the rectum you inflate it and then you feel
pain at a lower threshold of that balloon inflation meaning your gut is
sensitive to pain but we didn’t know why why is it sensitive to pain. Now, in
treating overgrowth when we treat overgrowth the pain disappears so the
question is the pain due to the bacteria that changes, we don’t know. Is the pain
due to the fact that the bacteria are gone and there’s less gas and distension
because let me tell you when you’re bloated like this you’re in pain and you
have discomfort so most of my patients when they speak to me they say when the
bloating is down the pain is gone and we see that routinely and so
basically what I would do is treat the overgrowth, the overgrowth goes
away the pain gets less. But let me say one thing about methane because
methane is special. So when methane is present during a breath test as you’re
looking for bacterial overgrowth. Number one we know methane constipates but
methane does something else it’s not constipating you by paralyzing the gut
it causes the gut to spasm or contract therefore restricting flow so it’s
sort of key to know this because pain can be generated from these contractions
from methane and so you can get cramping discomfort just from the methane gas
itself. So there’s multiple ways that you can get
discomfort from this illness. Why does stress aggravate IBS? The question is why
does stress aggravate IBS. So, if you go back to all the clinical trials and
anxiety, depression, and stress as as potential culprits in IBS none of them
have been level one evidence. So there’s never been a study that says you impose
a huge psychological trauma on a group of 500 people and then no psychological
trauma on another 500 and the first 500 is getting IBS because of that exposure.
Never been done, there’s no such study. If you compare stress anxiety depression in
Crohn’s disease or ulcerative colitis compared to IBS, this is a paper that we
published a couple of years ago, IBD ulcerative colitis and Crohn’s has more
anxiety and depression even than IBS. So but we don’t say that’s the cause of
inflammatory bowel disease. There is one study that we quote now because it is
the definitive trial if you looked at the US military deployments to war zones
and you looked at people before and after they experienced tremendous
anxiety psychological trauma from witnessing human death and suffering,
experiencing you know psychological injuries, even physical injuries all of
those creating such psychological trauma for them and they did develop IBS. Had
nothing to do with the stress anxiety or psychological events it had all to do
with whether they got food poisoning when they went abroad into active combat
zones. So we now know stress is not a cause of IBS but rather food poisoning
is the major cause but stress of course you can give you diarrhea. Extreme
stress does this. So if you know before an exam and you’re really stressed and
then you have to go to the bathroom that’s common but extreme stress just
causes it in that moment not chronically. What’s your advice to someone who thinks they have IBS and their doctor thinks it’s all in their head? So the
advice is the question about if your doctor says it’s all in your head and
you’re sitting there and not knowing what to do. So this has been very
frustrating to me and there’s a lot of things that are frustrating to me
because and I’ll get to them but let me address the question first. The first
thing is there are still doctors who haven’t been educated on this new data
in 2019 if you’re a gastroenterologist and you don’t understand that food
poisoning causes IBS because the Mayo Clinic two years ago published 45
prospective studies all mashed into a meta-analysis saying we are confident
food poisoning causes a portion of IBS that’s fact now there there’s no contest
about food poisoning leading to IBS. If that’s fact you can’t say IBS is
in your head the blood test that we develop is a biomarker it says you have
IBS with definitive piece of paper that measure the two antibodies that are from
food poisoning. You had food poisoning you now have IBS this is an organic
disease. So you have to point your doctor towards the testing maybe, you have to
point your doctor towards the the literature, and it’s a shame that you as
patients have to educate that clinician but they are undereducated in the area.
For people with SIBO do you recommend continuing with antibiotics or herbal
treatments until they achieve a negative breath test. The question is if you have
SIBO do you recommend taking antibiotics or herbal antibiotics until you’ve
completely gotten them into remission meaning a negative breath test. So my goal
in my clinic is 80% improvement in symptoms. I don’t think we can ever get a
hundred percent because the motility of the gut is damaged by the antibodies
that I’ve been speaking about a number of times during this thirty minutes and so you want to take an antibiotic and clear the overgrowth but also if the
patient comes back and they say look doctor I’m 90% 80% better I don’t need
to do another breath test because it’s not going to make me
treat again likely the end bacteria have shifted and we’re just going to leave it
at that and then either put them on a low-dose prokinetic or just diet alone
to see how it last. The trouble is when it doesn’t eradicate or when the patient
comes back and feels 20 to 30% better then it becomes important for you to
really start to investigate the patient more as a doctor and see if you can
figure out what’s going on with the patient. So this is the ultimate question
the antibodies that are you know really taking off right now to measure these if
we can get them out of your bloodstream we think IBS goes away. At least in the
ones who have this to anybody. So this is what we’re working on day and night in
our lab and trying to figure out if we can get those antibodies down with
something and make this go away. Another technique we use is if you don’t know
you have the antibody you don’t know what to do.
Meaning in our clinic if we measure the antibody and the antibodies positive
we’re telling patients okay you travel but we’re gonna give you
prevention for this country. We’re going to guide you not to eat at these types
of restaurants and and avoid food poisoning. If you avoid food poisoning
long enough and you don’t have the auto antibody just the anti CD TB it will
diminish and I have patients where they don’t need anything anymore
the IBS has disappeared. So I think the antibodies are the key to the next phase
of making people better and possibly even curing some of these patients. Do I have any updates on the small bowel
microbiome with deep sequencing. Well so in about five weeks we’re going to
present a ton of data on this and I can’t tell you today and I’m sorry but
it’s being presented at the ddw we will be of course tweeting about it and using
social media just to help all of you maintain and stay ahead of the curve so
to speak but this data will be very compelling that I can tell you and
very exciting where we can’t wait to present
it so stay tuned please because it’s going to be a big deal. The question
is tell us about the root cause of SIBO. So thank you for that question. It’s sort
of as I explained it that we think food poisoning and the development of these
two antibodies one of which can paralyze the gut or affect the flow of the of the
gut because it affects the nerves and then you get this build up of bacteria.
Think of it like sort of like a plug drain when the drain is sort of not
flowing well you start to get more bacteria building up because it’s like a
swamp instead of a nice flowing river and that’s what we think is causing this
change in the bacteria in the gut. Does a patient who takes prokinetic
to keep the bacterial overgrowth away need to stay on it forever? So let me
tell you sort of my vision. So the vision here is yes if the if the motility is
impaired you need to take the prokinetic usually we do it for a prokinetic is to
make the gut move correctly so that the bacteria don’t come back. My goal is you
take the antibiotic once then you don’t need it for a period of time because
you’re taking things and using diet to keep the bacteria from coming back
because my goal is not to go antibiotic, antibiotic, antibiotic that’s not
fruitful. We want to treat once see how long we can keep it away. Inevitably you
will have to treat it again I do believe in a lot of the patients but some patients
just one and done. A third of patients who respond for example to rifaximin
and they take it and then they never need it again. I see them at the mall or
I see them out out shopping and I and they say nice to see you everything’s
still good. So there are patients like that but still the majority need the
prokinetic. There are some people who continuously need prokinetic. There are
others who only need it for a few months and then they’re able to wean. But it’s
all sort of depends on how the flow goes in the clinic.
What are your thoughts on charcoal tablets? What are my thoughts on charcoal
tablets. So charcoal adheres to things it’s can stick to some of the gases it
can stick to some of the bacteria even people believe but the gases principally.
The problem with charcoal is you’d have to take a ton of charcoal in order to
get all those that gas out and it really isn’t getting rid of the bacteria so
it’s a temporary sort of solution. I don’t use it that often because I don’t
find it to be all that beneficial but it’s same thing with simethicone which
is a gas breaker it breaks bubbles doesn’t get rid of the gas. So you have
one big bubble instead of a whole bunch of little bubbles so it’s these things
are really great in principle but don’t always work well. So the question
are there effects of hydrogen sulfide on gastrointestinal motility and the answer
is hydrogen sulfide is what we call a gasotransmitter. Gasotransmitter
means it effects the nerves and cell function. Hydrogen sulfide is very toxic
at high doses. Methane is now a gasotransmitter because of the work we did
here at Cedars. It basically causes the nerves and the muscles to spasm and
that’s a gasotransmitter so yes they both have an influence except on
opposite ends hydrogen sulfide being associated with diarrhea and methane
being associated with constipation. Should I try to get my methane below 5
if constipated and still having symptoms. So some
of our early work says you really need to get the methane below 3. There was a
North American consensus for breath testing which we were part of. Again a
consensus is you get a series or a group of scientists together to try to look at
the literature and decide on what the best criteria are for research but also
for patients and we decided methane by consensus 10. I happen to be one of
the ones who said it should be lower but you know you go with the consensus.
However at three parts per million is really where I think is the pivot point
for constipation. So every time we looked at it if you rose a greater than three
meaning you had more than three parts per million on the breath that’s when
you started to see the curve of constipation develop. The question is
using bone broth for SIBO patients. So bone broth would fit into a low fodmap
would probably fit into a low fermentation diet. So there are benefits
to bone broth what we’re seeing with bone broth is that people are ingesting
it a lot and not getting enough calories and not getting enough nutrition as a
whole so it isn’t a cure-all but there is some good health benefits to it. Hydrogen sulphide bloom what has mass
found to be the culprit organism and the answer to that is stay tuned for later
this year. Can I talk about using a biofilm disrupter. So biofilm disruptors
are used to try to break up some of the biofilms that are associated with bad
bacteria if you want to call it that. first of all let me set my record
straight from how I look at things I don’t think of bacteria as bad or good.
I think of bacteria as either healthy or unhealthy meaning it’s not one organism
usually unless it’s food poisoning which we talked about. Your microbiome is
composed of a balance a balance of good and bad in the sense that you have to
stay in a balance let me let me say it another way. The microbiome is like a
city and we use this analogy all the time you have plumbers you have doctors
you have lawyers you have sanitation workers. You need all of these key people
and they’re all almost equally important in the sense that if you don’t
sanitation workers trash builds up everywhere. So it’s the same thing with
the microbiome you need a collective and the right proportion of that collective
to maintain balance and when you don’t then things go off the rails. The same
thing happens in the case of a biofilm the question is if you disrupt the
biofilm are you getting rid of all the good and the bad equally or are you just
getting rid of the bad and I don’t think anybody’s answered that question. So work
is being done and we’re also interested in biofilms and we’re studying them in
the reimagine study. The reimagine study just to give that a bit of a plug is
we’re getting 10,000 consecutive patients aspirates from the small bowel
to try and find out exactly what’s going in the small bowel microbiome and some
of that data is being presented in five weeks so stay tuned for that as well. Question is can you get an accurate
breath test if you’re having chronic long-term diarrhea. So I’ll give you some
examples of where the breath tests can really go wrong. So somebody comes in
they want to do a breath test but they were constipated they took a laxative
last night cleaned out their whole call and they come in for a breath test it’s
a flat line it’s a flat line because they clean their whole colon out and so
you’ve got to be careful not to to do that the night before the breath test
but if you’re having long-term diarrhea also you can have a flatline because
you’re constantly purging so that type of patient really needs further workup
to be sure of what’s going on. So the question is can you comment on C fo overgrowth,
a small intestinal fungal overgrowth. Dr. Satish Rao from Georgia is really one of
the pioneers and looking in that area. I’m sure he has more research to be
presented at this big meeting I keep talking about but we are looking at the
small bowel microbiome right now in this reimagined study and fungus is on our
list so stay tuned we will we will have some data on fungus shortly. Is water
helpful for IBS patients? Is water helpful for IBS
patients. Look, I told my patients water is needed of course we’re made of water
so that’s obvious what I really say to patients there are patients for example
who have one bowel movement every two weeks that I see in my clinic these are
extraordinarily sick people in terms of constipation. One in particular I
recall very distinctly was drinking two gallons of water a day.
She was urinating like crazy but not a drop more stool came up your small bowel
is twenty feet long the if you spread it out it’s the size of a tennis court you
put two gallons of water on a tennis court
believe me it never reaches the colon it’s gonna all be absorbed so it’s a
drop in the bucket and what the capacity of the small bowel is to absorb water. So
you can’t make constipation better by drinking more water I’ve seen that time
and again. So can chronic IBS or having chronic IBS cause bad breath. So the
answer to that it’s is it’s complicated we do see some patients when they have
hydrogen sulfide that they feel like they’re emitting some foul smell and
we’re looking into that with a new breath test that’s coming out. I think
we’ll have some answers by the end of the year but we don’t have that answer
currently. Question is what are my thoughts on probiotics. People always ask
me this question I am not against probiotics I am against science
meaning I’m against probiotics without science. I don’t like the idea of 50 or
60 different probiotics on a shelf but hardly any of them have science in IBS
or data in in small intestinal bacterial overgrowth. I think we will be able to
find links meaning some probiotics for example bifida is a prokinetic,
lactobacillus can be a prokinetic, others are anti-inflammatory but it doesn’t
quite work that way and it’s not quite that simple. Remember there’s a city and
an balance in the city and so you can’t
imagine putting just a million lawyers in the city every day and hope that the
city becomes amazing. That’s the notion of probiotics as you’re putting one
organism or two organisms or five organisms and hoping to balance out
1,000 organisms. So it’s not quite simple and that’s why we’ve gone to fecal
transplant as a method of trying to re-establish a good micro flora. Problem
is and I’m gonna say this now be coal transplant has been proven to be
unhealthy or at least placebo is more beneficial than fecal transplant in some
of the studies the double-blind studies that have been done. So fecal transplant
don’t do it for IBS for now. We’re going to take one last question. What if smart blood test is negative for both
antibodies? So if you do the IBS smart test or they measure the antibodies the
anti van keulen, anti cdtv antibodies and they’re both negative then you need to
think of another reason why you have your symptoms. So the way I would
approach it which really so let me take another start at this.
IBS patients go to their doctor the doctor thinks it’s in their head but
doctor thinks it’s in their head but still does a colonoscopy big patient
gets a bill, does a cat scan patient gets a bill, does an ultrasound patient gets a
bill, does blood test stool tests, etc etc a patient gets a bill, and a copay.
Patients spend thousands and thousands of dollars and in the end the doctor
says well we can’t find anything I think it’s IBS. Do the blood test it’s positive
you have IBS four days later stop all the madness stop all this expense that’s
really where we need to be and the patient comes out of it saying yes now
the problem is if the patient is negative so what’s key here is if you’re
negative then maybe you should have some tests. Why are you doing all these tests
before you do a test that can diagnose it so I think for the for the person
asking that question asking that question maybe there’s another reason
maybe you need further investigation. In my clinic that’s how we would approach
it. Well I think that’s all we have for
today and I’m sorry I see a bunch of questions continuing to come across and
I apologize for not getting to all of them it just means we need to do another
one of these sometime soon. Maybe after ddw because that’s when we’re gonna be
presenting some super exciting data and I think you’ll all be interested to hear
more details about that. So remember it’s IBS Awareness Month
but it’s IBS Awareness Day every day for patients with IBS don’t forget that and
please stay tuned to our follow us on Twitter and Facebook because we do post
some of our science there so that you can keep up to date thank you.

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