# My log of the Cedars-Sinai Protocol (Dr. Pimentel's protocol)



## 17908

I thought I'd post a thread of my expereinces, rather than random bits in different threads. I'll keep this short, so you don't have to sift through too much BS.







I was never tested for bacterial overgrowth. I live in an extremely rural area, and I was able to get my local doctor to read Dr. Pimentel's book and proceed with the regimen (minus the breath test). I was diagnosed and treated for colitis (caused by a bacterial infection) prior to my troubles with IBS. I feel fairly confident in thinking that the bacteria in my lower colon that caused the colitis probably traveled into my small intestine.I was prescribed Xifaxan for 10 days (1200mg per day). After the 10 days, I felt my symptoms improved 50% to 70%. It's hard to say exactly. Diarhea was always my my main symtom, and for the first time in many years I have only gone to the bathroom once a day. However, I still have about 50% of the gas and bloating that I usually do in the mornings.Because the Xifaxan alone didn't improve my symptoms to 90% or better, I have now started neomycin (1500mg per day) and Xifaxan (1200mg per day). If the combination works wonders, I'll proceed to Zelnorm once a day.I'll keep everybody posted.


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## 17908

UPDATE: Day 5The first 2 days of neomycin and Xifaxan were a little rough. The drugs were causing some pretty intense gas, and I went to the bathroom several times to try to relieve my bowels, only to sputter little bits of poop mixed with lots of gas.On the third day, things started to calm down. Now on day 5, I have only gone to the bathroom once each of the last 2 days, and each time it was only a little bit. The poop was still a little loose, though. I'm hoping for some nice solid turds, for the first time in YEARS.The amazing thing is that the last 2 mornings, I've had very little gas pain. This is usually the most painful time of day for me. Xifaxan alone didn't do away with near this much of the gas, but it did help control the loose stools a lot. I'm thinking the neomycin has really helped the morning gas pains.More days of analysis are needed, but so far I'm progressing nicely, I'd say.I'll keep you updated.


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## 17908

UPDATE: Day 8Day 8 of the neomycin/Xifaxan combo. I still feel better than I ever did without the antibiotics, but I still have occasional gas/bloating. I normally have constant loose stools and D, but now I can barely go once a day. I hope this means the bactieria is gone, and I just need to restore gut function.I'm interested in trying the Zelnorm. I believe I'm feeling good enough to proceed with the Zelnorm as soon as I'm done with the antibiotics.


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## SpAsMaN*

Thanks i'm really interested to follow the effect of Neomycin.


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## 17908

The only difference, that I can tell, from taking just Xifaxan compared to neomycin/Xifaxan, is that the combo gives me less gas and bloating, especially in the mornings. This could be from the neomycin, or it could simply be from the prolonged use of Xifaxan . . . or I guess it could be a combo of those to things.


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## 17908

UPDATE: Day 10I finished my Xifaxan/neomycin combo last night, and I also took 3mg of Zelnorm before bed last night.For the first time in YEARS, I woke up with NO gas pain, and I also felt like my stomach was cleared out. Normally I feel like my dinner from the previous night is still being digested.I don't know if this was because of the Zelnorm of the antibiotics, but if the Zelnorm helps me get rid of that "full" feeling, I'm all for it.I don't feel like the antibiotics were a "cure", because the "fullness" and "bloating" thing are caused by slow motility in the small intestine. I'm just going to assume that 20 days of antibiotics killed off most/all of the bacteria, and I will proceed with the Zelnorm to see how that works for me.So far I'm very happy with the way I'm feeling. I have almost no discomfort during the day, and my mornings are becoming much better.By the way, I am also following Pimental's diet pretty closely.I'll keep everybody updated.


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## Moises

npearce,Good for you! I'm glad to hear you are getting some relief.By the way, have you ever had a gastric emptying study? You mentioned that you now feel as if your stomach was clearing out properly. This test would have indicated if your stomach were emptying slowly.


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## 17908

All the studies I had done were when I had colitis. So I had a barium swallow study, which indicated that I had "sluggish" digestion. The study is mostly only designed to show if I had an obstruction or stricture. They weren't too concerned with something as simple as "sluggish" at the time. After the GI's found out I didn't have colitis any more, I was literally brushed off because my symptoms indicated ONLY IBS. That's why I went back to my family doctor, who is very smart, by the way.


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## 17908

UPDATE: DAY 3 without antibioticsZelnorm is still doing a great job of clearing my stomach at night. I can feel that a litte gas is coming back every now and then, but I'm assuming this would be normal, since bacteria of different varities will be growing back now that I'm off the antibiotics.So far, I'm very happy with my progress. No solid poop yet, though. My morning poop, which is my only poop, is nice and gooey. But who cares, since all my gas, bloating, and pain are gone.


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## Moises

That sounds like great progress. My own feelings are similar to yours. I always felt that diarrhea was less significant than gas, bloating, flatulence, and, for me, the worst which is belching.


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## cynthia

npearce - You mention that you are following Pimental's diet protocol. What exactly are you eating? The restrictions present me with an enormous problem of what to feed my son. I keep giving him the few foods that don't make him overly gassy, but it's so boring for him. And he's been eating like this for 2 years now. What are you eating in a given day and still sticking to Pimental's diet? Thanks, Cynthia


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## 17908

cynthia,I live in the boonies, so it is hard for me to find much of anything pre-packaged to eat. Some oranic/health-food stores would probably have a good selection of that kind of thing.So what I eat, is basically no dairy and very minimal fructose. I also get fiber only from about 2 or 3 servings of well cooked vegetables. For vegetables I only eat well cooked green beans, brocolli, carrots, cauliflower (occasionally), and maybe a few others. Nothing raw, and nothing slightly cooked. Only weel cooked. I mostly like just brocolli and carrots, but I'm finding I can tolerate a little more than before the antibiotics.I eat most meats, but I make sure they are prepared at home and low in fat. No fried chicken or anything like that. My wife has many cook books that have helped her find recipes. Look for cook books that are healthy and low residue.For carbs, I eat mostly white rice and white bread my wife makes at home. She has a bread machine and claims it is easy.Basically I'm lucky to have my wife to help with all this.Here's a list of some basic meals I have:1) Cream of wheat with some brown sugar, scrambled eggs with chopped mushrooms.2)Tuna wrap with white flower tortilla, olives, oil, and vinegar.3) Barbeque chicken sandwich on home made white bread bun (the barbeque sauce is also home made without fructose), cooked carrots.4)Hamburger with mustard and dill pickle relish.I could go on, but basically my diet is a little boring. But we keep getting better at it. I'm going to start adding flax oil to just about everything because I have a hard time no losing weight.


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## Nanobug

Cynthia,My understanding is that, at the end of the day, what Pimentel proposes is not too different from plain old Atkins. Just makes sure your child takes a good multivitamin/multimineral.Nano


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## Moises

npearce,I don't have a copy of Pimentel's book with me. But I think he recommends staying away from legumes, which would nix the green beans.On the other hand, I think he says that if his protocol works, you can eat whatever you please. I just wanted to make sure that others get a fair sense of his dietary recommendations.


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## 17908

> quote:Originally posted by Moises:npearce,I don't have a copy of Pimentel's book with me. But I think he recommends staying away from legumes, which would nix the green beans.On the other hand, I think he says that if his protocol works, you can eat whatever you please. I just wanted to make sure that others get a fair sense of his dietary recommendations.


Yes. You're right. Green beans just seem to work OK with me. I only occasionally have them.


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## 17908

UPDATEEverything has been going great. The Zelnorm really seems to be helping.BUTI had TERRIBLE gas pain (at least I think that's what it was) from about 2pm yesterday all through the day and night. I couldn't sleep at all last night. Does anybody know what could be causing this? It seems to feel a little better this morning after going to the bathroom. But this is the the WORST gas pain I've ever had. I'm a little worried it could be related to the 20 days of antibiotics or maybe the Zelnorm. Can anybody help me here? I sure hope it goes away and never comes back, because I've been doing so good.I did eat some home made cinnamon rolls and peanut butter cookies (my wife was trying to be nice, and I couldn't reisist). Would peanut butter cause all this?


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## Kathleen M.

Do you normally eat that much starch all kinda at the same time.I can't think there would be enough in the few peanuts in a peanut butter cookie to cause that much of an issue (did the pain go away after you fart, sometimes it feels like gas pains, but it is pain for any number of reasons). Peanuts might have some of the sugars in legumes that make you more gassy than usual, but there isn't that much peanut in a peanut butter cookie, I mean there is some, but not like eating a bowl of beans.With the size of some cinamon rolls you do get a lot of wheat starch, and then more in the cookies, and some people do get gas when they consume a lot of wheat flour in a fairly short period of time.K.


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## Moises

npearce,Pimentel emphasizes low-fiber in his dietary recommendations. Peanut butter might have had too much fiber.Of course, if there were no bacteria in your SI to digest the fiber, the gas should not have been a problem.


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## 17908

I'm currently waiting for my doc to call me back. I don't have any gas coming out as farts or burps, and I have a terrible side ache type of pain. I'm wondering if this has nothing to do with SIBO or IBS. I hope I figure something out soon, because I'm in pain.


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## 18835

Npearce: I would guess that the home made cinnamin rolls you had were a much more likely source of overgrowth gas than peanut butter - but then I subscribe to the "simple carbs like white flour and sucrose are the worst thing" theory. I cringe at the thought of eating cinnamin rolls - would be in trouble for days afterwards if I ate them. Peanut butter on the other hand, no problems for me whatsoever.


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## 17908

I agree that it was the cinnamon rolls. I've had PB before, and no problems. I think I just had too many over the course of about 2 days. I was so excited about my stomach feeling so good, I think I just thought I could eat without consequences.Anyway . . . I talked to the doc, and he said to keep taking the Zelnorm. He thought the pain was most likely a very stubborn air pocket. He thought it should get better soon. Well, I slept a little better last night, and sure enough I'm feeling quite a bit better today. I still think there is some gas built up in there, but I'm feeling much better.The lesson here is that antibiotics can kill most/all of the bacteria in your gut, but as soon as you start putting things back in there (including germs, etc.) the bacteria start coming back. The Zelnorm is supposed to keep the stomach moving like it did before the "bad" bacteria slowed it down, and thus I am hoping that the "bad" bacteria won't come back.As long as the gas episode passes completely (pun possibly intended), I am still happy with my progress. Zelnorm actually helped the gas get better, in my opinion.


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## Rick (never give up)

Hi npearceI found your diary very useful since I'm about to start the Vivonex diet myself next weekend.I just have one thought for you. I think Pimentel says that the problem is not actually about "good" or "bad" bacteria, but rather their overgrowth in some sections of the GI track where they are not supposed to reside in such numbers.So far I agree on the motility theory as the basis for complete remission. Personally, I've found that enteric coated peppermint oil capsules helped me because they slow down my hipermotility and at the same time the mint kills some of the bacteria. I confirmed that several times by eating specific amounts of fructose (which gives me problems). If I take peppermint oil capsules shortly after the fructose, I hardly get the symtoms I get if I don't. However that's just me, but I think the point is still valid.In your case I guess is not necessary to take anything else besides the Zelnorm to keep your motility in control. Lucky you







Anyway, thanks again for all your valuable info.


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## eric

"I think Pimentel says that the problem is not actually about "good" or "bad" bacteria, but rather their overgrowth in some sections of the GI track where they are not supposed to reside in such numbers."Exactly, its not really about good or bad bacteria, but normal bacteria that are swept up into the small intestines.Small Intestinal Bacterial Overgrowth(SIBO) Medical Author: Dennis Lee, MDMedical Editor: Jay W. Marks, MDWhat is small intestinal bacterial overgrowth (SIBO)? What causes small intestinal bacterial overgrowth? What are small intestinal bacterial overgrowth symptoms? What is the normal relationship between bacteria and the small intestine? What conditions cause increased production of gas? How does small intestinal bacterial overgrowth cause symptoms? How is small intestinal bacterial overgrowth diagnosed? Is there a relationship between small intestinal bacterial overgrowth and irritable bowel syndrome? How is small intestinal bacterial overgrowth treated? Whatâ€™s new in small intestinal bacterial overgrowth? Small Intestinal Bacterial Overgrowth (SIBO) At A Glance http://www.medicinenet.com/small_intestina...wth/article.htmIrritable Bowel Syndrome (IBS)http://www.medicinenet.com/irritable_bowel...ome/article.htmI also highly recommend watching this on IBS.Integrated Approach to Irritable Bowel SyndromeThis is an online CME course featuring Dr. Drossman http://www.ja-online.com/dukeibs/#


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## eric

PS Peppermint could help IBS regarless if you have sibo.It is not a good thing to take if you have upper gi conditions like gerd or functional dyspepsia, as it can make it worse.fyi Altern Med Rev. 2002 Oct;7(5):410-7. Links Comment in: Altern Med Rev. 2003 Feb;8(1):3; author reply 4-5. The treatment of small intestinal bacterial overgrowth with enteric-coated peppermint oil: a case report.Logan AC, Beaulne TM. Integrative Care Centre, 3600 Ellesmere Road, Unit 4, Toronto, ON M1C 4Y8, Canada.Recent investigations have shown that bacterial overgrowth of the small intestine is associated with a number of functional somatic disorders, including irritable bowel syndrome (IBS), fibromyalgia, and chronic fatigue syndrome. A number of controlled studies have shown that enteric-coated peppermint oil (ECPO) is of benefit in the treatment of IBS. However, despite evidence of strong antimicrobial activity, ECPO has not been specifically investigated for an effect on small intestinal bacterial overgrowth (SIBO). A case report of a patient with SIBO who showed marked subjective improvement in IBS-like symptoms and significant reductions in hydrogen production after treatment with ECPO is presented. While further investigation is necessary, the results in this case suggest one of the mechanisms by which ECPO improves IBS symptoms is antimicrobial activity in the small intestine.PMID: 12410625


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## 17908

UPDATE5 days after the extremem gas attack, I seem to have recovered about 99%. The gas was way higher up than I was used to, and way more painful. Not just annoying. It's gone now, and I've learned my lesson. DO NOT EAT TONS OF CARBS! No matter how good you feel.The Zelnorm is still doing great for me. I'm one of those with terrible D, but after the antibiotic, I'm doing fine. The Zelnorm makes me poop once in the morning. I occasionally poop again in the evening.I'm still trying to stick to Pimental's diet recommendations, and I've started taking peppermint pills again. They never did it for me in the past, but I figured at the least I'd burp up Christmas flavoring.


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## cynthia

npearce - Good to hear you're doing better. What's the dose of peppermint that you're taking? I believe I read somewhere that you can't do any harm by overdoing - but I was just wondering what the recommended dose is for fighting SIBO.


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## 17908

> quote:Originally posted by cynthia:npearce - Good to hear you're doing better. What's the dose of peppermint that you're taking? I believe I read somewhere that you can't do any harm by overdoing - but I was just wondering what the recommended dose is for fighting SIBO.


I'm taking 180mg 3 times a day. I don't know what the recommended dose is. I'll have to look that up, I guess.


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## Rick (never give up)

Hi Cynthia,I've been talking peppermit oil capsules for 6 months now and I'm pretty sure that the normal dosage is around 250mg to 300mg daily.And yes as npearce says it is OK to take more than that since peppermint oil is pretty safe, unless you have GERD or a stomach ulcer.One word of caution, though. Peppermint oil may influence the gut motility (it calms the muscles by interacting with calcium receptors, among other things), so in your case npearce, since you are already talking Zelnorm I think it would be wise to at least ask your doctor.


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## 17908

I'm now wondering if I should take the peppermint oil or not. I know my stomach moves way too slow, but I'd like to take the pills for the anti-microbial properties. I'll check with my doctor, and do some more research online.


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## Moises

npearce,I've looked around and I can't find your Zelnorm dosage. Do you mind telling us what it is?If all goes to plan, my Vivonex will arrive tomorrow via UPS. I will start it the day after Thanksgiving (this Thursday). If I feel that Vivonex has helped I might give the Zelnorm a try. I believe Pimentel recommends 2 to 8 mg before retiring.


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## 17908

I think Pimental recommends 2mg to 6mg before bed. The pills come as 2mg tabs or 6mg tabs. I got the 6mg tabs and tried half a pill (3mg) for a few days. It worked awesome for about 3 days then quickly felt like it wasn't enough. I'm now taking 6mg per day with nice results.If you go over to the forum for people that take Zelnorm (IBS-C people), you can find a lot of information on how to correctly take Zelnorm.The instructions that came with the medication say to take it before a meal, but that is drastically different than what people with C are actually doing.It is very important to take it on an empty stomach. I take mine as late as I can. Basically right before bed. I never eat very close to when I go to bed. For those of us that suffer from that slow digestion feeling and gas and bloating over night, I think it is very important to take Zelnorm right before we got to bed.I'm contemplating doing a dosage variation schedule, because a lot of people say that they get better results if they don't use Zelnorm every day. However, I want to stick to Pimental's regimen as closely as possible. I'm considering doing something like thisay 1) 3mgDay 2) 3mgDay 3) 6mgDay 4) 12mgDay 5) repeat cycleOr something along those lines. Just something to keep in mind if you try Zelnorm.I'm really interested to see what some more SIBO people think of Zelnorm. The first time I felt it's magic, I woke up feeling like I'd been touched by an angel . . . then I had to hit the can.


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## Rick (never give up)

Hi npearce,I just spoke with my local GI (the only one I trust besides Pimentel







) and he says that as long as you are talking Zelnorm the peppermint oil shouldn't be a problem, since Zelnorm is more powerfull and acts on a different level.Anyway, ask your doctor and let us know what he says.Sorry if I scared you.


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## Moises

npearce,Thanks for the Zelnorm explanation. To be perfectly honest, I've had diarrhea all my adult life. The thought that I'd be taking a medication for constipation still boggles my mind. But I can always hope.


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## eric

The new IBS drugs zelnorm and lotronex work on cells in the gut that release serotonin."Serotonin and IBSFrom the Winter 2000 issue of ParticipateHow do the new serotonergically active drugs currently being developed for the treatment of irritable bowel syndrome (IBS) differ from the selective serotonin reuptake inhibitor (SSRI) class of drugs [e.g., fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft)]? The SSRIs have been specifically developed as antidepressant drugs. Serotonin is found in both the brain and the gut, but it is now widely understood that 95% of the serotonin in the body resides in the gut."http://www.aboutibs.org/Publications/serotonin.html"MedGenMed GastroenterologyIBS -- Review and What's NewAmy Foxx-Orenstein, DO, FACG, FACP Medscape General Medicine. 2006;8(3):20. Â©2006 MedscapePosted 07/26/2006Abstract and IntroductionAbstractIrritable bowel syndrome (IBS) is a highly prevalent gastrointestinal motility disorder broadly characterized by abdominal pain/discomfort associated with altered bowel habits. The chronic and bothersome nature of IBS symptoms often negatively affects patient quality of life and activity level and places a substantial economic burden on patients and the healthcare system. Advances in research have led to a greater understanding of the underlying pathophysiology of IBS, particularly regarding the role serotonin plays in the gastrointestinal tract; the development of stepwise, symptom-based diagnostic strategies that allow for a diagnosis of IBS to be made without the need for extensive laboratory testing; and the development of treatment options targeting underlying pathophysiologic mechanisms that provide relief of the multiple symptoms associated with IBS. This review highlights recent advances in research and discusses how these findings can be applied to daily clinical practice.IntroductionIBS -- a complex, multifaceted condition broadly characterized by abdominal pain/discomfort associated with altered bowel habits -- is among the most prevalent gastrointestinal (GI) motility disorders. Prevalence estimates for IBS range from 3% to 20%, with most estimates in North America ranging from 10% to 15%.[1-3] Women are affected by IBS more often than men (2:1 in the community setting and 3:1 to 4:1 in the tertiary care setting).[2] IBS-related symptoms are often chronic and bothersome, negatively affecting patient activities of daily living (eg, sleep, leisure time), social relationships, and productivity at work or school.[4-6] Patients with IBS typically score lower than population norms or those with other chronic GI and non-GI disorders on measures of quality of life.[7-10] IBS also puts a heavy economic burden on patients, employers, and the healthcare system, resulting in more than $10 billion in direct costs (eg, from office visits, medications) and $20 billion in indirect costs (eg, through work absenteeism and reduced productivity) each year.[11-14]Advances in research during the past several decades have provided insight into the underlying pathophysiology of IBS, particularly the role of serotonin in the GI tract; the development of stepwise, symptom-based diagnostic strategies; and the development of targeted treatment options. This review discusses recent advances in research and explores how these findings can be applied in the clinical practice setting.""Serotonin Signaling*Of the putative mechanisms underlying the pathophysiology of IBS, the strongest evidence points to the role of serotonin in the GI tract.* The effect of serotonergic mechanisms in the manifestation of IBS symptoms has led to development of a new drug class for the treatment of IBS patients: the GI serotonergic agents.Normal GI function relies on a properly functioning brain-gut axis, which involves the coordinated interplay of the GI musculature, the CNS, the autonomic nervous system, and the enteric nervous system (ENS). The ENS contains millions of neurons embedded in the wall of the digestive tract and functions, at least in part, independently of the CNS. The size, complexity, and independent function of the ENS has resulted in application of the terms "the second brain" and "the mini-brain."[81] Impaired function or coordination of any of these systems, or the communication between these systems and the GI musculature, can lead to symptoms of dysmotility and altered sensory perception, which are characteristic of IBS and select other GI motility disorders.[82]The neurotransmitter serotonin (5-hydroxytryptamine [5-HT]) is a predominant signaling molecule in the ENS. Most (90% to 95%) of the body's serotonin is found in the gut, and smaller amounts are found in the brain (about 3%) and in platelets (about 2%).[83] In the GI tract, serotonin facilitates communication between the ENS and its effector systems (muscles, secretory endothelium, endocrine cells, and vasculature of the GI tract), thus playing a key role in normal GI tract functioning.[84] In addition, serotonin plays a role in the communication between the ENS and the CNS."In the gut, serotonin is synthesized by and stored in the enterochromaffin cells, which are located within the mucosa of the intestinal wall. When material passes through the lumen and the mucosa is stimulated, enterochromaffin cells release serotonin, which then binds to its receptors (primarily 5-HT1P receptors) on intrinsic primary afferent neurons, initiating peristalsis and secretion. Serotonin also binds to 5-HT4 receptors on interneurons, which augments the transmission of signals to motor neurons, resulting in enhanced peristaltic activity. In transgenic mice lacking 5-HT4 receptors, colonic motility is abnormally slow, confirming the role of these receptors in facilitating normal colonic motility.[85] By binding to 5-HT3 receptors on efferent sensory innervations coming from the vagus and the spinal nerves, serotonin mediates signaling between the ENS and the CNS and, thus, modulates pain perception.To regulate the signaling process, excess serotonin must be removed; this is accomplished by the SERT molecule expressed by intestinal epithelial cells.[86] Human studies have shown that defects in serotonin signaling contribute to the pathophysiology of IBS and, potentially, other GI motility disorders. In a recent study by Coates and colleagues,[87] biopsy specimens from patients with IBS showed significantly lower mucosal serotonin concentrations than those from healthy controls, potentially the result of lower mRNA levels for tryptophan hydroxylase (the rate-limiting enzyme in serotonin synthesis), which were also significantly lower in patients with inflammatory bowel disease.[87] There was no significant difference in the number of enterochromaffin cells or in the capacity of these cells to release serotonin under stimulated conditions. In another study, higher serotonin levels were observed in mucosal biopsy samples from patients with IBS with constipation (IBS-C) than in patients with IBS-D or in healthy volunteers.[88]Serotonin levels may also be affected by altering the amount or function of SERT. The study by Coates and colleagues[87] showed a significant decrease in the level of SERT mRNA and SERT protein expressed in the intestinal epithelial cells of IBS patients compared with that of healthy volunteers. In another study,[89] SERT expression and binding capacity in platelets were decreased in women with IBS-D compared with expression and binding capacity in healthy controls. Furthermore, Chen and colleagues[90] showed that mice with a SERT gene deletion had altered colonic motility. It is interesting to note that the mice thrived in laboratory housing conditions, indicating that other transporters could compensate for the lack of SERT. Additional studies have focused on SERT polymorphisms. Yeo and colleagues[91] showed an association between patients with IBS-D and the homozygous short polymorphism of the SERT gene promoter. This mutation results in lower levels of SERT gene transcription and reduced amounts of SERT protein available for reuptake of serotonin. In addition, Camilleri and colleagues[92] showed a possible link between the long promoter polymorphism and patient response to therapy.Thus, a substantially large body of work shows that normal gut physiology is predicated on the interplay between the GI musculature and the ENS, autonomic nervous system, and CNS. One of the central mediators of this complex interplay is the neurotransmitter serotonin. Impairment or imbalance in serotonergic signaling, which can affect GI motility, secretion, and visceral sensitivity, may be affected by defects or deficiencies in serotonin production, specific serotonin receptors, or proteins such as SERT. *These changes can manifest in symptoms associated with IBS, including abdominal pain, altered bowel habits (constipation, diarrhea, or alternation between these 2 states), and bloating.*http://www.medscape.com/viewarticle/532089_print


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## eric

by the way the above could explain altered motility in IBS which may then lead to sibo?It also helps to explain chronic pain in IBS, which they have not yet that I am aware of with SIBO.


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## 17908

> quote:Originally posted by Moises:npearce,Thanks for the Zelnorm explanation. To be perfectly honest, I've had diarrhea all my adult life. The thought that I'd be taking a medication for constipation still boggles my mind. But I can always hope.


Diarrhea is also my main symptom (besides gas/pain/bloating/sluggish disgestion). I've NEVER been constipated. I was very nervous about taking the Zelnorm, and I was more than happy to only start with half a 6mg pill (3mg). In fact, I didn't sleep very good because I was so worried I'd #### all over my wife in my sleep or something.The first couple of nights on Zelnorm I did wake up several times from mid night until I got up at 5am (which is when I always get up). I felt like I had to go each time I woke up, but after I laid there for a minute I just fell back to sleep.Zelnorm will probably still leave your poop runny, but as long as I don't have that morning gas/bloating/pain I don't care.I should also note that by the time I was done with the antibiotics I was going to the bathroom once or twice a day. I would say that if you still are going several times a day when you're finishing up Vivonex, you might want to be cautious about starting Zelnorm.The feeling of not having anything in my stomach when I wake up is definitely worth it. Zelnorm doesn't make you poop like a laxative. You can actually hear and feel that it is just telling your intestines to move along. It is pretty cool as far as I'm concerned.Do you have that sluggish digestion feel, Moises? Especially in the morning.By the way, I've actually had a couple solid turds lately. Progress? Hopefully . . .


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## Moises

npearce,I am not sure I know what you mean by the feeling of "sluggish digestion." But I don't think it's something I have.My GI wants to schedule me for a gastric emptying study. There is the possibility that my stomach takes a longer time than normal to pass its contents to the duodenum. Perhaps that explains my burping problem.It appears that you and I both have a paradoxical combination of symptoms. Diarrhea, as I understand it is the sign of a fast transit time and a fast digestion. Yet you feel as if you have diarrhea and slow digestion. I have diarrhea and burping. In some studies, burping is associated predominantly with constipation and slow digestion. Yet I would not characterize my digestion as slow.


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## cynthia

Is it possible that what is being referred to as "slow digestion" or "sluggish digestion" is not actually food being held up in the stomach, thereby taking longer to travel to the small intestine, but rather the stomach being filled up with an abundance of trapped gas?


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## Moises

Relevant factoid from page 65 of Pimentel's _A New IBS Solution_:


> quote: recent research has demonstrated that stress can cause CRF (corticotrophin-releasing factor) to increase in the brain (see Chapter 3). Interestingly, when this happens, three things occur in the gastrointestinal tract: The colon empties faster, at times causing diarrhea; the emptying of food from the stomach slows down, causing people to not want to eat; and cleansing waves become inhibited. Therefore, though stress does not cause IBS, the increased CRF that is associated with stress can exacerbate IBS symptoms.


 npearce, do you suffer from loss of appetite? If so, the above scenario might be describing you. I almost never lose my appetite.


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## 17908

Moises,That paragraph sounds exactly like what I experienced before I did the Pimental regimen.I never felt hungry, even though I know I was eating way to little out of fear that I would just have to go to the bathroom a million times.The sluggish digestion was simply a nightmare over the last several years. I literally HATED myself for being so disfuntional. I honestly think that symptom alone was so much worse than any discomfort or diarrhea during the day. I mainly noticed the sluggish digestion at night.UPDATE:After a trip to the in-laws for Thanksgiving, I'm amazed at how little discomfort I had. I was forced to eat things that Pimental doesn't want you to have, although I avoided lactose. Nonetheless, I am feeling pretty darn good considering. I still haven't had diarrhea or any gas or bloating to bother mentioning. I sure could hear the Zelnorm doing it's thing at night. It was kind of funny how loud my stomach got!I still think the antibiotics were a huge help, and the Zelnorm is just amazing releif for my sluggish digestion. I love to wake up in the morning starving. It's been years since I felt this way. I'm hoping to gain back maybe 10 lbs of the 45 lbs I lost over the last several years.


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