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 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