The Bi-Phasic SIBO ProtocolModule 4 Prebiotics,ProbioticsRetraining A Sluggish Colon

Dr Nirala Jacobi, BHSc, ND

Author, SIBO Bi-Phasic Treatment Protocol and the SIBO Bi-Phasic Diet

Medical Director, The SIBO Doctor and host of TheSIBODoctor Podcast

Module 4

• Pre and Probiotic use in SIBO

When and why

• Constipation

• Atonic or hypertonic, ”spastic”

• ANS

• Diet, microbiome, digestion

• retraining a sluggish colon

Probiotics – what are they?

What are they NOT?• the majority of the microbiome – they are in fact a tiny sliver of the pie• “replaceable” by taking oral probiotics

They ARE• metabolic response modifiers• Shift towards protective microbiome• a tiny minority of the microbiome thus far studied• exert beneficial effect on other species (ie can stimulate growth of

other beneficial organisms)• a rapidly evolving field of research

Probiotic use during SIBO Tx – some key points• Use strain specific products as much as

you can (more strains are not necessarily better)

• Mainly for symptom alleviation

• Often patients will react to probiotics early on in tx (ie cause more bloating, etc)

• Lactobacillus and Bifidobacteria do not produce hydrogen, methane, or hydrogen sulfide

SIBO/SIFO Symptoms

• Gas/Bloating

• Abdominal pain/hypersensitivity

• Gastroesophageal reflux

• Constipation

• Diarrhea

• Leaky gut/food allergies

• Histamine/ oxalate intolerance

Probiotic use during SIBO treatment

Motility and Constipation

• L. Rhamnosus GG

• Bifidobacterium lactis HN019

• E.coli Nissle 1917

• L. reuterii DSM 17938

• L. plantarum 299v

Probiotics for Constipation

Probiotics for abdominal pain

Abdominal Hypersensitivity:

• Lactobacillus rhamnosus LGG

• E.coli Nissle 1917

• L.plantarum 299v

• L.reuterii DSM 17938

Probiotics

Leaky Gut

• Saccharomyces boulardii (cerevisiae)

• Lactobacillus rhamnosus GG

• Multiple Bacillus strains:

Bacillus coagulans (unspecified strain), Bacillus indicus HU36, Bacillus subtilis HU58, Bacillus licheniformis (unspecified strain), Bacillus clausii (unspecified strain)

Reflux

• L.reuterii DSM 17938

Probiotics and Histamine intolerance

Some species of bacteria have been shown to increase histamine production:

• L. casei and L.bulgaricus

Others have shown to decrease histamines:

• L. rhamnosus GG,

• B. infantis

• L. plantarum

Special Probiotics for

Methane and

Hydrogen sulfide

Probiotic L.reuteri (DSM17938) and Methane

Probiotic Lp-8 and Hydrogen sulfide

• Lactobacillus plantarum (Lp-8)

• single daily oral dose of Lp-8 (6 1010 colony forming units) for 4 wk

• Results showed an increase in Bifidobacterium (P < 0.05) and other beneficial bacteria, whereas Desulfovibrio (P < 0.05) and other opportunistic pathogens decreased after taking Lp-8 for 4 wk. Lp-8 consumption also affected fecal levels of SIgA, total bile acids, and SCFAs

Prebiotic use during SIBO treatment

• Prebiotic: feeds bacteria. Different bacteria ferment different prebiotics and fibres. This is why the SIBO diet is low FODMAP

• SIBO as “dysbiosis”: therapeutic prebiotics (consider on case by case basis)

- Lactulose

- Partially hydrolysed guar gum (PHGG)

- Galactooligosaccharides (GOS)

• Usually introduced in Phase 2

Lactulose

• Restores microbial balance

• Increases lactobacilli, bifidobacteria, Feacalibacterium p., and Akkermansia mucinophilia

• Decreases Bacteroides spp (therefore less bile acid deconjugation)

• Decreases absorption of endotoxins

• Decreases intestinal permeability

• Decreases production of ammonia

Credit to Dr Jason Hawrelak, 2016 SIBO Summit

Lactulose

• Do NOT use if Lactulose breath test is positive (ok to use if LBT neg and glucose breath test positive) I usually wait until SIBO has been eradicated

• Start with VERY small dose

• 1/4-1/2 teaspoon – work up to 1-2 tsp over 2-3 weeks

• Optimal dose 10g 1-2 x daily

PHGG (partially hydrolysed guar gum)

• Decreases methane production

• Potentiates effects of Rifaximin

• Accelerates colonic transit time

• Increases Bifidobacteria and butyrate-producing bacteria

GOS

• Galactooligosaccharides are the only prebiotic fibre found in breast milk. Its sole purpose there is to feed Bifidobacteria in the newborn

• Research shows reduction in hydrogen and methane (I still don’t use it early in the treatment plan due to increase in gas, frequently)

• Possible reduction in hydrogen sulfide production

• Dose is ¼ packet daily, increase to 1 sachet (5.5g) daily over a few weeks.

Constipation

1. Hypotonic—poor nerve impulses and muscle contraction response. No urge to defecate, erratic peristalsis. Essentially a “lazy colon”.

2. Hypertonic: excessive contractions, spasms, often stress, Methanogens

• In both cases of long standing constipation, the brain needs to be ‘retrained’ in terms of proper nerve impulses to stimulate peristalsis (the rhythmic colonic movement downwards)

• Long standing constipation can result in large intestinal ‘inertia’ due to stretch receptor among other issues

Retraining a sluggish Colon

Key Factors:• Hydration and mineral status • Movement and Breathing • Enteric Nervous System

- Stress/sympathetic dominance- Dyssynergia

• Diet• Bile/cholestasis• Microbiome factors• Medications: many cause constipation

Constipation treatment matrix- Summary

Hydration and mineral status

Many people are dehydrated even if they think they drink enough water

• Required for detox processes

• Intra and extracellular matrix

• Stress and Adrenals “have to pee every time I drink a glass of water”- Aldosterone has been affected, hypokalemia, renal acidosis

• 500ml -1000ml of water with trace minerals

• Slowly - before breakfast

• Total at least 3 L of water

Movement and Breathing

Movement

• Circulation and lymphatics

• Walking

• Rebounder – several times daily

• Proper position during BM

Breathing

• Shallow breathing (chest) – lack of diaphragmatic massage of transverse colon

• Nadya Andreeva -https://www.youtube.com/watch?v=WLF9pqmSymE

The ANS of the Enteric Nervous System

SNS (“fight or flight”)

• Stop saliva

• decrease HCL

• Decrease motility

• Retain colonic contents

• Delay rectal emptying

PNS (“rest and digest”)

• Increases salivation

• Increase HCL

• Increase motility in SI and LI

• Empty colon and rectum

Gut and the Sympathetic Nervous System

• Main Neurotransmitters of peristalsis:

• Serotonin

• Acetylcholine

• Stress reduction/management is a MUST

Breathing exercises (regular), Buteyko breathing

HeartMath- Inner Balance Device

Meditation- Examples: HeadSpace, Chopra

Gut centered Hypnotherapy

• Neurofeedback-- Neuroptimal

Vagal exercises

• Lot of you tube videos for improving vagal tone

• Alternating nostril breathing

• Dr Datis Kharrazian:

• Humming

• Gagging

• gargling

Microbiome factors associated with constipation• Low Butyrate/SCFA

• Low native bifidobacteria spp

• Dysbiosis

• Candida spp

• Endotoxemia

Other Digestive factors

• Low bile/cholestatis

• Hypochlorhydria – toxic biogenic amine formation in colon

• Pancreatic enzymes

Stool test results – Short Chain Fatty Acids

PCR results

copyright Dr Nirala Jacobi 2018. All rights reserved

Retraining a sluggish colon – getting things moving• Magnesium oxide or sulfate (osmotic laxative)– increase incrementally

at night

• Lactulose (only in those without rise in hydrogen on breath test)

• Herbal laxatives- may be necessary short term:

• Triphala- (3 Indian fruits amalaki, haritaki, and bibhitaki)

• Rhubarb (Rheum officinalis)

• Cascara segrada

• Senna

• Aloe (latex)

• NOTE: prune based laxatives contain Sorbitol

Diet and Fibre

• Low FODMAP diet is LOW IN FIBRE

• High meat, fat, low fibre diet worsens constipation for many

• I usually adjust the diet to contain some insoluble fibre (brown rice, rice bran, increase dark leafy) or flax seeds/chia seeds if tolerated

• Use PHGG – work up to 1 scoop daily

• Consider more vegetarian protein if tolerated (yellow lentils, plain non GMO tofu, tempeh)

Colon cleansing

• Has a long history in medicine- back thousands of years

• Helpful for anyone with long standing constipation

• Manual removal of colonic content with repeated water rinses

• Stimulates valve function

• Stimulates microcirculation of the liver

• Gut lymphatics

• Rehydration

Colon cleansing

Enema

• Convenient- at home treatment

• Difficult for those who have mobility issues

Colonic hydrotherapy: gravity method, machines

• More “thorough” than enema – advances further

• Do 3 in a row after a good purge

• Various skill levels of operator

• Refrain form vigorous abdominal massage

Contraindications to colonic irrigation

• Acute colonic inflammation (including diverticulitis)

• Acute IBD

• Recent colorectal surgery

• Infectious diarrhea

• Megacolon

• Bowel obstruction

• Active rectal bleeding

• Pregnancy

• Bowel perforation

• Hypotension

The Enema – the oldest self help in the world

• See Handout instructions

• Start with 3 in a row, then 2-3 x weekly for a few weeks

• Tepid filtered water, can alternate warm and tepid

• Additions to the filtered water:

• Coffee

• Probiotics

Constipation treatment matrix- Summary

Thank you

Module 5

• Management of Histamine, salicylate, oxalate and sulfur sensitivities

• Management Phase: How to

transition out of the Bi-

phasic Diet