Nirala Jacobi:

Welcome back to part two of the SIBO Doctor podcast. And let's jump right back into it. Let's move into testing and I'll just try to summarize my understanding of the testing. So we have three types of tests. We have antibodies to H. pylori that are blood based. We have stool antigen tests, and we have a urease breath test, which looks more at the activity of H. pylori. Can you just go through the different uses of testing and its relative accuracy or usefulness?

Steven Sandberg-Lewis:

I have to add two more kinds of tests that aren't standard, but are done. And one is stool DNA testing for H. pylori. You see that all the time, my patients come with it all the time. And the other is salivary antibody testing, which I know we do here in the United States.

Those aren't considered standard tests, but the ones you mentioned are, of course. So, first we start with the blood antibody IgG for H. pylori. That's a test that should be positive if a person has been exposed, has had H. pylori in their body. So, I consider that test problematic because if you are part of that 10% of the population that still has H. pylori as a commensal in your stomach, I want to know more.

So if a patient comes to me with a positive test, whether it's the blood test that shows that their immune system has been exposed to the organism, or the breath test that shows that it now is there in their stomach. That'll tell you that it's there now. As well as the stool antigen tells you it's there now.

So let's say someone comes and says, "Oh, I had a positive stool antigen. My doctor wants to treat it. I'm not sure I want to treat it. Should I treat it?" My next suggestion is, well, if you really want to know if you should treat it, you don't have ulcers. You don't have any of this indication of other problems. It would be ideal if you could get an upper endoscopy. If you have an upper endoscopy, we'll know that you do or don't have lymphoma in your stomach, that you do or don't have stomach cancer, that you do or don't have gastritis.

And if you do have gastritis, where is it? Is it antral? Or is it Pangastritis? Then we can make an educated decision about whether or not you want to treat this. Because we'll actually know if it fits the situation. Now again, if they just got tested, because everybody who goes to Dr. Jones gets the stool test and that it's included in the panel, that's problematic to begin with from my point of view.

But like I said, just to reiterate there. So the stool antigen or the breath test tell you, you have H. pylori in your stomach now. H. pylori lives in the stomach. It doesn't actually live in the duodenum much at all if it does. It's the ancient dominion organism of the stomach. It's totally designed to live in the stomach.

The reason the urea breath test is called urea breath test is because H. pylori is one of the few bacteria that can make an enzyme called urease, that can break down your urea into ammonia. Why does it want to make ammonia? Because it hates acid. It doesn't like acid. It's dangerous for it. So, that's why it makes urease, one of the reasons, so that it can create a little cloud of ammonia around itself so it doesn't end up getting destroyed by the acid.

It has other mechanisms too. It's shaped like a spiral. So it can corkscrew its way into the mucus in the stomach and protect itself from acid that way as well. So, those are the three forms of testing. And if you want to know, if you have it now, you do the stool test, or you do the breath test.

If you had a positive IgG blood test for H. pylori, well, you can take it two ways. It might mean that you just have commensal organism. But it could also mean that your body sees it as foreign, that your immune system is seeing it as something it needs to respond to. So it's making higher levels of antibodies.

Nirala Jacobi:

But generally, it's not such a great test because you don't know how active it is currently. It could have been a previous infection or a previous, even if you were treated, your IgG would still be positive, even though you've eradicated it. Right?

Steven Sandberg-Lewis:

Yeah. It's not as reliable as a marker that it's no longer there. So if you know that you were treated for H. pylori a year ago and your blood test is still positive, it doesn't mean that it wasn't eradicated. It might not be there anymore, but your immune system still makes it. As you know, IgG is an antibody that tends to be long-term. And sometimes we see IgG antibodies for three, five years or more afterwards.

Nirala Jacobi:

So, let's move into treatment. And we don't have to spend a lot of time at all on the triple therapy, the conventional triple therapy, because it's pretty standard. It's kind of a...

Steven Sandberg-Lewis:

There is a question that everybody asks though.

Nirala Jacobi:

Okay.

Steven Sandberg-Lewis:

And that is, if H. pylori doesn't like acid, why do you give it proton pump inhibitor with the antibodies, with the antibiotics?

Nirala Jacobi:

Okay. We'll definitely go into that.

Steven Sandberg-Lewis:

Okay.

Nirala Jacobi:

And then we'll go into the naturals. And my big question there is, if somebody, as you say, has had no history of repeated ulcer formation, is the goal really to completely eradicate it, or should the goal be just tame it down to where it's no longer causing a problem.

And is that a feasible or a reasonable approach to H. pylori? And I'm just speaking on behalf of many practitioners that I've spoken to that have similar questions. So, let's start with the triple therapy then and move into the naturals.

Steven Sandberg-Lewis:

So the triple therapy, in the US, is typically clarithromycin, amoxicillin, and a proton pump inhibitor. It used to be seven day treatment, but because of resistance that's developing, it's now 10 to 14 days. And there are some parts of the world where clarithromycin resistance is so high that even 14 days may not take care of it.

And so, let's say someone has H. pylori, positive testing, especially breath or stool antigen. So you know it's there now. It's not just a antibody. And you as the practitioner, definitely want to treat it. The patient wants to treat it. It makes sense to you to treat it. You can use triple therapy, but you want to augment it by using sextuple therapy. No one calls it that. I just made that up.

So you want to use six things, not three. Of course, there's a quadruple therapy too, but it's not used as much. And that's where you add bismuth. Or if someone's allergic to penicillin, you don't want to use the amoxicillin, so there they'd use tetracycline.

Anyway, what I like to do is even standard triple therapy. I like to add three things. One is lactoferrin, which people might recognize is something that's normally present in breast milk and colostrum. Which has been shown in research to significantly improve the effectiveness of triple therapy.

The next thing you want to do at the same time that you're taking the H. pylori is, especially if you've been treated before and you haven't responded is you want to use a biofilm disruptor. The one that I've seen the studies on most is NAC. In some studies, they start NAC anywhere from 500 to 1,500 milligrams a day, start it a week prior to the triple therapy, to start to liquefy the biofilms. And then they continue it during the 10 to 14 day treatment.

So that's the second thing. And the third thing is a probiotic. And certainly, that could be Saccharomyces boulardii. It could be a lactic acid bacteria. They have been shown to significantly improve the effectiveness of triple therapy. So I give those in addition, during the time that they're on a triple therapy.

Nirala Jacobi:

You forgot to mention why the PPI's are being prescribed.

Steven Sandberg-Lewis:

Yeah. Well, I didn't know if you wanted that yet.

Nirala Jacobi:

Yeah. If it's a question that you get a lot, yeah.

Steven Sandberg-Lewis:

Yeah. The two main theories as to why that's effective. One is that it's believed that proton pump inhibitors, they don't just inhibit acid production by the proton pump, they also inhibit H. pylori from making urease. So it can't protect itself from the acid as well, like a sitting duck.

Nirala Jacobi:

Okay.

Steven Sandberg-Lewis:

The other theory is that proton pump inhibitors have antibiotic effects on their own, which makes it even more scary that so many people are on them because it's going to affect their microbiome over time. So, those are the two theories I have seen the most.

Nirala Jacobi:

Interesting. Okay. So lactoferrin and probiotics, along with the triple therapy.

Steven Sandberg-Lewis:

And a biofilm. Yeah.

Nirala Jacobi:

And NAC. I forgot about NAC. That's right. I remember reading about that a while ago. But I usually do a combination of HCL, bismuth, mastic gum and some combination of berberine, which is marginally effective for H. pylori. Although I've had some really, really good success with some of the combinations of that. And I usually also adds in carnosine for mucosal protection. But what would be your top five treatment approaches or herbal remedies for H. Pylori?

Steven Sandberg-Lewis:

Well, everything you mentioned makes sense and is commonly used in some combination. My thought though is, and I haven't looked at the literature on herbal treatments for H. pylori in about a year. So I should update that and see if anybody's done a study.

But as far as I can tell, no matter what you do, if you do one thing, you're not going to eradicate H. Pylori. Right. I mean, even one antibiotic doesn't do it, except if you do it over and over and over in mice over a lifetime, then it will weaken it and perhaps destroy it. So, there's no drug and there's no natural substance as a single agent, that's going to get rid of H. pylori.

Nirala Jacobi:

Should that be the goal because of everything we've talked about here today? Should that be the goal or should that be reserved for those that show repeated ulcer formation and some of these other risk factors that you mentioned? But your run of the mill male H. pylori infection, should that really be the goal? Or should we just reduce it and pacify it into a more neutral state?

Steven Sandberg-Lewis:

Well, I think what we're doing when we give mastic gum and zinc carnosine and berberine, or other berberine containing herbs, and other treatments like that, or even demulcents like DGL and Althea and things like that, marshmallow root, what we're doing is we are improving the gastritis because those are fantastic medicines for gastritis of all kinds.

And so, the patient feels a lot better. And so you figure, "Yeah, we've done this. We've reduced the H. Pylori." I don't know that we're actually doing that. I know that it's smart. You're aiming at treating the gastritis, if they have gastritis. If you know that. If they had an upper endoscopy, you'll know it.

So, I think that what doctors think they're doing, reducing H. Pylori, is not really what they're doing. What they're doing is treating the gastritis, and the other irritations, which is fine. It's different than triple therapy which is really aimed at trying to eradicate it. So, I think you, first of all, if the doctor and the patient understand whether that patient really wants to be and should be treated for H. pylori, that's the first step. And that's a discussion that should happen.

We haven't even talked about anything besides reflux as being things that H. pylori presence protects against. Because Crohn's disease, hay fever, food allergies, eczema, asthma, the list is big. Even cancer of the larynx. That's protective and Barrett's esophagus and reflux and those things we talked about.

So, I think the first thing that should happen is if somebody accidentally got tested and I really don't think they should have in the first place. Then they're coming to me and saying, "Oh, how should I be treated for this? Should I be?" The first question is should you be treated? And the next question is, if you should be treated, if we decide you should be treated, let's do it the most effective way.

Now, if you really think you need to eradicate it, triple therapy plus three other things we talked about, makes sense. If you're just thinking, "Well, there's a Pangastritis, that gives me a tiny increase in risk of getting stomach cancer. Nobody in my family's ever had stomach cancer. I'm not living in a place where stomach cancer is high risk, say like in Japan. Maybe we should just quell my Pangastritis and treat my hypochlorhydria if I am having problems from that, like iron deficiency. And then call it good and not worry about normalizing the test."

There's nobody breathing down my neck saying you've got to treat H. Pylori. And then you have to retest them and make sure it's gone. Nobody tells me I have to do that. So yeah, you could treat them.

Nirala Jacobi:

I like that. I do like that approach of just taking... People get so concerned and worried that they're going to automatically develop stomach cancer from H. pylori. And especially after reading Dr. Blazer's book, it's really great book to demystify it to some extent. Now he does talk about different variants and virulent strains and stuff like that off H. pylori.

Steven Sandberg-Lewis:

Yeah. We haven't gotten into that.

Nirala Jacobi:

Yeah. And that's like, you can't really determine that from a breath test. But I have before and after urease breath tests that were really high and then normalized, with the strategies that we talked about here, the natural strategy. So again, not eradicating it, but just more or less below that threshold where it is active.

I felt comfortable with that outcome, but again, it's always up to the patient who comes straight from their gastroenterologist. And they're talking to me about, "Well, I've got this prescription. What do I do now?"

So it's a really good conversation we're having for, I'm sure a lot of practitioners will find that really helpful to discuss this because there isn't a whole lot of guidance when it comes to how to really talk to people about H. pylori. So that's really good.

Steven Sandberg-Lewis:

I'll have a chapter on it in my book, but can I say a few words about the virulence factors.

Nirala Jacobi:

Yes, yes. Please.

Steven Sandberg-Lewis:

So, the more you see things from a naturopathic perspective, the more you realize nothing's good and nothing's bad. Everything is just there for a purpose. Right. And being in balance is the answer. Right. So, virulence factors, there are a couple of labs that do that stool DNA testing for H. Pylori, that will measure the virulence factors as well.

And I don't know that we know enough about them to actually use them wisely. And you can read about this in Blazer's book as well, the research on virulence factors, such as cagA and vacA, if you do read research on H. pylori, you really should see if they tested for virulence factors or not, when they've studied it, because not all H. pylori is the same.

And there's a good, a dark side and a light side to the virulence factors because they've found that certain combinations of virulence factors are actually protective against certain conditions. So, having a strong H. pylori with virulence factors of certain types and a mix of them, is actually more beneficial for certain conditions, protective.

Although we know, for instance, cagA actually makes the H. Pylori, we think from research makes it more able to interact with the mucosa in the stomach, which could be a good thing or a bad thing. It makes it interfere and talk to the mucosa more. So, with certain types of H. pylori that have certain variance factors, that may make it more virulent and more disease causing perhaps. For instance, stomach cancer for certain types, or peptic ulcers for other types.

Nirala Jacobi:

Okay. I think that just about wraps up our conversation on H. Pylori. Was a really, I'm so glad we got a chance to do this, Steven. I want to plug your clinic for a bit. And also, definitely let us know when your book is ready to be released and we will definitely promote it.

Steven Sandberg-Lewis:

Yeah.

Nirala Jacobi:

I forgot to mention in my very, very brief intro to SSL, as we call Dr. Steven Sandberg-Lewis, he has created a couple of courses for the SIBO Doctor. One is the functional gastroenterology, the physical exam skills that are available on the SIBO Doctor website, as well as the liver and gallbladder course. Which was such a great, rich course, that really goes through the whole liver, gallbladder, all the different processes and stuff that we can do for the liver and the gallbladder.

So, Dr. Sandberg-Lewis, you also have a wonderful clinic that I do refer my American patients to if I need them to see somebody really fantastic. You're in Downtown Portland. Tell us a bit about your clinic and where people can find you.

Steven Sandberg-Lewis:

Actually, because of how bad COVID is in the US the clinic we were in, we couldn't work there anymore with COVID. So, we are not in that downtown clinic. We're in a interim clinic, we're looking for a new clinic that has windows that open, and not HVAC systems. So you're not getting the COVID from everybody else's office in your office.

Nirala Jacobi:

Yeah.

Steven Sandberg-Lewis:

So we're in the process right now of looking. And we're in an interim office in Sellwood, which is Southeast Portland. And it's called Hive Mind Medicine. And I have a resident physician each year for the last five years.

And Dr. Lisa Shaver, who is an acupuncturist, a celiac and gluten sensitivity expert, who team teaches advanced gastroenterology with me. And then also, Dr. Roz Donovan, who I'm so happy to have somebody in my office who is expert on Lyme and co-infections and mold disease.

Nirala Jacobi:

Big one.

Steven Sandberg-Lewis:

And chronic inflammatory response syndrome, because I don't really want to be an expert on that. I just...

Nirala Jacobi:

You already are. Being a naturopath, you kind of are. It's so naturopathic. The whole thing is...

Steven Sandberg-Lewis:

I help funnel people there when I think that that's what they need. And then my wife, Kayla, who is a stress management coach and specializes in working with people with traumatic brain injury. So, it's a great group.

Nirala Jacobi:

It's a great group. And if you are in the US and you need a fantastic naturopathic doctor who is very hands-on, old school, but also new school, go see Hive Mind Medicine in Portland.

Thank you so much for your time. I really appreciate it. This has been super helpful, I think for a lot of practitioners out there. And we can't wait to hear all about your new book when it comes out. You should have plenty of downtime with COVID. Should be done now. Where is it, Steven?

Steven Sandberg-Lewis:

I am so busy with patient care. It's all over telemedicine, but it consumes me. I just occasionally have to take a couple of weeks off so I can write.

Nirala Jacobi:

Yeah. Okay. Thanks again. And all the best to you and your family. I don't know when we'll run into each other again in these crazy times.

Steven Sandberg-Lewis:

In this lifetime.

Nirala Jacobi:

In this lifetime, I'm sure I'll see you again. All right. Take care, Steven.

Steven Sandberg-Lewis:

Thanks.

Speaker 3:

Thank you for listening to the SIBO Doctor podcast. We hope you find 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, the maker of outstanding breath testing equipment. Thanks again for listening.