20 Key Takeaways- Global Outreach Symposium on IBS & SIBO 2016

I compiled the following key takeaways from watching the 2nd Global Outreach Symposium on IBS and SIBO.  It was a conference organized by Dr. Mark Pimentel and colleagues at Cedars-Sinai Medical Center in Los Angeles, California.  There were some fascinating new concepts presented that may help some of you suffering from IBS and SIBO.

Please leave your comments below and share with others who might be interested!  Here we go:

1. Approximately 48 million people worldwide have IBS, but only 10-15 million have been diagnosed.  For those of you who are suffering silently, please know that you are not alone.  I have noticed that when you begin to share your story and not worry about the embarrassment, people are more comfortable opening up to you about their own suffering and suddenly you do not feel so alone.
2. It takes an average of 6.6 years to get diagnosed with IBS.  For so long, I had no idea that the way I felt was not “normal”.  I have likely had IBS since middle school or high school, but did not receive a diagnosis until late college.  I recommend that you educate yourself on health and nutrition so that you can catch problems early and have a better chance of being able to turn your health around.
3. A variety of gases can be produced in the gut, based on which organisms are present.  When bacteria ferment carbohydrates, hydrogen and carbon dioxide are produced.  Other organisms can then use hydrogen and carbon dioxide to produce other gases: methane by methanogens, acetate by acetogens, hydrogen sulfide by sulfate reducers, and ammonium by nitrate reducers.
4. A consensus paper on breath testing methods and interpretation prepared by experts from around the world will be released in December.  But here are some highlights:
   1. Need to fast for 8-12 hours before breath test (water is okay)
   2. For the initial breath test for diagnosing SIBO, it is best to have avoided antibiotics for 4 weeks prior to the breath test
   3. Physical activity impacts carbon dioxide production and therefore should be limiting during a breath test to avoid impacting the results
   4. It is not necessary to stop proton pump inhibitors (PPIs) before performing a breath test if symptoms do not allow
   5. Laxatives and promotility agents should be stopped 1 week prior to performing the breath test because they can speed intestinal transit and therefore cause a false positive (hard to interpret on the breath test which numbers are representing the small and large intestines)
   6. Avoid complex/fermentable carbohydrates 1 day prior to breath test for prep diet
   7. The amount of test substance that should be used is 10g lactulose with 1 cup water or 75g glucose with 1 cup water
5. Hydrogen sulfide producers- a test has been developed for you (and me)!  Stay tuned for updates in 2017- more information will be presented at Digestive Disease Week in 2017 in Chicago.  At this point, breath tests that have a flat line (that means 0 across the entire test) of hydrogen & methane are suspected of indicating hydrogen sulfide production.  One interesting note is that hydrogen sulfide has been proposed as a risk for development of Crohn’s disease.
6. An elevated baseline hydrogen that rises and is NOT caused by a poor prep diet is believed to indicate a different type of bacterial overgrowth that has not yet been identified.
7. A single fasting breath test (spot test) is believed to be very accurate for detecting elevated SIBO methane levels.  This is when someone fasts for 8-12 hours, then a single breath test sample is taken without ingesting any test substance (glucose or lactulose), and the methane result is positive.  The importance of this is that for those who have methane and want to retest their levels, they can do a much quicker and cheaper test.
8. On average, it takes 105 minutes for lactulose to travel all the way through the small intestine. However, transit time varies by person so it is sometimes difficult to know looking at a breath test whether the amount of hydrogen or methane at a certain point in time is indicating levels in the large intestine or the small intestine.
9. A healthy microbiome is characterized by having a rich diversity of microorganisms.  Consuming a Western-style diet has been associated with less microbial diversity in the gut.
10. Proteobacteria have a tendency to produce hydrogen sulfide.  Proteobacteria are a major phylum of gram-negative bacteria that include organisms such as escherichia, salmonella, and vibrio.
    1. My note- if you want to see how much proteobacteria you have compared to other people, check out the Ubiome gut kit (plus- this link gives you 15% off!).  These are home test kits that determine how much proteobacteria (among others) is in the sample you provide.
11. The fingerprint of our gut bacteria is pretty consistent by 3 years of age.  Therefore, it is more difficult to manipulate the architecture of the microbiome after this time.
12. Obesity and diabetes may be partially caused by or at least related to SIBO.  Specifically, it appears that those who produce methane or methane +hydrogen seem to be more likely to be obese and have insulin resistance.  It is proposed that methanogens help other microorgnisms around them to digest things that are undigestable by humans more completely, resulting in greater energy (calorie) production.
13. You know when your stomach gurgles in the morning and someone says “you must be hungry, eat something”? Well, Dr. Pimentel said that this is a sign that your migrating motor complex (MMC) is doing its housekeeping duty- it is sweeping bacteria from your small intestine into your large intestine which is a good thing.
14. Food poisoning is believed to be a major cause of IBS, especially IBS-D.  Although not everyone with IBS has food poisoning at the root of their condition, it is a common cause, especially in those with IBS-D.   Interestingly, approximately 1 in 10 people (2 in 10 women) develop IBS at some point after an incident of food poisoning.  The more severe the food poisoning event, the more likely someone is to develop IBS.  It does not necessarily occur right away, but sometimes people do notice that they were just never the same after their food poisoning incident.  The mechanism for this is proposed to be the following:
    1. The microorganims that cause food poisoning generate a toxin called CdtB.
    2. The immune system then produces antibodies to that toxin called anti-CdtB.
    3. Unfortunately, this toxin looks similar to a protein called vinculin which is on the nerve cells of the gut.
    4. The immune system then generates anti-vinculin antibodies which damage the nerves in the small intestine.
    5. The result is backup of bacteria in the small intestine –> SIBO
    6. CdtB and vinculin antibodies can be checked using a blood test called IBSChek that can be ordered by your doctor.
15. You have a 2.9x higher risk of getting bacterial gastroenteritis if you have pre-existing IBS.  So IBSChek can be helpful for determining if you are at higher risk so that preventative action can be taken if you will be travelling to an area where the risk of catching food poisoning or traveler’s diarrhea is high.
16. A variety of conditions can cause SIBO: scleroderma, diabetic enteropathy, Crohn’s disease, Celiac disease, chronic intestinal pseudoobstruction, gastric bypass, ileocecal resection, adhesions, and hypermobility syndromes (such as Ehlers Danlos).
17. There is no one perfect diet and it is important to remember food should be social and enjoyable as much as possible.  To read my recap of the diet section, check out my guest post over at SIBO Action Network.
18. A variety of pharmaceutical interventions are currently in the pipeline.  Here they are:
    1. For IBS-D: ibodutant and ramosetron
    2. For IBS-C: SYN-010 (for reducing methane), tenapanor, plecanatide, and elobixibat
19. SYN-010 is the new drug that is designed to reduce methane levels.  It is a statin drug that works by preventing methanogens from producing methane by blocking an enzyme.  Basically, it makes them unable to utilize hydrogen in the production of methane.  So far, it has been shown to improve constipation.  Phase III trials are scheduled to begin in January 2017.
20. Heard of the Human Microbiome Project? What about a small intestine microbiome project?  Well Dr. Pimentel mentioned that on the horizon is the study of the small intestine microbiome.  The goal is to try to compare certain microorganisms in the small intestine and link them with certain diseases.  Fascinating stuff is going on in the world of microbiome science!