Get Gut Answers with Dr. Mark Pimentel - Live SIBO & IBS Q&A

Watch world renowned gastroenterologist, Dr. Mark Pimentel, as he shares the latest insights in SIBO, IBS, and gut microbiome research during this fascinating Q&A webinar replay.  Whether you’re newly diagnosed or seeking advanced insights, this webinar is packed with real answers.

🎯 Watch to Learn:

• What actually causes SIBO — from IBS to structural blockages like adhesions

• How food poisoning can lead to IBS via autoimmune damage to gut nerves

• The role of anti-vinculin and anti-CdtB antibodies in diagnosing IBS

• Why IBS is no longer just "in your head" — and the new gut-brain model

• Why 60% of IBS cases may stem from bacterial overgrowth (SIBO, IMO, ISO)

• The importance of testing for all 3 gases: hydrogen, methane, hydrogen sulfide

• How Trio-Smart is different and more accurate than standard breath tests

• Why lactulose breath testing detects more cases than glucose

• Treatment protocols for

  • Hydrogen-dominant SIBO 

  • Methane-dominant SIBO (IMO) 

  • Hydrogen sulfide overproduction (ISO) 

• When to retest after treatment 

• How high anti-vinculin levels predict tougher cases

• Why elemental diets work — and what’s changed to make them more tolerable

• The role of prokinetics like Motegrity in preventing relapse

• How to avoid relapse with a low fermentation diet

• Special considerations for pregnancy and SIBO/IMO

• Can a carnivore diet help SIBO? Dr. Pimentel explains its pros, cons, and limitations

• New therapies in development

🎁 Plus: Learn how to use the exclusive webinar code GETGUT50  to SAVE $50 + Free Shipping on Trio-Smart and IBS-Smart tests (Offer is for online orders only and expires 9/30)

About Mark Pimentel, MD:

🔬 Dr. Mark Pimentel is a renowned gastroenterologist and researcher, serving as the Executive Director of the Medically Associated Science and Technology (MAST) program at Cedars-Sinai. He is widely recognized for his pioneering work on IBS and SIBO, having published over 150 scientific papers and authored two books on the subjects. Dr. Pimentel's research has led to significant advancements in understanding the relationship between gut microbiome and gastrointestinal disorders, resulting in the development of new diagnostic tests and treatment approaches.

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Read the Full Webinar Transcript

Paige with Gemelli Biotech:

Hello everyone, I’m Paige Betts with Gemelli Biotech, the makers of the Trio-Smart and IBS-Smart at-home GI tests. We are absolutely thrilled to have you here tonight, and we hope that this webinar provides you with valuable insights on your gut health journey and hopes of helping you feel better quickly.

It is my absolute honor to introduce Dr. Mark Pimentel. He is an internationally recognized leader in the field of gastroenterology and microbiome research. Dr. Pimentel is the executive director of the Medically Associated Science and Technology Program, or it's called MAST, at Cedars-Sinai and one of the foremost experts in SIBO, IMO, ISO and IBS. His groundbreaking research continues to revolutionize how we diagnose and treat these complex conditions, and he's paving the way for more effective solutions for patients everywhere.

Dr. Pimentel tonight will begin with a presentation covering some of the key insights of these conditions, and afterward he will answer some of the pre-submitted questions that came in when you registered for this webinar. And then we will transition into live chat questions as well through the chat box. So without further ado, Dr. Pimentel, the floor is yours.

Dr. Mark Pimentel:

Thank you so much. I had a hard time coming up with 10 slides. I have a little over 20 slides because there's so much new information. And then I always have trouble because when there's so many people coming online, I don't know how many people online are familiar with SIBO and how many people are newbies to this space. So I want to at least cover some basics and then cover some of the new advances and try to at least... And I could do 200 slides because there's just so much going on right now. And I mean that really truthfully, because it's crazy what's going on with SIBO right now.

But let's start with what are the causes of SIBO? So remember SIBO, it's a diagnosis. It's causing bloating, it's causing symptoms of pain, diarrhea, and in some cases constipation. We'll get to that. But something has to make the overgrowth occur. Why is it happening? So this is the list of things that make it happen. So mechanical causes, so if your bowel is blocked or it's not flowing correctly, it's going to fill up with material, fluid, debris from food and those sorts of things and so then you're going to get a buildup of bacteria. So there's a laundry list, but if you look at the bottom, irritable bowel syndrome is the number one reason... When I say the number one reason. So if you had a hundred people with SIBO, the majority of people, it's irritable bowel syndrome.

So I'm going to spend a lot of my time focused there. But I want you to understand that if your SIBO doesn't get better, if you get treated and it doesn't get better, you have to be looking for some of these other things, or at least the doctors that are treating you should be thinking about these things. And I've got the list here. I'm not going to go through them in detail. But I do have a slide that sort of walks through some of the things that I worry about, because adhesions are quite common. So if you have an adhesion because you had previous surgery or you had a tubal ligation or an appendectomy because you had appendicitis, you can get adhesions and it's sort of like a bent hose. You got a scar that's connecting two loops of bowel and creating this bend here, and then fluid can't go through it and then bacteria builds up. That's one example.

Endometriosis can do this, Crohn's can do it because Crohn's can cause the thickening of the bowel and then things don't flow correctly because the bowel can't move freely, the muscles can't contract freely. And so you can get there. There's all sorts of weird things I'm not going to get into. Cecal bascule is quite rare. Tumors, of course, are also on the list because if something's blocking the bowel that can cause overgrowth. So we shouldn't close our minds. So if somebody's not responding to the treatment for overgrowth brilliantly, think about why their overgrowth is there and see if you can treat the underlying cause as another way of evaluating why the SIBO is there.

But I really want to turn my attention to the biggest group, irritable bowel syndrome. And the fact that we think IBS is caused by SIBO in a bulk of it, in the majority of it, has created some controversy because IBS was always thought of as a psychological condition. But we now know that's not the case. And we are looking at root causes of IBS and we think about 60% of IBS is SIBO, ISO or IMO, and we're going to get into those three categories of overgrowth of bacteria as we get through this lecture. And then I'm going to try and take you to some treatment options.

But there's this theory that is evolving, the brain and the gut are connected. Absolutely the brain and the gut are connected because of the vagus nerve, because of various communications with the bacteria producing chemicals like serotonin and other chemicals. So yes, there is a connection. But when your gut is not working and your brain’s check-engine light comes on, but you don't break the light on your dashboard because it's on, you go to the engine to fix the engine problem and the light turns off. And I think that's a good analogy of this gut-brain connection is that what's broken, in my view, in most patients with IBS is the gut and the brain is getting these check engine lights and sometimes not only the check engine light, but the fact that you're running to the bathroom over and over again has got to be anxiety provoking, et cetera. So we know that that connection is there.

So I don't want to dismiss that, but I just want to address that because you get a lot of noise on the internet, on social media about all these different aspects of IBS. And I want to make sure we cover a little bit of everything. But what we know for a fact, and this is undisputed now, is that food poisoning triggers the development of IBS. So you were fine until you went to Cabo or you were fine until you went and ate at a particular restaurant and you got food poisoning or you were fine until... And so food poisoning is an absolute cause of IBS. It's like one in seven people who get food poisoning will develop IBS from food poisoning. That's amazing. And we know this to be a fact. So we now know the cause of IBS.

But the question is, is that connected to SIBO? And this took over a decade of work in our lab and by others around the country that food poisoning has a toxin in it. And that toxin called cytolethal descending toxin in Salmonella, Shigella, Campylobacter, E. coli, the four horsemen, you could call them, of food poisoning that trigger IBS. And that toxin in and of itself can lead to irritable bowel syndrome. And how it does this is that the toxin has a similar sequence to it to... It forms antibodies to the toxin, part of this has a similar sequence to vinculin, and vinculin is a very important protein for the nerves of your gut so they can interconnect. And it's sort of like the wiring in your house and half the wires are pulled out, so only half the lights turn on in your small intestine. So your small intestine is not moving correctly because half the lights are on or half the wires are there when you have these antibodies to vinculin.

So if you want to say what is causing SIBO, what is the root cause of IBS? This could be the root cause. So if we can get rid of this antibody, everything wakes up, the nerves reconnect, the wires reform, and we're back to normal. And that's what we're really focusing on in our research for the future. We don't have such a drug yet, but stay tuned to the end of the presentation because we're close. So this antibody though can be measured as part of the IBS-Smart test, which Gemelli has, and you'll hear a little bit about that from Paige. It tells you food poisoning causes it, and you have these destructive antibodies. But if we give this toxin to rats, they get antibodies to this toxin, CdtB. And because of that, the fluid, the water weight of their stool goes up and the higher the antibodies, the worse their diarrhea is, if you look at this third graph on the right.

But what happens when the wires are pulled out? Like I told you earlier, the gut slows down and bacteria build up and this is the connection to SIBO. And even in animals, the bacteria building up go in one of three directions. One direction is not much happens, the green balls here, or they go in one of two bad directions. Too much E. coli, which is hydrogen production or too much hydrogen sulfide, which is other bacteria specifically desulfovibrio in rats. So we know that if you develop IBS from food poisoning, you're going to get one of these two bad microbiomes in your small intestine or one of two types of SIBO or overgrowth. So now going to IBS, breath testing in IBS, it's a knock out of the park here. This is a 25 study meta-analysis saying if you do a breath test in IBS, the chance of it being positive is much higher than healthy people. Full stop. Full conclusion. You don't need more studies. We have 25, 15 of them are considered high quality studies, and so we know that IBS and SIBO go together by breath test.

Now one of the things that you're going to be in a tug of war with, if you read social media, if you read anything about breath testing is, "Can I do glucose or should I do lactulose?" Glucose, you don't need a prescription for glucose. Lactulose for some strange reason is a sugar but still requires a prescription and it's just 10 grams of lactulose, but it still requires a prescription. But what happens with glucose is it gets absorbed so quickly that you run out of steam.

So you'll see the breath test, it goes up and then it starts to go down because it's being absorbed by you. You're absorbing all that glucose. And I'm 6'4", I'm going to absorb more in my mouth, in my esophagus, in my throat, in my stomach before it even reaches the small intestine than somebody whose smaller frame or smaller body or smaller GI tract. And so glucose is not the greatest substrate. What we learned this year is that glucose misses people who are sick because the people who are negative on the glucose breath test are sicker than the people who are negative on lactulose. So the glucose is missing people who could benefit. So this is proof of what I've been saying for years that lactulose is better, it's going to pick up more people who have a problem with the overgrowth.

But now we have three-gas breath testing. For years it's been two gas breath tests and the new development with the Trio-Smart is three gases because now we know there is hydrogen sulfide producing, I showed you that in animals and in humans it is the same thing, and hydrogen producers. Their third gas is methane, which is associated with constipation. So you really have to measure all three gases to get an understanding of the microbiome in you. The sensors in the new Trio-Smart are more accurate than the typical sensors in other instruments because it can measure it within a fifth of a part per million. So you never get confused about what the results are. The bags are able to hold the three gases for 10 days for shipping. The bag system is designed to keep those gases stable in that bag for that period of time and it doesn't alter the hydrogen sulfide. So it's important to measure all three gases.

We now know, I mean prior to this year, people said, "Well, how do you know it's in the small bowel? How do you know that when you measure a breath test with the three gases that you're measuring the bugs that are in the small bowel?" And this is now accepted for publication. And basically it shows that if you use the three gas breath test, the Trio-Smart Breath Test, if you have methane, methane bugs are in the small intestine. And these are the bugs, and the most important one is this Methanobrevibacter smithii.

If you measure hydrogen sulfide on a human's breath, you have hydrogen sulfide producers correlating with that breath sample when you look at the small intestinal microbiome. So proves that the breath test is actually telling us exactly quantitatively how many of these bugs are out of proportion, out of the normal range. What's super interesting, and this goes with what we've always known about irritable bowel syndrome and particularly hydrogen sulfide, we now know so much about hydrogen sulfide in a short period of time. But basically, whether you look at hydrogen sulfide in humans or you put these bugs from humans into animals, you get the same changes in the gut. And the changes are your motility has changed, you feel pain more, you get fluid shifts, meaning you get diarrhea and immune responses and other things.

So now that we know there are three gases, we have to treat this. So one of the things that we've known for a long time is that rifaximin is quite good for hydrogen and this is hydrogen breath testing, this is treatment of SIBO with rifaximin. This is a meta-analysis of 32 published studies showing rifaximin helps SIBO. Now one of the questions that always comes up is, "Does it help all SIBO?" And there's always a percent that gets better and a percent that doesn't. But overall, rifaximin is beneficial for SIBO in general.

I threw this study up there because I like prevention, I want to prevent IBS. But it's also a really important slide, it's an animal study, but it's a really important slide to prevent the antibodies from going up further. So this is an animal study we did. This is 2011. But if we gave food poisoning to animals and we gave them rifaximin the day before they got the food poisoning, the day of the food poisoning and the day after, they had a much lower chance of developing IBS. And why is this important? Because you can prevent IBS if you're going somewhere where food poisoning is a very high rate. So treating food poisoning is really important. Don't let it ride. And secondly, if you have IBS already and you have these antibodies, you have to prevent it. And rifaximin also prevents, and we do that with our patients and I can get into that in the Q&A.

For methane, it's different. This is a double-blind study we did in 2014. You have to give neomycin plus rifaximin. This is what we recommend to our patients with methane. Methane constipates. Methane slows your gut down. The methanogens are different. They don't come from food poisoning. They come from reasons we don't understand why they're now blooming or growing in high numbers in the colon and in the small bowel of patients with this constipation side of things. But neomycin and rifaximin are what we use. And sometimes we substitute neomycin for metronidazole.

We published a paper on a new elemental diet. This is palatable, it tastes good, so it's tolerable, it can be done for two weeks. And we did 30 subjects in this clinical trial. Everybody finished the trial, everybody was able to take the diet. So it was tasty enough for people to finish it. 73% normalized their breath test and 83% had symptom relief based on their symptom questionnaires. And also, that bug that produces methane and those that had methane was decreased when methane was decreased. And Fusobacterium went down, which is a hydrogen sulfide producer. So the elemental diet is a good option A, if you can pay for it and B, if you can put up with a liquid diet for two weeks, but at least it tastes good now.

I'm going to talk to you about three exciting things, because I like to give you the future because this is the future. We now have a drug that can reduce methane by 70 to 90%. And so by blocking methane production, and this is the animal study, these animals had the methanogen, that methane bug, M. smithii, they had constipation. We gave them the drug, their constipation diminished, their methane went down. This is for the future. This is the future of treatment of IMO, or intestinal methanogen overgrowth. The treatment future for IBS-D or patients with SIBO and ISO, the hydrogen sulfide, we now believe is based on this work.

Half of the bugs, meaning the bugs that produce hydrogen and the bugs that produce hydrogen sulfide are living in the mucus and the other half live above the mucus sort of floating. The bugs above the mucus, rifaximin can hit them. The bugs in the mucus, rifaximin doesn't dissolve in liquid so it doesn't get to them. So we decided to mix rifaximin in a particular way and deliver it to the small bowel with N-acetyl cysteine, which dissolves mucus and we get much better improvement. This is your regular rifaximin in a study we finished and presented at the big meeting in San Diego this spring, and this is what happens if you add the NAC and rifaximin together. So many more things are better. So many things are more statistically significant. We're starting a three-center Phase 3 national FDA-approved study to get this along so that patients can get this new better-improved treatment for IBS-D and SIBO and ISO.

Finally, we published this paper this summer and it's just out. And if you can get the anti-vinculin antibodies down, those patients, the IBS starts to disappear and the SIBO starts to disappear. And we now have sequenced all these antibodies and we're in the process of developing a treatment to get these antibodies out of the bloodstream. Stay tuned for that. In about a year, I'll have some big information on this because we should have something in hand in a year to start trials or safety preparations for the FDA. So super excited about this because this could be the cure, quote, unquote. I know that's ambitious. I don't want to overpromise. But we're working on it. That's all I'm saying. We're really trying to get to the bottom of this.

But in the meantime, we have these three groups, and the only way you know these three groups is you measure the three gases. So we have the traditional SIBO in the middle, we know the bugs there, E. coli and Klebsiella. We got the condition on the right, the constipation condition. We know the bugs that are producing the methane. And now more severe diarrhea is ISO or hydrogen sulfide production. And to be honest, we have patients who have combined, so we have some with ISO and SIBO, ISO and IMO, and so you have to tailor your treatments accordingly.

So the root, we're getting to the root of IBS in that 60% of IBS patients. The root is there's SIBO and we use either rifaximin or elemental diet for that at the moment. If you're IMO or methane, we use rifaximin plus neomycin or rifaximin plus metronidazole. For ISO, we use rifaximin plus bismuth. That works for now until we get these new drugs through the FDA process. The two new therapies I talked about today are coming. Super excited about that. Measuring anti-vinculin and anti-CdtB antibodies through the IBS-Smart test, I do this routinely because if the anti-vinculin antibody predicts that you have IBS and we know what caused it it's also important to tell us how easy you are to treat and take precautions when you travel. And we're developing a new therapy we hope, so keep your fingers crossed for us on that because that may solve the whole problem in the long run.

So in conclusion, SIBO is common. It's important to know the cause of SIBO. If you're not responding, make sure you don't miss something other than just IBS. Food poisoning causes the bulk of this. And we talked about the two antibodies that are up. This is not your grandpa's SIBO, this is not the old SIBO that used to be in the textbooks. This is the new generation of SIBO with these three categories that we talked about and hydrogen sulfide as that new kid on the block, which is giving us a better understanding of some of the more challenging patients that we've had and new therapies are coming.

So I'm going to stop there and move on to the next section. So Paige, I think you wanted me to do the pre-submitted questions first, right?

Paige with Gemelli Biotech:

Yes, perfect. That would be awesome. We're going to spend some time with 10 or 20 questions that were pre-submitted from the registration link that [inaudible 00:22:43] had.

Dr. Mark Pimentel:

Okay, perfect. Well, I am super excited to get to these because they're really, really good questions and clearly a lot of you have some experience with this or are having trouble being managed with this as well. I can't give you medical advice, but I can tell you what I do from my perspective for some of these problems, and that's the way I will answer it. And I will do this for about 10 minutes and then I will go on to the live questions because there's more questions here than I can answer and probably more questions live. But I want to make sure the live folks have a chance as well.

So Melissa, I hope you're on. But Melissa asks, "After SIBO or IMO has been eradicated by antibiotics, what can you do to restore a healthy microbiome?" So what's interesting is that there's a lot of people trying to develop things or sell things online, pills that will reconstitute your microbiome and all of that. So what I want you to do is I want you to think of it this way. You've got E. coli and Klebsiella and these hydrogen sulfide producers there. And when they're there, they're producing chemicals, they're out competing everything else and they're destroying your microbiome. It's sort of like weeds in your garden, right? So the weeds take over, the vegetables don't grow, nothing is produced. As soon as you take the weeds out, the garden grows. So the rifaximin treatment, we've seen this in our microbiome data, as soon as we give the rifaximin and we check the microbiome after all the bugs are coming back.

There was a massive study that was done out of Cork, Ireland, we weren't on that paper, but it's a very important paper. And it showed that the way rifaximin works in IBS is that it makes the microbiome alive again and shifts back towards normal by getting rid of the bad actors. So we see it in our data and the massive study that combined all existing data on IBS showed that in this recent paper that was just published less than a year ago. So you shouldn't have to do anything. And the problem is we're not fixing the wiring, right?

Remember I told you at the beginning the wiring is a little broken, so you don't want to put fish food in there. You don't want to put fiber, you don't want to put... And we'll get to diet here in some of the other questions because you're feeding the bad guys. The bad guys are 60 times more capable of fermenting than the good guys. And so like E. coli and Klebsiella is 60 times more efficient at fermenting. They're going to win. So if you put food in there for them, you want the food for you, not for them. Because of the wiring and the slow transit, they're going to come back and overgrowth comes back.

Jim asks, "I just finished a two week course of rifaximin and neomycin for intestinal methanogen overgrowth," that's one of the things that we do in our clinic, "And have heard archaea repopulate quickly if not eradicated." Archaea are actually quite slow to repopulate because they're slow growing organisms. So it's not quite like that but, "How long would you recommend waiting before doing another breath test?" So usually I wait a week after the completion of treatment to do another breath test in my clinic. "And when would you consider a second course?"

So if you're incompletely treated, so this is going to answer a few of the questions that I've perused here, is that if you're 90% better after rifaximin or rifaximin and neomycin, you don't need another breath test. Don't waste money, don't waste time. Because the breath test isn't going to make you that extra 10%. But if you're 40% or 50%, you might've been completely eradicated. And if that's the case you need to know, you need to do another breath test. There is an occasion where you want to do another breath test. Let's say you've been treated and you don't feel better and you do another breath test and the overgrowth is still there and you don't feel better or the overgrowth is gone and you don't feel better, then you need to look for some of the other causes of symptoms.

So for example, if you had an adhesion, you'd be bloated and distended from the adhesion, plus you'd have overgrowth on top of that. And if you treat the overgrowth, you still got the adhesion, you still got the distension. So you have to look for the adhesion. So the breath test by finding that it's normal, but you're still symptomatic tells you better look for something else. The breath test saying, "Hey, the overgrowth is still there. Why is it so difficult to treat?" You need to look for why the overgrowth is still there and could something be more sinister going on? So I think that answers a few questions.

Adam asked this question, "If you test positive for the antigens on the take-home blood test indicating that you had food poisoning, what do you do next?" So one of the reasons that maybe people don't do the blood test as often is because, "Well, I'm not going to do the blood test cause so what? I can't treat it yet. There's no drug for it yet.| But that's not my approach in the clinic because if I know that those antibodies are positive, I make for darn sure that the patient travels correctly, that I counsel them about traveling, and careful eating. And I don't mean careful eating what you eat, I mean carefully eating, maybe you shouldn't eat at the roadside stand where they're cooking food in the open or a food truck. You need to think about your food choices so you don't get food poisoning again, because IBS patients have three times higher chance of getting food poisoning.

What we think is those broken wires because of these antibodies means that you're the person that can easily get food poisoned again. That's why they damaged you. That's why the Campylobacter, the Salmonella damaged you so they keep using you, but then your antibodies go higher, then you're sicker and sicker and sicker and you're harder to treat for your SIBO. So knowing you have these antibodies, I change exactly how people behave, where they go, how they go. And then in some cases if the antibodies are really high, if you're traveling to places, certain places in the world, I'm giving rifaximin prevention a little bit with every meal so food poisoning does not come.

Leslie asks, "So if you have the IBS-Smart, those antibodies, should you retest and how often?" If you take rifaximin for your SIBO and you have the antibodies and your SIBO goes away, you feel great, the antibodies aren't going to change. So you don't need to measure the antibodies after a treatment with antibiotics like you would the breath test, you want to measure it at a longer interval because it takes about a year, two years to see the change in antibody because this is like you getting a vaccine, right? The antibodies are going to stay up because you have vinculin, your body has vinculin. So it's going to keep forming those antibodies and only slowly come down. But if they are coming down, that's a good sign. And I've had patients where the antibodies go back to normal and their IBS goes back to normal, which is fantastic. So once a year is sort of a rule of thumb.

Lizzie asks, "When do you test after finishing rifaximin?" Oh, I'm sorry. "When do you test and what diet do you use?" So I kind of mentioned this seven to 10 days after completion of the antibiotics, that's when I would do the second test to be sure it's gone. The diet, I use the low fermentation diet. I don't use low-FODMAP. And the reason I don't use low-FODMAP is because it's too restrictive, it actually reduces the microbiome diversity. So I use low fermentation, which is more liberal. And Paige can provide that for you if you like if you just put a message in the chat, the diet.

Mary Jo asks, "After doing the elemental diet mBiota, when should we retest for SIBO?" If you're doing elemental diet, I always test again because that's a lot of work, it's expensive, because you have to pay for the elemental diet, and so I want to know that it's gone right after you've done the elemental diet, so I'm more likely to retest after with elemental.

"Are there any new remedies for IBS-M?" So IBS-M is really D. So when we did the original rifaximin study, it was D and M together, so it was non-constipation IBS, so it's really the same. So the way I see M is it's riding the fence between D and C. And so when you do a breath test, some of the M's are methane, some of the M's are hydrogen and SIBO. And so it's just on the spectrum of the gray parts of the spectrum.

"Are there any new treatment protocols or research on methane-dominant SIBO?" So I told you about CSO6. So in about a year we're going to start clinical trials in that, fingers crossed if all the safety lines up perfectly. And we're super excited about that. So stay tuned for that because I think that's going to replace what we're doing now.

"What can I do after eradication to prevent relapse?" So there's two things I do to prevent the overgrowth from coming back. And so let me describe this to you. First of all, low fermentation diet. And as I mentioned, Paige can send that to you. But the second is if this is your first time treating overgrowth, I would just do a low fermentation diet and see how long it is to relapse. If it's two years, you don't need to do anything more. And so why waste money? Why get another prescription? Why take a drug? My goal is to give people safe options and to minimize misery. I want people to be able to go to a restaurant, enjoy food, and be as back to normal as possible.

The low fermentation diet's like that, it's less restrictive. You could find any restaurant in this country with a food item from the low fermentation diet that we created because the whole point was you don't want to be at a table with a bunch of friends and you're the one asking 20 questions. It's not convenient for you, it's not fair to you, it's anxiety provoking to you. Why would you want that? So it gives you the option to be able to easily pick something from the menu without being that person. And I think you know what I mean.

But if your SIBO relapses and relapses and relapses or you have these high vinculin antibodies, we sometimes need to give a prokinetic at nighttime to make the wiring work. So remember when I said there was less wiring? So you can't bring the wiring back unless you get rid of the antibodies, which we haven't figured out yet, but you can turn the energy up on the wires that are there. So it's sort of like you have half the lights in the house, so the only way to see is to make the light bulbs that do work turn brighter. And so that's why we use a prokinetic, at least that's sort of a simple way to describe the prokinetic effect. All right, I'm going to do two more questions here then we're going to open up to the main group.

"What can I do to prevent relapse? I have hydrogen SIBO and I took three rounds of rifaximin with no success. What are my options?" This is from Patricia. So Patricia, again, I can't give you medical advice, but if I have a patient where they're not responding, you have to do more workup. The doctor has to take some effort and see why this is happening, why it's not getting better, or it's hydrogen sulfide and you didn't treat the hydrogen sulfide. So I don't know if you did a three gas breath test or a two gas breath test. So that's another thing to think about.

And then one last question. "If a person has fructose intolerance, could that be the root cause of recurring SIBO rather than food poisoning symptoms?" This is Heather. So fructose intolerance is that you have the inability or a lower ability to absorb fructose and then it gets to the colon. And so as a result of that, you get this gas production and bloating. So you can't diagnose fructose intolerance unless you do a breath test for SIBO because all SIBO patients will test abnormal for fructose. It's just a thing. Almost all. So you have to do the SIBO breath test first and make sure before you check for fructose.

Okay, so now I'm going to go to the chat and look for what questions are here. Let's see.

Paige with Gemelli Biotech:

Okay. Jill has asked, "What kind of treatment would you recommend for a new diagnosis of IMO," they used the Trio-Smart test to reveal that they had high methane.

Dr. Mark Pimentel:

So in my clinic, again, I can't give you medical advice, but in my clinic and based on the randomized control trial I showed here in the slides, intestinal methanogen overgrowth, the first treatment would be rifaximin plus neomycin. Now, I'll give you just some pointers on neomycin. Some people are reluctant to take it because it can cause ear toxicity. So if you have hearing loss to begin with, when they say ear toxicity, they're talking about gentamicin, which is a drug they give by intravenous. Neomycin is the same class of drugs but given orally, it doesn't get into your bloodstream, but it still has that label because the FDA says, "Okay, same category of drug, got to get the same side effect label." So I've never seen ear toxicity with neomycin, but if you do have any hearing loss, don't use that. Use metronidazole instead is what I do in my clinic.

Paige with Gemelli Biotech:

Awesome, thank you. Okay, we have Donna asking, "How long can I actually be on Motegrity?"

Dr. Mark Pimentel:

So Motegrity's been approved in Europe before it was here and probably been about 10 years on the market. People have been on it for 10 years straight, taking high dose Motegrity in and around the world. It still appears to be very safe. I'm not saying you should be on it for 10 years. What I'm saying is that what we do in our clinic is we use it at night after the overgrowth has been treated if you're getting relapses, and we use only a half a milligram, which is half the dose of the lowest dose of Motegrity. So you could be on it for a long time, considering a lot of people have been on two or four milligrams for almost a decade. So it is just a small dose, enough to kind of just get those light bulbs brighter so that prevents the overgrowth from coming back.

Paige with Gemelli Biotech:

Awesome, thank you. Okay, we have Tricia who's asking, "What do you personally think of Fodzyme? I cannot get my teenage son with post-infectious IBS and SIBO to follow a special diet and this seems promising."

Dr. Mark Pimentel:

Yeah, so Fodzyme, it's an enzyme to break down FODMAPS. That's the purpose of it. The challenge, if you remember lactate, the lactate pills, if you were to drink a cup of milk and pop two lactates, you're going to digest 50% of that milk lactose, maybe if you're lucky, the other 50% not. So it's going to take the edge off, but it's not 100% because you'd have to mix the Fodzyme with the food, put it in a blender, leave it overnight on the counter at room temperature or 37 degrees so that the enzymes can work because the enzymes work at 30 body temperature, and then you risk getting food poisoning from the thing you left on the counter overnight because it's food. So if you just push them together in a meal, you're not going to get full coverage as we know with these enzymes, but it'll help a little. So it's possible that it has some benefit.

Paige with Gemelli Biotech:

Thank you. Great. So Elliot is asking, "I have a post-infectious IBS diagnosis. What would be next? I cannot take rifaximin."

Dr. Mark Pimentel:

So if you have post-infectious IBS and you have SIBO, one of the SIBO types, it depends which SIBO type. So you can do an elemental diet, that's not an antibiotic, if you can't do antibiotics. That's what I would do in a patient who is intolerant. To this date, and I've been doing rifaximin for almost 20 years, I can't recall on one hand allergies to rifaximin. So rifaximin is one of the safest drugs we've seen. Doesn't change the microbiome in a bad way. In fact, it makes it more normal. Doesn't cause bacterial resistance, doesn't accumulate yeast in the stool. So women would not get vaginal yeast infections from rifaximin. So it really is one of the safest drugs out there. In fact, we did what's called a harm study and if you took all the studies of rifaximin and the matching placebo in those trials, the placebo was more harmful than rifaximin. Crazy. I mean you don't see that very often with drugs.

Paige with Gemelli Biotech:

Yeah. Okay. I think this is actually a good moment, I'm going to transition over to some of the Gemelli Biotech products that do answer some of the questions that you're asking now. Dr. Pimentel, are you able to stay a few minutes afterwards and answer a few more of these questions that are coming in?

Dr. Mark Pimentel:

Yeah, let's continue with some questions after you're done. I'm happy to do that. So stick around.

Paige with Gemelli Biotech:

Thank you. Thank you. We are from Gemelli Biotech. Again, we are the makers of Trio-Smart and IBS-Smart. So the Trio-Smart test and the IBS-Smart Test are both at-home mail-in tests. The Trio-Smart is a breath test that is the only test available that can measure the three gases that can help identify SIBO, IMO and ISO. IBS-Smart is also an at-home test, but it is a blood capillary test, so it attaches right to your arm. And that is going to detect the two antibodies to identify post-infectious IBS or IBS that is caused from food poisoning.

Trio-Smart, again, is the only breath test to measure these three gases. The results when you order online do directly get emailed to you, so they look like that on your phone with the different levels over the timeframe of the test. And then also you have qualitative and quantitative results that will tell you if it's abnormal, elevated or not elevated. The Trio-Smart Test is a very highly sensitive test. It's 20 times more sensitive than other instruments that normally only test for two gases. And we do test for three. We are a CLIA-certified test. And the best part is that there is no doctor's appointment needed to get this test. We do have an online system where you can enter your information, answer a few questions, and then we submit that to a doctor that we work with and they review your submission and then they approve and prescribe the test if need be, and the test gets delivered straight to your door.

Also, we have always, always used glucose and lactulose. Lactulose was not available online through the online system, but now it is. So you have the option of ordering your Trio-Smart 3-Gas Breath Test with either substrate of glucose or lactulose. And the Trio-Smart Breath Test is validated for both of those substrates. So you would want to work with your doctor to determine which substrate was right for you. The IBS-Smart Test, if you wanted to look at this picture here, that is the capillary TASSO+ device and that is where you attach it, it sticks to your arm and it is virtually painless. You get a little bit of blood to fill up the vial, you pack it up and you send it into our lab and we can determine within seven days you'll get an email of if you have abnormal or elevated antibodies in your blood to determine if post-infectious IBS is your diagnosis and how to move forward.

Post-infectious, again, IBS is the IBS that's caused from food poisoning. It is about one in nine people who've had food poisoning in the past, or can remember having food poisoning in the past, will develop this post-infectious IBS as a result of a previous food poisoning. We have a code going right now because of this webinar you're joining us with tonight for $50 off and we have free shipping on all of our Gemelli tests. The $50 is for all of our Gemelli tests, which are available on getgutanswers.com. We have IBS-Smart, we have Trio-Smart. We also have malabsorption tests as well, which you can look into on that website as well. But GETGUT50 is for a limited time you can get $50 off when you order online.

We also have a giveaway. This is for Dr. Pimentel and Dr. Rezaie's book, The Microbiome Connection. A lot of what he was discussing about LFE, the low fermentation diet and how to eat and manage and live with what you have to deal with for now and manage it accordingly. And there's some really good tips in there, really good information. So if you wanted to enter with a QR code or that bitly code that's on there, you just enter your name and information and we'll pull two winners to receive a copy of this book. Again, I just wanted to post this GETGUT50 code. And again, it is for getgutanswers.com. You can also visit triosmartbreath.com or ibssmart.com, that'll bring you to the same places. But getgutanswers.com, and when you go into your checkout, you can put in GETGUT50 and you'll receive $50 off your order.

All right, so I think that's all I wanted to mention just in case you had some questions about the tests that I saw coming in. But I will send it back over to you, Dr. Pimentel, when you're ready.

Dr. Mark Pimentel:

Okay, thank you. I'm back. There was one question that was sent in advance and I wanted to bring it up because it's kind of like an unfortunate thing. Janice sent this in. She says, "My doctor will not order the test, and it sounds like we won't order either test and says that it's a research test only." That to me is beyond shocking, considering the fact that breath testing for SIBO has been around since the 1980s. So 50 years this doctor hasn't read a book? That to me is shocking. So I'm sorry, Janice, you're going through this. I hope you can find a way to get the test if you feel that you need it or find a doctor who is a little more up to date. So that isn't even an answer because of 50 years of research, not just me, even before me, the test has been available. It's just more modernized and better, but it's been around a long time.

All right, Paige, I think you still had some more questions.

Paige with Gemelli Biotech:

Yes, I have one here from Manuela, "How to treat IMO while pregnant and breastfeeding. Is ginger strong enough as a prokinetic?"

Dr. Mark Pimentel:

So I have many patients, obviously IBS is more common in women and IMO is quite common in female patients of younger age groups. And then they do get pregnant or start to have a family. And generally what we recommend... Well, let me say a couple of things. I don't want to get too far into treatment before I talk about this. For some reason, when women are pregnant, a lot of things improve. So in Crohn's disease, just to digress even further, in Crohn's disease, there's a one third, one third, one third rule. One third get better, one third stay the same, one third get worse. In SIBO, IBS, we see about 70% get better when they're pregnant and 30% stay the same. Almost never do we see people getting worse during pregnancy, which is great. And we see that women who are pregnant, their autoimmunity is less. And it's very strange.

So we haven't actually measured vinculin antibodies during pregnancy from before pregnancy to see if they go down. That would be a very interesting study to do. And I just thought of it as we're talking here. So this is a very good question for me to answer sometime in the future. But people get better. But what we do is we try to manage the bowel habit during pregnancy because you can't take rifaximin, you cannot take rifaximin during pregnancy. It is not a good drug for pregnancy. And a lot of these drugs are not good for pregnancy and you can't do an elemental diet during pregnancy as well. It just wouldn't be wise. So we generally manage symptoms. For example, magnesium is very safe in pregnancy, and so magnesium as a treatment for constipation is a common one that's used. And there are other therapies as well. Ginger probably won't work very well, but it's worth a try.

Paige with Gemelli Biotech:

Thank you for that. Dina is asking, "Do you ever titrate Motegrity with the severity of anti-vinculin levels?"

Dr. Mark Pimentel:

So we titrate the Motegrity to make sure a person has a beautiful bowel movement once a day, first thing in the morning, and we will do that. And if that's not happening, and usually it's because the antibodies are high and when the antibodies are high, there's more bloating still because the wiring is not working, so we will titrate that. So we will go up to two milligrams, even four milligrams in some rare instances where the antibodies are very high. But I can't say, "Oh, if the person's over three for their antibody, all of those patients get four milligrams or all of the ones from two to 2.5 get two milligrams." It depends on the person. But generally speaking, yes, the higher the antibody, the sicker the patient is, the more challenging they are.

Paige with Gemelli Biotech:

Thank you. Karen is asking, "What if you are lactose intolerant? Can you use the glucose test?"

Dr. Mark Pimentel:

So glucose is a simple sugar, it's a monosaccharide. Lactose is a disaccharide. If you're lactose intolerant, you don't have the enzyme to break the disaccharide, but glucose is perfect. If you can't digest glucose, you wouldn't be here because glucose is the only molecule that's your energy molecule from carbohydrates, everything breaks down to glucose. So you can't be allergic to glucose, you can't be intolerant to glucose. That's just not a thing.

Paige with Gemelli Biotech:

Okay. We have another question coming in. "I'm hoping to find out when to take NAC with rifaximin. Same time or before or after you take the rifaximin pill?"

Dr. Mark Pimentel:

Yeah, so the new formulation of NAC is a special delivery system that's going to be in the trials for the new product. People try to take NAC with rifaximin to treat SIBO and ISO now. What we find is that there's so much mucus in the stomach most of the NAC is used up in the stomach and never gets to the small bowel. But if you want to try it, I usually give it together with the rifaximin, not separately. And sometimes it works, sometimes it doesn't, but it's going to be better when it's all together in the capsule.

Paige with Gemelli Biotech:

That makes sense. Okay. All right. Omar is asking, "SIBO hydrogen, why do I have such excessive burping, especially when I don't eat? Is there any relief?"

Dr. Mark Pimentel:

Yeah, so the gas is being produced everywhere and principally when we do the re-imagine study samples and we collect juice from the small bowels from the duodenum, and we see such high amounts of E. coli and Klebsiella right there in that duodenum, that gas is coming up as well. And so we also see an association between hydrogen sulfide and reflux. It's a new association. We presented this at DDW. I'm not going to get into too much detail because it's kind of exciting, but I can't talk about part of it. We haven't published it all yet. But hydrogen sulfide can lower the valve between the esophagus and stomach pressure, and that can also make belching more. So if some people with hydrogen sulfide could actually have more reflux, more belching because of the way it's changing the muscular function of the valves.

Paige with Gemelli Biotech:

Okay, great. Thank you. Devon is asking, "I took rifaximin and neomycin after the breath test. I had severe diarrhea even while taking these antibiotics. Any thoughts as to why?"

Dr. Mark Pimentel:

So did Devon have methane? I don't know. Did you say that?

Paige with Gemelli Biotech:

It just says, "I took rifaximin and neomycin after the breath test."

Dr. Mark Pimentel:

So we have noted that in a group of men who take rifaximin and neomycin, if they don't have methane or their methane is quite low-ish, that they can end up having more diarrhea on the rifaximin and neomycin. So I would only give rifaximin and neomycin in a patient who has methane and is simultaneously constipated. So I would not do it if they're having on the loose side or diarrhea or mixed because of that issue that sometimes happens. So I hope that helps Devon, but I don't have any further information from Devon.

Paige with Gemelli Biotech:

Thank you. Do you have time for one or two more?

Dr. Mark Pimentel:

Yeah, one or two more sounds good.

Paige with Gemelli Biotech:

Great. I have Shima here and she says, "I had an appendectomy and got diagnosed with Hashi at the same time. Can you talk about the adhesion in relation to SIBO? Thank you."

Dr. Mark Pimentel:

So Hashimoto's, is that what?

Paige with Gemelli Biotech:

I believe so, yes.

Dr. Mark Pimentel:

Okay, Hashimoto's. So interestingly, we just published a paper, it just got accepted and it was presented as an oral at the Endocrine Society, that Hashimoto's thyroiditis, that autoimmune thyroiditis is associated with IBS and SIBO. So that paper will be out in literally maybe two weeks. But we already presented it, so it's public information, I can say it online. So if you had appendicitis and you took the appendix out, you might want to be careful that you don't have adhesions that could be causing SIBO also. I think that's the gist of the question. But you have to do a barium to look for adhesions from appendicitis.

Paige with Gemelli Biotech:

Okay, thank you. And then we have Celine asking, "If you've done the elemental diet for two weeks for IMO and then reintroduced food and had a resurgence of symptoms, would you recommend doing the elemental diet again?"

Dr. Mark Pimentel:

So we have patients who've done it more than once or a little bit longer than two weeks. So in the original elemental diet trial, which I did in 2003 when I was a child, the elemental diet, in the pre trial stage, we did seven, 10, and 14 days and 21 days. And seven didn't work, 10 was better, 14 was good. We got about 70% eradication and 21 days was 5% better than 14 days. But asking a person to do an extra week of elemental diet to get that extra 5% is a little tough for most people because that's three full weeks of elemental. So there are patients who can benefit from a third week, and so I don't know whether that's the situation for this person, but that is something that we do. What I worry about is doing it over and over again because it is expensive and I don't want the folks on the line here to think that they should do elemental over and over again because it's $750 each time for two weeks. Now you don't buy groceries because you're just eating this, but still it's expensive.

Paige with Gemelli Biotech:

I do have one last question, if you don't mind. It does kind of go together with the diet conversation.

Dr. Mark Pimentel:

Okay.

Paige with Gemelli Biotech:

But Steve has said, "I'm starting to lose hope. I have to keep trying new things over and over again. I have heard that the carnivore diet can heal SIBO. Is this true? Can you help me?"

Dr. Mark Pimentel:

Okay. So first of all, never lose hope because we're working day and night and I try in my presentation to give you a high degree of optimism because we have new therapies coming and they are so much better than what we've ever had before. And it's just going to take time. And I wish it could happen faster. I wish we could just start putting it in capsules and giving it to people now. But it has to be done properly. It has to be FDA regulated. You have to do the proper studies for safety and that has to be that way.

But a carnivore diet, a high protein diet, low carb diet does help overgrowth because the bacteria in the gut, it's sort of like this. If you have your olive oil, you don't put it in the fridge, you leave it on the counter, bugs don't grow in olive oil. They just don't grow in oil. If you put two tablespoons of sugar in that olive oil, it won't last a week. They want sugar, they want sugar, they want sugar. The problem with a pure carnivore diet or a paleo diet or a pure protein diet is that it doesn't always contain all the nutrients that you need. So there are some disadvantages to that.

But the less carbs you have, especially fiber, you can make the overgrowth symptoms less. But it doesn't solve the entire problem and it's not going to work as good as getting rid of the overgrowth with antibiotics in general. So I have not routinely seen patients getting more than 30, 40% just with diet alone better, where I can see 80, 90% improvements when rifaximin works, for example. So yes, you can do it, but just understand that it may not be perfect.

Paige with Gemelli Biotech:

Thank you very much, and I really appreciate you taking the time to answer these questions and kind of get into the things that we want to know, the hard to find information on. So I really appreciate you being with us tonight. And thank you to everybody for joining us tonight. I hope and we hope that you found this webinar informative and empowering is really what we want you to feel, that we get through this all together and share this information. If you have any questions or you want to find out some more information, please visit our websites, triosmartbreath.com, ibssmart.com or getgutanswers.com. And don't forget if you order any of your tests online use the GETGUT50 coupon code for $50 off when you order any of the tests online. Thank you. Thank you again for spending a few extra minutes with us, Dr. Pimentel. And everybody have a wonderful night.

Dr. Mark Pimentel:

Thank you, everybody. Thank you.