Dr Jason Hawrelak

Nirala Jacobi:

Welcome back to part two of the SIBO Doctor Podcast, and let's jump right back into it. Now, moving towards other types of parasites and my first question would be, what do you most commonly see in your practice? And I'll preface this by saying that I just don't see that many parasites in my practice, and I do a lot of stool testing. I see it very rarely and I wonder if that's part and parcel of this decimation of the microbiome, is that we have lost some of these other species and obviously, we're certainly not saying that parasites are a wonderful thing to have onboard for everyone, like tapeworms and cryptosporidium and Toxoplasmosis.

Jason Hawrelak:

No.

Nirala Jacobi:

That's not what we're saying, but we started off with the harmless neighbors, or the ones that don't seem to be causing a problem. So what would you say, or what do you most commonly see after these two? Because they are very common, I would say. Those are the only ones.

Jason Hawrelak:

They are. I agree, based on ... frequently I tend to just note it in my notes but don't focus on them at all and keep looking. [inaudible 00:01:56] we will find what's causing the symptoms in these patients in that scenario. I'd say that's almost always the case. But I would put Giardia on the list of the ones that probably comes up next, and that one is I would put it in a different category that when it's present, someone has symptoms, our generally assume that's the cause and treat it. And luckily with using the right natural medicines you can usually eradicate blast ... sorry, Giardia in 10 days to two weeks, pretty consistently.

Nirala Jacobi:

Pray tell?

Jason Hawrelak:

Yeah. And I'm lucky because I started off practicing up in northern New South Wales, where you are. And I think I was working where, remember those Rainbow Gatherings that would happen. And I think you'd have these floods of people with Giardia after certain Rainbow Gatherings and had a chance to do lots of trial and error on patients and see what actually worked. And I still see them, less commonly now than I did up there. But still that's probably the most common, what I'd see as a real disease causing protozoa organism in the gut of my patients. And I think it does respond really well to some dietary changes, like reduction of fat.

Jason Hawrelak:

Actually fat is a huge thing with Giardia. That one, it induces symptoms, because you get this massive fat malabsorption with Giardia, because Giardia multiplies so quickly it covers up your entire, pretty much your entire absorptive capacity of your small intestine. It's just loaded with ... every millimeter is coated with these little Giardia, so you malabsorb fat. It eats bile as well, and actually likes bile to actually grow on. So you malabsorb the fat you end up getting worse, nausea and [inaudible 00:03:29] if you eat some of higher fatty sort of food and also tends to go better on ... this is one of the organisms said don't eat sugar.

Jason Hawrelak:

It does tend to on processed foods it does ... cakes and soft drinks, things like that. You tend to get a flareup of acute symptoms with that as well. So it's often just eating probably whole food plant based, mostly high fiber sort of foods. We know that, that fiber itself is associated with improved clearance of Giardia for example. And then it's using the right herbs and years ago I used to use, primarily Coptis, Coptis chinensis, which is hyper green herb. Just high doses for 10 days, great outcomes.

Jason Hawrelak:

These days I tend to use probably more things like pomegranate husk, guava leaf, oat bark, Propolis, Ribwort. There's a number of herbs there that I, perhaps I see us having more nurturing effects on the colonic ecosystem, lower down. But not that I'm actually particularly worried about 10 days dosing of high dosing Coptis, because I'm really not. But it just tastes pretty foul.

Nirala Jacobi:

It does.

Jason Hawrelak:

And I find some of the other herbs are more palatable.

Nirala Jacobi:

Is that your favorite berberine-containing herb, because you use that a lot, that Coptis?

Jason Hawrelak:

Yeah it is. And to be honest, I don't use it so frequently anymore because probably it was just changing patient presentations compared to 10 years ago, plus. But when I first started playing with Coptis I remember making a tincture with pretty basic supplies, like a home blender, blend it with some alcohol. Let it sit. Then, I was lucky to be working at Southern Cross University at the time. I was helping out with a phytochemistry lab and we actually run an HPLC, and I brought in my Coptis tincture to compare it to the goldenseal tincture and the Oregon grape and the barberry tinctures that were available. And it was a powerhouse of Berberine. It had I think at least three times more Berberine than goldenseal. And heaps, heaps more than Mahonia or Berberis vulgaris, they weren't even comparable. Yes. So for that point I was like, this is my herb of choice from a Berberine perspective, because it's much higher. And at the time the raw material costs were less than with goldenseal.

Nirala Jacobi:

Right. Well one of the more popular ones in these compounds now is phellodendron.

Jason Hawrelak:

Yes.

Nirala Jacobi:

Do you find ... I find that, well I would say my favorite still in a tincture form would be Oregon grape, just simply because I love that herb and I use it in a lot of different ways, but as a standalone, I don't know about phellodendron for Berberine content, so I haven't used it-

Jason Hawrelak:

It's actually ... it's definitely higher than Mahonia. It's been a while since I've looked at the stats around that. And I used to make a tincture with phellodendron years ago and it was quite a lovely tincture actually. Because it had these sort of demulcent qualities that came out when you made the tincture, as well as the bitter of berberine compounds. So it actually felt like a nice gut tonic in that respect. At least a demulcent mucilaginous type of qualities alongside the antibacterial qualities. Certainly less than Coptis, but I think it's because it grows on a bigger tree. It's easier for, commercially to extract larger quantities from phellodendron and Coptis, which is that little plant that grows in hard to find, rainforest probably covered valleys. As you know, small plant that takes probably years to get the root up to a harvestable size. Probably a bit like goldenseal [inaudible 00:06:58].

Nirala Jacobi:

Well, good to know that Giardia is quite responsive then to high dose berberine. Good to know.

Jason Hawrelak:

Yeah. And often you use probiotics alongside that too. Things like [inaudible 00:07:14] GG, I do have ... [inaudible 00:07:18] LGG has got some good animal studies, which is the best starter we have on helping to eradicate Giardia. And listen, even in most people you do nothing, 90% of people will clear the Giardia on their own in four weeks. It's just, it can be a very unpleasant for weeks. We can shorten that to one week or 10 days, that's obviously a much better bet, and there'll be that small percentage of people that aren't able to throw off Giardia on their own. And that's perhaps what I see more in my practice, now.

Nirala Jacobi:

And I always associate Giardia with camping and drinking out of streams when I lived in the Pacific Northwest and, not that I ever did, but that's what I was taught. And here is it ... where do we find it here in Australia? Same thing?

Jason Hawrelak:

I would say it's probably not too dissimilar, that it's often in creeks. Yeah. And all it takes is someone had one of those Rainbow Gathering festival to-

Nirala Jacobi:

Oh my God, we're going to get hate mail Jason.

Jason Hawrelak:

Yeah, some sort of fecal matter ... sorry. I love most aspects of those festivals, sorry. It just goes in my mind because I just remember these outbreaks would occur from some festivals where I don't think they dug the pit toilet quite far enough away from the river system everybody's swimming in. And you know what the rains are like up there. There can be just huge amounts of rain. Some Giardia gets to the creek, people drink or inadvertently drink some, or they're playing in the water, and then a whole bunch of people get Giardia.

Nirala Jacobi:

Well luckily we've had just masses of water here in the past couple months. So we're really happy that our streams are ... be there Giardia filled, but hey, we love it.

Jason Hawrelak:

They'll wash downstream now. Yeah. I picked up Giardia from drinking Creek water up that way, first time. So that was my first experience of a diarrhea protozoa organism was Giardia, and this was before I was a naturopath.

Nirala Jacobi:

Let's kind of go back to testing for just a moment because ... well actually yeah, but just because I was like a conversation I had or I think it was a lecture from Alana Gourevitch who's a well-respected naturopathic doctor and IBD specialist and she talked about parasites and that parasitology as an actual science is sort of like a dying art that these parasitologists are ... really well trained parasitologists are a dying art because everything is now PCR and stuff. But there's a lot that can be also macroscopically ... I get patients, I don't know if you get patients like this, but they fish something out of the toilet that they have passed and they are convinced it's a parasite. Right?

Jason Hawrelak:

Yeah.

Nirala Jacobi:

So ... and sometimes it looks very darn close to something weird and you send it to the lab and it just says negative for ... macroscopically microscopically, there's just nothing there. Has that happened to you?

Jason Hawrelak:

Yeah, I certainly have patients that have done similar things too. And I think it's been great to have a resource of someone like that, that can actually just look at it probably under a microscope and just go, okay. Is that just a vegetable fiber of some description that looks a bit like a worm or is it actually something that is a worm, for example.

Nirala Jacobi:

Well, just recently I had a patient pass an actual intact caterpillar. It was like ... he has a lot of diarrhea and microscopic colitis, but he passed ... it was so fast, his transit, that he ate some kale and the caterpillar came out the other end intact. So it does happen when you have a transit of what, 20 minutes or 30 minutes.

Jason Hawrelak:

Yeah.

Nirala Jacobi:

So yeah, that was the first though. That was definitely a first. But I've had other-

Jason Hawrelak:

That's the first I've heard of such a thing too.

Nirala Jacobi:

Yeah, and it was bizarre. So yeah. So you also get some of those odd Mason jars that end up on your desk saying, what is this? I've just passed this and there are things like gastrointestinal lining or shedding when there's massive inflammation that can also look like ropey kind of mucilaginous worms. And just talking out loud for them, for the listener, because sometimes we think we see a parasite but it actually isn't. And there just is so much, I find, misinformation about parasites on the internet that I really wanted to clarify. That I actually, when I test for it, I don't find them often. Then there's also an argument that they hide out. They hide out in areas like the gallbladder and in the mucosa. And there is some evidence around that, especially with gallbladder issues. So what are your thoughts on that, Jason?

Jason Hawrelak:

I mean, I would probably concur in terms of my clinical practice reality is that I don't think that these things are nearly as common as you might guess from reading the blogosphere, but I do think there certainly are. Some organisms that I'm probably more familiar with, things like salmonella which is obviously a parasite, or bacteria, or organism that can get up into the gallbladder and make it hard to actually deal with. And I think there probably are some other organisms that have that same capacity that I'm less familiar with as well.

Nirala Jacobi:

Yeah. What do you think about ... I've started to, before we do stool testing, like the stool testing that you promote and that I promote from different labs. Sometimes I give a biofilm disruptor. Do you find that to be helpful? Just a week or so before to try to disturb and irritate any sort of potential pathogens to come out of their hiding so that they're easier diagnosed?

Jason Hawrelak:

Interesting. No, I haven't tried that approach. And interesting thought, the thought process. I mean I might think that it might change the ecosystem dynamics as well in terms of, not even just pathogens, but other microbes that also live in biofilm. Many different bacteria [inaudible 00:13:40] et cetera, that the populations might change in some way when exposed to that too. That would be my only concern around that.

Nirala Jacobi:

Yeah. I think of it more like when symptoms aren't ... just as a retest as a potential-

Jason Hawrelak:

Okay. Yeah.

Nirala Jacobi:

Where we might get more bang for our buck because we know those stool tests are so darn expensive. Just a thought, yeah.

Jason Hawrelak:

Yeah. And God, we're still learning as you'd expect. But I think there was one person that had Blastocystis, that they did a stool sampling every single day. This has been a few years since I've read this study, but it certainly did not show up in the stool every single day. It was missing when it came out. So it wouldn't surprise me if it's similar with other parasitic organisms, depending on the overall quantity in the gut, et cetera.

Nirala Jacobi:

So moving onto our next category of parasites, which are worms or helminths. And recently there ... for those, I think I may have mentioned this in other podcasts, but there are worms that are obviously like tapeworms that are quite parasitic in terms of eating your calories and attaching themselves to the gut wall. Like most worms. But there are some worms, not all, but some like hookworm that are used therapeutically to induce sort of, or down regulate an immune response for those with IBD, I believe. So. Have you had any experience with that?

Jason Hawrelak:

No. I mean I've certainly read the studies around it and I've read some of the preliminary data looking at, I think it was American hookworm for celiac disease for example.

Nirala Jacobi:

Yeah, celiac disease.

Jason Hawrelak:

The original research was less than exciting, but that had slightly decrease the amount of inflammation induced by gluten, but actually caused pretty severe symptoms at the time they were inoculated. But they'd may have fine tuned their approach since I've looked at that research. But I think you're right around IBD, there's more consistent positive out around that.

Nirala Jacobi:

So just as a take home, that not all ... the use of those kinds of things is not always pathological. It really can actually be therapeutic administration of ... that really speaks to the fact that, creepy as it might be. But we all have had ... we've all evolved from that, in terms of our microbiome used to be ... it's not all just bacteria and to some fungi and some viruses. It was creepy crawlies as well.

Jason Hawrelak:

It's true.

Nirala Jacobi:

Right.

Jason Hawrelak:

You're right. And I think you hit the nail on the head with the evolution aspect is that our immune system, our gut, guts, gastrointestinal system has evolved with this constant interaction with bacterial species, fungal species, protozoa species and you're right, helminths as well, that have allowed it to evolve in a certain way. And we take that sort of interaction away, there are consequences. And certainly we're seeing the consequences of bacterial dysbiosis, I think all around us now. But I think as research moves on, we'll be teasing at the consequences of the lack of diverse fungal ecosystem, a lack of diverse protozoa ecosystem and the impact that has, and potentially there needs to be a discussion around that, that lack of helminths as well, is having some impact on immune overactivity to certain things that it shouldn't be overreacting to.

Nirala Jacobi:

Yeah, we've become too hygienic. And yeah, this is why I always love your message off treating the terrain rather than just the individual organisms. I think that's a very holistic approach and much more aligned with my view of, that it's, we got to get away from this one bug, one disease or that kind of approach. But sometimes it's kind of harrowing when you get these test results back and it's just like a desert in somebody's gut, it's like, "Wow, I'm not surprised you can't get up in the morning. Your energy is in the toilet and you're aching all over and you've got diarrhea ... " or whatever, maybe. It seems to be like a long journey back for some people and they have a lot of issues systemically.

Jason Hawrelak:

Yeah. That's correct, and it just makes me think, when you mentioned that, of a patient I had, that had essentially run a 0% diversity score and 0.6% butyrate producers, I kid you not-

Nirala Jacobi:

Oh my God.

Jason Hawrelak:

0.6%. And keeps very high hydrogen sulfide gas producers, LPS like crazy. And you're like, ah, this person was only eating one, essentially just chicken, by the time they came to see me, just chicken, two chickens a day. That was it. And you look that ecosystem going, "gosh, I can see why you're feeling so horrible, and I can see why any sort of ... at this point, any plant food causes you symptoms." A little inflation in your guy is surreal, but you also need to nurture those species and feed them for any chance of your gut getting better longterm. Yeah. So it is fascinating to see that correlation between ecosystem disturbance, dysbiosis, and then can be quite severe levels of symptoms in many-

Nirala Jacobi:

Yeah. And you know, I think you and I see a lot of this sort of microbiome decimation. And do you at that ... for someone like that would you, is it too hard to get to coax it back into a viable microbiome or do you think about FMTs or fecal microbiota transplants? Is that a good viable option for these people?

Jason Hawrelak:

I think for some of those people definitely is, it's just trying to find, for me, that you're trying to find that the donor that has the right ecosystem to donate to fix up those gaps. Which in a case like that I reckon is probably pretty easy because it's so disturbed that probably anybody, almost everybody's will be better than what that ecosystem actually was. Other people, it's challenging. But in terms of, I mean with this particular patient we've actually made, through her efforts in keeping in incorporating new things into her diet and putting up with levels of discomfort as part of that process, because any intestinal gas causes abdominal discomfort when the guts that inflamed, which it is in her case.

Jason Hawrelak:

So it's been, her dietary diversity is far better, her symptoms are actually far reduced systemically, and then a whole range of other symptoms are reduced. But we're about to do a second followup stool tests. So we'll see the sea of what impact there actually is. And I've been surprised at times at how resilient that ecosystem actually can be in some of these people where it looks pretty horror ... the ecosystem looks very damaged, looks very low and diversity. But with the right tools and the right effort, the right lifestyle stuff that we're actually able to restore a certain degree of normality. Now, obviously if species are extinct or extinct, and this is the thing, you don't necessarily know until you attempt to revive certain bacterial populations, whether they come back or not. And that depends whether they can handle the treatments that help bringing those species back as well. But I think there's some cases where FMT screams out as a potential treatment that [inaudible 00:21:20] much quicker fix than a person like that.

Nirala Jacobi:

And the crapsules have been around for a while now, I think. I talked to Dr. Andrea McBeth who, on the last podcast about ... she teaches at, I think it's NUNM the microbiome classes and she actually has a clinic herself. A sort of boutique clinic about specific use of FMT. It's still around [inaudible 00:21:43]. But that's all coming now, where we seeing these boutique things. And her and Mark Davis actually have been using oral FMT since, for some time, apparently. So that's, I think a lot more ... I think maybe less palatable, but a lot easier than doing an FMT through the rectum. But it's all just, it's going to be very interesting moving forward.

Jason Hawrelak:

Yeah, [inaudible 00:22:14] and I look forward to when we start doing fecal banking for kids before they ever get exposed to antibiotics. We'll take a lovely specimen to reintroduce their ecosystem back in. And then we could sort of take away many of the concerns that there are out there about FMT, introducing new organisms that may not be the good match for that person. Or you know, obesity or depression or anxiety that might get passed from person to person, it takes all that aspect away. So I look forward to that. And then just that burgeoning research on the impact of FMT for a range of other conditions, because it's pretty well proven to be helpful for things like C. diff, but there's a growing body of research for IBS and IBD. And I think we'll be looking at using it to treat depression, anxiety for type II diabetes, obesity, coming up.

Nirala Jacobi:

Yeah.

Jason Hawrelak:

So there's a whole bunch. Anything that's associated with microbiome disorders, which is a lot. Alzheimer's, Parkinson's, Multiple sclerosis. I think that there's a huge avenue here for fecal microbiota transplants to actually impact that. As there is for gut microbiota modulation, which is perhaps where my clinical practice is really at, is optimizing people's ecosystems. And I'm not actually doing the FMT so much as people, Mark Davis for example. But I look forward to seeing that sort of research because I think for some people that could be a quick, viable option. They just have to get their head around ingesting poo, and that's a little of a leap for some people, whether orally or rectally. I think you're right that for many people it would actually be easier to do crapsules, but to get their head around orally ingesting feces is trickier than using rectal administration.

Nirala Jacobi:

I think that those people that are ... some people are just at the end of their rope, so they are at that point, I think sort of they don't mind it as much. Okay. Before we wrap up, this has been really extremely helpful. So again, for people listening, I'm not quite done. I still want to ask you about what's the latest and greatest on the probiotic front in terms of particular strains dealing with issues like SIBO or hydrogen sulfide or a number of things that we've discussed before?

Nirala Jacobi:

So I still want to have you talk about that, but before we end, definitely check out the probiotic advisor. If you're a practitioner, it's a great tool to quickly search for recommended strains that have been researched, particular conditions, and also the Blastocystis and Dientamoeba course will be on the show notes. And also we still have the microbiome restoration course by Dr. Jason Hawrelak on The SIBO Doctor. So you've got a lot of resources if you've just tuned in for the first time and you're not sure where to start. So back to you, Jason, in terms of what's the latest and greatest on the probiotic front, other than crapsules?

Jason Hawrelak:

I think there's things I look forward to, in moving forward into the future. And that certainly crapsules and I would say that probiotics made from Faecalibacterium prausnitzii and Akkermansia muciniphila, but I think they're still a few years away. And even [inaudible 00:25:43], again, which is probably-

Nirala Jacobi:

That's great news, yeah.

Jason Hawrelak:

... a couple of years away. But it's all happening. So at some point we as clinicians and the general public will have access to a range of tools that we don't now that will actually open up, I think a range of treatment opportunities. And a range of butyrate-producing bacteria in a capsule will be fantastic. Because so far our probiotic dispensary is so much focused on lactobacillus and bifidobacteria, even if they're using 12 strains a bifidobacteria, it's still just bifidobacteria. You're not looking at the organisms in healthy people's gut, which could be Faecalibacterium, [inaudible 00:26:19] producing bacteria.

Jason Hawrelak:

So again, I'm super looking forward to what the future holds in terms of future probiotics that will potentially allow us to recolonize in way that current batches don't, and we introduce more diversity ecosystems. And I think there's that Canadian study that used a product called RePOOPulate, which I loved the name of, and essentially it was, they simply took the poo out of a fecal transplant and just conjured up the microbes. So the FMT without the F. And that has I think better compliance rate, because people aren't going to be so concerned about, without the fecal component and as ways of repopulating the gut in a way that we can't.

Nirala Jacobi:

Fantastic. Thank you so much for spending some time with me again. And all those resources will be in the show notes, as well as how to find Dr. Jason Hawrelak, and work with them. Are you still actually taking new patients, Jason?

Jason Hawrelak:

Yeah. There's a-

Nirala Jacobi:

Two year, two year waiting lists now?

Jason Hawrelak:

... a queue, for the most part. But you know, for people. Yeah. Except for emergency cases that sometimes get slotted in very quickly.

Nirala Jacobi:

Okay.

Jason Hawrelak:

People who need help ASAP, or they lose their colon for example.

Nirala Jacobi:

Oh yes.

Jason Hawrelak:

Sometimes you get slotted in more quickly.

Nirala Jacobi:

Excellent. That's good to know. But yes, he is in beautiful Hobart Tasmania. So if you can make your way down there, it's a beautiful part of the world. Thanks again, Jason. Always a pleasure to talk to you and I'm sure I'll see you soon at one of these conferences.

Jason Hawrelak:

You will Nirala. Thank you. It's been great being here, once again.

Speaker 3:

Thank you for listening to the SIBO doctor podcast. We hope you found the information in this episode useful in the treatment of your SIBO patients. Thanks to our sponsors, sibotest.com, a breath testing service with easy online ordering. And QuinTron, maker of outstanding breath testing equipment. Tune in again for another episode of The SIBO Doctor podcast. Thanks again for listening.