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Saturday, July 18, 2015

Bacterial Overgrowth (and in many cases IBS) Treatment

Dr. Mark Pimentel’s Protocol

Dr. Mark Pimentel is the pioneering researcher and gastroenterologist who discovered the link between bacterial overgrowth in the small intestine and Irritable Bowel Syndrome. He is director of the Gastrointestinal Motility Program at Cedars-Sinai Medical Center in Los Angeles and author of the book A New IBS Solution Bacteria – The Missing Link in Treating Irritable Bowel Syndrome.

His treatment protocol is three-fold:

First he prescribes a short course of antibiotics to eradicate bacterial overgrowth. If a patient has high levels of hydrogen they take rifaximin (Xifaxan), and if they have high levels of methane they take rifaximin and neomycin. These antibiotics are particularly effective because they are not broad based, and they remain inside the gastrointestinal tract. Dr. Pimental is the Director of the Gastrointestinal Motility Program at Cedars-Sinai (http://giving.cedars-sinai.edu/page.aspx?pid=2423)

After finishing the antibiotics a breath test is repeated. If gas levels are still abnormally high he prescribes another round of antibiotics. If bacterial overgrowth remains resistant after several rounds of antibiotics, he recommends that patients follow a two week elemental diet where they drink only water and replace meals with a formula (brand name Vivonex Plus) containing protein from free amino acids, carbohydrates in the form of maltodextrin, fat as various oils, vitamins, and minerals.

Second, Pimentel places his patients on a diet of foods that are easily digested, so that most of the food can be absorbed higher up in the intestine–away from the problem bacteria. This means eliminating high fiber foods such as beans, peas, whole grains, nuts, and soy. The diet also avoids all kinds of sugars that feed the bacteria, including lactose found in dairy products.

Prokinetic agents
Third, he places his patients on a prokinetic drug for at least three months to increase small intestine motility with a corresponding decrease in the duration of migrating motor complex cycles. The most effective prokinetic drug is tegaserod (Zelnorm), but it was withdrawn from the US market in 2007 due to FDA concerns about possible adverse cardiovascular effects. Alternative prokinetic drugs are low dose naltrexone (LDN) and low dose erythromycin. The body produces the most cleansing wave activity when a person is not eating, which is why the drugs are prescribed to be taken at bedtime. For this same reason Pimentel advises to limit food intake to three meals a day, and to avoid snacking and consume nothing except water between meals.


Possible Autoimmune
Connection According to Pimentel, bacterial overgrowth in the small intestine causes an autoimmune response that damages the nerves that control the migrating motor complex. Eradicating the bacteria alone is not enough to completely heal from SIBO. Patients who take antibiotics and do not follow up with diet recommendations and a prokinetic drug often relapse.

Increased Risk Factors for Fibromyalgia and Chronic Fatigue Syndrome Patients
Dr. Pimental believes low levels of stomach acid in ME/CFS patients increases their risk of bacterial overgrowth in the small intestine. Pimentel thinks that food poisoning may initially cause cleaning wave inhibition, setting the scene for SIBO in many patients with IBS. Patients with ME/CFS or FM are particularly susceptible to SIBO because they typically have low levels of stomach acid that reduce bacteria at the onset of digestion, and they have low levels of endorphins that regulate contractions in the intestinal walls.

Pimentel did two studies linking SIBO and FM. In the second study, published in 2004, he found that FM patients had hydrogen levels significantly higher than non-fibromyalgia IBS patients and healthy control patients. [2] These high levels of gas produce exceedingly large amounts of bacterial toxins or endotoxins, which could explain some of the symptomology of FM. Furthermore, he reports a case history of a woman who was diagnosed with FM whose symptoms resolved after completing Pimentel’s treatment.

SIBO Center for Digestive Health
A group of naturopathic physicians associated with the National College of Naturopathic Medicine in Portland, Oregon founded a SIBO specialty called the SIBO Center for Digestive Health.

Their treatments are based on the research of Dr. Pimentel, but they also include herbal antibiotics and various diets. The SIBO Center for Digestive Health has information on SIBO and SIBO testing

Dr. Allison Siebecker, a founder of the center, has an educational website with information about SIBO including overviews of treatments, diets, studies and resources.   Included on the website are lectures that can be downloaded for a fee from leading clinicians and researchers at the SIBO Symposium that took place in Portland in January of 2014. The physicians at the SIBO Center have found that herbal antibiotics are often as effective as pharmaceutical antibiotics, although the course of treatment is typically longer.

See Cheaper, Safer, Better: the Herbal Approach To Small Intestinal Bacterial Overgrowth

The herbal treatment of choice is Allimed, a high potency, concentrated form of allicin extracted from garlic.

The SIBO Center recommended diets include the Specific Carbohydrate Diet (SCD) described in Elaine Gottschall’s book Breaking the Vicious Cycle; the Gut and Psychology Syndrome Diet (GAPS), an expanded SCD diet and protocol created by Dr. Natasha Campbell-McBridge; the Low Fermentable Oligo-Di-Monosaccharides and Polyols Diet (FODMAPS), a diet low in fermentable carbohydrates that has been shown to be effective in persons with IBS; the Cedars-Sinai Diet (Dr. Pimentel’s diet); and some combination of these diets.


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