# Spoke with Dr Lin/ bacterial overgrowth



## Pete (Jan 20, 2000)

Hi. I friend of mine knows the cheif of staff at Cedar Sinai. Through this connection I was lucky enough to get to speak with Dr. Lin regarding his new study about bacterial overgrowth in the small intestine being a possible cause of IBS. What I got out of the conversation is that this is a very strong possibility if your syptoms include gas, fatigue, diarrhea, bad breath, bad taste in mouth. I do have some of these symptoms and have to travel to California on business in a couple of weeks. Dr. Lynn said he would squeeze me in for the breath test on my visit. I will let everyone know what I learn. I told him that I just had a gastric emptying study which showed only 14% of food had left the stomach after 90 minutes. He basically told me that the test must have been wrong because if that was the case I would be have a lot of trouble keeping food down. The first question he asked was whether I was on PPI's(antacids) during the test. My answer was yes. He said that PPI's delay gastric emptying and this obviously flawed the results. My local doc who did the test said that they do not delay emptying and that gastroparesis is definately what I have. Every doc I go to seems to have a different opinion. Flux, what is your opinion about PPIS and gastric emptying? Well my plan is to take the test and if I have bacterial overgrowth, then I will try their treatment plan. If I do not, then I will try domperidone or other prokinetic drugs. Does this sound reasonable to the experts on the board. Thanks for listening and any info I find about bacterial overgrowth, I will share.Pete


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## flux (Dec 13, 1998)

> quote:He basically told me that the test must have been wrong because if that was the case I would be have a lot of trouble keeping food down.


Now you see why I was recommending a feeding tube.


> quote:Flux, what is your opinion about PPIS and gastric emptying?


Yeah, it could, but so much? That's hypocritical logic. How does that explain the failure of the expected prediction that you'd have trouble keeping food down?


> quote:Well my plan is to take the test and if I have bacterial overgrowth, then I will try their treatment plan. If I do not, then I will try domperidone or other prokinetic drugs. Does this sound reasonable to the experts on the board.


What's their treatment plan? I wonder about the gastroparesis results. What was the emptying at 180 minutes? What are their normative data? You could have an antroduodenal motility to study to see if the problem extends into the small bowel. If you were checking SIBO then do you have other indicators, blood chemistries out of whack, fat in the stool, vitamin B12 malabsorption and a whole gut scintigraphy? What does a barium meal show?


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## HipJan (Apr 9, 1999)

Pete--good luck and, yes, keep us informed!


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## FPHHT! (Feb 1, 2000)

Dr Pimental's office in Cedar-Sanai called and asked me if I want to be in the study. I guess folks diagnosed with adult onset IBS are the best candidates. I said it's up to my Dr.s My GP wanted to know about the type of bacteria and my GI wants to know the incidence in the general pop without symtomology. If my 2 Doc's give Pimental the thumbs up, I'm going in.They said I take a 3 hr breath test, then if positive I get neomycin or the bush! (Half of the folks get the fake.)I have been doing well latley so hitting the bug killer makes me a bit jittery, but, hey! I might be messed up for a few months, but maybe not!Wish me luck. I'm still waiting for approval from my GI. (The GP said: "Go for it.")Fartman


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## eric (Jul 8, 1999)

They put the study into pubmed, although there is not much in the way of new info here it is. Am J Gastroenterol 2000 Dec;95(12):3503-6 Related Articles, Books Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome. Pimentel M, Chow EJ, Lin HC Department of Medicine, Cedars-Sinai Medical Center, CSMC Burns & Allen Research Institute, and School of Medicine, University of California, Los Angeles, 90048, USA. [Medline record in process] OBJECTIVES: Irritable bowel syndrome is the most common gastrointestinal diagnosis. The symptoms of irritable bowel syndrome are similar to those of small intestinal bacterial overgrowth. The purpose of this study was to test whether overgrowth is associated with irritable bowel syndrome and whether treatment of overgrowth reduces their intestinal complaints. METHODS: Two hundred two subjects in a prospective database of subjects referred from the community undergoing a lactulose hydrogen breath test for assessment of overgrowth were Rome I criteria positive for irritable bowel syndrome. They were treated with open label antibiotics after positive breath test. Subjects returning for follow-up breath test to confirm eradication of overgrowth were also assessed. Subjects with inflammatory bowel disease, abdominal surgery, or subjects demonstrating rapid transit were excluded. Baseline and after treatment symptoms were rated on visual analog scales for bloating, diarrhea, abdominal pain, defecation relief, mucous, sensation of incomplete evacuation, straining, and urgency. Subjects were blinded to their breath test results until completion of the questionnaire. RESULTS: Of 202 irritable bowel syndrome patients, 157 (78%) had overgrowth. Of these, 47 had follow-up testing. Twenty-five of 47 follow-up subjects had eradication of small intestinal bacterial overgrowth. Comparison of those that eradicated to those that failed to eradicate revealed an improvement in irritable bowel syndrome symptoms with diarrhea and abdominal pain being statistically significant after Bonferroni correction (p < 0.05). Furthermore, 48% of eradicated subjects no longer met Rome criteria (chi2 = 12.0, p < 0.001). No difference was seen if eradication was not successful. CONCLUSIONS: Small intestinal bacterial overgrowth is associated with irritable bowel syndrome. Eradication of the overgrowth eliminates irritable bowel syndrome by study criteria in 48% of subjects. PMID: 11151884, UI: 21025202 ------------------ http://www.ibshealth.com/ www.ibsaudioprogram.com


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## FPHHT! (Feb 1, 2000)

PUBMED? Thanks! How do I access thei pubmed?


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## Kathleen M. (Nov 16, 1999)

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi also I like http://www3.infotrieve.com as another access to Medline (it's one of the options in the frame on the left). It makes alot of the options that you might want to use in a search string and some of the boolean logic things really easy to do for those who aren't pros at it.K.[This message has been edited by kmottus (edited 01-11-2001).]


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## Pete (Jan 20, 2000)

Flux,I don't know what their treatment plan is. I suppose it is antibiotics if the breath test is positive. The antro manometry that you speak of- is that where they put a tube in your stomach and have you eat to check the motility of your stomach? I had this test done and they said motility was normal. I don't understand how this could be normal and my gastric emptying study could be so delayed? They once had me do a gastric emptying study on propulsid and my results were normal, yet my symptoms were still the same. So something does not add up here. If me problem is gastroparesis and propulsid normalized my emptying, why did my symptoms remain the same? I disagree with you that the gas is swallowed air. I am sure some of it is but the amount of gas does correlate with the type of foods I eat and the amount of food I eat. Any thoughts?I appreciate your help. Pete


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## flux (Dec 13, 1998)

> quote:The antro manometry that you speak of- is that where they put a tube in your stomach and have you eat to check the motility of your stomach? I had this test done and they said motility was normal. I don't understand how this could be normal and my gastric emptying study could be so delayed?


The antroduodenal manometry looks at both the stomach and duodenum. It should pick up ineffective contractions of the stomach, such as bradygastria, that should explain in more detail just how stomach is not emptying. So I agree the results are contradictory. But I think it is possible to have normal contractions in the duodenum and gastroparesis at the same time.


> quote:They once had me do a gastric emptying study on propulsid and my results were normal, yet my symptoms were still the same.


This is not a big surprise. What the data the show and how a person feels doesn't always correlate. That could be due visceral hypersensitivity, meaning your gut nerves think your stomach is agony, but your stomach is doing its thing just right, having a ball (This I would call functional dyspepsia). Or it could be that the stomach is really sick, but the studies aren't detailed or complete enough to show it. For example, how was the manometry done? With a tube that had water in it? This is not as precise as the electronic tubes are. There is also electrogastrography which could also be informative.


> quote:I am sure some of it is but the amount of gas does correlate with the type of foods I eat and the amount of food I eat.


Most of the gas is probably air, but there could also be some reflux of CO2 from the duodenum, which I hadn't thought about before. The CO2 is produced when the acid in the stomach is neutralized. Finally, the behavior of the stomach nerves, especially if diseased, could be erratic, so you can't always draw accurate correlations between what you eat and the amount of air present.


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## Pete (Jan 20, 2000)

Flux,I appreciate your help. From everything that you state wouldn't it make sense that my treatment plan should be a drug like propulsid or motilium to improve emptying accompanied by a drug that works on neuroreceptors like imitrex or elavil to help with the hypersensitivity(functional dyspepsia) What do you think? My doc usually will go along with my suggestion.Also if I test positive for bacterial overgrowth with Dr. Lin is it your opinion that this overgrowth could be a cause of excess gas and hypersensitivity to the gas. IF the test is positive could it be a cause to all my GI symptoms? Could it be positive just as an effect of being on high doses of PPIS for so long? Sorry about all the questions. Just trying to gain as much knowledge and info as possible so I am educated when I meet with Dr Lin next week.Thanks


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## flux (Dec 13, 1998)

> quote:my treatment plan should be a drug like propulsid or motilium to improve emptying accompanied by a drug that works on neuroreceptors like imitrex or elavil to help with the hypersensitivity(functional dyspepsia) What do you think? My doc usually will go along with my suggestion.


The effects of Imitrex are bit confusing. It seems it could go either way, sort making things worse by making them better :This study sounds good: www3.infotrieve.com/medline/infotrieve/detail.asp?med2000+229519+But an earlier study seemed to be saying that this positive result could make matters worse: www3.infotrieve.com/medline/infotrieve/detail.asp?med2000+72178+The studies seems to be saying it will let you tolerate more food, but at the same time, it might make you belch more easily!


> quote:Also if I test positive for bacterial overgrowth with Dr. Lin is it your opinion that this overgrowth could be a cause of excess gas and hypersensitivity to the gas. IF the test is positive could it be a cause to all my GI symptoms?


I would not place all my bets on a single lactulose breath study. Better at least to back it up with some other study, such as the radioactive xylose or 80g glucose test. If you had overgrowth, then I'd suspect you have other symptoms from malabsorption.Also, what was the result of antroduodenal manometry? Did you convert to fed state after feeding? Did they give you erythromycin during the study? Did you have MMCs, including phase III?


> quote:Could it be positive just as an effect of being on high doses of PPIS for so long?


I don't think that has been formally studied, but my guess it wouldn't by itself; otherwise, a lot of people would be having symptoms of bacterial overgrowth.Was does your regular GI say?[This message has been edited by flux (edited 01-15-2001).]


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## Blair (Dec 15, 1998)

If the Bacteria Overgrowth is a fact, Then how do we pass the blood tests, and stool fat tests? Assuming at least these tests have been done? Or does bacteria overgrowth not show up as Malapsorption?


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## Pete (Jan 20, 2000)

Sorry flux but you are getting a little too technical for me. I really don't understand the studies on Imitrex. Could you explain in more detail. As far as the andro manometry goes, I am not even sure that it what the test was. All I know is that after waking up from my endoscopy I had a tube in my nose that went in to my stomach to measure the contractions. They had me eat food with the tube in my stomach. They said the contractions were normal yet my emptying study is extremely delayed. I can eat a lot of food so I don't know if the emptying study is correct. My problem is more dyspepsia. I know I have excess gas cause I am always passing it but I know that I also have a heightened sensitivity to it also. To make matters more confusing I have a small hiatal hernia(I don't know if this is contributing) and may have food allergies(skin testing showed reaction to wheat, rye, and soy) I don't think allergies could contribute to delayed emptying, do you? I literally develped my symptoms overnightThanks againPete


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## Pete (Jan 20, 2000)

flux,Is there anyway you could direct me to those studies. I can't pull them up with that address. Also I forgot to mention that all my bloodwork is normal. No absorption problem or defiencies. I will let you know what Dr. Lin says next week.Pete


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## Guest (Jan 16, 2001)

Blair,I think because they're talking about a small intestine bacterial overgrowth. The tests you are talking about only test things on the way out, after stuff has gone through the large intestine (colon) which is full of bacteria. So, you need to do a breath test to determine the gas released by bacteria before something reaches your colon.


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## flux (Dec 13, 1998)

> quote:Could you explain in more detail.


Basically, they found that Imitrex allows the stomach to relax and hold more food, so you won't feel or bloated. *This is something for bloated people to inquire about!*But it also seems to make the stomach lazy, and it doesn't empty. That should make things worse, but does it really?The studies werewww3.infotrieve.com/medline/infotrieve/detail.asp?med2000+229519+"(Sumatriptan)+AND+(gastric)"www3.infotrieve.com/medline/infotrieve/detail.asp?med2000+72178+"(Sumatriptan)+AND+(gastric)"


> quote:As far as the andro manometry goes, I am not even sure that it what the test was. All I know is that after waking up from my endoscopy I had a tube in my nose that went in to my stomach to measure the contractions. They had me eat food with the tube in my stomach. They said the contractions were normal yet my emptying study is extremely delayed.


Do you have the report? What does it say about your MMCs? Or better yet the actual graph. You should see four separate graphs that look like an EKG?


> quote:I can eat a lot of food so I don't know if the emptying study is correct. My problem is more dyspepsia. I


You could have very good compliance to distension. Your stomach easily expands to distension, so even though it doesn't empty, your stomach just expands, almost as if you were already taking Imitrex.


> quote:To make matters more confusing I have a small hiatal hernia(I don't know if this is contributing)


I don't know either.


> quote:and may have food allergies(skin testing showed reaction to wheat, rye, and soy) I don't think allergies could contribute to delayed emptying, do you?


I don't think food has much to do with motility disorders at all, let alone food allergies.


> quote:I literally develped my symptoms overnight


A famous case in the literature is about a women who got cytomegalovirus (CMV) and then her stomach just bit it. Healthy people rarely get CMV, let alone in the gut. It's possible you got a stomach bug and then it screwed up the nerves, but most of the time, it's probably a common pathogen that doesn't do serious damage. That's what might be happening in some cases of IBS.


> quote:I will let you know what Dr. Lin says next week.


What happened to that woman doctor at Columbia?


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