# Dr. Pimental discussed SIBO and IBS



## flux

Dr. Mark Pimental recently discussed SIBO and IBS at a symposium on gastrointestinal motility, http://www.agmd-gimotility.org/Information...20symposium.htm.He first reviewed three theories for IBS.Transit theoryâ€"this is basically serotonin and how its dysregulation leads to diarrhea and constipation. We now have drugs to address each of these, Alosetron and Zelnorm, respectively.Brain-Gut theoryâ€"this is Dr. Drossmanâ€™s theory that there are issues with the brain-gut that bring about IBS. For example, pain processing in IBSers is different from healthy folks and some people are gut-reactors, that stress influences the brainâ€™s influence on gut behavior.Bacteria theoryâ€"this is Pimentalâ€™s theory.Dr. Pimental explained his theory in great detail and there is now significant stash of supporting data to backup his claim.The main explanation for how people develop bacterial overgrowth is related to the lack of or reduced frequency of Phase IIIs MMCs.The migrating motor complex (MMC) is the regular pattern of gut motor activity during a fasted state. It migrates from the stomach on down and consists of three phases. Phase III is the most important because it acts like a housekeeper, clearing the gut tube of all material that hasnâ€™t previously been cleared from the previous meal digestion.It is also important to understand that food is not sterile. Normally, the bacteria on food, which people eat, arenâ€™t a problem because most are killed by stomach acid and those that survive get flushed into the colon by phase III of the MMCs. However, if the MMCs are disrupted, particularly it can allow bacteria to grow, overgrow in the small intestine, which normally has very few bacteria.There is now evidence that some fair percentage of IBSers have a reduced frequency of phase IIIs MMCs.There are a number of papers, not by Pimental, corroborating his findings that SIBO is present in a significant subgroup of IBSers. Ordinarily, diarrhea is a symptom of SIBO. (Malabsorption and steatorrhea are *not* symptoms of SIBO as I previously claimed they were.)Some IBSers have constipation. It turns out that one of the gases produced by gut bacteria in some people is methane. There is now good evidence to indicate that methane increases non-propulsive gut motility, contractions known as segmentation. The increased frequency of these contractions appears to result in constipation.There is now some evidence that bacterial overgrowth results in an immune response by the gut and that may be responsible for producing pain. Dr. Pimental finally explained his theory does *not* discount the other two theories of IBS, but instead adds to them and taken together the three explain all the symptoms of IBS.Dr. Pimental was very convincing. I think I believe him.


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## cookies4marilyn

Thanks for posting this Flux! Much appreciated.You know, I am wondering, if SIBO should be even called "IBS" - maybe it is a "condition" or syndrome unto itself - rather than a subset of IBS - or do they consider it a subset? And are these three divisions, Transit, Brain-Gut and Bacteria, really called theories? Did they use the term theories? I am just curious, because that implies not fully proven as fact. Yet, there is research and there are treatments to address each theory - in my case, the brain-gut one - which applies to many of us - but that was after I had the SIBO ruled out for me.The more findings as time goes on, the more sub-categories for IBS etiology there may be!!! The gastro at Mayo (way back when) put me on Flagyl "just in case" tho all the testing I had was negative for SIBO, etc. Yet I still presented with IBS symptoms. I think this is interesting, because it points out that the docs have three avenues of diagnostic and resultant treatment approach. It makes you wonder, tho, if a high percentage of IBSers do test postively and have SIBO, then is it really IBS - if treatment for SIBO resolves the problem - is this condition IBS? A semantics thing, I guess, but what do you think about that - as a label - and did Dr. Pimental think it should be still within the term and diagnosic critera for "IBS?" Thanks again for posting this info - very interesting!


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## SpAsMaN*

Methane induce C!That's basically how i feel!I was waiting for his conference to made a medication out of it next month with my breath doctor.Does Pimentel told about medication(S) to get rid of SIBO?Anyway i will get the tapes hopefully.


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## Jeffrey Roberts

Flux,Thanks so much for posting such an informative overview of the presentation.Did Dr. Pimental talk at all about the overlap of symptoms with IBD and IBS? Also, did he correlate the micro-inflammation that is being seen in a subgroup of IBS sufferers as being due to the immune response from the bacteria overgrowth?I hope you took the opportunity to talk with Dr. Pimental after his presentation.Jeff


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## flux

I should clarify that Dr. Pimental referred to SIBO-mediated IBS as being triggered by a gut infection, aka post-infectious IBS>


> quote:if SIBO should be even called "IBS" - maybe it is a "condition" or syndrome unto itself - rather than a subset of IBS - or do they consider it a subset? And are these three divisions, Transit, Brain-Gut and Bacteria, really called theories? Did they use the term theories?


Yes, Dr. Pimental specifically use the term theories in his speech and on the slides. It's very clear. He mentioned at the beginning and again the end. At the end, he described them as a single unified theory to explain postinfectious IBS.Dr. Pimental said that SIBO is part of the mechanism of IBS, not a separate condition. He even made a little joke about IBS being a diagnosis of exclusion:Of course, IBS is a diagnosis of exclusion. They (meaning ROME criteria authors) keep excluding every condition found to explain it









> quoteid Dr. Pimental talk at all about the overlap of symptoms with IBD and IBS?


No, I don't recall his mentioning IBD at all.


> quote:Also, did he correlate the micro-inflammation that is being seen in a subgroup of IBS sufferers as being due to the immune response from the bacteria overgrowth?


He mentioned it only briefly, I recall.


> quote:I hope you took the opportunity to talk with Dr. Pimental after his presentation.


No, he just vanished during the lunck break. He may have left early. Do you (or anyone) have any specific questions? I can pose them to others on the experts panel.I forgot to mention that he said neomycin doesn't work and that's why they weren't get good results and not because the theory was wrong.There is evidence that another antibiotic rifaximin works very well. He himself didn't mention probiotics. But the other experts agree with this theory and Dr. McCallum, a well-known expert on stomach motility, said he is now using antibiotics and probiotics with his IBS patients. He said that antibiotics and probiotics especially will start playing a larger role in IBS treatment.Dr. McCallum called Dr. Pimental the Barry Marshall of IBS.







Barry Marshall is the discover of H. Pylori.


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## cat crazy

Cheers Flux. This is exciting news. If SIBO is part or subgroup of ibs then it would be treated quite easily with antibiotics and even be gotten rid of. Wow! I had almost resigned to thinking I have to live with ibs till I die. This gives me so much hope. Long story short whenever I've had to take antibiotics for anything my ibs symptoms improved while on antibiotics and shortly after. But symptoms would return back after about a week or two. I have seen this happen repeatedly. Maybe they can do trial studies for a lengthy course of antibiotics. To offset any problems of disturbing the flora they can take probiotics not same time with the antibiotics but maybe a few hours apart.


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## cat crazy

FluxWhat is the duration of the treatment with the antibiotics and probiotics that the doctors are using?


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## SpAsMaN*

> quote:antibiotic rifaximin


Yes we want the exact treatment and duration.Too bad you could'nt get an hold on him.


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## bonniei

flux, how is SIBO diagnosed? Lactulose? Funny joke about exclusion. He has a good sense of humor. Anyways I feel like I have beenvindicated. I have always ad a lot of confidence in the SIBO theory for IBS. Also what percentage of IBS'ers have SIBO according to him?


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## SpAsMaN*

> I should clarify that Dr. Pimental referred to SIBO-mediated IBS as being triggered by a gut infection, aka post-infectious IBS> [/QUOTE
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> ,it was not my trigger.
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> Anyway,i don't think the trigger is a big deal in his theory.


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## bonniei

I also want to say flux how lucky that you were able to attend this conference. And I am pleasantly surprised or you can even say that I am reeling from shock that you were convinced by Pimentel


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## flux

From Dr. Pimental's lecture notesr. Pimental is discounting the reports of "micro-inflammation", which are in the rectum, saying these studies were not well-controlled and the results could simply be an irritant effect from diahrrea itself He also briefly described a study using Crohn's steroid which found no effect on IBS.He also mentioned that the stress hormone corticotrophin releasing factor reduces phase III of the MMC and could be how stress sets the stage for the bacteria to overgrow.He showed pictures of this change in a mouse, practically causing a mouse to develop IBS.







He seems to be saying that gastroenteritis should be treated with antibiotics in all cases as a means to *prevent* IBS.He says by using Zelnorm and erythromycin in concert with the antibiotic rifaximin in apparently one time course, he has outright cured several patients of IBS. There is also now onging trial to use these three to *prevent* IBS (in a person who has just developed gastroenteritis).If something like that works out, it sounds as if-my opinion here-he is seeking to develop an IBS vaccine!


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## SpAsMaN*

Even your signature has changes.







Mine has not.







Take a look at your forum please.


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## SpAsMaN*

Edited







Impressive







Thanks


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## SpAsMaN*

Take a look again dude.


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## bonniei

flux all very interesting but you forgot to answer my qyestionss. To quote them again


> quote: flux, how is SIBO diagnosed? Lactulose? Funny joke about exclusion. He has a good sense of humor. Anyways I feel like I have beenvindicated. I have always ad a lot of confidence in the SIBO theory for IBS. Also what percentage of IBS'ers have SIBO according to him?


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## flux

I am formally submitting that as a question to the experts' panel, but Pimental definitely said glucose won't work because it's absorbed nearly instantanously upon ingestion.He said 20-30% but that he thinks that number is artificially low simply because patients don't recall the infection, which likely had occurred a long time before they see the doctor. It looks like 60-70% from the SIBO studies, which were done by others.


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## cookies4marilyn

> quote:He said 20-30% but that he thinks that number is artificially low simply because patients don't recall the infection, which likely had occurred a long time before they see the doctor. It looks like 60-70% from the SIBO studies, which were done by others.


So again, to clarify (I am learning this aspect too, and want to make sure I get this right, so my apologies for being basic!) - so he is referring to 60-70% having SIBO out of those who have post-infectious IBS which isIBS as being triggered by a gut infection.Am I correct in saying that the 60-70% do not refer to ALL diagnosed IBS patients, just those who have had IBS triggered by gut infection - and because that percentage is so high, that anyone who has IBS should be evaluated for SIBO because they may not recall having the gut infection, so that needs to be ruled out or diagnosed and treated as such, as the case may be.So, then, in an ideal world, if the doc finds that the IBS patient does NOT have SIBO, then the other two theories could be approached as a determiner for the next avenue of search for appropriate treatment.I think it is important to make that distinction because of the frustration we IBS sufferers see on this BB - if folks are routinely checked, then this will eliminate a lot of treatment frustration.I did not have SIBO, but because the docs were giving me everything possible, I was treated for SIBO, and since that didn't help,I was really frustrated until I found that my IBS, and many others here as well, was the mind-gut connection/anxiety type - so, in my situation, I was treated for the "wrong" subset first - and in Bonnie's case - vice versa - so each of us was frustrated in the opposite direction!This just goes to show how important it is to know that there are many variances of IBS causes and out of that - different treatments, and not to rule anything out!Good discussion - thanks for sharing all this information with us. Much appreciated.







====================================


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## bonniei

Thank you flux!


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## SpAsMaN*

I'm not gonna beleive anything until my symptoms are all gone.There stil scepticism around his theory.Because of the frustration around IBS,it is easy to be "blind by the ligth".Anyway it is great news and i'm happy to have had the *lactulose breath test*earlier this year.The odd thing is that i don't know the results yet.Next week i will know and ask for medication.I know some anti-biotic help BUT there is the hypersensitivity factor who is a plague.


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## 22058

What test do you take to see if you have bacteria overgrowth?


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## SpAsMaN*

Lactulose breath test or apparently more accurate the D-Xylose which has radioactivity associated with.You need to find a specialize gastroenterology lab.Pretty rare.There is a post about the St-Louis journal in the news section,take a look at it.


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## NancyCat

The place where I go to the gastro is a major teaching hospital in Boston. They do the breath test among many other tests and proceedures. My gastro who is an IBS expert never had me do a breath test, she never even mentioned it. I think she is an excellent Dr and apparently she doesnt think my IBS would be helped by doing so.In my expereince antibiotics, especially erythromycin based ones flare me up badly, she said they are a "trigger". She did also mention psot-infectious IBS, not that it applied to me but just in general as well as other triggers.If ones IBS occured post infectious than I suppose the antibiotic coctail mentioned would help, but IMO this needs to be explored on an individual basis as we don't all fall into the same catagory IBS wise. But I'm glad to see that Dr's are working on it. I dont think the breath test is invasive but I'm pretty sure that its only available at major centers. Having said that it seems that IMO it would be a useful test for many who may fall into that subset of IBS. I think more gastro's and pcp's need to be more informed about these things. Cost of the test will probably influenece who can get it and if insurance covers it.


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## eric

Ah the plot thickens.Are far as I know the first two theories are part of the same theory and problems and have come from the same basic science on IBS, as well as substantial evidence to them.and again I would refer to Mayers work from UCLA for one.http://www.aboutibs.org/Publications/VisceralSensations.htmlAlso in PI IBS there has been obsevered an increase in both ec cells(that contain serotonin) and mast cells. Both of which are connected to infection and stressors.also since pain is processed in the brain and there is viceral hypersensitvity in many IBSer, and stress does influence gut behavior, I say no matter what were looking at there are brain gut axis dysfunction and issues, that have not been fully resloved or explained yet. They know serotonin is involved in sensations from the gut to the brain as well as playing a vital part in contractions.Also the pet and fmri studies on the brain in IBS are still ongoing and have not been resolved completely. So what causes the Phase IIIs MMCs in the first place?Very importantly how are they explaining pain in IBS via the immune system? I believe that is a big question.Does IBS cause sibo or sibo cause IBS, or are they still two seperate conditions?How may people with IBS, don't have sibo and how many in the general population have just sibo?How about people who develop IBS very early, perhaps with no PI IBS?I have a million questions. LOLInteresting however and points out once again about being tested for sibo.I also think that caution is still warranted, with the information as a theory. As well we all know IBS is extremely complex and there is a lot still not known and some which is already known.It is however a good thing I believe that anyone with possible sibo be tested for it and treated for it. I also have seen that Pimnetal and Lin are patenting and creating a home test kit for sibo detection in the future.Jeff, did you see this, just for the info?http://ibsgroup.org/eve/forums/a/tpc/f/71210261/m/900102561Flux, does Dr Pimental plan on giving himself (sibo and IBS) like Marshal did with the HP?







"Dr. McCallum called Dr. Pimental the Barry Marshall of IBS. Barry Marshall is the discover of H. Pylori."


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## cookies4marilyn

Yep you are right Nancy - At the IFFGD and the DDW we met up with the sales rep for a manufacturer of the breath test machines. She says that they are trying to encourage more gastros to have them in their offices. But she said they are expensive, and if they have a major medical center nearby, they just refer them. But she was telling me the docs are getting more interested in them as the time goes on, but it is still a slow process - as is with anything of this nature. But it was interesting, as we got to talking, she mentioned a family member had IBS, and was interested to hear my experiences, and she took the hypno information, which just shows that there are so many facets, she wanted to learn more from us, as we were learning from her...


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## cat crazy

FluxIn my other post you mentioned that SIBO is tested in the endoscopy test. Question. Does the doctor have to look for it specifically in the biopsies? Or if they don't routinely look for it then it should be suggested to him?Other question. What specific pathogen is found in the SIBO? Like H.Pylori is the pathogen for infection in the stomach. In the post-infectious ibs which pathogen is found or identified? Or the pathogen is not named as yet.


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## Kathleen M.

From what I've read of the SIBO lit, when they take a sample from the small intestine and culture it you may find a fair number of different bacteria in the culture, some of which are normally found in the mouth, some of which are normally found in the colon.Sounded like he suspected any of the usually GI infections that could start IBS as being the thing your post-infectious from, but those pathogens don't seem to be what is in SIBO patients that have things other than IBS as the underlying problem (various conditions are associated with SIBO)K.


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## flux

> quote: how is SIBO diagnosed? Lactulose?


Dr. McCallum said that Dr. Pimental uses lactulose, while he is glucose despiteâ€™s Dr. Pimental earlier criticism of glucose.Dr. McCallum said he is using Xifaxan at 200 mg x 3 for a monthbut Dr. Pimental is using it at 400 mg x 3 for two weeks.There is more info on this drug at http://www.salix.com/hcpcenter/xifaxan.asp


> quote: Am I correct in saying that the 60-70% do not refer to ALL diagnosed IBS patients


It refers to all: http://www.ncbi.nlm.nih.gov/entrez/query.f...2370&query_hl=8


> quote: if the doc finds that the IBS patient does NOT have SIBO, then the other two theories could be approached as a determiner for the next avenue of search for appropriate treatment.


You may be implying the other theories are not a factor in PI (postinfectious)-IBS, but they are.


> quote: So what causes the Phase IIIs MMCs in the first place?


Phase III MMCs are part of normal gut functioning. Iâ€™m not sure anyone fully understands how they are controlled.


> quote: importantly how are they explaining pain in IBS via the immune system? I believe that is a big question.


He only touched briefly on a possible bacterial role for the pain. The pain is probably mediated largely through brain-gut axis and visceral hypersensitivity.


> quote: Does IBS cause sibo or sibo cause IBS, or are they still two seperate conditions?


SIBO is a step in the mechanism. You need to have some underlying motility disruption to permit overgrowth. This appears to be mediated by stress via corticotrophin releasing factor.


> quote: does Dr Pimental plan on giving himself (sibo and IBS) like Marshal did with the HP?


Pimental was no there today; otherwise it would be a kick to ask him â˜º


> quote: uestion. Does the doctor have to look for it specifically in the biopsies? Or if they don't routinely look for it then it should be suggested to him?


Generally, an aspirate of fluid is taken and that is cultured.


> quote: What specific pathogen is found in the SIBO? Like H.Pylori is the pathogen for infection in the stomach. In the post-infectious ibs which pathogen is found or identified?


There are no â€œpathogensâ€ in SIBO? Itâ€™s a mass effect of many bacteria ordinarily live elsewhere in the gut.He mentioned strains of E. coli as a cause of gastroenteritis.


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## 13903

Mate, if ibs'ers have good absorption then why do I have healthy nails with bloody great white spots







. This indicates an absorption prob if there was one.i have the relapsing remitting, and when there is no problem the white spots remain.


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## SpAsMaN*

Then fermentation would be at the root of IBS.Like my signature link claims.His theory makes sense in a way.I wonder why you mention so many kind of antibiotics.I guess it depend which one is available in each part of the world.If motility problems cause SIBO,how could the SIBO healing would solve the motility problemsman,that's weird?!


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## 13903

spasman, bit of trivia for you. small bowel bacterial overgrowth was treated in a group of vietnamese children. can't remember where the info is, try a search. if this was the same thing. surprising, in those tropical regions you would think they will develop a resistance.


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## SpAsMaN*

The scientist answer to his treatment would be:Some factors like temporary(or not) motility alteration(S) would cause a sudden SIBO resulting in IBS symptoms.Then if you correct the SIBO then the motility return his normal function breaking the vicious circle of SIBOmethane induced C.


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## bonniei

> quoter. McCallum said that Dr. Pimental uses lactulose, while he is glucose despiteâ€™s Dr. Pimental earlier criticism of glucose


That is really strange- you would think for them to agree that SIBO is behind IBS, they would have to agree what SIBO is - in particular how they diagnose it- given that the percentage of IBS'ers with SIBO differs with whether lactulose is used or glucose and would affect whether IBS should be a real concern forIBS'ers or not.


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## bonniei

Also, flux,


> quote:He says by using Zelnorm and erythromycin in concert with the antibiotic rifaximin in apparently one time course, he has outright cured several patients of IBS.


 Is Zelnorm used only temporarily?


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## cat crazy

Could it be that with SIBO the immune system is so taxed that then the immune system plays into the mind/gut connection causing the pain and FM and CFS? Just my two cents worth.As most of ibsers have FM and CFS and pain as part of their ibs symptoms were any of the patients treated for SIBO have these other symptoms get resolved or only the diarreah was resolved in those patients? Or were the patients treated for SIBO did not have any of the other symptoms?


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## SpAsMaN*

That would be great to have an exact Pimentel protocol treatment.Then i could turn to my doc with it.BTW,i will buy the videotapes.


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## SpAsMaN*

Definitly Hanna,this is brilliant.







Gas induce diseases.


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## Kathleen M.

In other causes of SIBO I do not think there is any immune system involvement.I suspect the gas level from the SIBO could be a factor in triggering the visceral hypersensitivity through the nervous system without having to invoke any other mechanisms. Inflamation has been pretty much shown to be not really a good mechanism for explaining the pain of IBS. The normal movment of stuff through the small intestine is normally enough to keep it clear of the bacteria that your immune system thinks are totally normal and don't attack when they are in the colon.Sounds like when the movement gets messed up (which is what causes SIBO in other disease conditions where it occurs) then the bacteria may not be cleared out and can live.They produce gases and for many IBSers diets that reduce gases or probiotics that reduce gases work to reduce sympotms. Clearing out the SIBO should reduce gas production as well I would think.K.


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## flux

> quote:if ibs'ers have good absorption then why do I have healthy nails with bloody great white spots . This indicates an absorption prob if there was one.


These spots have nothing to do with IBS, nor are they a specific indicator of generalized malabsorption.


> quote:how could the SIBO healing would solve the motility problemsman,that's weird?!


I think it's too soon to tell what will be the long-term effect of short term antibiotics and short-term motility drugs. However, there are other motility-enhancing agents and also corticotrophin releasing factor antagonists in the pipeline.


> quote: in particular how they diagnose it- given that the percentage of IBS'ers with SIBO differs with whether lactulose is used or glucose and would affect whether


Well, Dr. Pimental was not present; otherwise, they could have discussed with each other at panel.


> quote:Could it be that with SIBO the immune system is so taxed t


No, you'd need a majorly severe infection to tax the system.


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## bonniei

> quote:Well, Dr. Pimental was not present; otherwise, they could have discussed with each other at panel.


Well last question flux which I hope you will pose to them-If they agree that SIBO is behind IBS, do they mean IBS as diagnosed by the lactulose or IBS as diagnosed by glucose. Because as diagnosed by glucose, not a whole bunch of IBS'ers have SIBO so on what basis do they say SIBO is behind IBS? Thanks a ton for all your effort in responding to us as well as asking them.


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## SpAsMaN*

> quote: I am formally submitting that as a question to the experts' panel, but Pimental definitely said glucose won't work because it's absorbed nearly instantanously upon ingestion.


You have formally talk to him?









> quote: He showed pictures of this change in a mouse, practically causing a mouse to develop IBS.










For those interested by the Pimentel research,you can take part of it.I have a direct link in the pain,gas,bloat section.He NEED NORMAL SUBJECTs AND IBSERS to evaluate the prevalence of SIBO.


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## SpAsMaN*

Alrigth Flux,do you think SIBO is a small bowel contamination from the ceacum?That's what i feel Pimentel seems to claims when he talk about motility as a trigger.But hey,we have an ileocecal valve to prevent backflow!Do you means the valve is overwhelm or something?http://www.capefearvalley.com/outreach/out.../Physiology.htm*



quote: The ileocecal valveâ€™s primary function is to prevent backflow of fecal contents from the large intestine into the small intestine. A portion of the valve actually protrudes into the first portion of the large intestine and is forced closed as the large intestine fills----

Click to expand...

*


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## flux

> quote:lux,do you think SIBO is a small bowel contamination from the ceacum?That's what i feel Pimentel seems to claims when he talk about motility as a trigger.


Yes, he said this, but I vaguely recall he said that he would explain that in more depth later in the talk. But did he? I don't remember. Gosh, I hope there is no quiz.


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## SpAsMaN*

Good works.The video will tell hopefully.I would claims that the valve is overwhelm by the pressure.I restart my XP tommorrow,i think i will turn to Mac LOL!See you tommorrow...


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## eric

Just fyi for those interested.The newer report from the IFFGD will be out in the fall.However, this is about Post Infectious IBS and cytokines, and pain and inflammation and serotonin and other research. This for some background also on the discussion here and some context.PI IBS has been found from bacteria, but also now maybe from viruses and if I remember correctly which maynot be the case, even with some parasites. Food poisoning could be one for example. A person becomes infected and when the infection is resolved they develop IBS. From - Report on the 5th International Symposium onFunctional Gastrointestinal DisordersApril 4, 2003 to April 7, 2003 Milwaukee, Wisconsin By: Douglas A. Drossman, M.D., UNC Center for Functional GI and Motility Disorders at Chapel Hill, and William F. Norton, IFFGDBasic Principles -- Brain-Gut Moderators: Emeran Mayer MD; Robin Spiller MD. Panel: Robin Spiller MD; Jackie Wood PhD; George Chrousos MD; Yvette TachÃ© PhD; Lisa Goehler PhD; G.F. Gebhart PhD; Emeran Mayer MD. http://www.iffgd.org/symposium2003brain-gut.htmlFlux, yes thanks for helping here.Flux, I sure hope he talks about pain and IBS and SIBO, because that is major here for sure. You also can't have pain coming from the gut or viceral hypersensitvity without the brain gut axis of course, so that would have to be explained in its role in sibo and in IBS.I have not seen personally anything about it explained really with its connections to sibo.I would really like to here what Dr Esther Sternberg, would say or add to this and Neuroendocrine and Neuroimmunology or Dr Wood, Dr Mayer, and especially Dr Spllier as the PI specialist for examples.


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## meckle

Wow. Nice post flux......and congrats on believing someone for once !!


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## Talissa

Well, this is refreshing...Thanks for the info flux. Never thought I'd see the day.







What concerns me is the dysbiosis of not only the small bowel, but also the colon. And is the very slight submucosal intestinal inflammation resolved when the dysbiosis has been eliminated? Also, my bug is citrobacter freundii 4+. This is a hardy gram-negative bacteria that seems to develop resistent strains to all but the most damaging antibiotics...unfortunately, the rifaximin that Pimental favors, which is relatively safe, is easily resisted by c. freundii by the 3rd day, I've read...It is effective ag most bacteria though. Just some gram-negatives give it problems.But anyways, this is great the more conservative, must-have-more-proof folks here are beginning to come around!!Thanks for listening to my rambles..Tal


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## flux

> quote:What concerns me is the dysbiosis of not only the small bowel, but also the colon.


I'm not sure I use the term dysbiosis. That to me implies something is wrong in what's growing, not in only quantity. I'd call it an hyperbiosis. Dysbiosis would mean something is there that shouldn't be. For example, someone who has trouble swallowing would have dysphagia, but someone who swallows too much would have hyperphagia. It's not exactly clear to me, for example, that if one had some hypergrowth of probiotic bacteria in the small bowel they be any better off than if they no bacteria.


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## cat crazy

FluxWould it be reasonable to say that due to the motility problem causing SIBO it is causing maldigestion also? It would explain the undigested foods ending up where it does.Am I correct in saying that different parts of the small bowel or intestine digest and absorb the foods at different intervals?Something like a conveyer belt where food is going thru the tube in a smooth fashion. But one little malfunction on the conveyer tube and it messes the end result?


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## meckle

random off topic comment:I can't send PM's - apparently I don't have permission ?Whats up with that ? Mods ??


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## flux

> quote:Would it be reasonable to say that due to the motility problem causing SIBO it is causing maldigestion also?


Since IBSers don't have maldigestion, it appears thaat SIBO does not impact digestion or absorption. SIBO would affect bile acid absorption because of direct bacterial action on the bile acids and that in turn can lead to diarrhea.


> quote:It would explain the undigested foods ending up where it does.


This is normal.


> quote:Am I correct in saying that different parts of the small bowel or intestine digest and absorb the foods at different intervals?


No, most everything is absorbed in the jejunum. Vitamin B12 and bile acids are absorbed in the ileum. Water not absorbed by the small bowel is absorbed by the colon.


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## eric

I wonder how this theory fits into the other functional disorders, functional abdominal pain, functional D and functional C, functional dyspepsia ect..I also wonder how it causes rectal hypersensivity? Since at one point they were close for that being a biological marker?As well as it fitting into the altered brain fmri and pet scans?Flux is it correct in saying SIBO is a type functional disorder?


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## eric

alsoRifaximin Dose-Finding Study for the Treatment of Small Intestinal Bacterial Overgrowthhttp://ibsgroup.org/eve/forums?a=tpc&s=500...04561#737104561Digestive Disease Week 2005Functional Bowel Disorders -- Clinical Highlights CMESmall Intestinal Bacterial Overgrowth in IBShttp://ibsgroup.org/eve/forums?a=tpc&s=500...04561#947104561


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## Kathleen M.

> quote:Originally posted by meckle:random off topic comment:I can't send PM's - apparently I don't have permission ?Whats up with that ? Mods ??


NO ONE has permission right nowsee this thread http://ibsgroup.org/eve/forums/a/tpc/f/74110261/m/800107461K.


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## SpAsMaN*

> quote:I also wonder how it causes rectal hypersensivity?





> quote: Dr. Pimental is discounting the reports of "micro-inflammation", which are in the rectum, saying these studies were not well-controlled and the results could simply be an irritant effect from diahrrea itself


I think this bold makes sense:*irritant effect from diahrrea itself *Eric,i guess it depend if IBDers,celiacers etc have rectal sensitivity,if yes,it couldn't be an exclusive marker to IBS.


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## eric

Perhaps and make sence with d people, but what about c and alternators?Also"The most common symptoms of IBS patients are related to altered perception of sensations arising from the GI tract, and frequently from sites outside the GI tract, such as the genitourinary system or the musculoskeletal system. Sensations of bloating, fullness, gas, incomplete rectal evacuation and crampy abdominal pain are the most common symptoms patients experience. Numerous reports have demonstrated that a significant percentage of FBD patients (about 60%) rate experimental distensions of the colon as uncomfortable at lower distension volumes or pressures when compared to healthy control subjects. This finding of an increased perception of visceral signals ("visceral hypersensitivity") has been demonstrated during balloon distension tests of the respective part of the GI tract regardless of where their primary symptoms are â€" the esophagus, the stomach, or the lower abdomen."http://www.aboutibs.org/Publications/VisceralSensations.htmlThen there is also the 'SENSATION' of incomplete evacuation.Even though the rectum is empty there can still be the 'sensation' of having to go.I can tell you spasman and I am an alternator, and have also had d from food poisoning and other issues and my rectal sensivity with IBS is not just from d being an irritant. I can be normal for weeks now and still have rectal hypersensivity.


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## SpAsMaN*

My edit from my last post:


> quote:Eric,i guess it depend if IBDers,celiacers etc have rectal sensitivity,if yes,it couldn't be an exclusive marker to IBS.


Eric,thanks for yor post.I"m scared that the hypersensitivity could be an entity.


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## bonniei

> quote:Originally posted by eric: Sensations of bloating, fullness, gas, incomplete rectal evacuation and crampy abdominal pain are the most common symptoms patients experience.


If anything indeed falls short of explaining distension, it is abnormal motility, visceral hypersensitivity, altered brain-gut interaction, autonomic dysfunction, and immune activation. They above don't explain distension ,the physical evidence of increased intestinal gas that is localized to the small intestine, the effect of probiotics on bloating, or the increased gas excretion after lactulose ingestion. This increased gas excretion could well be explained by the fact that the bacteria expanded into the the small intestine and worked on the substrate there and this could also explain bloating.


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## eric

The colon works by distension.When distended it releases neurotransmitters for communication and for gut function and importanly to communicate with the brain bidirectionally. Distension is a term for normal gut function.Just altered motility does not explain IBS."abnormal motility, visceral hypersensitivity, altered brain-gut interaction, autonomic dysfunction, and immune activation. "All of the above have been found in IBS.They have also found altered motility, viceral hypersensivity and altered brain gut axis function in dyspepsia and some other functional gi disorders.alsoExpert Commentary -- Bloating, Distension, and the Irritable Bowel SyndromeDefinition of Bloating and DistensionThe Epidemiology of BloatingThe Relationship Between Bloating and DistensionThe Pathophysiology of BloatingHow to Manage Patients With BloatingConclusionhttp://ibsgroup.org/eve/forums/a/tpc/f/71210261/m/656101261So gas does not explain bloating and distension fully.The serotonin receptors and dysregulation of it already in part explain altered motility and some of the brain gut axis dysfunction and viceral hypersensivity.Spasman, I will look that up some.


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## bonniei

> quoteistension is a term for normal gut function.


I am not talking about normal distension. I am talking about the distension which is called bloatiing, the increase in abdominal girth which IBS'ers say happens to them during the day i.e they are flat in the morning anf look 6 mths pregnant by the end of the day. Altered brain gut axis function does not explain this distension


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## kitkat17 Lady of the Loo

I live in St Louis and there was a article in the news paper about all this. Of course allot of big words I did not understand. They had it on TV this morning and going to be in paper again tomorrw. I will have to keep it and let you all know. But form what I read it is all about this breath test and bacteria etc. Wouldn't be NICE to finally get a cure.


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## bonniei

Also in addition to my previous post


> quote:Originally posted by eric:So gas does not explain bloating and distension fully.


Immune Activation Is Also Present in IBS: postinfectious IBS patients have an increased number of intraepithelial lymphocytes, just like the patient with documented bacterial translocation.However acute gastroenteritis is not the only factor which leads to immune activation in IBS'ers. Infact there is greter immune activation in IBS'ers without a history of gastroenteritis. *SIBo can explain immune activation*. Further in postinfectious IBS patients, along with immune activation, there is also increased intestinal permeability, which has a known association with SIBO in animals and humans.*Immune Response to Bacteria Explains Abnormal Motility and Visceral Hypersensitivity*:Lipopolysaccharide, a product of gram-negative bacteria, accelerates small intestinal transit. This leads to hypersecretion and power peristalsis. The immune response to these bacterial products also explains *Visceral hypersensitivity*. Also Weston et al proposed earlier that increased mast cells in the ileum of IBS patients might be linked to altered visceral perception*Activated Immunity May Explain Altered Brain-Gut Interaction and Autonomic Dysfunction in IBS*:Since inflammation in animal models leads to multiple changes in the brain, including activation of neurons as documented by Fos expression,84-85 alteration of hypothalamic-pituitary-adrenal axis including elevation of corticotropin-releasing factor (CRF) concentration and change in neurotransmitter levels such altered brain-gut interactions may be a part of the systemic response to a trigger of inflammation.*Yes so SIBO explains distension AND hypersensitivity- i.e all of bloating.*


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## Talissa

Great info Bonnie. Thx for sharing. T-


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## eric

What link is the info coming from, as I may have missed it?To say that they know the cause of viceral hypersensivity as fact, is NOT a fact.These are still theories were talking about here when it comes to SIBO.However brain gut interations in general digestion is of course a fact.There are still theories on the causes of bloating and distension, both from the SIBO group as well as many others.There is also a ton of research on immune activation in IBS and stress and mast cells.Even mounting evidence of increased stress hormones.There is also more going on in IBS then just immune activity. Bloating and distension are NOT understood yet. You completely contradict what your saying here, by this"Altered brain gut axis function does not explain this distension"then posting abstracts on how altered brain gut axis function causes distension and bloating.The hypothalamic-pituitary-adrenal axis is part of the brain gut axis, involved in both fighting infection and as the bodies Stress system. Hence the Hypothalamus, a part of the brain.SIBO has to explain more then bloating and distension anyway, it needs to explain the constellation of symptoms in IBS, especially and specifically pain and discomfort, a hallmark to IBS. I can already see posts here that this seems to be all fact and its all figured out and people telling others SIBO is the cause of IBS. Perhaps to go and take antibiotics?Well we all know Dr Dalhman said antibiotics cause IBS.







Here Dr Pimental is saying they might cure IBS?Larger studies need to be done and there is a lot of work that still needs to be done.None of the studies show SIBO as a biological marker in All IBSers.here"McCallum and colleagues[12] presented additional evidence on the association of small intestinal bacterial overgrowth with IBS. They evaluated only patients with IBS with diarrhea using the glucose breath test, assessing both H2 and CH4 production as criteria for a positive test. They defined a prevalence rate of small intestinal bacterial overgrowth of 38.5% in their population of 143 patients with IBS with diarrhea. For the breath-test analysis, 74.5% of patients were positive only by H2 analysis, and 23.6% were positive only by the CH4 analysis. These investigators suggest that both the H2 and CH4 analysis should be performed to optimize the interpretation of these breath tests in this population of patients."They found sibo in people without IBS."The study authors found a significantly increased (P < .05) proportion of patients with small intestinal bacterial overgrowth among patients in the IBS group: 20 of 65 (30.7%) compared with 4 of 102 (3.9%) controls. These findings are consistent with an increasing awareness of a postinfectious IBS syndrome."That 30% is lower then the 70 to 80 whatever in pimentals group and still not all of the ibsers in the group. Then sibo in people without IBS.There is also a large amount of evidence on PI IBS, which is not being presented here.


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## bonniei

> quote:Originally posted by eric:What link is the info coming from, as I may have missed it?


It is coming from Pimente's SIBO as a framework for understanding IBS.


> quote:To say that they know the cause of viceral hypersensivity as fact, is NOT a fact.


No what I am saying is in response to you saying SIBO cannot explain visceral hypersenitivity. I am giving a mechanism by which visceral hypersensitivity can be explained by SIBO.


> quote:However brain gut interations in general digestion is of course a fact.


HOWEVER as much of a fact that brain gut axis dysfunction is it does not explain distension









> quote:You completely contradict what your saying here, by this"Altered brain gut axis function does not explain this distension"then posting abstracts on how altered brain gut axis function causes distension and bloating.


i did not post abstracts saying brain-gut axis dysfunctiobn causes visceral hypersensitivity. Read it carefully. I said bacterial dilsocation causes immune system activation in the form of intraepithelial lymphocytes. This immune system activation causes visceral hypersensitvity. However I also did say that immune sustem activation can cause brain gut dysfuction. I posted that to show that anytrhing which is covered by brain gut axis dysfuction is covered by immune systen activation hence SIBO is a much broader theory than brain gut axis dysfunction.


> quote:SIBO has to explain more then bloating and distension anyway, it needs to explain the constellation of symptoms in IBS, especially and specifically pain and discomfort, a hallmark to IBS.


Like IO said brain gut axis dysfunction is covered by SIBO so anything that your theory explains is explained by SIBO.


> quote:Here Dr Pimental is saying they might cure IBS?


You know that Dr Dahlman is not in the same league as Dr Pimentel.


> quote:None of the studies show SIBO as a biological marker in All IBSers.


I'll let flux comment on it.here


> quote:That 30% is lower then the 70 to 80 whatever in pimentals group and still not all of the ibsers in the group. Then sibo in people without IBS.


This is a point I have already made to fluxx and asked for clarification on when I asked the question how is SIBO diagnosed because if by glucose it is a far smaller percentage of IBS'ers who have SIBO


> quote:There is also a large amount of evidence on PI IBS, which is not being presented here.


I will let flux comment on that. He has already partially commented on it I think . Go through his posts._edited to add that Lin could be the author of the link I am posting from and not Pimentel_


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## Arnie W

This is a most encouraging thread. And it drew talissa out of the woodwork. Woopee! So good to have you around again. I know you have a great interest in this topic, as I do too. Nice to see meckle back too. Are you still seeing Dr Mckenna in Naas?Thought the following link might be of interest to those who want to know what other possibilities are on the horizon.http://www.ruraldelivery.net.nz/absolutenm...eid=97&zoneid=5As for SIBO, I do understand that bacterial overgrowth in the small intestine is quite common in people with CFS, IBS and fibromyalgia.


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## gilly

How do we read what Dr Pimental said at the symposium? Gilly


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## SpAsMaN*

I would post a thread soon Gilly,i think i will have the videotapes.


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## flux

> quote:I wonder how this theory fits into the other functional disorders, functional abdominal pain, functional D and functional C, functional dyspepsia ect.


I think it fits into functional constipation. Methane is the gas that is altering colonic motility to produce constipation. It appears that functional dyspepsia may be a different condition entirely.


> quote:As well as it fitting into the altered brain fmri and pet scans?


I don't think they are discounted, but part of the pathophysiology.


> quote:is it correct in saying SIBO is a type functional disorder?


Well, I think functional disorder is a holdover term from the days when a disease didn't have an obvious structural entity and were in a sense non-diseases. I'm not sure the term will go away even though from a technical point of view SIBO is a structural change inside the gut lumen.


> quote:If anything indeed falls short of explaining distension, it is abnormal motility,


It certainly explains it nicely. Phase III of the MMCs clears stuff, gas included, out of the small bowel. Reduce their frequency and that could lead to distension.Also, methane alters colonic motility and could also theoretically produce distension.However, it doesn't necessarily mean they are the cause or sole cause of it.


> quote:So gas does not explain bloating and distension fully


That's what I mean by not the sole cause of it. X-rays don't seem to correlate with distension and almost never with the sense of bloating.


> quote:None of the studies show SIBO as a biological marker in All IBSers.


This is certainly true. IBS is definitely more than a single disease. Would be very interesting if ROME III identifies PI-IBS as a new clinical entity which has breath-tested demonstrated SIBO as a criteria. I don't know this is happening, but I wonder if that's where the thinking might be heading in the next year.


> quote:How do we read what Dr Pimental said at the symposium?


Pimental did not provide slides to us only an summary article, but the presentation was videotaped. Spasman is the BB's official stenographer.


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## bonniei

> quote:quote:If anything indeed falls short of explaining distension, it is abnormal motility, It certainly explains it nicely. Phase III of the MMCs clears stuff, gas included, out of the small bowel. Reduce their frequency and that could lead to distension


I meant they the cuurrnt models of IBS excliding Pimentel's- do not explain all of IBS including distension.


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## bonniei

flux


> quote: should clarify that Dr. Pimental referred to SIBO-mediated IBS as being triggered by a gut infection, aka post-infectious IBS>quote:


can you elaborate more on this.? How does an infection lead to SICO , via Lipopolysaccharide, a product of gram-negative bacteria, awhich ccelerates small intestinal transit and leads to hypersecretion and power peristalsis?


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## Jhouston

Great question, Bonnie. I may have misunderstood but it seems as if IBS C is requisite for SIBO? usually bacteria causes d? Joann


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## Kathleen M.

Bacterial infections cause diarrhea because the body responds by flushing out the system.The bacteria causing the problems in SIBO are totally normal bactiera to have in your body. Your immune system has no interest in kicking them out of the body.They are just living in the WRONG place. They shouldn't be able to get going in the small intestine because they should be swept out by the normal housekeeping that goes on in a normal body. Seems in some IBSers the normal sweeping (the Phase III of the MMC's like Flux keeps talking about) aren't doing the job so you got bacteira in the small intestine with access to food you aren't done with yet. Which may alter how much of what gases you get.One of the very normal types of bacteria to have in the colon are methanogens. Methane effects motility and can slow things down, which could be one way SIBO could have a constipating effect.A good percentage of the normal bathroom going population have methanogens, and often people with some inflamatory bowel issues seem to be low on them, so I don't know we need to get them out of the body completely as they are totally evil, like most things in the right place at the right time they are fine.It is this "in the wrong place" thing that is the problem.K.


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## Talissa

If anyone's interested, this link has some good natural antibacterials listed:http://www.ei-resource.org/anti-bacterial.aspThey also name some Rx anti's...like flagyl, which is the drug I used for giardia, which isn't effective ag some aerobes, which is what c. freundii is, and this may explain why I've an overgrowth of it...Hey Arnie & Joann







I'd pm you if I could....so glad you guys are still around too. Hope you're doing really well.T-


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## Nath

This may explain why people have problems with lactose and fructose, which are not absorbed as quickly as other sugars, leaving them available longer to bacteria.Personally this fits well with my PI-IBS, I have experienced a lessening of symptoms while on antibiotics in the past and recently have had a worsening of my symptoms after trying a new probiotic.


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## Kathleen M.

I was reading this article today and noted a couple of interesting things in it with regards to some of the things that bother IBSers. and may be part of the whole SIBO/IBS sort of stuff.I figured I'd post it here and see what anyone else thought.Curr Opin Gastroenterol. 2005 Mar;21(2):141-6. Small intestinal motility.Jones MP, Wessinger S.They note that not a whole lot has been known about this aspect of digestion although there is some new info coming out. And they do discuss the whole altered mmc thing that we've gone over before so I won't repost that.


> quote:Infusion of lipid into the small intestine also results in intestinal gas retention and abdominal distension in healthy volunteers





> quotehysical inactivity (measured as the number of steps taken daily) in elderly individuals is also associated with small bowel bacterial overgrowth


Fatty meals bother some IBSers and this may be one mechanism.Some people really find exercise helps, this might be part of why that is as well.


> quote:This is similar to previous studies by Farthing and others demonstrating relationships between altered digestive motility or transit in relation to affective disorders or psychiatric distress


And that the whole brain/gut axis may still play a role in the whole thing as it also can effect the motility. (this is likely not an either/or one paradigm is completely right one is completely wrong thing, I see it as more of an and/also where all the paradigms have some role and interact with each other...just saying)K.


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## Kathleen M.

Nath--you might like this


> quote:Aliment Pharmacol Ther. 2005 Jun 1;21(11):1391-5. Abnormal breath tests to lactose, fructose and sorbitol in irritable bowel syndrome may be explained by small intestinal bacterial overgrowth.Nucera G, Gabrielli M, Lupascu A, Lauritano EC, Santoliquido A, Cremonini F, Cammarota G, Tondi P, Pola P, Gasbarrini G, Gasbarrini A.CONCLUSIONS: In irritable bowel syndrome patients with small intestinal bacterial overgrowth, sugar breath tests may be falsely abnormal. Eradication of small intestinal bacterial overgrowth normalizes sugar breath tests in the majority of patients. Testing for small intestinal bacterial overgrowth should be performed before other sugar breath tests tests to avoid sugar malabsorption misdiagnosis.


K.


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## cat crazy

> quote:Originally posted by flux:
> 
> 
> 
> is it correct in saying SIBO is a type functional disorder?
> 
> 
> 
> Well, I think functional disorder is a holdover term from the days when a disease didn't have an obvious structural entity and were in a sense non-diseases. I'm not sure the term will go away even though from a technical point of view SIBO is a structural change inside the gut lumen.________________________________________________Flux From the quote above 'from a technical point of view SIBO is a structural change inside the gut lumen' Would this be obvious in the capsule endoscopy test as of current testing with the pill camera?
Click to expand...


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## eric

Let me rephrase that flux.SIBO is a result of abnormal motility?But just abnormal motility doesn't fully explain IBS and since there is abnormal motility in IBS, is the sibo a result of the IBS.So anyone is not confused by my posts, I am glad Dr Pimental and lin are working on SIBO and its relationship to IBS. All real research is a good thing.I am a little concerned about calling sibo the CAUSE of IBS however at this stage in the research. Especially because its highly controversial.So what causes the "structural change inside the gut lumen" in the first place?This is from Dr Spliier one of the leading doctors in PI IBS.This talks about changes in the gut from PI IBS.http://ibsgroup.org/eve/forums?a=tpc&s=500...05561#557105561 and how do these molecular changes apply here.Gastroenterology. 2004 Jun;126(7):1657-64. Related Articles, Links Comment in: Gastroenterology. 2004 Jun;126(7):1897-9. Molecular defects in mucosal serotonin content and decreased serotonin reuptake transporter in ulcerative colitis and irritable bowel syndrome.Coates MD, Mahoney CR, Linden DR, Sampson JE, Chen J, Blaszyk H, Crowell MD, Sharkey KA, Gershon MD, Mawe GM, Moses PL.Department of Anatomy and Neurobiology, University of Vermont College of Medicine, Burlington, VT 05405, USA.BACKGROUND & AIMS: Serotonin (5-HT) is a critical signaling molecule in the gut. 5-HT released from enterochromaffin cells initiates peristaltic, secretory, vasodilatory, vagal, and nociceptive reflexes. Despite being pathophysiologically divergent, ulcerative colitis (UC) and irritable bowel syndrome (IBS) are both associated with clinical symptoms that include alterations in the normal patterns of motility, secretion, and sensation. Our aim was to test whether enteric 5-HT signaling is defective in these disorders. METHODS: Rectal biopsy specimens were obtained from healthy controls and patients with UC, IBS with diarrhea (IBS-D), and IBS with constipation (IBS-C). Key elements of 5-HT signaling, including measures of 5-HT content, release, and reuptake, were analyzed with these samples. RESULTS: Mucosal 5-HT, tryptophan hydroxylase 1 messenger RNA, serotonin transporter messenger RNA, and serotonin transporter immunoreactivity were all significantly reduced in UC, IBS-C, and IBS-D. The enterochromaffin cell population was decreased in severe UC samples but was unchanged in IBS-C and IBS-D. When 5-HT release was investigated under basal and mechanical stimulation conditions, no changes were detected in any of the groups relative to controls. CONCLUSIONS: These data show that UC and IBS are associated with similar molecular changes in serotonergic signaling mechanisms. While UC and IBS have distinct pathophysiologic properties, these data suggest that shared defects in 5-HT signaling may underlie the altered motility, secretion, and sensation. These findings represent the first demonstration of significant molecular alterations specific to the gut in patients with IBS and support the assertion that disordered gastrointestinal function in IBS involves changes intrinsic to the bowel.PMID: 15188158


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## flux

> quote:SIBO is a result of abnormal motility?


Yes.


> quote:But just abnormal motility doesn't fully explain IBS and since there is abnormal motility in IBS, is the sibo a result of the IBS.


Abnormal motility is not occuring in a vaccum. Stress is a significant factor:http://www.ncbi.nlm.nih.gov/entrez/query.f...0474&query_hl=2I believes this includes physical stress to the body from a gastrointestinal infection.


> quote:I am a little concerned about calling sibo the CAUSE of IBS


SIBO is *not* cause of PI-IBS. It is a step in the complex series of mechanisms.


> quote:So what causes the "structural change inside the gut lumen" in the first place?


I was just referring to the SIBO itself here.


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## bonniei

> quote:quote:should clarify that Dr. Pimental referred to SIBO-mediated IBS as being triggered by a gut infection, aka post-infectious IBS>quote:can you elaborate more on this.? How does an infection lead to SIBO ,


flux again you forgot to answer my question. SIBO cannot happen without abnormal motility can it, even in the presence of infection?. And in your last post you saifd abnormal motility happens say in the presence of stress. So is it right to say that infection+ factor leading to abnormal motility=SIBO? In fact it seems to me if there is a factor leading to abnormal motility then infection is not cnecessary to cauese SIBO. bacteria from food can grow in the SI.


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## flux

I'm preparing some questions to ask Dr. Pimental. Stay tuned...


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## bonniei

YaY! ok.


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## bonniei

Oh I just read in one of your last posts that bacterial infection is also a stress. So that is how IBS which is triggered by an infection is SIBO mediated . Ok everything is clear! Thanks!


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## Jhouston

Hi All, Is it correct to say Abnormal motility causes constipation? anyone? Hi Tal, Glad to see you too. no pms...you can email me directly. Joann


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## SpAsMaN*

> quote:I'm preparing some questions to ask Dr. Pimental. Stay tuned...


Do you still in contact with him?







Ask him if it is a pollution from the ceacum and why the ileoceacal valve is not doing it's job!!!!!!!!!!!!Jhouston,you're correct about the motility.Your in California!See my post on Pimentel in Pain,bloat and contact them!


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## SpAsMaN*

Also Flux,ask him about the exact treatment.I need it rigth now!







I'm gonna see my expert here for my *LACTULOSE* AND GLUCOSE TEST.


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## SpAsMaN*

Third question:Ask him why there is HIGH prevalence of hypoglyceamea in SIBOers.







Or maybe it is a high comsuption of protein from the BO itself who mimics hypoglycemea.


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## bonniei

> quote:Hi All,Is it correct to say Abnormal motility causes constipation? anyone?


Abnormal moti;ity is one of the causes of constipation. For e.g slow transit constipation. Or in the case of SIBO and constipation methane increases non-propulsive gut motility increasing constipation. So both abnormal propulsive motility as in the case of slow transit const and abnormal non-propulsive motility in the case of SIBO mediated const can cause constipation


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## 13903

why would people get good results from renzapride? without the CV issues of cisapride. Is it becuase on normalising the contractions, the bad bacteria is not shunted back up the intestine, alot like if you view a conveyor belt and some of the grain does not move forward and moves back or stays in one place. Motility of the intestine recycling the bad bacteria, not pushing it out.


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## SpAsMaN*

Guang,how do you know about Renzapride?It is not on the market.Why people get bad ressults from Zelnorm?


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## Talissa

This article may've already been posted here, & if so, my apologies...Uninvited Guests: The Impact of Small Intestinal Bacterial Overgrowth on Nutritional StatusNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES CNSDOren Zaidel, M.D., Division of Gastroenterology,Department of Medicine, Cedars-Sinai Medical Cen-ter, CSMC Burns and Allen Research Institute, LosAngeles, California. Henry C. Lin, M.D., Division of Gastroenterology, GI Motility Program and Section ofNutrition, Department of Medicine, Cedars-Sinai Med-ical Center, CSMC Burns and Allen Research Insti-tute, Geffen School of Medicine, University of Califor-nia Los Angeles, Los Angeles, California."When large numbers of bacteria colonize the small intestine, a syndrome known as small intestinal bacterial overgrowth occurs. Nutrient malabsorption is a hallmark of the disorder and can result in a multitude of problems for the host. Understanding how these bacteria exert their deleterious effects on the host via competition fornutrients, damage of absorptive surfaces, and the production of symptoms, whichreduce or alter food intake is key to diagnosing and treating the condition. New linksbetween small intestinal bacterial overgrowth (SIBO) and disease entities such as irri-table bowel syndrome (IBS) provide intriguing new insights into the pathophysiologyof the syndrome." by Oren Zaidel and Henry C. Lin--------------------------------------------------------------------------------So, um, maybe there is a problem with absorption? Motility is at the heart of it...& of course the MMC.They also talk abt damage to the mucosal intestinal wall...."Nutritional support is a major part of the therapeutic regimen in SIBO. This may be needed despite completeeradication of overgrowth because of mucosal damagethat may persist even after treatment. Fluid, nutritional support, and replacement of vitamin deficiencies (partic-ularly fat soluble vitamins) are part of the initial management strategies in SIBO"Uninvited Guests: The impact of SIBO on Nutritional Status____________Kathy, very interesting re: its best to take the SIBO test prior to sugar intolerance tests. thx.


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## bonniei

Wow! Thanks talissa. So flux how does this line up with what you say about malabsorption in IBS as well as SIBO-mediated IBS? How do you reconcile the two? Or are you going to change your sig on that one too?







Oh Poor flux, he will never live down the ragging!


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## bonniei

JHouston I guess you are asking whether the low frequency of the Phase III of the MMC's seen in SIBO causes constipation? And if only the addition of bacteria results in D. ? I don't know the answer to your question though bacteria are always present in the food you intake for instance and that would lead to SIBO in the presence of reduced frequency of the MMCs and would always lead to diarrhea.


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## SpAsMaN*

With Antibiotics,the phantom C-difficile can be around.It can happen.


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## Jhouston

bonnie, yes, I am looking at the info and thinking overgrowth of bacteria would cause d but low frequency phase III MMC's would cause cand initiate the environment for overgrowth. Interesting, since I have been c and the past 6 weeks prone to d. Spas, I left a message at cedars, lets see if they still need subjects. but I am not sure I qualify anymore.....IBS C I think is what they want. Joann


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## cookies4marilyn

This may be the story that KitKat saw - just sent to me on one of my med topic alerts:http://www.ksdk.com/news/health_article.aspx?storyid=82589Controversial Theory Links Bacterial Overgrowth to Irritable Bowel SyndromeLink also has video report.







=================


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## Talissa

I think c. difficile is still susceptible to rifaximin, thus you won't get it's overgrowth from taking this part. antibiotic.I also think I read the following incorrectly in re: to c. freundii. I now -think- its saying rifaximin is actually effective ag my bacteria...In vitro activity of rifaximin, metronidazole and vancomycin against Clostridium difficile and the rate of selection of spontaneously resistant mutantsAnybody?Maybe we should all take the test & talk to our MDs abt taking this new anti before these bacteria grow resistent to it, which they will eventually....


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## SpAsMaN*

Talissa,you know i like you isN't?







Let me guess,you're 36 years...














Alrigth,back to Flux.Please stop calling him Pimental,his name his Pimentel.I wonder if the people laugh at you in the auditorium when you told his name.hmmmm just wondering...







http://www.cedars-sinai.edu/2629.html


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## flux

Good thing I didn't send the note yet


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## SpAsMaN*

Good for you that i'm not a normal subject,i would'nt be here to help your "note".







ASk my 3 questions BTW.







Take your time for my offer in your forum Flux.


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## jjohnson

flux,I noticed in one of your earlier posts on this thread that corticotrophin releasing factor (CRF) has been implicated as a cause of SIBO. Just thought people might be interested to know that GSK is developing a CRF antagonist for the treatment of IBS. Don't expect this one at the pharmacy anytime soon, but could be a very significant step forward if this theory is correct (which I have absolutely no qualifications to judge.)http://science.gsk.com/pipeline/index.htm


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## Pete

Spasman,The correct treatment is as follows:Rifaximin 400-600 mg 3x a day for 2 weeksThis is followed by 2mg of zelnorm at bedtime indefinatley.


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## SpAsMaN*

Big thanks Pete.I see my doc in 2 weeks,a too long time in my opinion.I think i can have a quicker appointment.But there is mention of another drug with Rifaximin.I hate Zelnorm even 2mg.


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## bonniei

flux are you going to change this part of your sig-"IBSers have normal digestion and absorption" in light of what Talissa posted about nutritional deficiencies in people with SIBO?


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## cat crazy

TalissaAmazing post about the Uninvited Guests and the link explaining it. I've printed it and will fax it to my gi doc hoping he will test me for SIBO and then treat it. That description of SIBO is such a true depiction of my very own symtoms to a T. I want to thank you and Flux and bonniei, Kath M and all the other experts in posting such knowledgeable and helpful posts and links. This bb has been like a life line for me and I've learned more about ibs here and how to deal with it in better ways than any doctor could provide in a lifetime of visits to their office.________________________________________________Flux.One question remains in my mind. How do the 5HT drugs work for SIBO? The serotonin antagonists help control the bacteria also?


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## eric

Hanna, the majority of the bodies serotonin is found in the gut. 95 percent.This is a neurotransmitter. Serotonin plays a critical role in the regulation of gastrointestinal (GI) motility, secretion, and sensation.In the gut there are receptors, the 5ht 3 and 5ht four receptors are important in IBS and gut function.Serotonin intiates gut contractions.So the serotonin drugs help control the gut functions that are impaired alowing the bacteria to enter the small intestines.Serotonin does work to help fight infections also, but not really in this case.They have found molecular defects in the serotonin signaling processes in IBS.this will help also"A: Irritable bowel syndrome is now recognized as a disorder of serotonin activity. Serotonin is a neurotransmitter in the brain that regulates sleep, mood (depression, anxiety), aggression, appetite, temperature, sexual behavior and pain sensation. Serotonin also acts as a neurotransmitter in the gastrointestinal tract. Excessive serotonin activity in the gastrointestinal system (enteric nervous system) is thought to cause the diarrhea of irritable-bowel syndrome. The enteric nervous system detects bowel distension (expansion) on the basis of pressure-sensitive cells in the bowel lumen (opening). Once activated, these pressure-sensitive cells promote the release of serotonin, which in turn promotes both secretory function and peristaltic function (the contractions of the intestines that force the contents outward). At least four serotonergic receptors have been identified to be participants in the secretory and peristaltic response. Patients with diarrhea-predominant IBS may have higher levels of serotonin after eating than do people without the disorder. This recognition led to the development of the first drug used specifically to treat diarrheal symptoms of IBS, alosetron (also known as Lotronex). Alosetron blocked the specific serotonin receptors responsible for recognizing bowel distention. In doing so, it blocked the effects of serotonin and reduced both bowel secretions and peristalsis. Constipation was the most common side effect seen. (Note: Alosetron was removed from the market by the manufacturer after repeated reports of a dangerous condition known as ischemic colitis became known.) Tegaserod (Zelmac) is another drug under development and under review by the U.S. Food and Drug Administration for approval. Tegaserod is indicated for the treatment of constipation-predominant IBS and works to increase enteric nervous system serotonin activity. So, increasing serotonin activity in the enteric nervous system produces increased bowel secretions and peristalsis (and potentially diarrhea), whereas depressing serotonin activity produces reduced secretions and reduce peristalsis (and potentially constipation)."Serotonin and IBShttp://www.aboutibs.org/Publications/serotonin.html


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## bonniei

Hi hanna you may have noticed that flux said Zelnorm is a drug which is used by Pimentel to restore the motility, presumably the MMCs. Zelnorm is a 5HT-4 agonist drug which by activating 5HT4 receptors, stimulates the peristaltic reflex and normalizes impaired motility in the GI tract. It does not directly affect the bacteria,just speeds up the hoousekeeper waves to sweep the bacteria out of the Sm Int more often so they don't overgrow.


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## Jhouston

Would they still give zelnorm if IBS d?


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## flux

> quote:would cause d but low frequency phase III MMC's would cause c


They probably wouldn't impact either one since it's small bowel process.


> quote:are you going to change this part of your sig-"IBSers have normal digestion and absorption" in light of what Talissa posted about nutritional deficiencies in people with SIBO?


I don't know why IBSers do not experience maldigestion and malabsorption. Will have to wait to Pimentel to answer this.


> quote:Would they still give zelnorm if IBS d?


Yes, but you'd be getting antibiotics at the same time.


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## bonniei

Actually by the logic I have given they would give Zelnorm to a person with D since they affect the MMC's. flux didn't say they give Zelnorm to only those with C. Zelnorm taken by a person with D would cause more D it would seem but if the MMCs are fixed then the D caused by the bacterial overgrowth wouldn't be there. Zelnorm doesn't cause D, all it does it stimulates the peristaltic reflex. Specially useful if the peristaltic reflex is absent. flux am I right?


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## bonniei

> quote:I don't know why IBSers do not experience maldigestion and malabsorption. Will have to wait to Pimentel to answer this


I saw what you wrote before you edited and wrote the above







Good edit


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## SpAsMaN*

Am not sure if Zelnorm is systematickly(sp?) used.


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## eric

This is interesting as a reference to this also and the whole article.Gut Thoughts""We now know quite a lot about the library of programs run by the [gut brain]," says Jackie Wood, professor of physiology and cell biology and of internal medicine at Ohio State University. "For example, when the bowel is empty, one particular program runs." Called the migrating motor complex (MMC), this involves a series of movements running from the stomach to the end of the small intestine, which is believed to function in keeping the potentially dangerous bacteria stored in the colon from moving upwards rather than out. At least 500 different species of deadly bacteria have been found to inhabit a person's colon at any given time; "traveler's diarrhea" often results when this mix is changed through exposure to new pathogens. If this happens, the gut runs a program designed to expel as much of its contents as quickly as possible â€" unpleasant for the vacationer, but much better than a fatal infection. "Another program involves a flood of serotonin throughout the entire circuit, which produces the digestive pattern that mixes and stirs the contents," says Wood. Because the gut brain is smaller and more accessible than the brain itself, understanding it could offer insights about how to parse the more complex organ. "[That idea] was what lead me to begin my research when I was a fledgling neuroscientist," says Gershon. "I looked at the brain and found it daunting, and I still do, so I looked for a simpler nervous system to study." He adds, " 'Simple nervous system,' of course, turned out to be an oxymoron." Unlike the cranial brain, however, the gut brain doesn't seem to be conscious â€" or at least, in health, it doesn't impinge much on consciousness. "The gut is not an organ from which you like to receive frequent progress reports," says Gershon. For most digestive processes, no news is good news. "http://www.kiwiterapi.dk/whiplash/frames/gutthoughts.htm


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## eric

Flux, you have seen this yes?"United States Patent Application 20020039599 Kind Code A1 Lin, Henry C. ; et al. April 4, 2002 --------------------------------------------------------------------------------Methods of diagnosing and treating small intestinal bacterial overgrowth (SIBO) and SIBO-related conditions AbstractDisclosed is a method of treating small intestinal bacterial overgrowth (SIBO) or a SIBO-caused condition in a human subject. SIBO-caused conditions include irritable bowel syndrome, fibromyalgia, chronic pelvic pain syndrome, chronic fatigue syndrome, depression, impaired mentation, impaired memory, halitosis, tinnitus, sugar craving, autism, attention deficit/hyperactivity disorder, drug sensitivity, an autoimmune disease, and Crohn's disease. Also disclosed are a method of screening for the abnormally likely presence of SIBO in a human subject and a method of detecting SIBO in a human subject. A method of determining the relative severity of SIBO or a SIBO-caused condition in a human subject, in whom small intestinal bacterial overgrowth (SIBO) has been detected, is also disclosed. "http://appft1.uspto.gov/netacgi/nph-Parser...=1&f=G&l=50&s1='20020039599'.PGNR.&OS=DN/20020039599&RS=DN/20020039599


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## eric

The link didn't work, but it will get you to the page where you can type in the abstract title.


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## eric

FYIMedical EncyclopediaSmall bowel bacterial overgrowthhttp://www.nlm.nih.gov/medlineplus/ency/article/000222.htmand very interesting.Small Intestinal Motilityhttp://www.medscape.com/viewarticle/470568_print


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## 13903

they must experience both. white spots on fingernails. all contents getting sloshed around due to bad motility, and this means the nutrients cannot be absorbed through the gut wall effectively, imo.bad bacteria recycling, causing inflammation??5-HT4 agonist would make someone with soft stools even worse, theoretically, sending pain through the roof.


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## Talissa

Hanna, I know what you mean. I'm abt to leave for vacation in the states & will have abt a week during that time to try for an appt for the test. I'm taking all sorts of info w/ me to show the doc, if I can snag an appt. That antibiotic isn't available down here yet...though its originally for travelers diarrhea....go figure. Btw, I'm no expert.







Spasman, how'd you know my age??? You must be psychic. I'm actually a year older, but that's btn you & me...







So now, of course, you must tell all & spill your age...Bonnie, You're crackin me up girl.All, I thought people w/ D tend to get hospitalized/dead if they take zelnorm???


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## SpAsMaN*

> quote:You must be psychic.

















I have 4 years less than you.







I'm sure you look great







I would love to see your "spas center" in the island.Only in my dream i guess.Be wise,go to Cedars-Sinai LA and call them.See my post on pain,bloat section.Eric i will look at your link.The small bowel is not quite known.


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## flux

> quote: all contents getting sloshed around due to bad motility, and this means the nutrients cannot be absorbed through the gut wall effectively,


What you just described should *improve* absorption.


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## overitnow

Boy, this has been an encouraging thread to read. Really, the first time we have seen a basic cause fingered. (Apologies to eric, but the serotonin disfunction is probably caused by something else. Stimulating serotonin production or retention would be much like whatever the flavonoids do for me, correcting a secondary problem brought on by the original cause.) Given the amount of attention Dr. Dahlman gives to tracking down bacteria in the system, there would seem to be a significant convergence there, as well.If the doctor is right in his estimates, this would eliminate millions of people from our club. Bravo Dr. Pimental and flux for this.Mark


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## 13903

share c'mon, what are the flavinoids? quercetin, or some jumped up bull**** from the health shoplets challenge the doc, allthough all work is good. how will he explain total relapsing remitting ibs? the marker should be there 24/7 whether or not the symptoms are. bacteria theory could be right at least in some who can date it back to a time where everything came out undigested nearly and severe pain began.i was eating asian food last summer in china, hong kong. sbbo, could be there. this sort of growth will not show up in a state sanctioned stool culture.


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## Talissa

Hi Mark, Very well put....And this is also the longest thread I've ever seen here that wasn't long because of arguments/disagreements/egos! There's still the chicken or the egg issue, but we all know that. Some may feel very strongly that the IBS brings on the SIBO, while others feel its the opposite. And then there's whether the SIBO applies only to PI-IBSr's.So while the different opinions may still be in tact, may the respectful peace continue on this kinder, gentler board....We all want the same thing. To be a normal again!!!!Like you Mark, you lucky dog.


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## overitnow

No Guangs, it's even worse...some jumped up bull**** from a direct marketed company. The blend includes red grape seed and skin from a variety highest in proanthocyanidins, ginko, bilberry and quertecin. (It also includes a blend of co-enzymes for 4x absorption, which seems to be the key to it's effectiveness.) It is made to stop cholesterol buildup and strengthen the cardio system--with in vivo proof--and has successfully stopped my D since 1999. Can't say why, with any assurance, although I think it is brain circulation based. (All research money on the product has gone to testing for heart disease.)I did have a large exposure to water borne fecal bacteria 30 years ago, drinking untreated surface water while living in cow country. It certainly softened my stools, but not the all out D that developed in the late 1980s. It is possible that I have carried SIBO since then, it is possible that has caused the circulatory (or some other) problems that the flavonoids have addressed. It is also possible that bacteria, heart disease, diet, smoking, and drinking have all added to the deterioration that eventually these insults to my system expressed as diarrhea and reflux. Don't know. I just think it would be great if 70% of us could return to a normal life, like I have with a course of anti-biotics.Now, back to Dr. Pimental...Cheers. Mark


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## eric

"white spots on fingernails"this could possibly be from malnutrition?"the first time we have seen a basic cause fingered. "There have been many causes fingered. You also have to remember this is a highly controverial "theory" on IBS for many reasons.Also people without IBS can have sibo.You should read this carefully mark.Post-Infectious IBS Robin Spillerhttp://ibsgroup.org/eve/forums/a/tpc/f/71210261/m/557105561"Functional Bowel Disorders -- Clinical Highlights CMESmall Intestinal Bacterial Overgrowth in IBS"CommentaryBoth of these studies are provocative in suggesting a high prevalence of small intestinal bacterial overgrowth in IBS. However, there are limitations before these data can be extrapolated to the "world" of IBS. The study by Lupascu and colleagues did not separate patients by subtype of IBS (eg, IBS with diarrhea vs IBS with constipation). There is an emerging body of evidence regarding postinfectious IBS. In these patients, there is a clearly defined start date (ie, symptoms) and the condition is typically more homogeneous (ie, generally IBS with diarrhea). Clearly, we will need prospective randomized controlled trials with identification of the specific patient IBS subtypes to further explore the potential of this association."http://ibsgroup.org/eve/forums/a/tpc/f/71210261/m/947104561The serotonin dysregulation maybe a molecular defect. Also in PI IBS there is an increase in EC cells that store and release serotonin."correcting a secondary problem brought on by the original cause."You might have this backwards. That is one of the points.Because the serotonin problem maybe causing motility problems that may lead to sibo.The majority of IBSers effectivly demonstrate serotonin dysregulation. They know for sure its dysregulating, just not completely why yet.Molecular defects in mucosal serotonin content and decreased serotonin reuptake transporter in ulcerative colitis and irritable bowel syndrome. "These data show that UC and IBS are associated with similar molecular changes in serotonergic signaling mechanisms. While UC and IBS have distinct pathophysiologic properties, these data suggest that shared defects in 5-HT signaling may underlie the altered motility, secretion, and sensation. These findings represent the first demonstration of significant molecular alterations specific to the gut in patients with IBS and support the assertion that disordered gastrointestinal function in IBS involves changes intrinsic to the bowel. "http://ibsgroup.org/eve/forums?a=tpc&s=500...06561#837106561This is very interesting info on Hydrogen breath testing.http://health.medicomm.net/tp/tp_h8.htm


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## eric

ISSN 1007-9327 CN 14-1219/R World J Gastroenterol 2005 April 7;11(13):2016-2021Effects of psychological stress on small intestinal motility and bacteria and mucosa in miceShao-Xuan Wang, Wan-Chun Wu Conclusion: Small intestinal dysfunction under psychological stress may be related to the small intestinal motility disorder and dysbacteriosis and the damage of mucosa probably caused by psychological stress.http://www.wjgnet.com/1007-9327/11/2016.asp


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## bonniei

flux, are you still at the conference?. I thought Pimentel had left. Or are you back in New York and plan to e-mail him or something? Is your note complete? I think we have asked all the questions we possibly could. Wondering if you could post your note toPimentel here on the board? Approximately when will Pimentel get your note?


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## eric

Mark some infoImproving Diagnosis, Serotonin Signaling, and Implications for Treatment"IntroductionMany patients with irritable bowel syndrome (IBS) have walked into their physician's office and said, "The last doctor told me my symptoms were all in my head." Those physicians may have been right, but not in a way they anticipated.Over the past 50 years, evolving conceptual mechanisms have been proposed to explain the pathophysiology of IBS. These mechanisms have ranged from a purely psychological disorder to such physiologic conditions as a primary abnormality in gastrointestinal (GI) motility or visceral hypersensitivity. However, recent scientific data have increasingly supported that a dysregulation in brain-gut interactions resulting in alterations in GI motility, secretion, and sensation is the principal pathophysiologic mechanism underlying IBS.[1] Brain-gut interactions are mediated largely by the autonomic nervous system, which is comprised of the parasympathetic (vagal and sacral parasympathetic), sympathetic, and enteric nervous systems (ENS). Many factors (both central and peripheral) may contribute to an altered brain-gut axis, including genetic predisposition, chronic stress, inflammation/infection, and environmental parameters.[1] These alterations may subsequently lead to disturbances in intestinal motility, visceral sensitivity, and mucosal immune response and permeability. In IBS, these disturbances result in symptoms of abdominal pain or discomfort and altered bowel function, the defining characteristics of this disorder.[2]"The rest of this important article here.http://ibsgroup.org/eve/forums?a=tpc&s=500...06561#918106561


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## eric

Flux, not sure if you can add these to your very long list of questions or if you already have them, but Is there a higher incidence of sibo and women and how that relates to IBS?Why would there be mild, moderate and severe forms of IBS symptoms based on the sibo theory?and of course the alternator question of c/d?Good talking to you last night by the way.


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## bonniei

eric I know you are flailing your hands in the water that you are rapidly sinking in


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## 18548

lol i wish i'd followed this from the start, that was a hard going couple of hours reading over it!!!







so on that note, forgive me if any of these questions are slightly dippy







I don't understand how, going on all this, IBSers can't experience malabsorption. could someone please explain this?Also, why couldn't IBS/SIBO cause c?Is it possible that you could get a good idea what path of treatment to take from the symptoms present? for instance, i don't have a problem with bloating, could this be an indicator for the type of treatment required? Could it be that each of these is inter-related in that the 3 theories set each other off, so one is the base problem but this causes problems with the other 2 elements? and the base element needs to be located for effective treatment?Is SIBO present in ucers, crohn's and coeliac's? as this would suggest surely that the SIBO resulted from a disturbance in the gi systemm


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## Jhouston

cat, if you go back a few pages Tallisa has a great link I think it is called "Uninvited Guests". it would answer some of your questions Joann


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## bonniei

> quote:Originally posted by The Cat:I don't understand how, going on all this, IBSers can't experience malabsorption. could someone please explain this?


Even though talissa's link says there is malabsorption in SIBO, flux has looked at several studies of IBS'ers which shopw that IBSers have normal digestion and absorption. I guess we are waiting for flux to send his note to Dr Pimentel so that he can help us make sense of all this.


> quote:Also, why couldn't IBS/SIBO cause c?


Yes it can cause C if you are a methane producer as methane increases the non propulsive contractions


> quote: Is it possible that you could get a good idea what path of treatment to take from the symptoms present? for instance, i don't have a problem with bloating, could this be an indicator for the type of treatment required? Could it be that each of these is inter-related in that the 3 theories set each other off, so one is the base problem but this causes problems with the other 2 elements? and the base element needs to be located for effective treatment?


I think the first two theories are a part of the third theory though that is not entirely clear friom what flux wrote so I don't know.


> quote:Is SIBO present in ucers, crohn's and coeliac's? as this would suggest surely that the SIBO resulted from a disturbance in the gi systemm


They say tha people with celiac who are not totally responsive to diet chnges should be tested for SIBO. Bt not all celiacers have it. And nor do all with SIBO have celiac


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## Talissa

I not only snagged an appt while on vacation, I got the doc's okay already on Rx'g the rifaximin. ! That is, as long as I can show him my GSDL test showing c. freundii 4+. He said he does hydrogen breath tests(he's an osteopath), but since the aerobe has already been detected & I've all the clinical signs of SIBO, there's no need. It'd be "superfluous."I'm really hopeful here guys, keep your fingers crossed...If interested, here's an IBDr's success w/ rifaximin(not Pete) & he links an interesting article on the MAP bug in milk & IBD...one doc implies this should also be a concern in IBS:http://ibd.patientcommunity.com/new/displa...246&forum_id=10Here's a nice short summary re: changes in knowledge on how closely linked IBS & IBD & celiac disease are:http://highwire.stanford.edu/cgi/medline/pmid;16045602


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## SpAsMaN*

Look like our friend need 2 others changes in his signature.Read the IBS article here.*bloating is generally due to gas coming from the small bowel*Colonoscopy vs virtual colonoscopy:http://www.gut.nsw.edu.au/pdf/GutNews3.pdf


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## bonniei

Wow Talissa that was quick!. Good luck with the rifaximin. Actually I was wondering -the first studies of rifaximin came out in 2001 and at that time it was not approved in the US fo SIBO. Wonder if it has got the apprioval in the States now.


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## bonniei

> quote:Originally posted by SpAsMaN*:Look like our friend need 2 others changes in his signature.Read the IBS article here.*bloating is generally due to gas coming from the small bowel*


Not true. The sensation of bloating could be due to hypersensitivity which is possibbly due to immune system changes -read my post on the immune system in response to eric on page 5 at the top.


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## Talissa

Hey Bonnie, Good question. It was approved by the FDA just last May. It's very $$$ & isn't yet approved by many insurers unless for travellers D...Cat, Oh to not have bloating. I'm turning green. You're pretty "lucky". It's no fun. Esp when you teach yoga & pilates...who wants an instructor with a little pot belly sticking out??? Ugh.Re: the nutritional aspect of SIBO, or lack thereof, IMO from what I've read, it can literally take years for malnutrition to manifest full blown. It isn't readily apparent in the beginning years. I am a CN, & while that may not count for much here, sometimes I know what of I speak. Sometimes.


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## bonniei

> quote:isn't yet approved by many insurers unless for travellers D...


That was what I thought. That was all I could find on the web. Is your insurance paying for it? What are we going to do?


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## bonniei

And


> quote:Re: the nutritional aspect of SIBO, or lack thereof, IMO from what I've read, it can literally take years for malnutrition to manifest full blown. It isn't readily apparent in the beginning years. I am a CN, & while that may not count for much here, sometimes I know what of I speak. Sometimes.


Hey no one is doubting you but I think the IBS'ers have been followed for many years. Anyways I am going to keep shut about it and let flux defend himself although there was a study about IBSers that I had seen. I'll see if I can find it. If not flux could you please post the studies that you are deducing that IBS'ers have normal digestion and absorption from?


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## Talissa

Hey guys, Just re-read my already twice edited post above & realized I said last May, I meant of 2004. See, only sometimes.


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## bonniei

It is ok Talissa, we forgive you , LOL. But re:,malabsorption-see my sig over 70% suffer from fructose/lactose malabsorption even though flux says that is not IBS. Given that most people on the board haven;t tested for it I think it is a cop out on flux's part to say that. And who knows perhaps a major proportion of them suffer from SIBO by the lactulose test,


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## SpAsMaN*

From a Pimentel view(A patient has recorded it recently i guess):http://www.healthyawareness.com/archives/_...31/0000023e.htmInteresting SIBO articleFrom: JonTime: 9:21:35 PMRemote Name: 195.92.67.74CommentsFound this on a site and it makes for interesting reading . The bottom part especially as it shows that parasites and low seritonin causes problems in the small bowel which can cause further problems....its a bit long but worth a read for sure! For some, fibromyalgia appears to be associated with bacterial overgrowth in the small intestine. Dr. Pimentel, a gastroenterologist at Cedars Sinai in Los Angeles, has been conducting studies with fibromyalgia patients. (310) 855-6143 He measures the amount of bacteria in their small intestines using a hydrogen-lactulose breath test. If the hydrogen level is high, indicating overgrowth, he gives the patients antibiotics (usually Neomycin) until the bacteria overgrowth clears. (When the measured hydrogen level in the breath test goes to zero, this indicates that the overgrowth is gone.) I personally know three people with fibromyalgia who were at least temporarily cured by Dr. Pimentel. One was a 13-year-old for whom both the fibromyalgia pain left and the attention deficit disorder (ADD) left. In March, 2000, Dr. Pimentel presented the results of his most recent study to the local fibromyalgia support group. In his study of 207 people with Irritable Bowel Syndrome, 157 people or equivalently 76% had small intestine bacterial overgrowth (SIBO). Of those with fibromyalgia, 42 of out of 46 or 91% had SIBO. People with chronic fatigue usually had this overgrowth too, but the amount of overgrowth as measured by the hydrogen-lactulose breath test was much higher for those with fibromyalgia. The higher the hydrogen reading, the more pain that was present. Many people with fibromyalgia have symptoms indicative of SIBO. The most significant symptoms of SIBO are bloating and abdominal pain. Bloating, diarrhea, and gas are present in 80% or more of the patients with fibromyalgia. The overgrowth can be of a type of bacteria that is normally found in the colon. Since it can be a type of bacteria that is normally present, I would assume that the problem might not be picked up by a urine or stool test. Some doctors use a hydrogen-glucose test instead of the hydrogen-lactulose test to detect the SIBO. However, since glucose is absorbed rapidly, this other test can miss the overgrowth in the lower small bowel where most of the overgrowth usually occurs. (I suspect that the Specific Carbohydrate Diet (SCD) should help people with this condition since this diet is designed to limit the sugars that reach the lower track.) Overgrowth can also occur near the beginning of the small bowel. When it occurs here, it can be caused by a lack of stomach acid, pancreatic enzymes and bile. A poor immune system will contribute to the overgrowth. Another cause for the overgrowth can be a non-functioning ileocecal valve, which allows bacteria from the colon to back up into the small intestine. However, a primary contributor to the problem appears to be a missing housekeeper wave, which clears the small intestine of debris. Of the 12 people Dr. Pimentel had funds to test, 9 of them had no housekeeper wave. The other 3 patients had a weak wave. The housekeeper wave is a strong contraction of the bowel, which occurs inbetween meals Â¾lasting 5 to 15 minutesÂ¾and cleans the small intestine. It is also called phase three of the migrating motor complex. The wave is thought to be initiated by the central nervous system, but may be implemented in part by a burst of the hormone motilin. Some antibiotics like Erythromycin are thought to improve this wave motion by their ability to elicit the production of more motilin. See http://arbl.cvmbs.colostate.edu/hbooks/pat...gi/motilin.html . In Dr. Pimentel's study, the patients with SBIO were given antibiotics (usually Neomycin). They would be sick for about 5 days with die-off symptoms, then they would gradually get better over the next two weeks. Using antibiotics to eliminate small bowel intestinal overgrowth (SBIO) had been tried before in a 1970 study. The antibiotics worked, but the results only lasted for one or two months. Therefore this line of research was abandoned. However, Dr. Pimentel's study had much better results because he took the research one step further. When he induced the housekeeper wave with antibiotics like Erythromycin, the improvement lasted for about 6 to 8 months. Usually he was able to get the wave functioning by giving the patients a very low dose Erythromycin tablet of 50 mg taken at night on an empty stomach. 25 of the 47 who returned for follow-up in his study had complete normalization. Why Is The Housekeeping Wave Missing? Susan Owens, an autism researcher, mentions several things that are known to arrest or interfere with the housekeeper wave. (See http://osiris.sunderland.ac.uk/autism/owens.htm) [2] These are 1. Excessive histamine caused by allergies or caused by an immune attack against parasites will arrest the housekeeper wave. 2. Dysregulation could be caused by opiates (e.g. endogenous opiates from a reaction to inflammation or dietary opiates from things like undigested wheat gluten or milk casein.) 3. Low serotonin in the gut will stop the housekeeper wave. Cheers, Jon


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## flux

From http://www.gut.nsw.edu.au/pdf/GutNews3.pdf


> quote:While the bloating is due to gas in general,


I think they meant "While the bloating is *not* due to gas..."?


> quote:A poor immune system will contribute to the overgrowth.


Not an issue in IBS.


> quote:Another cause for the overgrowth can be a non-functioning ileocecal valve


Who has that?


> quote:Of the 12 people Dr. Pimentel had funds to test,


Who would write something like this? He seems to be a well-funded researcher. And it was 68 IBSers in the study and 30 controls. Could this be referring to some unpublished pilot study?


> quote: 9 of them had no housekeeper wave.


Actually, 35, but it's also a half-truth because it implies they don't have Phase IIIs at all, and the study period is too short to conclude that.There are other problems with the study, so while it's probably true there is a statistical difference it isn't as great as even the paper makes out to be.


> quote: The other 3 patients had a weak wave


Huh?


> quote:They would be sick for about 5 days with die-off symptoms


They would?


> quote:However, Dr. Pimentel's study had much better results because he took the research one step further.


What study is this?


> quote:Why Is The Housekeeping Wave Missing? Susan Owens, an autism researcher, mentions several things that are known to arrest or interfere with the housekeeper wave. (See http://osiris.sunderland.ac.uk/autism/owens.htm) [2] These are 1. Excessive histamine caused by allergies or caused by an immune attack against parasites will arrest the housekeeper wave.


Wouldn't histamine cause the opposite effect?


> quote:2. Dysregulation could be caused by opiates (e.g. endogenous opiates from a reaction to inflammation or dietary opiates from things like undigested wheat gluten or milk casein.) 3. Low serotonin in the gut will stop the housekeeper wave.


It looks like it's due to an increase in corticotrophin releasing factor.


----------



## bonniei

flux you are nicely sitting quiet on the absorption issue. I think it has come to a head don't you with you saying ythere is normal dig/abs and Pimentel saying there is SIBO which naturally leads to dig/abs issues. I don't think it is fair of you to sit quiet. Show us where you have read that there is normal dig/abs. If not a paper, a book maybe, anything. The time has come to show your cards buddy!


----------



## bonniei

Ok since flux won't oblige I dug up an old thread where flux talked about normal digestion and absorption.







This is where it kind of bears some relevance to this thread.flux said


> quote: Do IBSers even have fast small bowel trasnit at all?


What is your opinion on that flux now?


----------



## bonniei

Oh I forgot to post the thread. Here it ishttp://ibsgroup.org/eve/forums/a/tpc/f/743...m/329104001/p/1


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## flux

> quote: Show us where you have read that there is normal dig/abs.


It's considered common knowledge.


> quoteo IBSers even have fast small bowel trasnit at all?





> quote:What is your opinion on that flux now?


Apparently, their nondigestive transit is slower than normal, but it's not clear if food transit is also slower. CRF may delay gastric emptying and that suggests they do though. That's also relates to some IBSers' having dyspeptic symptoms.


----------



## bonniei

Thank you flux for that. So it is actually slowr you re saying. But when it flushes everything out doesn't it become faster







oh do I meed a lesson in motility? oh do I meed a lesson in motility!


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## SpAsMaN*

I think i like the idea of "flushing the bad guys" especially with bloating and C.The thing is how long someone can be symptoms-free?They also talk about low dose antibiotic for maintenance.There is a lot of info in the patent link:http://www.pharmcast.com/Patents100/Yr2004...Bowel101904.htm


> quote:For purposes of the present invention, a prokinetic agent is any chemical that causes an increase in phase III interdigestive motility of a human subject's intestinal tract. Increasing intestinal motility, for example, by administration of a chemical prokinetic agent, prevents relapse of the SIBO condition, which otherwise typically recurs within about two months, due to continuing intestinal dysmotility. The prokinetic agent causes an in increase in phase III interdigestive motility of the human subject's intestinal tract, thus preventing a recurrence of the bacterial overgrowth. Continued administration of a prokinetic agent to enhance a subject's phase III interdigestive motility can extend for an indefinite period as needed to prevent relapse of the SIBO condition. Preferably, the prokinetic agent is a known prokinetic peptide, such as motilin, or functional analog thereof, such as a macrolide compound, for example, erythromycin (50 mg/day to 2000 mg/day in divided doses orally or I.V. in divided doses), or azithromycin (250-1000 mg/day orally).


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## eric

"CRF may delay gastric emptying "CRF: corticotropin-releasing factor"The stress alarm Whatever messages may be passing back and forth, they can easily become garbled in times of stress. When the brain senses a threat, real or imagined, it sounds the alarm by flooding the body with adrenaline and another hormone called CRF (short for corticotropin-releasing factor). These hormones trigger the "fight or flight" response -- helpful back in the days when humans had to run from lions, but a potential liability when we lose a job or go through a divorce.If you suffer from frequent emotional distress -- perhaps because of extreme stress, depression, or anxiety -- the unrelenting flood of adrenaline and CRF will take a toll on your digestive system. For one thing, the hormones can make the cells in the stomach and intestines extra-sensitive to pain. As a result, normal contractions and movements can become excruciating. The new signals can also disrupt the motion of the intestines, causing bouts of constipation or diarrhea."http://www.ahealthyme.com/article/primer/101186767Stress and the Gastrointestinal TractIII. Stress-related alterations of gut motor function: role of brain corticotropin-releasing factor receptors http://ajpgi.physiology.org/cgi/content/full/280/2/G173"The central stress system involves the release of chemical stress mediators in the brain (such as corticotropin releasing factor), which in turn orchestrate an integrated autonomic, behavioral, neuroendocrine, and pain modulatory response. This biological response in turn will alter the way the brain and the viscera interact, and this altered brain-gut interaction can result in worsening of IBS symptoms. Thus, pain and discomfort, fear of these symptoms, activation of the stress response, and modulation of the brain-gut interactions by stress mediators are part of a vicious cycle which need to be interrupted to produce symptom relief. "http://www.aboutibs.org/Publications/StressDefined.html


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## 18548

> quote:If you suffer from frequent emotional distress -- perhaps because of extreme stress, depression, or anxiety -- the unrelenting flood of adrenaline and CRF will take a toll on your digestive system.


and if you don't? i used to stress a lot but not for a very very long time and i had food/water poisoning in the past but years before i had ibs.how many people on this board have lost weight? I have, granted prob partly through lack of appetite but that doesn't explain the anaemia.and to the lack of bloating







thank goodness!!! the pain and bms are quite enough!!!! lolmy goodness, this is all very very complicated!!!!


----------



## bonniei

> quote:Ordinarily, diarrhea is a symptom of SIBO. (Malabsorption and steatorrhea are *not* symptoms of SIBO as I previously claimed they were.)


Looks like flux already addressed the issue of malabsorption in his first post. He got that straight out of the horse's mouth


> quote:There are a number of papers, not by Pimental, corroborating his findings that SIBO is present in a significant subgroup of IBSers.


Did they give any references for the papers, flux?


----------



## bonniei

> quote:The thing is how long someone can be symptoms-free?





> quote: Using antibiotics to eliminate small bowel intestinal overgrowth (SBIO) had been tried before in a 1970 study. The antibiotics worked, but the results only lasted for one or two months. Therefore this line of research was abandoned. However, Dr. Pimentel's study had much better results because he took the research one step further. When he induced the housekeeper wave with antibiotics like Erythromycin, the improvement lasted for about *6 to 8 months*. Usually he was able to get the wave functioning by giving the patients a very low dose Erythromycin tablet of 50 mg taken at night on an empty stomach. 25 of the 47 who returned for follow-up in his study had complete normalization.


 from your own linkhttp://www.healthyawareness.com/archives/_...31/0000023e.htm . Don't know how good your site is. This from Pete


> quote: took rifaximin 400mg 3x a day for 2 weeks. Zelnorm gave me problems so now Pimental has me taking 1 200mg rifaximin a day for 3 months. After 3 months, he wants to go to 1 200mg every other day.





> quote: Continued administration of a prokinetic agent to enhance a subject's phase III interdigestive motility can extend for an *indefinite* period as needed to prevent relapse of the SIBO condition.


 from your sitehttp://www.pharmcast.com/Patents100/Yr2004...Bowel101904.htmZelnorm is a prokinetic.


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## SpAsMaN*

> quote:He says by using Zelnorm and erythromycin in concert with the antibiotic rifaximin in apparently one time course, he has outright cured several patients of IBS.


What about Neomycin?It is the first line of treatment AFAIK.







Xifaxan is the same thing as Rifamixin:http://www.salix.com/hcpcenter/xifaxan.aspI hate when they use 2 words for a drug.







It's already complicated.


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## Kathleen M.

I don't know that we know enough to say for certain which is the best antibiotic for this.Several have been used, and Neomycin is one of them, but I don't think it is proven to be the bestest of the bunch and the one that must be tried first.K.


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## SpAsMaN*

I'm from Canada,i'm getting confuse. Our meds are 1 or 2 years late from you.







K,i will comment on Neomycin.


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## bonniei

I think someone said, I can't recall who, that Neomycin didn't give Pimentel as good results as Rifamixin and in fact might be one of the reasons his results were challenged.


----------



## Kathleen M.

I mean I know it was one of the antibiotics used in the original studies (one of them, I don't think the only one, I thought they sometimes had to treat with a couple of different ones to get an effect in those first Pimental studies.)I think the more recently mentioned antibiotics are probably getting mention because maybe over the course of studying this they found they worked better.That happens a lot.And I think all these antibiotics have been around in the US for years, so I'm not sure what timing of Canada getting drugs has to do with it??







??I really haven't seen a head to head gold standard Neomycin is the best antibiotic...Did I misunderstand that you seemed to think that was the one they should be using and was questioning why they aren't saying that is the only one to use??ETA: In Pubmed there doesn't seem to be a lot of neomycin papers, more with rifamycin which tends to indicate it is more the antibiotic of choice.K.


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## bonniei

> quote:Originally posted by flux:.I forgot to mention that he said neomycin doesn't work and that's why they weren't get good results and not because the theory was wrong.There is evidence that another antibiotic rifaximin works very well. He himself didn't mention probiotics.


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## 19955

what kind of problems was had with Zelnorm.


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## bonniei

I don't know ron, You could probably ask Pete on this thread.http://ibsgroup.org/eve/forums/a/tpc/f/43110261/m/325105561


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## Talissa

Well, after all these references to Rifaximin (S, its brand name is Xifaxan), I'm beginning to think its too good to be true~ie, doesn't & won't create bacterial resistence, bifidobacterium (the good bug in the colon) is resistent to it, it doesn't effect the good gut microflora, & its excellent ag gram-positive bact. & pretty darn good ag gram negative. But wait! There's More!...It's biggest plus is that it doesn't cause all those adverse reactions throughout the body like other anti's (ahem, can you say Cipro? Flagyl? Tetracycline?) because it doesn't get absorbed into the bloodstream, even with a damaged mucosal surface....The only thing Rifaximin is proven not to effect is Campylobacter.Other than that, it's, like, the best thing since sliced bread!! (my Dad uses that phrase...but not so great, slice bread, for us PI-IBSr's!!)Anyways, I want stock in this Italian company...________________________________________________http://www.ncbi.nlm.nih.gov/entrez/query.f...8778&query_hl=3http://www.ncbi.nlm.nih.gov/entrez/query.f...5748&query_hl=3http://www.ncbi.nlm.nih.gov/entrez/query.f...5750&query_hl=3http://www.ncbi.nlm.nih.gov/entrez/query.f...0885&query_hl=3http://www.micromedex.com/products/updates.../rifaximin.htmlhttp://www.ncbi.nlm.nih.gov/entrez/query.f...778&query_hl=14http://www.ncbi.nlm.nih.gov/entrez/query.f...929&query_hl=14________________________________________________


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## bonniei

I don't know how many of you were around in 2001 when we first discovered rifaximin. See this threadhttp://ibsgroup.org/eve/forums/a/tpc/f/713.../m/52410948/p/1There was a lot of excitement about it then and it seemed to hold out a lot of hope for flatulence. Finally it is here. Yay!


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## flux

Dr. Pimentel graciously answered my questions on the phone.







The basic gist behind meshing the three different IBS theories is that we simply don't know how it all fits together at this point.First, the idea that SIBO may lead to malabsorption is a myth from the days when people diagnosed with it had some other condition which gave them malabsorption. While it's theoretically plausible that at some level SIBO may lead to it, we don't know how much that is. IBSers seem to be immune to any malabsorptive effects. Second, he thinks that the majority of IBSers have PI-IBS and other cases may, in fact, be cases of other GI diseases, including celiac and Crohn's and a condition he referred to as prodromal Crohn's (see http://www.ncbi.nlm.nih.gov/entrez/query.f...1877&query_hl=4) and finally some other unnamed disease. He didn't really say one way or another whether this is a "true" IBS, the IBS with exclusive brain-gut pathophysiology that has not been induced by a gastroenteritis.Third, he thinks that gastroenteritis is altering the enteric nervous system. Gastroenteritis itself is responsible for inducing visceral hypersensitivity. It's not clear how gastroenteritis alters gut motiity to reduce phase III MMC frequency. While it has been shown that increasing corticotrophin releasing factor can, in fact, cause SIBO through this mechanism, we don't know if this is the mechanism occuring in IBS.Fourth, I asked him specifically to explain how one of the studies, http://www.ncbi.nlm.nih.gov/entrez/query.f...4983&query_hl=1,[/URL] found very little SIBO in IBSers and he said that he may address this formally. He said that he doesn't use 14C-xylose test because it's more complicated and expensive. Some people have argued that his breath studies are just giving transit times and are not indictative of SIBO. He said that measuring transit as an absolute is difficult because lactulose a column of fluid in the gut and you want to measure the midpoint. They have measured it indirectly by comparing their IBS-D and IBS-C patients and found they have same lactulose curves.Finally, he said there are more studies planned both by him and others that will rigorously test and extend this theory further. For more answers, we just have to stay tuned.


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## SpAsMaN*

My first comment on Neomycin:-----https://ssl.adgrafix.com/users/lifestag/irr...ble/latest.htmlAm J Gastroenterol 2003 Feb;98(2):412-9Normalization of lactulose breath testing correlates with symptom improvement in irritable bowel syndrome. a double-blind, randomized, placebo-controlled study.Pimentel M, Chow EJ, Lin HC.GI Motility Program, Department of Medicine, CSMC Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.OBJECTIVE: We have recently found an association between abnormal lactulose breath test (LBT) findings and irritable bowel syndrome (IBS). The current study was designed to test the effect of antibiotic treatment for IBS in a double-blind fashion. METHODS: Consecutive IBS subjects underwent an LBT with the results blinded. All subjects were subsequently randomized into two treatment groups (neomycin or placebo). The prevalence of abnormal LBT was compared with a gender-matched control group. Seven days after completion of treatment, subjects returned for repeat LBT. A symptom questionnaire was administered on both days. RESULTS: After exclusion criteria were met, 111 IBS subjects (55 neomycin, 56 placebo) entered the study, with 84% having an abnormal LBT, compared with 20% in healthy controls (p < 0.01). In an intention-to-treat analysis of all 111 subjects, neomycin resulted in a 35.0% improvement in a composite score, compared with 11.4% for placebo (p < 0.05). Additionally, patients reported a percent bowel normalization of 35.3% after neomycin, compared with 13.9% for placebo (p < 0.001). There was a graded response to treatment, such that the best outcome was observed if neomycin was successful in normalizing the LBT (75% improvement) (one-way ANOVA, p < 0.0001). LBT gas production was associated with IBS subgroup, such that methane excretion was 100% associated with constipation-predominant IBS. Methane excretors had a mean constipation severity of 4.1, compared with 2.3 in all other subjects (p < 0.001). CONCLUSIONS: An abnormal LBT is common in subjects with IBS. Normalization of LBT with neomycin leads to a significant reduction in IBS symptoms. The type of gas seen on LBT is also associated with IBS subgroup.


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## bonniei

Wow Thanks flux for getting back to us so soon on the malabsorption issue. So I think your answer settles it. The rest is a little too advanced. It'll take some time to absorb it specially about the midpoint of the lactulose curves and transit.


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## bonniei

> quote:Second, he thinks that the *majority of IBSers have PI-IBS* and other cases may, in fact, be cases of other GI diseases, including *celiac* and Crohn's and a condition he referred to as prodromal Crohn's (see http://www.ncbi.nlm.nih.gov/entrez/query.f...1877&query_hl=4) and finally some other unnamed disease. He didn't really say one way or another whether this is a "true" IBS, the IBS with exclusive brain-gut pathophysiology that has not been induced by a gastroenteritis.


Nanananana, eric.







I won't say that to flux since he is the bearer of such good news


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## bonniei

> quote:have measured it indirectly by comparing their IBS-D and IBS-C patients and found they have same lactulose curves.


Oh yes I recall reading that somewhere.


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## bonniei

> quote:Third, he thinks that gastroenteritis is altering the enteric nervous system. Gastroenteritis itself is responsible for inducing visceral hypersensitivity. It's not clear how gastroenteritis alters gut motiity to reduce phase III MMC frequency. While it has been shown that increasing corticotrophin releasing factor can, in fact, cause SIBO through this mechanism, we don't know if this is the mechanism occuring in IBS.


 Oh sorry for posting once more-got to remain on the cutting edge of things







- I think in yiur initial post you had mentioned that it was via the immune system that gastroenteritis affects visceral hypersensitivity. And then the physical stress of the disease affects motility. So it is all clear to me how SIBO, PI-IBS are both related.


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## SpAsMaN*

> quote:Originally posted by flux:.I forgot to mention that he said neomycin doesn't work and that's why they weren't get good results and not because the theory was wrong.There is evidence that another antibiotic rifaximin works very well. He himself didn't mention probiotics.


I can only blame the listener.














K,the only Neomycin that i found lately is in cream form.I wait for the pharmacist to confirm it's availibility in pill form as well as Rixaminin(sp?).Now that is scary(not beeing PI-IBS):


> quote:majority of IBSers have PI-IBS and other cases may, in fact, be cases of other GI diseases, including celiac and Crohn's and a condition he referred to as prodromal Crohn's (see http://www.ncbi.nlm.nih.gov/entrez/query.f...1877&query_hl=4) and finally some other unnamed disease.


----------



## Kathleen M.

But Spas, like I said there are a bunch of studies using the other antibiotic and it looks like it works well.Probably like anything else you need MORE THAN ONE drug to get the job done.You cannot expect one drug to be the end all be all, and even when it works well in one study that doesn't mean it is the only one that works well and 35% improvement is not that great.And after all they are both the same sort of not absorbed antibiotic, so does it REALLY make that much difference to you which one??







??Here it worked in 70% of patients where a different antibiotic only helped 27% study linkHere is the info that it works against a broad range of bacteria study linkFor some other things neomycin is used for rifamycin is just as effective study linkHere is a head to head where it looks like rifamycin may get more types of bacteria than neomycinn study link


----------



## SpAsMaN*

I have read that rifamycin(SP?) have the same purpose of Rixaminin but Rixaminin didn't affect the mucosa or something.So i presume it is better.


> quote: Probably like anything else you need MORE THAN ONE drug to get the job done.


You have never been so rigth.I know i look confident,i have an ace in my game.


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## SpAsMaN*

How stupid i'm am,i just eat 2 toast with peanut butter.Boy,i pay the price even 12minutes after it....Venting


----------



## Talissa

Great insights, Flux, from the doc. Thanks so much.Kathy, I esp liked your last link. My bug's aerobic. And I also liked that the study was done using mice. I think it was Bonnie who posted one of those earlier....times _have_ changed, I always got picked on when I did that. By someone, who was that, I -think- the name started w/ a "B"...*B*onnie,







, thanks for the 2001 link...fun to read.Where's Skinny???? He'd love this...


----------



## bonniei

I think I am going to do the lactulose test. I hope it is positive. It has been tantalizing me for 4 years now.


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## bonniei

Hi talissa I know I don't have much trust in animal studies. Now look at what flux said about Pimentel. He still has to do more rigorous studies after all the studies he has done on humans. K and I are not supposed to be talking to each other because these days something always goes wrong so I don't comment on her links or posts. Don't want return posts in capital red


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## bonniei

Yes and where is skinny?! He would love this!


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## SpAsMaN*

He's "cured"? haha!I would be unconfortable without Lactulose,ineed my results soo bad.I call them tomorrow,i need a quicker appointment.


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## bonniei

Oh I found this gem inthe 2001 link. flux said


> quote: If one is treating SIBO (which it is not likely to be affecting those reading this),


 Do you take this back flux







?


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## bonniei

> quote:I think it was Bonnie who posted one of those earlier....


Did I post a study on mice? Which one, talissa. I think I am either misunderstanding you now or earlier. Set me right,Yes spas, skinny is cured LOL>


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## SpAsMaN*

Bonnei,why not take the time to go at Cedars during your vacancy?







Time to blow?(think straigth LOL)


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## SpAsMaN*

Serious humor?


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## bonniei

That;s a good idea. But I don't know if Pimentel will see me on such short notice. Even to blow. Geez look at what you are getting me to say. Now behave spas!


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## cat crazy

SpasYou are a riot. I can't stop laughing.


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## SpAsMaN*

I'm confuse about the word blow.It means too many things.-LOL Bonnei,i'm not going there.HE'S GONNA SEE YOU,WELL NOT HIM BUt THEY WILL.I tell you this coz my lab takes any appointment in 24 hours delay.


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## bonniei

LOLYes but his clinic is such a famous clinic. Must be busy. I;ll call tomorrow and see. I am leaving on Fri.


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## Talissa

I'm confused too Spas...set us right on this "blow" Bonnie, you couldn't possibly mean _that_....I don't know who it was on this thread Bonnie. I just remember being surprised. It was probably someone else & I was surprised you didn't say anything abt it...who knows. I'm just kidding around anyways. I'm just enjoying thinking of the good old days when I first landed here...memories...last year, I know, but it seems longer.Anyways, I'm off to visit the STATES. Can't wait to see highways, malls, amusement parks, theatres, Starbucks...Stay well everyone. See you with an update in abt 3 weeks.Talissa


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## SpAsMaN*

Hmm you need a referal for the Lactulose..


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## bonniei

Oh I just checked the address. It is in LA. I am going to SF. I think they are seven hours by car apart. Can't go.Have fun T


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## SpAsMaN*

Aunt a doc in your area if Pim can't.


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## bonniei

Yes I will get DR Satish rao to do the lactulose test.


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## SpAsMaN*

He does it???????


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## bonniei

Yes. Why? i.e I will have to ask him to do it. He normally does glucose for SIBO


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## SpAsMaN*

I tougth that the Iowa web site wasn't mentionned it.Well,kind a weird that he miss that one.I had 5 breath t ordered the same day.


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## bonniei

Well he normally does glucose. But I will persuade him to do lactulose. I will present him with pimentel's research. They just have to give me a diffferent sugar. I don't see a prob. Atleast I hope not.


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## SpAsMaN*

Can you put his web site link?I have lost it,and i want to verify your statement.


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## bonniei

It may not be on his link because he normally does glucose for SIBO. I will have to persuade him to do it. I think the Pediatric section might do lactulose. Anyway I am not 100% positive that my powers of persuasion will work. Anyway got to go now for dinner.


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## bonniei

OK I am back from dinnerHere is the site for the Pediatric Depthttp://www.medicine.uiowa.edu/Path_Handboo...ok/test321.html


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## Jhouston

Spas, I called the cedars motility department Monday and left a detailed message regarding the study....not heard back yet. GSDL has the SIBO breath test. I have an appointment Monday with GI doc and I am going to ask himfor the breath test.  I asked the nurse in his office she never heard of it. AND I am in Los Angeles! Joann


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## bonniei

If my doc doesn't do it I am going to ask GSDL too.


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## Jhouston

What I don't get is Why the acid in stomach doesn't kill off bacteria??? since what I am reading is: This is a motility problem, therefore after antibiotics kill all since there is no way of knowing which bacteria in each individual is overgrown then eating food starts the process all over. I have said in the past that after anti's I think it is a good idea to not eat raw food for awhile. also make sure water is sterile. What about h.pylori? would the breath test be positive for that too? so many questions come up when talking about SIBO! not so when thinking of bacteria in the colon. Joann


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## flux

> quote: I am going to ask GSDL too


I heard anecdotally that they were having problems with getting good readings from people exhaling into the bag. Don't know if or how this was resolved.


> quote:Why the acid in stomach doesn't kill off bacteria???


Acid does kill a lot, but only very little needs to get through. Bacteria multiply as long as their material for them to consume.


> quote:I think it is a good idea to not eat raw food for awhile.


All food will contain some amount of bacteria.


> quote: also make sure water is sterile.


Where does one get that from?


> quote:What about h.pylori? would the breath test be positive for that too?


H. pylori I guess does not consume lactulose and may not be in greater enough numbers to impact the result if it did. Plus, it is in isolated location in the stomach. Lactulose is moving down the small bowel, probably some bacteria move with it.


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## bonniei

> quote: heard anecdotally that they were having problems with getting good readings from people exhaling into the bag. Don't know if or how this was resolved.


Thanks for the gossip


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## cat crazy

In the 'uninvited guests' link posted by Talissa, it says in SIBO the bacteria are feeding on carbohydrates/grains/sugars. Maybe that is why the SCD works quite well for ibs d when diet modification is done. ________________________________________________Flux.Just another speculation on the bacteria. Is is possible that when bacteria feed off the foods in the gi tract they release toxins and maybe gaseous toxins (yuck) that could be causing LG syndrome?


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## Jhouston

> quote:also make sure water is sterile.


 Boil it. lol Buy purified water. Thanks for info, flux Joann


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## flux

> quote:Is is possible that when bacteria feed off the foods in the gi tract they release toxins and maybe gaseous toxins (yuck) that could be causing LG syndrome?


Well, leaky gas is off-topic here, but most certainly, methane alters colonic motility causes constipation. Carbon dioxide may also alter intestinal blood flow and motility.


> quote:Boil it. lol Buy purified water.


Neither would be anywhere near sterile unless you did it in an OR. Your mouth is filled with bacteria so even if you were in an OR with sterile water, what reached the stomach might just as well be water from sewer. OK, maybe not that bad, but not sterile.


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## cat crazy

You are right, I will post this in the LG thread for some comments from LG ibsers.


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## eric

Flux, I am glad the Doctor was helpful in answering some of the questions for us here.FYI on PI IBS"Irritable Bowel Syndrome: Physiology and Management CMEDisclosuresNicholas J. Talley, MD, PhD Mayo Clinic College of Medicine Introduction The field of irritable bowel syndrome (IBS) appears to be entering a new and exciting phase; evidence that at least some aspects of this disorder represent an organic or neurologic bowel disease has firmed, and novel management approaches are currently under investigation.At this year's Digestive Diseases Week meeting, data on current and emerging pharmacologic interventions and psychologic therapies were presented. This report reviews and discusses some of this novel and topical information.Postinfectious IBS One of the most exciting areas in terms of new research in IBS relates to the potential role of infection, inflammation, and its therapy within the setting of this syndrome. Composition of Colonic Inflammatory Infiltrate On routine histology, colonic biopsies appear normal in IBS. Studies by Gwee and colleagues,[1] and Spiller and coworkers,[2] among others, have shown that in at least a subset of IBS patients, there is a quantifiable, albeit modest, increase in colonic inflammatory cells. Hollerbach and associates[3] prospectively evaluated 20 patients with IBS (disease diagnosis based on Rome II criteria) and 15 healthy controls. Following careful histologic evaluation with quantitative morphometry, the study authors observed that patients with IBS had significantly greater numbers of (1) plasma cells in the rectum and sigmoid colon; (2) goblet cells in the transverse, descending, and sigmoid colon (as well as in the rectum); and (3) mast cells in the terminal ileum, cecum, and appendix. In contrast, the number of eosinophils was decreased in IBS patients compared with controls at all anatomic locations. Although these findings represented subtle differences, they appear to be real, and confirm that a residual inflammatory process is indeed present in some patients with classic IBS symptoms. Clinical Subtyping Dunlop and colleagues[4] also evaluated 76 patients with IBS and 40 healthy controls, applying immunohistochemical staining for lamina propria and intraepithelial lymphocytes, enteroendocrine (serotonin-containing) cells, and mast cells. They subdivided their patients into 3 groups, those with: (1) postinfectious IBS; (2) constipation-predominant IBS; and, (3) nonconstipated, non-postinfectious IBS. These investigators found that cell counts in constipation-predominant IBS were not significantly different from that of controls. In contrast, patients with diarrhea, but without a postinfectious history, showed increased CD3 and lamina propria lymphocytes, in addition to mast cells, whereas patients with postinfectious IBS had increased enteroendocrine cells, CD3, and lamina propria lymphocytes. These findings suggest that subgrouping of IBS by bowel symptoms may identify distinct histomorphic phenotypes within IBS, which in turn suggests that treatment may need to be tailored to symptom subgroups.Mast Cells Park and colleagues[5] applied electron microscopy and found that mast cell counts were significantly higher in the cecum among patients with IBS, and that the number of activated mast cells close to nerves was increased in IBS patients vs controls. Similarly, Barbara and coworkers[6] employed immunofluorescence and found that tryptase-containing mast cells were increased 3-fold in IBS patients compared with controls. They also found evidence of mast cell degranulation. "


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## eric

opps, forgot the link and actually this in the rest of the cme. This I believe is important here. Commentary Many questions remain regarding the role of antibiotics in IBS. Do antibiotics change the host intestinal flora and predispose to IBS in some cases, while protecting in others? If antibiotics do benefit patients with IBS, which groups will respond and why? Is therapy required long term, and in whom? Are there safety issues, particularly with broad-spectrum antibiotics, including concern regarding bacterial resistance? The concept and findings suggesting that antibiotics may be useful for treating patients with IBS will need to be replicated and further investigated before the approach can be recommended. http://www.medscape.com/viewarticle/434526?src=search


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## Arnie W

quote [I heard anecdotally that they were having problems with getting good readings from people exhaling into the bag. Don't know if or how this was resolved.]I have had 2 breath tests and was shown each time how to blow properly. (It doesn't come easy, spas.) My tendency was to blow too forcefully and I ended up having practice runs for each session. Even then, I still had to repeat a couple of my blows because I had not done it quite right. You take a gentle breath beforehand and then breathe slowly and gradually into the bag. It was explained that if you take too deep a breath you might get a different reading. Make sense? So, in some ways, it is safer to get it done in a clinic, but if that's not possible, just go easy on how hard you blow.


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## Talissa

Hi guys, Just popped on this am before lvg in a couple of hours...Just for clarity's sake, the above medscape article is from 2002(I know since I've also posted the article). Re: the antibiotic treatmt for IBS...it seems like there've been some advances in this area....but it is nice to see eric post something that says IBS may be organic. Love it...He always "screamed" loud & large at me when I posted that....& don't get me started on the low grade inflammation. I knew the day would come. LOL







Ha. You have fun in San Fran B, the most beautiful city!


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## SpAsMaN*

> quote:just go easy on how hard you blow


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## Kathleen M.

> quote:Originally posted by Jhouston:What I don't get is Why the acid in stomach doesn't kill off bacteria???


It probably does kill off some bacteria, but a lot of bacteria survive by finding ways of surviving harsh conditions to get from one favorable location to another. Many bacteria form spores if they have to survive extreme conditions before finding a nice place to grow.Once they have a good place to grow they multiply rapidly.If the stomach were perfect at killing every bacteria and spore I suspect the colon would never colonize. Stuff that lives in people's colons have evolved mechanisms for getting from one colon to another through the outside world (which may not be the best place for them to live, some of the bacteria in the colon are killed by oxygen, so have to have a protected spore to get from place to place) and the stomach until they get to the next colon.When I was working with E. coli I got a spore in one of my buffers, it survived low food conditions, autoclaving (pressure cooking) for the amount of time needed to kill most everything, it survived soaking in ethanol and then having the alcohol lit on fire. It was a tough little bugger. So the spores (usually metabolically slowed down or inactive form for traveling) can survive a lot of conditions that active growing multiplying bacteria do not.K.


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## SpAsMaN*

> quote:J Infect. 2005 Feb;50(2):97-106. Related Articles, Links Rifaximin--a novel antimicrobial for enteric infections.Huang DB, DuPont HL.Department of Medicine, Baylor College of Medicine, Houston, TX, USA.Rifaximin is a poorly absorbed rifamycin antimicrobial drug with in vitro activity against Gram-positive, Gram-negative and anaerobic bacteria. The minimal concentration that inhibits 90% of strains of bacterial pathogens (MIC90) ranges between 32 and 64 microg/ml. Less than 1% of the drug is absorbed after oral administration. After three days of therapy, the average fecal level of this drug is 8000 microg/g of stool. Selection of resistant mutants, a problem with the related rifampin, appears to be unusual with rifaximin. Rifaximin shortens the duration of travelers' diarrhea and non-dysenteric diarrheal illness due to enterotoxigenic, enteroaggregative E. coli and Shigella sonnei without major alteration of aerobic fecal flora and without important side effects. The drug has been successfully used in preliminary studies of small bowel bacterial overgrowth syndrome and hepatic encephalopathy. To explain the beneficial effect of the drug on bacterial diarrhea without change in colonic flora or high rates of pathogen eradication, rifaximin may be more active against pathogens in the small bowel rather than the colon and/or the drug may alter the virulence of enteric pathogens in addition to organism inhibition.





> quote:And after all they are both the same sort of not absorbed antibiotic, so does it REALLY make that much difference to you which one????


For me Yes(i don't know if there is equivalent anti-biotic sort of things),i have been inform from a credible source.See my last thread on the main menu,2 antibiotics are mentionned,they should be taken together for better results.


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## Kathleen M.

Was that the erythromycin thing...I'm not going to sort through all your posts to find what you are refering to.Erythromycin is probably added because it has prokinetic activity.I'm not sure which non-absorbed antibiotics for enteric infections are available in Canada.I wouldn't get to obsessed with finding the exact drug as long as you can get a drug with similar effect.Regular antibiotics may work as well that are broad specturm, the advantage to ones that you can't absorb is then you only dose the GI tract and may reduce side effect from systemic treatment.One thing that might be something to look at study link In people with blind loops (so a non absorbable antibiotic might not get in there) another antibiotic worked pretty good and looks like you can buy this one in Canada http://www.xlpharmacy.com/online-pharmacy/...online/135.htmlK.


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## SpAsMaN*

This is interesting K,i know the Iowa U. told me that Metronidazole works well.Here your link:Absorbable vs. non-absorbable antibiotics in the treatment of small intestine bacterial overgrowth in patients with blind-loop syndrome.Di Stefano M, Miceli E, Missanelli A, Mazzocchi S, Corazza GR.Department of Medicine, IRCCS S. Matteo Hospital, University of Pavia, Piazzale C. Golgi 5, 27100 Pavia, Italy. m.distefano###smatteo.pv.itBACKGROUND: Small intestine bacterial overgrowth is associated with the presence of predisposing conditions, acting through different mechanisms. Therefore, the failure to define a standardized therapy may be due to a methodological bias: to treat a condition characterized by different pathophysiological mechanisms with the same pharmacological approach. Non-absorbable antibiotics could have a lower efficacy than absorbable drugs in patients with blind loops which exclude a portion of the intestine from the transit. AIM: To evaluate the efficacy of absorbable vs. non-absorbable antibiotics in this subgroup of patients. METHODS: A group of small intestine bacterial overgrowth patients with total gastrectomy or gastrojejunostomy and blind loop underwent a therapeutic trial comparing rifaximin to metronidazole. Seven patients underwent a course of rifaximin followed by a course of metronidazole on recurrence of symptoms. To compare the effect of the drugs, another two groups of patients underwent two consecutive courses of rifaximin or metronidazole. Hydrogen breath test after glucose administration and symptom severity measurement were performed. RESULTS: Both drugs reduced breath H(2) excretion but a much better improvement was achieved after metronidazole. Symptom improvement was higher after metronidazole. CONCLUSION: Metronidazole is more effective than rifaximin for the treatment of small intestine bacterial overgrowth associated with the presence of a blind loop.


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## SpAsMaN*

What is a blind loop?How it is diagnose?


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## Kathleen M.

I don't think you have to worry about it, it is a rare thing that can lead to SIBO in some people, but I'll get the definition if you want it (I thought it would be something that might be a result of surgery or crohn's or something like that)http://www.mayoclinic.com/invoke.cfm?id=AN00735http://www.drkoop.com/ency/93/001146.htmlYep, after things like surgery or complications of IBD's. So probably not what you need to worry about.However, if the antibiotics clear it up for people when in this case the non-absrobable ones can't get into part of the intestine then they should work when the intestine is normal.K.


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## eric

> quote:but it is nice to see eric post something that says IBS may be organi





> quote:Talissa


Talissa, I have been posting IBS has organic abnormalities since before you joined. I have posted a huge amount of research to the news forum in the last four years and have tried my best to explain systems and problems seen in IBS in this forum for a long time. I might add extremely complex issues. For whatever reason though, perhaps choosing not to read all the material and tring to understand it better and the big picture, there is a selective bias to inflammation and infection and especially bacteria.Why don't you do a search to see how many times I have posted to member here its "not all in your head".Even on this thread I am pointing out numerous abnormalities seen in IBS and especially in post infectious IBS, which I have seriously been studying for a long time now.The transit theory and the brain gut theory in the begining of this thread, still majorally applies even to the sibo "theory. The transit theory is part of the brain gut axis research.There are still many abnormalites seen in IBS that have not been explained. Especially in the SIBO theory. Which is why, it is provacative, but highly controversial and much larger studies are needed and confirmation from other research labs. One thing we have learned from the thread is its probably a good idea to get sibo tested. Which is not something new I have been saying either. Which is one of the reason I keep posting information on differetial diagnoses.From this post it would seem from a couple of jabs from you and bonniei, this is personal and "my theory is better then your theory" kindof thing. What I do see quite a bit is throwing out 50 years of research everytime a new theory comes along.For me that is not the case. It is not personal at all.


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## bonniei

> quote:From this post it would seem from a couple of jabs from you and bonniei, this is personal and "my theory is better then your theory" kindof thing. What I do see quite a bit is throwing out 50 years of research everytime a new theory comes along.For me that is not the case. It is not personal at all.


You never were able to gauge the pulse of the crowd could you? It is not personal. I won't describe it further, knowing that the moderators have a bias against me they will moderate me out. So I am keeping my mouth shut.


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## Jhouston

K, thanks for info. interesting about E.coli. you would think anything alive would not survive FIRE. On the other side Lactobacilus and Bifidus strains don't seem to make it through, manufacturers are still trying to get a handle on that. Tal, Have a great trip and Good luck! Joann


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## Kathleen M.

I don't know what the bug was (I killed it not identify it) it wasn't E.coli. The colonies looked different than the E. coli we were growing (it was motile and would form spreading colonies and take over a whole plate, it was a nasty bugger). It was contaminating my E. coli experiments and it took a long time to track it down and get it out of the lab.I think some of the probitoic stuff people put in pills does seem to be found in feces of people taking it, but it may depend on strain how much. I know some people are trying to up that, but I thought at least some of them do make it through (and based on how they effect my fart frequency some of them must be surviving the trip as they work for me)K.


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## Jhouston

Last Nov. I had GSDL 3 day test and had no growth on either Lact or bifid despite daily intake. The bottle states it is made to get through stomach acid. maybe some gets through but is transient. from my understanding Lacto is in small intestine and bifid is in colon. What do you think about stool tests to find out what bacteria is causing SIBO? I am wondering about rifaximin since it is in tetracycline category if it will cause a yeast infection like tetrcycline. Joann


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## Kathleen M.

I don't think it matters which bacteria is causing the SIBO. And I don't know how you tell bacteria from the colon vs bacteria in the small intestine by the time it gets out the back end.Yep the probiotic bacteria do seem to be transient in that if you stop taking for awhile they will go away. study linkHere is a study that is what I tend to see with it is there, but over time it goes away And another one study link with VSL#3 which some people find works.


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## administrator

On Page 15 of this thread some personal disagreements between posters appeared.Please take this as a warning that this needs to stop. It is not acceptable on any part of this board.This thread had been doing so well. Please do not ruin it by fighting with each other.If you see something directed at you. DO NOT RESPOND TO IT ON THE THREAD, please hit the alert key and let us deal with it. No matter what someone else says about you, it does not give you leave to violate the posting guidelines.We do not want to edit people's posts or suspend members because they are unable to drop it and move on, but should this continue we will be forced to do exactly that.SincerelyThe Moderator Team.


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## Jeffrey Roberts

I have just created a poll asking for your vote as to whether we should create a new forum dedicated to discussing SIBO.You can vote here:http://ibsgroup.org/eve/forums/a/tpc/f/77310261/m/976109561Jeff


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## Arnie W

I'm definitely not in favour of another forum. There are more than enough already and there are not enough hours in the day to visit all the ones I want to. Some seem to be so poorly patronised that they are almost unwarranted. I spend huge amounts of time on this board and what with reading the posts on the IBS forum plus the forum which relates to my own area of concern, I do not get as much time as I would like to check out the others. If flux's thread had been on a special SIBO forum, I would have missed out on it and all the invaluable info that has come from it.I believe the IBS forum is one part of the Group where you are able to reach the maximum number of people, without being limited to a specific area of GI problems. So, for what it's worth, I hope you stick with the status quo. And it's a good time to thank you again for a board which is a real lifeline for me.


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## SpAsMaN*

I don't know what to say Arnie.I have voted yes,well my finger have done it by reflex.


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## bonniei

Same here. I voted yes. But on second thought I want to vote no- because if like Pimentel says a huge proportion of IBS patients have SIBO, it seems that it applies to most so it is better in the main forum since most check into the main forum. Also it should get maximum exposure so it seems it can do that if it is in the main forum. So Jeff please cancel one yes vote and cast it towards the NO.


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## cat crazy

Just some more speculation on my part re SIBO.As I understand it, in SIBO the bacteria should not be in the small intestine (SI from hereon) as it's not the normal place for it to be. We have been told that the Phase 111 and the MMC are not functioning well in ibs, cause not understood yet and more research is needed.Speculation/Questions.1. The absorptive surfaces in the gi tract are all or mostly in the SI. Now if this area is covered with 'bad' bacteria then presumably it would hinder the absorptive power of the SI.2. The serotonin receptors are also presumably mostly in the SI. The 'bad' bacteria may be covering most of the surfaces of the receptors and interfere with the proper functioning of the serotonin receptors and cause the d, or in some cases c, causing some dysregulation of the serotonin.3. Most of the immune function 'actioning' for want of a better word is also in the SI tract. Again the bad bact is causing some sort of malfunction for the immune system giving rise to CFS, FM. Removal of the 'bad' bact from the SI tract and healing takes place or symptom relief. This is an extreme oversimplification and pure speculation/question on my part. Just thoughts and questions that I'm posting for a sounding board.


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## eric

Hanna, did you read this?http://ibsgroup.org/eve/forums/a/tpc/f/71210261/m/808106561


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## eric

and thisYour Digestive System and How It Workshttp://www.iffgd.org/Publications/DigestiveSystem.html


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## Popp

What Arnie Said.Too many forums now. I've had questions on other areas(5-HT4 Zelnnorm area) that have not been answered. Some people can't visit every area.My vote is NO


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## SpAsMaN*

> quote:I forgot to mention that he said neomycin doesn't work and that's why they weren't get good results and not because the theory was wrong.


I don't think that he actually said that.Why he would contradict his research on Neomycin?To makes himself more credible?I don't think so but i can tell you why.









> quote:He says by using Zelnorm and erythromycin in concert with the antibiotic rifaximin in apparently one time course, he has outright cured several patients of IBS


Do you means Zelnorm + Erythromycin?Both?









> quote:He says by using Zelnorm and erythromycin in concert with the antibiotic rifaximin in apparently one time course, he has outright cured several patients of IBS


Is it what they mean by "provocative"?


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## flux

> quote:I don't think that he actually said that.Why he would contradict his research on Neomycin?To makes himself more credible?I don't think so but i can tell you why.


In my notes, I have that when it worked, it really worked, but overall it didn't work which I believe means it worked only for a few patients.


> quoteo you means Zelnorm + Erythromycin?Both?


Actually, I am not so sure of the wording. It seems to be equivocal. It could be either way, but it seems that the clinical trials are going to use one or the other not both.


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## SpAsMaN*

Himself recommand Neomycin and by adding Rixaminin you acheiving better result.


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## SpAsMaN*

I understand your silence Flux,i wouldn't argue on the advices of my friend.


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## SpAsMaN*

Flux,what happen if someone has diverticles in the colon or small bowel?Are they gonna get a false positive breath test with Lactulose?See it can mimics IBS:http://ibsgroup.org/eve/forums/a/tpc/f/734...09561#913109561


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## Kathleen M.

It is rare to have diverticuli like that.I don't see how pouches in the colon even if you had a zillion of them would change the timing of hydrogen peaks in the breath test.They do not form in the small intestine.and SPAS, why is it IMPOSSIBLE to you that Dr. Pimental started out thinking one drug was the best to use, but based on his clinical experience they found that other drugs worked better.Let me try this slowly in short sentances.First studies.Used NeomycinSometimes worked for some patientsDid not work that well for other patients.More studies done.Used other drugs.Found other drugs worked just as well for patientsAND AND ANDFound it worked for MORE patients than Neomycin.Now recommends what works better for more people!!!!!!A lot can happen with FIVE YEARS of clinical research.It is somehow bad, wrong, evil, that he did this.He MUST STICK TO THE FIRST DRUG HE TRIED NO MATTER HOW MUCH SOMETHING ELSE MIGHT WORK BETTER!!!!Is that your point.It sounds like it to me.Treatments EVOLVE over time as doctors have time to experiment with things and find what works the best for most people.Otherwise we would still be using the same drugs and treatments we used a hundred years ago because it would be BAD to stop using something because something else might work better.If I'm missing your point let me know.But that seems to be what you are trying to say.Dr. Pimental must be ignored or his current treatment plan is WRONG because it is not what he use in a study 5 years ago and he shouldn't ever mention what he learned in 5 years of working on this because it is not exactly the same thing he did in his first paper????????????????????????????????????But maybe I misread your issues with the new version of what treatment works.K.


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## SpAsMaN*

That's what he recommand to me,in the 16 page in my respond to Flux.







Yes i have had an hold on him (for a second).


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## Kathleen M.

Did he know you are in Canada and can't get the other drug?When did he make the recommendation andwhat the heck does this mean


> quote:Yes i have had an hold on him for a second.


Or are you just in some kinda game with flux and I should just stop trying to make sense of it







K.


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## SpAsMaN*

Yes,i told him i was a frog







and he was aware of the possible delay for Rixaminin here.He was born in Canada.


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## Kathleen M.

He sounds like he is trying to help you.Do you realize your posts keep coming off as if he is doing something wrong in your opinion??At least it looks that way to me.Why is it bad he recommends something you might be able to get, but in a public forum recommends the best treatment that is available somewhere else.Maybe I am misreading your intent, but that is how it reads to meK.


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## SpAsMaN*

> quote:When did he make the recommendation and


Last week.


> quote:what the heck does this mean


Since you are a very curious and caring person K,i have had his sympathy by e-mail.


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## SpAsMaN*

> quote: Why is it bad he recommends something you might be able to get


That is confusing,i didn't ask him if he tried to help from a drugs available here or if it was the best treatment to his eyes.It is a little bit speculative but i'm gonna go with my intuition,HE says the 2 drugs ARE the better treatment.(Flux is not gonna sleep tonight







)


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## Jhouston

Spas, Both drugs are better? neomycin and rifaximin? my interpretation of drug protocol is Rifaximin is better since it mostly stays in gi tract, less side effects, more in gi tract. erythromycin is for the motility problem not for antibacteria effect. or zelnorm if tolerated for motility. Joann


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## Kathleen M.

Neomycin also is in the not absorbed readily class of antibiotics. So stays in the GI tract. I think that is why they tried it initally.So I can see recommending either it or the Rifaximine.But it sounds like from what Flux says that Pimental has found that overall the rifaximine is a better drug than the neomycin (and some of the data in the medical lit seems to back up the idea that neomycin works for few people than rifaximine). But if you live in a country that has not approved rifaximine (like Canada where Spas is from) then there isn't much point recommending a drug someone's doctor cannot prescribe (what it sounds like is going on in Spas's case but I'm having problems with my Spasglish to English translation today it seems







)It sounded like to me (and makes some logical sense) that adding something to normalize transport through the small intestine might help the antibiotic work better than it would just on it's own.K.


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## SpAsMaN*

I guess the clinical trial will tell.That's why i was so sceptical about the Flux notes Rixaminin + Zelnorm etc...Like K said,does it really matter at the end?


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## SpAsMaN*

> quote:But if you live in a country that has not approved rifaximine





> quote:then there isn't much point recommending a drug someone's doctor cannot prescribe


If it is the case,now i'm loosing credibility toward Flux notes.And i have to admit it begin to haunt me.Not his "notes" but the efficacy of the treatment.







O Canada...


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## bonniei

Hi this is what Dr Rao said by e-mail, "Whilst I agree with Pimentel that some patients with IBS symptoms may>have distal small bowel bacterial overgrowth, we don't have a test to>identify this. The lactulose breath test will be positive in almost>everyone, you, me and others. Hence, I don't believe in it. Their claims>are unsubstantiated and other workers in this field including Europeans>have been unable to confirm their assertions.>I have no objections to you having this test and if you insist we can>order this for you. I will predict that the test will be positive but>that does not mean that you have small intestinal bacterial overgrowth.>Lactulose is a nonabsorbable sugar that goes unchanged through the gut>and is fermented by colonic bacteria and thereby causes gas or diarrhea>and id used for the treatment of constipation. My feeling is that>fructose intolerance is a bigger problem for you. In any case, please>let me know if you want the breath test. Best wishes" Yay so I will get it done as soon as my antibiotic results wear off. I am writing from a cafe in SF.


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## bonniei

flux do you have references for papers which corroborate Pimentel's findings so I can present them to Dr Rao, please? TIA


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## SpAsMaN*

I highly respect Dr.Rao,can he but rigth about the Lactulose?European?







But that wouldn't not explain your constipation without fructose,that's sucks!We want one disease,one treatment!!


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## bonniei

Hi spas I am writing from a cafe so can't spend much time here. But it seems to me that the Phase III of the MMC's would not affect constipation. Anyway if I am wrong flux will probably set me right. I have to go now. Bye!


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## SpAsMaN*

Look like Dr. Rao beleive more in the europeen than Pimentel.That is disturbing.The thing who makes me falls for the antibiotic is that i have seen an improvement with it recently.But when the D induced by antibiotic stop,IBS-"C" comes back.


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## SpAsMaN*

K,i think diverticle can happen in the small bowelill camera web site:http://www.givenimaging.com/Cultures/en-US...MatthewAnci.htm


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## bonniei

hi spas I did an edit of my last post. Pase III would*n't* affect constipation. There are many reasons for antibiotics helping constipation but I know how this thread gives you hope.


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## Kathleen M.

Ok, but we are still talking the end of the small intestine.Most people get them by the time they are old.Most people have NO symptoms from them.I don't think they would give the EXACT same signal of H2 in the breath that SIBO does, which I think was your concern.K.


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## SpAsMaN*

Bonnei,I already told Dr.Pimentel about my IBS-"C" and he dosen't seems to pay attention to it as long as the breath test is positive.K,there is no way to see the entire small bowel except for the pill cam rigth?That means that many people are small bowel sick without knowing it.


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## bonniei

> quote:Bonnei,I already told Dr.Pimentel about my IBS-"C" and he dosen't seems to pay attention to it as long as the breath test is positive.


If the breath test is positive then it doesn't matter if you are C or D. It is generally the case that if you are C and hhave SIBO, then you are a methane excretor and methane tends to slow down the tract.


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## SpAsMaN*

POW







was asking if SIBO could be the cause for IBS-C.Flux,i think you have made a comment on this but this thread is almost one mile long.Perhaps a quick comment.Thanks


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## SpAsMaN*

Bonnei,What do you mean by this quote:


> quote:Hi spas I am writing from a cafe so can't spend much time here. But it seems to me that the Phase III of the MMC's would not affect constipation.


Constipation of the small bowel would not affect constipation of the colon?


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## cat crazy

FluxDo you think that SIBO also damages the lining or gut lumen of the s/i? If it does, would it show up in the pill camera test?


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## 22663

Hey Flux,One comment in your post really stood out for me:"Ordinarily, diarrhea is a symptom of SIBO. (Malabsorption and steatorrhea are not symptoms of SIBO as I previously claimed they were.)"What do most people think about Malabsorption not being a sympton of SIBO? I always presumed it was a major sympton & is infact one of the symptons I have. I will be getting a Lactulose Breath Test shortly for SIBO. After a year of virtually every test imaginable, SIBO looks as though it may infact be a high possibility for me.


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## flux

> quote:Constipation of the small bowel would not affect constipation of the colon?


What is constipation of the small bowel? Reduced frequency of phase III MMCs? I don't think they could on their own impact colonic transit.


> quoteo you think that SIBO also damages the lining or gut lumen of the s/i? If it does, would it show up in the pill camera test?


No and no.


> quote:What do most people think about Malabsorption not being a sympton of SIBO?


Apparently, people who had been diagnosed of SIBO had it because they had some other underlying condition and that condition was causing the malabsorption. So it appears that the SIBO in IBS cannot alone cause it.


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## Pete

I think it is not known whether SIBO could cause damage to the lining. Maybe an immune response to SIBO could do this. Pimental thinks it is possible


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## bonniei

spasman for instance on this linkhttp://www.ncbi.nlm.nih.gov/entrez/query.f...8348&query_hl=1people with idiopathic consti[ation had normal MMCs.


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## cat crazy

Well I had the endoscopy test today or I should say Aug 18/05 at 11 am. Last week I had faxed a lot of info from some links and abstracts from the bb to my gi doc. Just before the test today I asked him what he thought about SIBO. He said, 'they've known about it for a long time, nothing spectacular.' This conversation took place just before the sedation was about to be injected. And I'm thinking 'then why have you not checked me for it a long time ago?' Then I went out like a light. Anyway after the procedure he said they will check for it in the biopsy. I am even hoping that it will be positive then I can get the damned ibs treated.


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## bonniei

Hi hanna. if he took some sdpirate it might not be enough as tit can't reach the distal parts of the bowel. It will show up in a biopsy only if there is damage to the small intestine. You must have read on this thread that that is not always the case.


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## cat crazy

bonniei, I thought that the endoscopy was the gold standard for checking for SIBO. Which part is the distal part, you mean one right in the lower part of the s/i or middle part? But why would my gi doc tell me that they will check for SIBO in the biopsy?


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## bonniei

There is a lot of controversy about the gold standard.Pimentel has been arguing that you can't get good aspirates from the distal(furthest from your mouth) parts of your SI because it can't even be reached. He seems to think the breath tet is the gold standard. And then ofcourse there is the controversy abpout which breath test to use. Pimentel believes it to be the lactulose one. I read of a case who had SIBO but had the SI mucosaintact. It is possible that it has already damaged your mucosa and hence may show up in a biopsy. But even if it doesn't you might still have SIBO.


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## cat crazy

If it doesn't show up in the biopsy then I will find a doc who will do the breath test. Better to have 2 seperate tests to confirm the findings. I am quite convinced that I have SIBO.


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## SpAsMaN*

hanna,I have buy Rifaximin from http://www.pharmaparadise.com/I will receive soon.


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## cat crazy

SpasThanks for the info. You are a sweetheart. Let us know how the drug works for you. I hope it will be the end all to the misery of ibs. I will wait for my test results and if they take too long to report back I just may go ahead and order it.


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## bonniei

> quote:known about it for a long time, nothing spectacular


He is right it has been known for a long time-since 2001. What has happened recently is Pimmentel's findings that a huge percentge of IBS'ers have SIBO by the lactulose test has been replicated.


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## SpAsMaN*

> quote: known about it for a long time, nothing spectacular


Where this comes from?


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## bonniei

I was responding to hanna's post.


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## Gutguy22

How is Dr. Pimentel sure that the benefits of the antibiotics aren't from just killing off gas producing bacteria in the colon? Just how respected or well-known is Dr. Pimentel? Do you think the average GI doc is aware of this research? Also, if a lack of Phase III MMCs are causing the SIBO, why would the benefits of the treatment last a couple months? PI-IBS seems to take hold much quicker than that (at least it did for me). I'm very skeptical of all this because I've seen excitement like this before on this board and then seen the treatment not live up to the hype. Then again, the SI seems to be the hardest area of the digestive system to get data on, so I guess it wouldn't be surprising if it took them this long to find this out. P.S. Whatever happened with the guy in Australia using antibiotics followed by a bacteria colonic "transplant" from a donor to treat IBS? Maybe he was inadvertently treating SIBO.


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## Kathleen M.

Well he has been at this research for about 5 years or so and is slowly over time building up enough data that I think people are starting to take it seriously.He is pretty new in the field and his first papers were not so well received, but he seems to be doing the work needed to make his ideas fairly solidly supported.Average GI doctor may or may not be aware, or may not be aware of the stronger data presented recently. I don't know the specifics well enough to answer the technical questions.K.


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## bonniei

> quote:benefits of the antibiotics aren't from just killing off gas producing bacteria in the colon?


He is sure of the results from the way he interprets the graph and does athe before and after antibiotics graphs. Now if there is a double peak around the times the lactulose enters the small intestine and when it enters the colon, and the greaph is normalized after the a/b so that the first SI peak gets flattened, that proves that SIBO ha been eradicated. Hoever as flux and I were discussing on this thread (I think on this thread) it is strange is that he uses 20 ppm as the cut-off for any peak which happens in the first 180 mins- i.e he thinks that if you exhale more than 20 ppm in the first 180 mins then it is due yto SIBO and not the colonic bacteria. So he doesn't go by the timing i.e a peak happening after 90 mins is colonic but he goes by the height of the peak to distinguish between SIBO and abnormal coloic fermentation. Surprisingly I haven't read comments on this novel interpretation anywhere.


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## flux

> quote:How is Dr. Pimentel sure that the benefits of the antibiotics aren't from just killing off gas producing bacteria in the colon?


Another group, Dr. Hunter's in the UK, does, in fact, believe this is what is happening. His data is based on a different technique, one that is not easy to reproduce.However, the absolute values don't reflect an overgrowth in the colon. There are signficantly more bacteria in the colon than in the small bowel, so if there were an overgrowth there should be way way more gas. IBSers don't seem to have a problem with excess gas. The numbers in the lactulose studies don't reflect any increase in the absolute peak numbers of gas either.Of course, the biggest complaint is there is no overgrowth and the breath tests values reflect rapid transit and the hence the numbers being seen are normal values out of the colon. Further research is underway to determine if there is indeed really overgrowth in the small bowel, so we'll have to wait for that.


> quote:if a lack of Phase III MMCs are causing the SIBO, why would the benefits of the treatment last a couple months?


It takes time for the bacteria to grow back.


> quoteI-IBS seems to take hold much quicker than that


It's not clear to us yet where the bacterial overgrowth fits into things whether they are a consequence of the initiating infection or whether they are also involved later on a cause in the mechanism.


> quote:Whatever happened with the guy in Australia using antibiotics followed by a bacteria colonic "transplant" from a donor to treat IBS? Maybe he was inadvertently treating SIBO.


To my knowledge, he is still performing it with success.


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## SpAsMaN*

> quote: To my knowledge, he is still performing it with success.


His nurse told me on the phone last year that the chance are 50/50 to get "better" or "cured" with IBS.Beeing from Canada she told me:"I appreciated the idea that you dosen't comes here".I'm still questionning me about their 50/50 rate.







I also know a USA guy who has been cured of UC there.They have 100% sucess cure rate with C.difficile.I almost wish i had that instead of IBS.


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## bonniei

> quote: so if there were an overgrowth there should be way way more gas.


I assume you mean after 90 mins. flux what I find strange is that if it is more than 20 ppm anwhere in the first 180 mins then it is SIBO and not colonic fermentation. You seem to be implying that a graph like Spasman's with a peak of 110 ppm should be colonic fermentation, as you previously mentioned as it is so high, but Pimentel does the opposite, he thinks anything more than 20 ppm is SIBO.







I don't know if I have expressed myself clearly enough that you see my point. If you don't see my point please let me know because then I'll have another go at expressing myself.


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## SpAsMaN*

> quote:This test is absolutely positive for bacterial overgrowth because you havetwo peaks and are greater than 20 ppm by 90 minutes. In fact you are way over the top


What means by?


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## bonniei




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## bonniei

uh-oh! flux is going to say again that he doesn't see a peak at 60 mins.







flux save yourself some typing! We know before hand what you are going to say, LOL! It goes without saying from now on that the first peak (at 60 mins) is not a peak by scientific standards ok?But the peak at 110 mins is way above 20 ppm so Pimentel says it is SIBO and you say it is colonic fermentation. Pimentel just doesn't allow for the possibility that it is colonic fermentation because however high it is and even if it is after 90 mins, as long as it is higher than 20 ppm it is SIBO.







He doesn't even talk about when the peak commences. So strange. I have written to him about it. Hope he replies.


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## 18360

Questionid the good Dr. elaborate on the role of good bactera. As i have stated numeruous times on this site;Acidophilus - good bacteria Aloe Vera Gel - smoothes the lining of the intestines/stomachTHESE TWO DID THE TRICK FOR METhanks,Bill


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## Kathleen M.

I don't think we know in humans.In some animal studies adding probiotic bacteria (like acidophilus, which is one kind of these bacteria) seems like it might be a good thing.I know at first Pimental recommended staying completely away from probiotics, but I thought the latest was more of a "we don't know one way or the other".K.


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## flux

> quote:flux what I find strange is that if it is more than 20 ppm anwhere in the first 180 mins then it is SIBO and not colonic fermentation. You seem to be implying that a graph like Spasman's with a peak of 110 ppm should be colonic fermentation, as you previously mentioned as


Anything after 90 minutes is probably in the colon. 110 ppm has to be in the colon. I can't see SIBO causing 100. That's off the charts.


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## bonniei

I hope Pimentel replies. It should be interesting. I think he needs to modify his standards to say any peak *which commences before 90 mins* and over 20 ppm is SIBO. If the SIBO peak overlapped with the colonic peak then it could push the second peak over the top. There is something very wrong with his standards.


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## SpAsMaN*

Yes i'm off the chart,maybe that's why i'm very prolific.


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## bonniei

What do you mean by prolific, sspasman? BTW any colonic peak(usually those after 90 mins) which is over 60 ppm is over the top, I think.


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## SpAsMaN*

...Very prolific member.Flux,how do you know the mouse actually have IBS?It is kind of a funny image,Flux has been convinced by a mouse.


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## SpAsMaN*

I mean there is no visual marker for IBS.How does he know the mouse was struggling with IBS?Oh i see,the mouse blew too high.


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## SpAsMaN*

Huhum,Ok i have found on page 1:


> quote:He also mentioned that the stress hormone corticotrophin releasing factor reduces phase III of the MMC and could be how stress sets the stage for the bacteria to overgrow.He showed pictures of this change in a mouse, practically causing a mouse to develop IBS.


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## bonniei

These are three weird cases which show that the peks did not coincide with the substrate entering the SI and cecum. The graph is abnormal(positive) by the old standards for the lactulose test if either of the fiollowing conditins were met and normal if neither were met1)two consecutive hydrogen values in excess of 10ppm above basal distinguishable from a later "colonic" peak in excess of 20 ppm above basal 2) an increase in breath hydrogen concentration in excess of 10 ppm above basal, commencing within 20 min of lactulose ingestion and more than 15 min before a later peak.




























edited to say the top caption explains it all. I made a boo-boo. The theory was that double peaks coincided with the lactulose entering the SI and the colon.


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## SpAsMaN*

Oh i understand it now on my graph.Thankshopefully it is what he meant.


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## bonniei

Hi spasman the graphs show that the douvble peaks did ot coincide with the substrate entering the SI and colon. I have outlined the older standards at the beginning of the last post. I will try to post the graphs of what is positive by Pimentel's newer standards. Hope it helps.Happy graph reading.And yes it is an interesting question- how do they know mice have IBS.


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## bonniei

By Pimentel's newer standars , the test is negative(graph is normal) if the peak occurs no earlier than 90 ppm and no greater than 20 ppm. Anything else is abnormalThe following are graphs which are abnormal or positive for SIBO


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## bonniei

Sorry I made a boo boo. I have reedited my posts. You will see the edit note.


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## SpAsMaN*

Bonnei,i don't know if i will do a breath test after the course even if i improve.What do you think?


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## bonniei

I think it is a good idea to do the breath test. Otherwise how will you know that the antibiotics have worked since there is a time lag in seeing the improvements. Also you don't want the improvement to be due to a side effect. Doing the breath test is the only way to go.


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## SpAsMaN*

> quote:since there is a time lag in seeing the improvements


How can this be possible?I will print the "management of SIBO".Maybe it is explained.It's normal that Flux is stuck in his old standarts regarding the breath test analysis,he dosen't have this paper.


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## bonniei

Yes it is in that paper. I am not joking about flux. He is really a sweet guy who answered my thread promptly yesterday and today.


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## SpAsMaN*

They don't explain why it can improve 2 weeks after the course.I should begin my Rifaximin trial in the beginning of the week.I hope i will only get diarrhea.I HATE head aches.


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## bonniei

I suspect that the flora has got to have a chance to stabilize. All that killing and fighting for nutrients going on


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## SpAsMaN*

quote:then there isn't much point recommending a drug someone's doctor cannot prescribe K,i just want to say that you was rigth.Neomycin was his recommandation because i was from Canada.


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## cat crazy

> quote:Originally posted by bonniei:I suspect that the flora has got to have a chance to stabilize. All that killing and fighting for nutrients going on


bonnieiI like that comment. We have to wage a war on the sibo. A/b is just the battle but the war has to be won with nurishing the tract with the good flora army troops on a constant basis I think!


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## bonniei




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## cat crazy

Does sibo itself cause serotonin dysregulation, or does serotonin dysregulation cause sibo? Or one has nothing to do with the other?


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## cat crazy

I also have another question about sibo. How many on this bb who are P/I ibs would say that their ibs symptoms started 'SOON AFTER, OR SOME MONTHS, OR EVEN COUPLE OF YEARS AFTER' their infection? Just wondering when exactly does sibo manifest itself after the infection or the time frame.


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## Kathleen M.

Well It may be that the only people that get the serotonin dysregulation are the people that have the problems with SERT.It may be that sets you up for it, and SIBO just gets it going.I don't know that we have enough info to get the whole picture of who does what to whom when at this time. It is still an area of ongoing investigation. Science can't get all the answers in an instant. It can take years to get all the i's dotted and t's crossed when something new is discovered.Usually with PI-IBS it is less than a year after the GI infection that the IBS is going. I would say in the weeks to couple of months stage, but most often it is the "I had a GI infection and it never stopped" kinda thing.Someone who DOES NOT get IBS from a GI infection may have "sensitive" guts for 2-6 weeks after a GI infection as things heal up from the trauma of the inflamation. (sensitive meaning more like to react to diarrhea triggers, etc.)K.


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## bonniei

> quote: He says by using Zelnorm and erythromycin in concert with the antibiotic rifaximin in apparently one time course, he has outright cured several patients of IBS.


 One time course of rifaximin and lifetime course of Zelnorm/erythromycin, flux?


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## SpAsMaN*

If Rifaximin works better alone so i guess the pro-motility agent could be taken after the course.Or even stay on Rifa as a maintenance dose after the course.Pete actually doing this and has reduce the gas issue apparently.


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## SpAsMaN*

Also,if my symptoms disapear by a miracle after the course,i would not necessarly need another Lactulose.


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## bonniei

> quote:If Rifaximin works better alone so i guess the pro-motility agent could be taken after the course.Or even stay on Rifa as a maintenance dose after the course.Pete actually doing this and has reduce the gas issue apparently.


You did not understand my question spasman. Do you mind letting flux answer the question.please?. I am interested in knowing what Pimentel meant by that.


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## SpAsMaN*

He has made a comment on this exact quote from me in this thread.It wasn't perfectly "clear" if i remember.Thanks both of you BTW


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## bonniei

I don't know what you are thanking me for but you are very welcome, spaz


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## SpAsMaN*

I'm scared for you that you will have to rely on my comment.


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## bonniei

I am scared too flux won't reply because you have. flux, please reply, ig


> quote:He has made a comment on this exact quote from me in this thread.


Can you goive me the exact quote?. Then I won't have to rely on your comment.


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## SpAsMaN*

Don't be scared.







I'm credible with this treatment.


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## SpAsMaN*

> quote:quoteo you means Zelnorm + Erythromycin?Both? Flux reply:Actually, I am not so sure of the wording. It seems to be equivocal. It could be either way, but it seems that the clinical trials are going to use one or the other not both.


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## bonniei

You are not credible spasman







.I read through the *long* thread and this is what you asked


> quote:Originally posted by SpAsMaN*:
> 
> 
> 
> quote:He says by using Zelnorm and erythromycin in concert with the antibiotic rifaximin in apparently one time course, he has outright cured several patients of IBS
> 
> 
> 
> Do you means Zelnorm + Erythromycin?Both?
Click to expand...

You did not ask him about the length of the treatment. However hanna asked him about the length of the treatment and flux replied


> quote:
> 
> 
> 
> quote:He says by using Zelnorm and erythromycin in concert with the antibiotic rifaximin in apparently one time course, he has outright cured several patients of IBS
Click to expand...

 And then I asked him some more but flux didn't reply. My question to flux is this in case I was not clear; do you use Zelnorm/erythromycin temporarily or is only the Rifaximin used in a one time course while the others are used permanently?


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## SpAsMaN*

I don't necessarly need our friend Flux to be credible.







But i have to admit the actual SIBO research seems to be in a short term.


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## bonniei

I guess flux doesn't have the answer. I have asked him twice on this thread. spasman, you jinxed it, I think.


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## bonniei

This was Dr Pimentel's reply to my e-mail-"Unfortunately, the motility disturbances that precipitate the bacterialovergrowth do not correct on their own and many patients need to continuethe preventive measures with zelnorm or erythromycin."


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## SpAsMaN*

Interesting.


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## Arnie W

I finally have the results of my hydrogen breath tests.The lactose test shows no evidence of significant lactose intolerance, according to my gastro.Here are the results of the lactulose test. If I learn how to scan, I could do it in graph form, but will copy it out for now. ppm ppm (f)CO2 H2 CH40 minutes 008 000 1.14 15ml lactulose30 " 008 000 1.2240 009 000 1.3150 014 000 1.3560 018 000 1.2670 037 -001 1.2580 (005) -001 ( 2.00)90 010 -001 1.29100 089 -000 1.27110 094 -001 1.22120 103 -001 1.30140 115 -001 1.34160 085 -000 1.24180 072 -001 1.20The interpretation I have is that one of the readings (80 minutes) was an error and it could ppossbibly be a normal test otherwise.The options given to me were -Do nothing -Repeat the test - Try a 'standard course of therapy for bacterial overgrowth (one week of Augmentin)' to assess for improvement.I'm very busy and have to sign off, but will try to get back online later.


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## Arnie W

For some reason the graph is not lining up the way I typed it after I posted it, but I hope that bonniei and flux will be able to put 2 and 2 together.


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## bonniei

Hi Arnie I will put up a graph soon. but it looks to me like a double peak if you include bpoth the 80 mins as well as the 90 min reading- which means you have bacterial overgrowth. I would suggest repeating the test if they are not sure or alternatively assume the readings are right and take Augmentin. I think even flux will agree that this is SIBO.


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## flux

It looks like the readings for 80 and 90 are messed up, but my sense is that SIBO is *not* present. The top reading is a bit high, so you are definitely a H2 gas producer.The test also indicates that you do not produce any methane and your breath CO2 is low (that's a guess because I don't have details of the test protocol.)


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## bonniei

here is the graph







flux , look, two peaks


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## bonniei

Arnie, if you want a look at Pimentels standards for SIBO and judge for yourself, here it is


> quote: A normal breath test is if there is a peak no earlier than 90 mins and no greater than 20 ppm. Anything else is abnormal including if there is a single peak greater than 20 ppm after 90 mins.or a double peak after 90 mins as well as a single peak earlier than 90 mins and in your case a double peak one before 90 mins and one after 90 mins.


You obviously had a peak before 90 mins. That was what I was going by. Then I remembered another of Pimentel's standards and it said the drop of the peak should take over a longer period of time than 15 mins. The drop of the first peak in your graph was over only 10 mins from 70 mins to 80 mins. Perhaps that is why they think the readings didn't look right at 80 and 90.Also another standard of his is the the peak should be greater than 5 ppm . Clearly at the first peak it was 37 ppm and and second peak even higher. So no problems there


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## Arnie W

Thankyou both for the input and comments.Again I'm in a hurry, but I'll quote what the doc wrote in a letter to me."This possibly indicates some low grade overgrowth of bacteria in the lower small intestine. Potentially such a problem could lead to extra fermentation/gas along with weight loss, however, I would note that any level of potential overgrowth on this test seems too low to cause your problems. I think it is more likely that one of the breath hydrogen readings was an error and there is in fact no bacterial overgrowth, indicating a normal test."Under diagnosis he wrote:" Twin peaks. First peak consistent with SIBO. Second peak consistent with small bowel transit time of 90-120 minutes(normal)."If it's not SIBO, that's yet another straw I was clutching at which has now slipped from my hands.My next question is whether it would be worth pursuing the Rifaximin, or perhaps even go for the Augmentin. Though, to be honest, I don't hold much hope for the latter to do any good.


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## flux

> quote:flux , look, two peaks


I see *one* peak. There are invalid values for 80/90.I agree with the doctor's evaluation based on the data you have, *no* SIBO.


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## SpAsMaN*

Is it possible that SIBO occurs only 6-8 years after IBS?Then making the symptoms worst.


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## bonniei

Arnie I had very good results with Augmentin (875 g, 2 X day , 10 days). No gas and no D for a good two weeks and I still see I would say 50% of the improvement still there a month after the course. So I think it is worth it take Augmentin. And another thing I want to say- is that by Pimentel's standards a single peak greater than 20 ppm even after 90 mins is bacterial overgrowth. I think his thinking is that the two peaks are overlapping. While that is not the standard most docs use, if you are using Pimentel's theory, you have SIBO according to him even if the 80/90 min readings are off. This standard is in the paper Management of SIBO. I can send you a copy of the paper if you like(just give me your e-mail) so that you can discuss it with your doc. I really think Augmentin is worth pursuing and since you are on the C-side, taking the maintenance Zelnorm will be beneficial anyway for C and it will prevent the SIBo from relapsing. If I were you I would take the Augmentin. Also since you have gas problem, even if it were only colonic bacteria, Augmentin would help with that. I am hoping that you will see a major improvement in your gas problem aafter Augmentin.


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## Arnie W

Bonniei, I would appreciate it if you could send me a copy to arnie###ihug.co.nzThanks so much.I'm going to have to consider Augmentin very carefully. I've had a couple of UTIs in the past and will have to check with my doc whether I took Augmentin then, as I can't remember.When I say I get C, I'm not really correct,as I do have frequent bms throughout the day, easy to evacuate during the morning, but later on tending to become pebbly and difficult to pass, which are features of C. So I get C, but don't have C, if you know what I mean. The times when I have found it difficult to 'go' right throughout the day have been when I've been adhering to a low-starch diet. Whatever I have, my motility is stuffed. I wonder whether Zelnorm would help to get some normality to my bms.


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## bonniei

I sent the paper to you. I think Zelnorm would help the pebbly part, as it gets pebbly out of staying too lonng in the intestine and all the water being absorbed, since Zelnorm speeds up transit. Did you have some undesirable side-effects with the antibiotic you took for UTIs? Well if it was Augmentin I hope he finds a suitable replacement.


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## Arnie W

Thanks, Bonniei. That was very kind of you.I didn't notice any side-effects at the time, but it's just the ongoing effects of using a/b's too much which worries me. I do think that a/b's contributed to the problems I have today.


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## bonniei

You are very welcome, Arnie! I hope you find some resolution.


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