Dr. Nirala Jacobi:
Welcome to another episode of The SIBO Doctor Podcast. And with me today is a returning guest, it's Dr. Farshid Sam Rahbar, who is a holistic and integrative gastroenterologist and the medical director at the LA Integrative Gastroenterology.

In 2013, he delved into the relationship between tick-borne Lyme disease, with a special interest in gastrointestinal manifestations. Since this time he has witnessed clinical patterns involving the role of infections, acute and chronic, in causing ongoing GI related conditions and symptoms. And Dr. Rahbar's special interest areas also includes dysbiosis, SIBO and leaky gut.

And it's been three years that you've been on the podcast, Dr. Rahbar. Lots has happened since then, so welcome back to the podcast.

Dr. Farshid Sam Rahbar:
Thank you.
Dr. Nirala Jacobi:
So nice to have you. Actually, three years ago, you talked about SIBO in Lyme disease. That was pretty revolutionary. And since then, both of us have actually given presentations on methane at medical SIBO conferences, and it seems like we share this common fascination with methanogens and methane production.
Dr. Nirala Jacobi:
Now, recently you also commented on the connection between methane and yeast overgrowth, which is definitely something I see a lot in my practice. So I thought it would be great to discuss this on the podcast, because a lot of practitioners struggle with both methane and yeast overgrowth in their patients. So, really excited to have you on this podcast for this topic. And before we go into that topic, I thought it would be great if you could just briefly outline some of the methane types that you've presented on in, I think it was the SIBO symposium in Seattle, and just the way you categorize or classify your methane patients.
Dr. Farshid Sam Rahbar:
Well, thank you for this invitation. I feel quite honored. And every day as it comes to dealing with SIBO, methane, and yeast, I feel I'm still a student. So I hope everybody has the same spirit of learning as we go along here. The [inaudible 00:03:23] that I discussed in last year's SIBO conference, it relates to SIBO patterns and methane is part of it, they're not just methane patterns, but they're SIBO patterns. And we looked at not only the gas pattern, like is it hydrogen or methane or is it a combination of both? But also the response to the treatments and the outcomes and the behavior of the SIBO, and can we learn from the behavior and change the treatment model, if you will?
Dr. Farshid Sam Rahbar:
Now going back to that, what I call classification, it was something arbitrarily I put it together. I called them from one to 10 different subtypes. Just to be able to remember what they do, I gave them a little funny name. So, we're going to call them type one to type 10, but they also have a name that goes with it. Now quickly, I'm going to go over that.
Dr. Farshid Sam Rahbar:
The type one, I call it, the easy rider. Okay. And it's a type that you have somebody with SIBO most likely a hydrogen producer, you treat them and basically it resolves, it goes away, patient happy, everybody's happy. Then we have type two, which is persister. And you treat it, the problem is still. The other one, relapser, the condition that the patient gets better, but then it comes back again as if i the has to be treated again, the question's that what's wrong, what is the underlying immune system established that it allows, the SIBO to come back again?
Dr. Farshid Sam Rahbar:
And then I call it type four, the mega gas, you'd see these numbers in the hundreds. And if you have another scenario where the methane is very high, and I call it the make a meth. Okay. And then you have the blended, the fourth. And then you have the paradox and that's more like, you're treated, and actually the gases, they get worse. You know, I've seen this evidence sometimes I've treated SIBO, and actually when you repeat the test, again, it looks worse. And then the type eight, I call it the incongruent, which means that SIBO gets better, but the patient doesn't get better. There's incongruency between the clinical outcome and the results of the SIBO test, means that the SIBO was there, and it has nothing to do with the patient's clinical presentation. It were just the biological marker that something is wrong here.
Dr. Farshid Sam Rahbar:
And then type nine, I call it a silent abdomen. And this is the one which is interesting because you have the patient has a lot of bloating, but they don't have too much rumbling and noise, there isn't flatulence. There's just a lot of bloating. And you have a SIBO associated with it, but this is what I call a silent abdomen, because there's not much malabsorption type symptoms with it. And this scenario should be reminiscent of autonomic dysfunction, which means that the nerves may have a problem, and then further investigation in that respect may be necessary. And type 10, which is something we're still learning about, I call it the flat line or the H two S you know, and that's something that hopefully fully when the testing model is available, we can start to use it and learn more about it.
Dr. Farshid Sam Rahbar:
But the message from this pattern was this, that patterns two to nine, we have a high likelihood of being associated with an underlying systemic illness. And that means that one has to think like an onion with layers that may be sealing one after another, to look for environmental toxic exposure, heavy metals, immune dysregulation and, stealth infections. And among this last category, there were a lot of patients we saw with the tick borne diseases. You know, that would be Lyme, Bartonella and Babesia. And just for information, as we speak now, our article is ready for publication, and it has been submitted to editorial for editorial review. They have gone through it. They have given us feedback, and I'm hoping that after we have made the correction that they wouldn't be willing to publish this in an online journal that would be available to everyone.
Dr. Farshid Sam Rahbar:
And that's the pattern. Now obviously the methane is really fascinating. And I told you that I agree with you there because the main question that remains is what causes these methanogens to grow in an area where all the gas production, ideally should be less than three. And even though the SIBO consensus conference said well 10 and above is abnormal, but I think it seems that for the normal person, the majority shouldn't be around three or less. How do we get 70, 80, a hundred numbers in that area? What does it mean? How did we get to that point and what causes these bugs or archaea to basically sustain and survive in that environment, as if my gut has become a Petri dish. What are we doing there that allows this thing to grow? I'll let you ask questions now.
Dr. Nirala Jacobi:
You know, before I go into my first question, I already have probably 10 different questions on what you just said, but I really appreciate the classification, if you will, of them with methanogen presentations, because I see all of that in my practice. And I find, I think very often, first of all, we all know that that methane SIBO, now known as IMO, and I'll let you have, I think you have some comments about that, on intestinal methanogen overgrowth, is very difficult to treat. And perhaps because there are these different versatile causes or presentations that you've just outlined, it's not as simple as just having high methane, there are a lot of different contributing factors. So one of the reasons we wanted to have this discussion was that looking at methanogens and its connection, or their connection, to fungal overgrowth. And I found that totally fascinating when you reached out to me with these links.
Dr. Nirala Jacobi:
And when I first started my naturopathic practice, I was known as sort of the yeast queen. 'Cause that was like, everything I saw was candida related and, or I should say a lot of systemic illness that I saw had this gut connection. And this was before I knew much about SIBO at all, if anything at all, this is over 20 years ago. And here we are, and that methane may actually be connected to a yeast overgrowth. So I let you elaborate what you had communicated to me.
Dr. Farshid Sam Rahbar:
You know, so there's a time in life, you get to the point that thought keeps coming back to your mind and just can't sleep with it. And eventually I said, you know what? I got to throw this out, know Dr. Jacobi and Dr. Siebert can to see what they think because we were, we were seeing a pattern, among our patients, which has started me to think. You know, is it possible that presence of fungus is really necessary for the methane to grow to this level? Or at least it could be one factor in that. And I'm also a believer that persistent fungus is another reason to believe that there is immune dysregulation. Like somebody can have a vaginal yeast infection, give them one fluconazole. It goes away. But what about if the problem is recurrent? And you know, we can't just get rid of the biofilm and what's wrong with the immune system that, and really handle the fungus to put it back the way it was.
Dr. Farshid Sam Rahbar:
So the connection came when we started to see many of our patients, who had evidence of methane, they also were showing evidence of fungus. Now let's talk about how did I come to that conclusion, it's evidence of fungus, because there is no such discussion in classical textbooks. And this subject is not recognized. We realized in traditional medicine, invasive candidiasis and fungal infections in highly compromised patients, we recognize oral thrush, vaginal yeast, as orfrigal candidiasis. But as soon as it goes beyond that into the small bowel, we don't have a discussion. And SIBO or small intestinal fungal overgrowth, I don't think it still has any ICD 9 coding or any discussions. I think physicians are talking about it more, but it's not formal yet. And it may be a foreign language to some of our colleagues there. But it is not inconceivable to say that if we can get a group of growth of fungi in oral cavity and other parts, the same way that happened in sinus cavities or in the small bowel, I mean it's a nice and warm and dark place and bug love to grow.
Dr. Farshid Sam Rahbar:
The body has some mechanism that uses with it, but it allows these fungal elements to grow. So, we do the same thing you do, we frequently look for risk factors for patients who might have fungal scenarios. And some of those factors could be alcohol, or stress, waste eating, a lot of carbohydrate intake, use of the steroids, antibiotics and so forth, but also presence of mycotoxins, which is becoming very, very common. Again, this is an area that is not well discussed in traditional books, but highly sophisticated urine tests that are not available, show that some patients harbor large amounts of mycotoxins showing up in their urine, which may be from inhalation, it could be from the dietary source, it could be exposure to a water damage building, depending upon the type or mold that happens of course.
Dr. Farshid Sam Rahbar:
But I'm of the belief based on what I've seen, that these mycotoxins are immune suppressants and they commonly promote the growth of their own species. And I say, this is my own family, and I'm going to try to let them grow. So when you see it pattern that the fungal elements are there, then some of these risk factors easily show up if you're looking for them. And among those sometimes heavy metals for people who eat a lot of sushi, tuna and things like that, we see it quite commonly in the practice.
Dr. Farshid Sam Rahbar:
But how does that relate to the methane? I mean, that's another scenario. Say okay, first of all, what is my marker for fungal elements. First I have to recognize the clinical picture. So I'm going to say okay what's your story? The story has to feed them, my clinical judgment has to do with it, but then I may want to do some confirmatory tests. And among those most practitioners are familiar that there is a urine organic acids that is looking for almost eight or 10 different markers for fungal elements, that that could be supportive.
Dr. Farshid Sam Rahbar:
We consistently use Doctors Data Lab, and I'm not just to promote one lab, but this is one lab that it does culture for fungus. And when I'm suspecting it, I usually use this lab because they identify the fungus. And I don't believe the presence of fungal growth in man's stool is normal. Indeed, I don't recall any man that I've seen that they show of presence or one plus fungi of rhodotorula, or some other strange fungus that they feel good, and I just found this out of curiosity. I mean, usually they have systemic illness and there's something else that is going on with it.
Dr. Farshid Sam Rahbar:
So we look at the stool analysis. We look at organic acids. Nowadays, I'm also looking at fungal antibodies, multiple fungal antibodies, probably over a hundred of these with IgA and IgG antibodies to see if I can have further evidence.
Dr. Farshid Sam Rahbar:
We also check more antibodies by IgE to see if we can find additional evidence. But generally speaking, one of these things will show up. And occasionally what we have done is for patients have had violent gastritis, and I talked about this in my previous presentation, that we feel that the presence of violent gastritis is associated with proximal blood dysbiosis. And we have been obtaining the samples of the duodenal juice and in a rather informal way, checking it for microbiological findings and part of that is the PCR test of the juice to see if there are fungal elements. And occasionally we see some [inaudible 00:17:14] fungal elements in that one.
Dr. Farshid Sam Rahbar:
So this is my ideas of how I maybe looking for those fungal elements. But then some of these patients, we found that they have high methane. And I think in this scenario to treat the methane for example, with Xifaxan and Rifaximin, and with new medicine, it could almost be detrimental because if you have a fungus scenario sitting in the background, either the patient doesn't get better or they may get worse.
Dr. Farshid Sam Rahbar:
And on the other hand, what is deriving that growth of archaea with these numbers? Where there's 10 or 20. And I know, we're seeing some numbers that are really high.
Dr. Farshid Sam Rahbar:
Another thing which is interesting with methane is lack of complete clinical correlation. Like you have high methane, but you don't have constipation or they have diarrhea. It just doesn't fall. What we learned that methane causes constipation. It maybe just a biological marker sitting there in some cases. I'm not saying that treatment of methane is not always addressing the constipation, but I think are other layers that I think we need to think about this, especially some of these mega meth patterns are fascinating because one question, how did I get to this point this high level?
Dr. Farshid Sam Rahbar:
So when we asked that question and we started to look at the correlation with these common findings, of fungal clinical scenario, okay. Fungal clinical scenario and presence of the methane, could these be related? So when I studied this, I asked one question, how do you culture methanogens in the laboratory? And while I was doing a search, I found an article. And I sent you that article, then I went through methods and I read it very carefully. They were putting so many chemical to make all these methanogens, it was really mind boggling to go through all of that. And I wish I could get the PhD who wrote this to be on this call, maybe one day discuss it.
Dr. Farshid Sam Rahbar:
But the interesting part is that as part of the prep, I saw that they were using fungus to create an anaerobic environment. And we know that fungi they have interesting features. First of all, you can and have fermentation with dead fungus. The concept of having fermentation with dead fungus was published in chemistry some years ago. And I didn't know, this was before I was born, the guy who describe this, got a Noble Prize for it. Have you ever heard about this? No? I didn't know. And my talk, my time was too limited, but otherwise I would've gone into the historical part.
Dr. Farshid Sam Rahbar:
But I said, okay, so I couldn't have dead fungus there, and I could still cause fermentation and gas and bloating and things like that. But the fungi can also survive with oxygen or without oxygen. So yeah, many of them apparently they look like fungal elements. I mean, they liked the air and the oxygen. And that's why if you have the fruit sitting outside, you can see fungal elements kind of start to grow on that after a day or two.
Dr. Farshid Sam Rahbar:
So on the other hand, methanogens, they're actually anaerobic. They don't like oxygen. You can kill them by exposing them to the oxygen too. You have them growing in the proximal duodenum, which there suppose to be some air floating around. There must be some anaerobic environment created by something else. So it becomes a symbiotic arrangement that the presence of the fungus may actually be promoting the presence of the methanogens there.
Dr. Farshid Sam Rahbar:
So in our practice, when we do find evidence of fungi, based on some of those tests that I talked about, all based on my clinical judgment, I tend to treat the fungus first. Okay, before I even want to treat the methane. And I only treat the methane, if the patient did not get better.
Dr. Nirala Jacobi:
What is your preferred antifungal in that scenario?
Dr. Farshid Sam Rahbar:
Look, I mean, we tried to avoid this systemic ones as much as possible. I would say, I know you have talked about this before in a conference. I mean, I use nystatin and I increase the amount slowly because of the risk of die off reaction. And we used biofilm busters to the best we can. And I think two out of three patients, generally it will get better to using a locally acting antifungal. If necessary, then I may use econazole, I may use miconazole and other things. But really I may go to itraconazole or econazole and more systemic one.
Dr. Farshid Sam Rahbar:
But as we speak, I have couple of patients who actually needed to go to some of these more powerful antifungals because they were not responding, but they have immune suppression. So I won't be surprise, that they would need something of that nature. But as a first line for somebody who comes here, you work with your lifestyle, immune system, nutritional replacement, or it calls for antifungals, the diets and the nystatin.
Dr. Nirala Jacobi:
Well you know, one of the reasons why I was so fascinated with this connection is because I did see it clinically, but I never actually thought of cause and effect, with that yeast or candida might actually be promoting methanogen overgrowth. And that was sort of like when you said it, it was like a light bulb kind of went on and I do a lot of organic acid testing and I see a lot of high fungal markers on that. I rarely see a stool test, be positive and I use a different type of stool test because of the different markers I look for, but even, I see it all the time that arabinose is elevated on an organic acid test, which is the marker for invasive yeast. I think it checks for these hydrolases or so that candida secretes and nothing on a stool test.
Dr. Nirala Jacobi:
So this is what I use a lot when I suspect candida overgrowth or SIFO or LIFO really, or just intestinal fungal overgrowth because it's not location specific. So I do now specifically see this, very high levels of methane also correlate with a higher arabinose.
Dr. Nirala Jacobi:
So I think this is just something that we need to investigate further. And, and one of the reasons I think it's great to discuss this is because I want to see if other people are seeing this as well. And what is the connection other than is it that, what you described as providing an anaerobic environment? Is it the carbon dioxide? What is it that really drives methanogen growth in that environment? You know, so I think that's really the question. If we can find that, that could potentially open the door for a new therapeutic intervention in a way. So anyways, I'm just thinking out loud.
Dr. Farshid Sam Rahbar:
I think the persistence of also fungi generally implies to me that there's immune dysregulation in the form of the body's maybe reduced ability to deal with the fungal elements. That's why it's become persistent. In one of our cases that the patient had received antibiotics. I consider it when I did an endoscopy, I could almost see the biofilm on the small bowel. And when I did some scraping, we're using a very ERCP catheter, just to kind of. And I'm going to bet this is going to come back PCR positive in high concentration of the fungi. And it is almost the point that it was visually noticeable. If you almost envision what to look for.
Dr. Farshid Sam Rahbar:
But it's an area that I hope it will ignite more research, and it gets formally studied, but I have concerns about three things, with neomycin and Rifaximin, it was occasionally you see a paradoxical response, with some people saying I feel more bloated, I feel worse or it didn't work. Okay. And that means that obviously there's another layer to think about. And mycophenolic acid commonly comes up in a lot of these urine tests, and we have seen sometimes really high numbers. And as you know, this is a drug that they use in transplant industry to suppress the immune system. So I wonder if these things are connected, mycophenolic acids come from penicillium, and penicillium where of you find it? Hard cheese, cheese sitting outside. It could also be maybe from water damaged buildings.
Dr. Nirala Jacobi:
The whole mold topic. You know, I had two mold specialists on the program and we talked about elements of this, I mean the whole topic of mold is just so fascinating because we are seeing more mold illness or I'm definitely seeing more mold illness. And there's various speculations around why that's happening.
Dr. Nirala Jacobi:
But getting back to, intestinal fungal overgrowth, now candida is really one of those perfectly adaptive to the human digestive tract because it does, it has all these special features of changing morphologically from a budding yeast to a hyphae. And so it can change these morphological states, it can form biofilm, it can secrete proteases. It has all these sort of defenses in with which you can evade detection, with which it can invade mucosal surfaces. It has quorum sensing it does all this. So it makes sense that candida is sort of like perfectly adapted for that. But my question is, do you also see other fungi, the possibly involved? Like what other fungi do you frequently see with not just methanogen overgrowth, but in GI disorders? You mentioned rhodotorula, I see that a lot on stool cultures. How relevant is that at a plus one level? You know, do you see also Aspergillus do you see other types of fungi?
Dr. Farshid Sam Rahbar:
Aspergillus I have not seen in a stool, but I also wanted to say that the only lab that I've seen that consistently cultures, fungal elements is the Doctor's Data. And I know this is not a CME conference. [ectricial 00:29:01] I use a name and I don't have an attachment to one lab or another. And you know, the name of these fungi is always a challenge. How do you say it? How you pronounce it? How do you remember it? There are over a hundred species of these fungi. And I'm assuming sometimes seeing the laboratory reporting on other fungi that I've never heard about it, and I have to go and look them up and see what it is.
Dr. Farshid Sam Rahbar:
But interestingly, the majority of these ongoing elements, when you're studying them, they're opportunistic fungi. So is something you see in patients who in the hospital, or receive transplant, or they're under immune suppression. It is not something that you would think we encounter in person walking into the walk office.
Dr. Farshid Sam Rahbar:
So even to do with the laboratory may put it as one plus in the normal range. I don't believe this is normal because I've never seen anybody feeling good with that type of scenario. And I give you a quick story. At one time, I had the gentleman coming to me with bad body odor, and it was a very well built and healthy looking person. But this is something that was bothering him for a long time. And we do this to culturally show to one plus of these opportunistic ongoing. And I said, well, did you know about this? He said yes, I've had this for several years. But I said, did you ever get treated? He says no. So obviously it became an area for us to target.
Dr. Farshid Sam Rahbar:
But I did mention something to him. And I said, this is not norma, to me that you have another problem underneath that. This is just the tip of the iceberg. So I asked some questions, whether he lives pets and animals, and found that there was some cats around. Okay, I did a test for Bartonella, came back positive. Okay. So I mean, obviously this was sitting in the background and the marker were clearly positive too. This was not a questionable thing this in my mind. And we have seen other cases like this, you know, with a bit of a different variation if you will. But I think it would be prudent to have what I call an onion thinking, that you need to layers one, layer two, layer three, to see what might be sitting in the background.
Dr. Nirala Jacobi:
Do you have SIBO and want to learn how to help yourself? The SIBO success plan is now available from thesibodoctor.com . In this highly anticipated plan, you'll learn my tried and proven method to treat SIBO, including home treatments, online dispensary guides, diet handouts, and much, much more already being treated by a practitioner? No problem. The SIBO success plan is designed as a standalone program or to work under the care of a practitioner. Become a SIBO savvy patient and beat SIBO for good. For more info, go to www.thesibodoctor.com .