Nirala Jacobi:

Welcome back to another episode of the Sibo Doctor podcast. I'm your host, Dr. Nirala Jacobi, and I'm really excited to talk to today's guest and longtime friend and colleague, Dr. Allison Siebecker, who is definitely no stranger on this podcast. We've had her on several times, and many of you who are practitioners or Sibo sufferers will have heard of Dr. Siebecker's work. She has been specializing in SIBO since 2011. She is the 2021 Lifetime Achievement Award recipient from the Gastro ANP, has been teaching advanced gastroenterology at the National University of Naturopathic Medicine since 2013, and is also an award-winning author. Her SIBO protocols have helped thousands worldwide, and I'm so happy to welcome her back to the Sibo Doctor podcast. Welcome, Allison.

 

Nirala Jacobi:

We last had you on this platform when we discussed alternative treatments for SIBO back in episode 69 and SIBO and Prokinetics way back, episodes 44 and 45. For those of you who'd like to check in on some of these old classic episodes with Dr. Allison Siebecker, I'm so glad to have you back here.

Thank you so much today after it's been, what, 13 years that you've been a SIBO specialist now? Something like that, for 13-14 years. And I came close on your heels as a SIBO specialist as well. And I wanted to focus on SIBO lookalikes, or the SIBO imitators, as I call them, because in our practice, where we see so much gut dysfunction, it's not all SIBO. Just because somebody has symptoms of Sibo, it's not a foregone conclusion that all people that bloat, of course, have SIBO.

So basically, people that suffer from classic SIBO symptoms, but their breath test is negative for SIBO. So, let's get started with that topic.

 

Allison Siebecker:

Okay. You told me what we're going to be talking about ahead of time. And so, the first thing I just wanted to throw out before we get into what else could these diseases be, is just the concept that we could have a false negative test and just some things to quickly think about to really reassure that the test is negative. And it's not mean. One thing to think about is, what about hydrogen sulfide?

 

Allison Siebecker:

It is a rarer form of Sibo, one of our three types of SIBO, and there's only one direct test for it.

 

Nirala Jacobi:

Now.

 

Allison Siebecker:

That's, I think, only in the US. So that's not that helpful for people in other countries. But there was a way that we could at least identify some people with hydrogen sulfide with standard testing, and that's a flat line. So just consider the possibility of the test look negative because it's a gas we're not testing for, which is hydrogen sulfide. Okay.

 

Allison Siebecker:

And then I just had, like, just quick two or three other things to think about. Probably the most common would be, and these are things that probably you have in all your testing instructions, but it's just good for people to know about when they're going to various docs and things, is if there was a bout of heavy, watery diarrhea that was out of the normal pattern for somebody in case. If there was somebody that had diarrhea or colonoscopy prep, or about of like, gastroenteritis, where there was intense diarrhea, that can create a negative test if it was within two weeks of the test. These are just things to think about. I mean, I've had this happen with patients.

 

Allison Siebecker:

That's why I want to bring it up. Or what if somebody had gastroparesis, slow stomach emptying, and maybe you don't quite realize it, or you're not factoring that in. That would mean the substrate never even got to the small intestine. And last, something as crazy as. Did the person doing the test actually drink the substrate?

 

Allison Siebecker:

Sometimes it happens. They didn't and they don't even realize. And then the test comes in, and of course it's going to be a negative. False negative. And did they mix the lactulose syrup with water to disperse it properly?

 

Allison Siebecker:

So, I just wanted to mention those things to put them out of the way, that false negatives potentially put them out of the way. And now move on to this topic of what else could it be if it's not really Sibo, like the test is really negative, and what else could it be? So, I'll just start with a few. And I know you have a lot to put in on this, but there are some classic kinds of, like, other infections that we think about, like yeast overgrowth right away would be one, and parasitic infection. These can have similar symptoms to SIBO, and there are types of infections, and you don't need to have SIBO with any of these.

 

Allison Siebecker:

You could just have this alone and have the symptoms. In fact, we call it the differential diagnosis list. It's. What is the list of conditions that have the same or similar symptoms? It's really big.

 

Allison Siebecker:

If we're talking about SIBO or IBS, basically, there's the same symptoms as IBS. I made my own differential diagnosis list, and I got up to a little bit over 40 conditions, and then I kind of got tired and stopped writing. So, it's like, there are so many other things. What you bring up before we go into the other conditions is such an important point, because you don't want to make an assumption on the symptoms of Sibo. You don't want to make any assumption, because these are the symptoms of IBS and they are nonspecific symptoms, meaning they're not specific to any one condition, aka, there's 40 plus other diseases that have the same symptoms.

 

Allison Siebecker:

So, it's a good idea to test. And in this case, we're saying, okay, we've tested for Sibo. That's not it. So, yeast overgrowth, parasite overgrowth, of course, large intestine, bacterial infection or overgrowth, or dysbiosis, which I know you're going to talk about more later, because that's a major topic. Other things would be things like celiac inflammatory bowel disease, Ehlers Danlos syndrome.

 

Allison Siebecker:

Now, I would imagine many of your listeners are familiar with this by now, but it's sort of still newer on the scene to a lot of people who may not know about it. It's a connective tissue laxity disease, basically, that leads to joint hypermobility and a lot of gastrointestinal ramifications, as well as musculoskeletal. And I actually jotted down a figure from a study because I found it so amazing. But there was a study showing that 48% of IBS patients had Ehlers Danlos syndrome. Almost half.

 

Allison Siebecker:

I mean, it's really astonishing. And about 58% of those had constipation type, 35% had the diarrhea type. So that's something to think about. And then we have really, really common things like hyper or hypothyroid. I mean, so many people have thyroid issues, and that can cause constipation or diarrhea, bloating, discomfort, and similar symptoms.

 

Allison Siebecker:

Diabetes. Diabetes also has gastrointestinal symptoms. I mean, the list is quite extensive. Gastroparesis, Parkinson's. Parkinson's, many people think of as an elderly person disease, and it's not always true.

 

Allison Siebecker:

In fact, it's often that it starts when people are younger, and it's not caught until later. And one of the first symptoms is constipation because there's a lack of motility that's going on in the small and or large intestine. So, it's not to be scary, but it's just, it's good to get your yearly physicals and include a neurological exam and make sure these things are being looked at. And here we're talking about people who have these symptoms, and their Sibo test is negative. So, this is the kind of list you want to look at.

 

Allison Siebecker:

Of course, for females, there's endometriosis that is so similar in symptoms. And then we talked about some more serious diseases. Then we have things like insufficient chewing. I mean, that can actually cause the symptoms of SIBO, believe it or not. So that's kind of like a lifestyle problem.

 

Allison Siebecker:

Pancreatic enzyme insufficiency, low hydrochloric acid. Right. So, these are the kinds of things so many people have. Low hydrochloric acid. I know you're a big proponent of treating and correcting for that, but the issue is that that contributes to us not being able to fully break down our food.

 

Allison Siebecker:

And then additionally, we need hydrochloric acid for the secretion of. It stimulates the secretion of our digestive enzymes. So then our digestive enzymes aren't there, and so we can have undigested food that then bacteria, whether it's in the small or large intestine, can chomp on. And it's kind of like a malabsorption situation, because we don't have the right hydrochloric acid or enzymes. And then there's other things like mold, of course, there's MCAs and histamine intolerance.

 

Allison Siebecker:

These are things that I know we can talk a long time about. There's H. Pylori infection. There's basic carbohydrate malabsorption. I mean, people can have genetic lactose malabsorption, has the exact same symptoms.

 

Allison Siebecker:

Fructose intolerance or malabsorption. Sucrose, Maltese. There's these sorts of things. There's food intolerances, which are a little bit more based on proteins in food, like an allergy situation, they can give the same symptoms, histamine reactions, which can be to all types of things, Lyme disease. So I'll stop there.

 

Nirala Jacobi:

Very good. Thank you. That was definitely not an exhaustive list, but yes, those are the things that a very well trained practitioner would be familiar with to look for. But one of the reasons I really wanted to have this conversation with you is because over the years, I've noticed as Sibo gained traction in social media and online, and people are more aware of it, I do think. And also because I own a breath testing service, I do think that people are often diagnosed with Sibo when it actually is not Sibo, or they self diagnosed with Sibo.

 

Nirala Jacobi:

And that's one of the reason I wanted to have a conversation about this, because in the forums that I also host online, so many times people are saying, I can't get rid of Sibo. And my first thought is, is it really Sibo, though? And so that was the reason I wanted to have this conversation, to kind of hash out what the first things would be that I look for. And so my thought would be then, I know the two scenarios that I see often in my practice is either they immediately test negative for Sibo, and let's say they've had the proper Sibo testing and proper interpretation of that test, that they actually test negative, but they have the very classic symptoms of rapid bloating after meals, et cetera, et cetera. So that's one scenario.

 

Nirala Jacobi:

And then the next scenario would be, they have completed Sibo treatment. So they initially tested positive. They completed Sibo treatment, and now they test negative, but they're still symptomatic for Sibo. So those two scenarios I see very commonly, and I think partially. Well, not partially, but because it's also selection bias, because I'm a Sibo specialist.

 

Nirala Jacobi:

So I see these cases. And so my causes that I look for when I have ruled out all of it, because I do a lot of testing, stool testing as well, to look for microbiome imbalances and the digestive deficits that you've mentioned, and do lots of trials of enzymes and bitters and acid and also look at their nervous system situation, because a lot of people have very high stress situations that can also greatly affect the digestive tract. But, yeah, so I wanted to address this from a perspective of what are the first things that we think about, and for me, in my experience, would be, let's see what's going on with the rest of the digestive tract, because that's where it's one tube. Let's not forget that it's one tube. Yes.

 

Nirala Jacobi:

These microbiomes in the small intestine, it's different from the large intestine. We know that. But very often there are problems that we see in the large intestine where the microbiome is meant to be and in very large numbers. And that's where I think is really, I find, is the sweet spot, because when you have microbial imbalances that can lead to histamine imbalance, that can lead to food sensitivities, that can lead to food reactions that can lead to all these different things. So I just wondered what your thoughts are on that.

 

Allison Siebecker:

Oh, I want to hear you talk more about it. Tell us more.

 

Nirala Jacobi:

Well, when I was creating the microbiome restoration course that I've released earlier this year, I was just astounded by some of the research. When we think about the bacterial abundance that we're meant to have. For example, in the large intestine, we're meant to have basically trillions of bacteria, lots of different species. And you always hear that for every bacteria, for every cell, there's ten different bacteria in the human body. Well, that's not really the case, but we basically need bacterial diversity, because one of the most important aspects of bacterial diversity in our microbiome is the cross feeding of each other, right?

 

Nirala Jacobi:

So one bacteria will make one metabolite or substance that will feed another type of bacteria that then goes on to feed something else, or it becomes the end product that we're using of a metabolite, like short chain fatty acid, for example. So what happens when people have very, very low diversity or very low species count is this cross feeding cannot really happen. And whether that's in the large intestine or the small intestine, it's the same. The cross feeding can't happen. And so I think that's really going to be where the research is going to really explode a lot.

 

Nirala Jacobi:

Like what actually happens? How are they talking to each other? How are they feeding each other? And if you're missing key components of your microbiome, keystone species, we end up with a lot of these food intolerances that we see, like histamine and like things like solicit sensitivity and oxalates and all of that. So that was really what fascinated me the most.

 

Nirala Jacobi:

And because I do a lot of stool testing, where I assess the number of species, let's say the average number of species, you might be surprised, is actually only about 150 to 200 species that we have on board these days. Maybe when we were in the paleolithic age, we had way more because we had to handle different scenarios with our food. But now, because of the industrial revolution, where there were a lot of different factors that influenced our microbiome diversity besides antibiotics, the average person that is tested only has about 150 to 200 species. And then when I test people that have this scenario that I mentioned, where their test is SIBO test is negative, very high percentage of these people have extremely low bacterial diversity in their microbiome, where they have less than 100 species, potentially. So what does that do to the cross feeding.

 

Nirala Jacobi:

And what are we doing with continued SIBO treatment? So this is more like a public service announcement. For practitioners to stop continually giving people antimicrobials without really understanding what's happening in the large intestinal microbiome really is my thought with this.

 

Allison Siebecker:

And have you found the scary thing that we're all worried about and often hear is that once something's gone, it's gone and you can't get it back. And so what have you found when you address the low species? Because I know you've worked a lot on this.

 

Nirala Jacobi:

Yeah. So the key species would be faecalibacterium prausnitzii, which is one of the firmicutes bacteria that basically in some people comprises 15% of their microbiome. And it's a key butyrate producer. And some people just have nothing. So it's difficult.

 

Nirala Jacobi:

You have to kind of. Well, let me back up. When it says not detected on a stool test, that doesn't mean it's not there. It is just below detectable levels that the lab dictates. So you could have just a vapor of something and you could potentially regrow that.

 

Nirala Jacobi:

It is difficult when you have very low counts. And this is where I think the fecal microbiota transplants that are now coming forth with capsules and things like that, I think that's going to be the next frontier for probiotic supplementation, is actually using fecal microbiota transplant in capsules. Very likely that's coming very soon. It's already happening with certain species and for the treatment of C. Difficile, for example.

 

Nirala Jacobi:

But other species like Akkermansia, which is an organism that lives in the mucosa and is a very important mucosal regulator, and other roseburia, other species that are just key. It can be done. You have to be very patient. It's like looking at a piece of land that has been completely denuded and just weeds are growing all over the place. And if all you ever do is kill the weeds, you're not really fostering the growth of beneficial bacteria.

 

Nirala Jacobi:

So that's really what I'm interested in, is fertilizing the soil and seeing what wants to come back. And it's not undoable. It can be done. It just takes patience and understanding of what you're looking for.

 

Allison Siebecker:

That's really encouraging to hear. And it also sounds like you're not saying we can't use antimicrobials because we often do sometimes need to. It's just to balance that with this other sort of perspective of helping the microbiome to come back.

 

Nirala Jacobi:

Yeah. And I had this one really interesting case where, well, I see a lot of patients that have had multiple treatments of whether it's antibiotics or long term herbal medicine treatments for SIBO. And the first thing I do is I check their microbiome. And I had one case where I had tested that patient and then had fairly good or, no, she had been tested by another practitioner that then gave her a treatment protocol, but she decided to just source these products from the Internet from some other, I don't remember, like some outfit. And there were Chinese medicine herbs, and I love Chinese medicine, don't get me wrong.

 

Nirala Jacobi:

But this was like something that I'm convinced it had antibiotics in it, because I tested her afterwards, and it was shocking to see how much her microbiome was affected by these herbs that we don't normally see. We don't see herbal medicine be that catastrophic to a microbiome. So this was just my, I often tell people, do not buy products that aren't professionally endorsed or the good manufacturing principles, the GMP stamp and so forth. So that's a whole another topic is quality supplements for sure, but it's not that often. I see that.

 

Nirala Jacobi:

But yes, herbal medicines can also affect the microbiome, but much, much less so than antibiotics. Even with oregano oil. Yes. If somebody has a lot of imbalances and very low bacterial count, very low diversity, I might opt not to do oregano oil. And it's good to know that beforehand, but I haven't really seen it be completely catastrophic on a microbiome, to be honest.

 

Allison Siebecker:

That's very good news. Yeah. I mean, one thing that's interesting, I know that you've looked into small versus large intestine microbiomes. One thing that I find very interesting is some unpublished results from Dr. Pimentel with rifaximin.

 

Allison Siebecker:

Now, I know, we know rifaximin is not a typical antibiotic, so we really wouldn't want to quite lump it in with all the other antibiotics in the same category. But he's doing small intestine microbiome mapping, which had not previously been done, just large intestine had been done because he had to develop actually special instrumentation and such to be able to do it. And it's been fascinating, all the results he's had. But one of the things he did was he looked at microbiome profiles of people with Sibo before and after, compared to normal people without Sibo. Although I always wonder how do you really find these healthy controls.

 

Nirala Jacobi:

Exactly.

 

Allison Siebecker:

Compared to normal or healthy controls. And what he saw was after treatment with rifaximin. And these were people who had hydrogen type SIBO, okay, not methane or hydrogen sulfide. Their microbiome profile for the small intestine came back to looking like healthy controls. So I thought that was absolutely fascinating and put my mind at ease even more about rifaximin.

 

Allison Siebecker:

Problem is, sometimes we have to use other antibiotics along with. Which are not as careful and beneficial as rifaximin is. But I thought that was really very interesting. It's unpublished, but he's shown these slides in many of his presentations.

 

Nirala Jacobi:

Yeah, I think that the whole science of microbiome. Well, the whole microbiome science is absolutely fascinating because there's so much we don't really know yet. And there's so much of modern living practices that affects our microbiome. From the food we eat to the stress we have. Even adverse childhood events really affect our microbiome to ongoing stressors.

 

Nirala Jacobi:

It's just ubiquitous. And it's really interesting to see how science will actually investigate a lot of these factors. But yeah, the cross feeding was, to me, I think, some of the most fascinating aspects because I never really thought about it. I thought it was like these are just bacteria that are fermenting things. And then we absorb the things that they produce and that's the end of it.

 

Nirala Jacobi:

But this whole community aspect makes a lot of sense to me because obviously it's an ecosystem. Just like we have an ecosystem outside of us, in our forests and our oceans, everywhere are things that are symbiotically living together and work together. And I think to some extent, we've affected our microbiomes so much since the industrial revolution that. Yeah, who has a normal microbiome anymore? It's the good question.

 

Allison Siebecker:

Yeah, maybe there are some places, maybe. But it's also a really interesting question to think about what you started out with. So what do we see in people who have a negative SIBO test? Truly negative. And it brings to point something interesting, because it's really a matter of where we decide to look.

 

Allison Siebecker:

With a list that long, you're not going to look at everything. Obviously, history and other factors about the patient will help guide us where we're going to look. But really, it's like, I think our answers could be dependent upon where we've decided to look in these 40 other conditions. 40 other plus conditions. And where I've tended to look is large intestine, not so much microbiome, but overgrowths like yeast or parasitic.

 

Allison Siebecker:

And that can also, of course, be in the small intestine as well. So that's probably something I've seen a lot, but I have not done microbiome testing, so I haven't looked. Right. And then there's all these other things that I don't check for, but I send people on and refer them to be checked for. Right.

 

Nirala Jacobi:

Yeah. I mean, nowadays, with biohacking and hacking, this hack, you that. I think the microbiome has always been really fascinating to people with gut issues, and there's a lot people can do. I wanted to loop back to what you said about Pimental studies on the small intestinal microbiome. And we now know that in a Sibo scenario, we have Klebsiella and E.

 

Nirala Jacobi:

Coli. That's usually what's causing hydrogen elevation in a SIBO case, and Fusobacteria or Desulfovibrio in cases of hydrogen sulfide. And we see the same thing in the large intestine. Also, we see a lot of Klebsiella and E. Coli in cases of LIBO, or large intestine, bacterial overgrowth.

 

Nirala Jacobi:

And these are two normal species that we often see. But when they overgrow and are not kept in check like a weed, that's when we start to see problems that can also mimic SIBO. But to be honest, if somebody has had a long Sibo treatment that would also address bacterial overgrowth in the large intestine, it's not. That wouldn't be my first thing, is that they have LIBO. It's more that they have a deficit of these bacterial connections and that there is lack of cohesion in their microbiome.

 

Nirala Jacobi:

And because we're all sort of new to this idea of bacterial connections and communities and cross feeding, we're all learning together. We're learning as we go along as to how to really reestablish these bacterial connections and what the key drivers are.

 

Allison Siebecker:

Yeah. Like those keystone species and such.

 

Nirala Jacobi:

Yeah. It's so fascinating. It's been a passion of mine for a long time, microbiome science. And so it's been really rewarding to read some of the newer studies on what's really going on there. And I'm also curious to see small intestinal microbiome science that's not necessarily Sibo based.

 

Nirala Jacobi:

I think there's more to the story in terms of lactobacillus and other species that. Anyways, I'm fascinated with the whole thing.

 

Allison Siebecker:

Yeah. And on that note, something that's so interesting that came out of Dr. Pimentel's research that is on Sibo for the small intestine microbiome is know the hydrogen type of SIBO has reduced diversity as we would expect but the hydrogen sulfide actually has increased diversity in a way that is not in balance. And that was new to me. I've only ever heard of people speak about the problem is decreased diversity.

 

Allison Siebecker:

And I thought it was fascinating when this new thing came out. It's like, well it sure makes sense either direction off of center of what is healthy is going to be an issue. So yes there's going to be a lot more, I mean so much more is going to be coming out of those studies and I know that they look at other diseases as well which is fascinating. I know that they also have an emphasis to look at diabetes a lot because Dr. Pimentel's wife I don't know if this is why but is a diabetes expert and is involved in a lot of their studies.

 

Allison Siebecker:

So that's really fascinating to me to was just on this topic of the microbiome. I recently basically commissioned a masterclass from Dr. Lynn Patrick who is an environmental medicine specialist. And as I was listening to her discuss all of the different toxicants there were really like three things that stood out that they basically disrupt as a pattern. And the microbiome of course is the main one.

 

Allison Siebecker:

What do we mean? Plastics and BPA and all the different glyphosate, all of the so many different categories of environmental toxins that we're exposed to the microbiome. And the other one was obesity and metabolic issues which of course directly connects to the microbiome. So I thought that was very fascinating and a very interesting thing to look at.

 

Nirala Jacobi:

Yes, I mean look, that's a whole other topic for sure. That is very much linked to microbiome science. And yeah, she's amazing. She definitely has contributed a lot to this field. Yeah.

 

Allison Siebecker:

And on that note interesting because I wanted to know she has a lot to contribute towards what she thinks about Sibo and toxin relationship. And basically she thinks that you really should be treating for toxin exposure to help your Sibo treatment go better and to help it hold. And I think that's really fascinating.

 

Nirala Jacobi:

Yeah, I'm trying with my menopausal brain to think if I had her on the podcast. I know I have talked to her about coming on the podcast when I saw her last at the ANP and stuff because I was really interested in environmental medicine 20 years ago. I studied with Walter Crinnion.

 

Allison Siebecker:

Me too.

 

Nirala Jacobi:

Yeah, great. So we share that interest. Yeah, that would be a great, actually, podcast guest. Thanks for reminding me. I got to go back in the archives.

 

Nirala Jacobi:

Have I done this already?

 

Allison Siebecker:

She is absolutely fascinating.

 

Nirala Jacobi:

Yeah, she's great.

 

Allison Siebecker:

Yeah. I wanted to come back to this other topic you mentioned that is, I think, of real interest to me as well, which is the scenario that you said of where someone did have Sibo. They tested positive. They really had Sibo. You treat it, and the test becomes negative, but they still have the symptoms.

 

Allison Siebecker:

Putting aside, oh, fiddling around with the substrates. Oh, might they have hydrogen sulfide that you haven't tested for? Putting that aside, let's say the SIBO is truly gone. This is something that a lot of people and practitioners struggle with, and it can be really confusing. And there's kind of, like, two things I think about here.

 

Allison Siebecker:

But one of the main things is, I think it's important for us to remember that Sibo is caused by something. And, like, 70% of the cases, 60 70% of cases are chronic. So that would mean that there is still the cause there. The underlying cause of SIBO is still present, and it's good to remember that those underlying causes can cause gastrointestinal symptoms of their own by themselves, without even SIBO being present. A good example is endometriosis.

 

Allison Siebecker:

Obviously, that causes abdominal pain and bloating, nausea, vomiting from the pain. Often, if SIBO isn't there just from the endometrial tissue, swelling or something like adhesions, can do the same. Bloating, pain, discomfort, things like low hydrochloric acid, which we were talking about before, which so many people have, I don't think of that as a main cause of SIBO, more so a contributing compounding factor. But so many have it that will create symptoms, as we discussed earlier. So, just a good thing for us all to remember is that we may not know what the underlying cause is, but if somebody is struggling with ongoing Sibo, so, for instance, they're in remission for their SIBO, but they still have these symptoms.

 

Allison Siebecker:

Well, what caused it in the first place? So that's one scenario I just wanted to bring up.

 

Nirala Jacobi:

Yeah, sorry.

 

Allison Siebecker:

No, you go ahead.

 

Nirala Jacobi:

Well, I just wanted to just remind the listeners that I've done several episodes on the podcast about underlying causes of Sibo, and there's different categories of underlying causes. Sometimes it's difficult to work out what your underlying cause is, but if you have sort of a roadmap to understanding where to go with it, I think that's helpful. So just go back in the archives of the podcast about the different underlying causes of Sibo.

 

Allison Siebecker:

Brilliant. Yeah. And then the other scenario is that there's another disease present that creates similar symptoms. Like we just discussed, all the differential diagnosis, all the other situations, patients can and often do have more than one thing going on at the same time. And what's really confusing about this for a lot of people is to think the fact that, well, that means that the Sibo wasn't the main driver of the symptoms, because if the symptoms are still there, but the Sibo is gone, and that can happen, you can think you found what's causing the symptoms, you get rid of the SIBO.

 

Allison Siebecker:

I guess it wasn't the main driver of the symptoms. Sometimes I can say that what I saw a lot of was there are symptoms that are reduced, but they're not all gone. So getting rid of the Sibo took care of something, maybe one or two symptoms, but there's still one or two left. And sometimes those are the main concerning symptoms to the person. So they feel like nothing's better, and it could be anything that's left.

 

Allison Siebecker:

But I have to say, what I hear amongst my colleagues and what I saw a lot would be leftover bloating. Residual bloating is very common and mysterious in many cases, and it can confound a lot of people. And then we just have to work down that differential diagnosis list, basically, to see what else it could be.

 

Nirala Jacobi:

Yeah. And I think, just speaking to practitioners now that are very well versed in Sibo, perhaps, I think by the time you have done the test for Sibo or the repeat test, and the test is negative and person is still symptomatic, hopefully you've done some other ancillary testing, especially blood tests, to look for hypothyroidism and all these things that are not hard to rule out. So we're not saying you have to go on this year long quest to find, to ferret it out. It can all be done. The big ones can be ruled out.

 

Nirala Jacobi:

The diabetes, the hypothyroid Ehlers Danlos is a little more tricky, obviously. But even there, I would say that's then potentially a motility issue. So there are all these different nuances to finding what's wrong. But I think by get a good stool test, that looks for some of these digestive deficits and microbial deficits that already can help you a great deal with understanding what it is not, in a way, what is it, what it is or not, or even just a trial of hydrochloric acid. If the symptoms are suggestive of that, which is usually sense of fullness after high protein meal, and a lot of belching can happen.

 

Nirala Jacobi:

And those, I'd say, are the more classic symptoms of hypochlorhydria or low stomach acid. So, yeah, there's a lot to think about with the Sibo imitators, but we've known that before we ever got into Sibo, that there's a whole host of things that can cause digestive issues where you have to look at the digestive function a little bit more closely. So I think this is just dovetailing onto that.

 

Allison Siebecker:

Yeah, it's been sort of like a bugaboo about mine, of mine.

 

Nirala Jacobi:

As a.

 

Allison Siebecker:

Pattern for primary care physicians and gastroenterologists. As a pattern. I'm not signaling anybody out, and I know there's wonderfully trained and practicing people, but it has bothered me how much somebody who says, I have IBS or I have IBS symptoms or they say has IBS, how poorly they're investigated, and often there is no investigation at all.

 

Nirala Jacobi:

Or refusal to do Sibo testing. I hear this all the time from patients that have gone to gastroenterologists and have been ridiculed. And so this is just so not on. People are still experiencing that level of poor bedside manner from doctors. It's not on.

 

Allison Siebecker:

Because I had IBS. I guess that's what it was called for my whole life, with no one ever really trying to figure out what was going on, because what the training is, oh, if it's IBS, basically, we don't know. And then you're just given the diagnosis of IBS because you have the symptoms. So it's sort of like, well, what causes IBS? Well, we just went over all the things that could be a cause of it, because it's primarily just diagnosed by symptoms, and it's just a very frustrating situation for anyone suffering from those symptoms.

 

Allison Siebecker:

How so many practitioners will not check for those things. And as you said, what's easy? A physical exam, which would include bite and score for Ehler Stanley's physical exam, screening, blood work and stool testing, and SIBO testing. And, boy, you've covered so many bases.

 

Nirala Jacobi:

Right? Yeah, exactly. That's, I think, 90% right there. Because the other causes are more. Yes, endometriosis.

 

Nirala Jacobi:

You'd know if you have other symptoms besides IBS. As a woman, you have lots of other symptoms if you have endometriosis. So following that breadcrumb might not be too difficult to do. Same with hypothyroid diabetes, that type of thing. I'd say the biggest other imitator of where tests are two scenarios.

 

Nirala Jacobi:

Tests are either negative and you have the symptoms of Sibo, or you cannot get rid of Sibo no matter what you do. It would be mold.

 

Allison Siebecker:

Yeah, we haven't talked about mold.

 

Nirala Jacobi:

Yeah, mold is covered. I'll just tell you. Episode 84 and 85 and 54 with Dr. Jill Krista. So, yes, that is ever present now also with lots more events of flooding in people's, especially here in Australia, we have just had nothing but rain this.

 

Allison Siebecker:

Terrible.

 

Nirala Jacobi:

Yeah, lots of flooding and people. Now we're facing another La Nina. So we're expecting more rain next year or later this year. So it is something that's happening as the climate is changing, more humidity and more. Obviously, that's not everywhere on the planet, but some places don't have mold, but even in places that are very arid.

 

Nirala Jacobi:

I had somebody at a patient in Palm Springs have a hidden water leak and have massive mold problems. So don't ever rule it out just because you live in the desert.

 

Allison Siebecker:

Yeah. And the key thing is often you don't see it. People go, I don't see any mold. It's often behind walls or in places you can't see in attics or crawl spaces. I agree.

 

Allison Siebecker:

I believe it's ubiquitous. Like you said, it's not going to be absolutely everywhere, but it really has become, I would say, the dominant, overwhelming issue for me and us as Sibo practitioners. It's really so ubiquitous, and it makes it such that you can't treat Sibo very effectively. And it isn't the primary issue either. So you have to treat the mold first to really get anywhere, 100%.

 

Nirala Jacobi:

And that's what I usually tell patients. It's like, we got to do this first. So there's a real sort of like, what's the word I'm looking for? Anyways, there's a whole protocol of how to approach mold and then SIBO. So that's covered in these other episodes, but that is something that I've frequently found in that.

 

Nirala Jacobi:

And also those people have dysbiosis, large intestinal bacterial imbalances that contribute to this, where if you have a lot of metabolites that increase your. If you have a lot of absorption of LPs, for example, or lipopolysaccharide, which is a highly inflammatory substance that is produced by these gram negative bacteria, that just drives inflammation. That's another scenario where we see a lot of systemic symptoms, and not just mold, but other things.

 

Allison Siebecker:

When we say mold, we mean mycotoxins as well, the language.

 

Nirala Jacobi:

Yes, sorry.

 

Allison Siebecker:

Yes, of course.

 

Nirala Jacobi:

Very true, very true.

 

Allison Siebecker:

And can we just touch briefly on the histamine issue, because so many with mold, really what that then creates is histamine issues, and then that can create symptoms similar to Sibo, of course. But it can also make treating Sibo difficult because people are having histamine reactions to things we give them. And this can be such an issue with probiotics. And then there are people who say, oh, well, there are non histamine triggering probiotics, and then there are people who will still react.

 

Nirala Jacobi:

Yes, and I understand why that would happen because it's actually, in my research about this, I think it's really good marketing from companies to say, oh, these don't produce histamine. It's more about your microbiome that has species that can upregulate their histamine production under certain scenarios. Do you know what I mean? So it's kind of cheeky to say, well, these are strains that don't produce it. Well, maybe in certain scenarios they don't, but everybody has a unique situation, and some probiotics that some will react to, others won't, even though they both have histamine reactions.

 

Nirala Jacobi:

So I really learned that there is a lot of very good marketing to these are good for histamine reactions. That being said, I usually stick with single strain probiotics or definitely not multistrain probiotics. That is just like ten different species or strains. You want to kind of keep it simple when that happens. But there are lots of different reasons why histamine can be elevated, not just the microbiome producing it, that's for sure.

 

Allison Siebecker:

In fact, earlier we were talking about chronic hidden sinus infections. But before, if we even talk about that, I wanted to ask, do you find certain probiotics are, as a pattern, generally tolerated, more tolerated for people with histamine over another, or do you find it completely individual?

 

Nirala Jacobi:

To some extent individual. And again, this is based, what I do is stool testing with a particular lab that I talk about in my microbiome course. But basically it looks at the microbiome as a whole, and it actually can measure histamine production by the microbiome or the genetic potential of histamine production. That's one of the reasons I really like this particular lab. And listeners of this podcast will have heard me talk to somebody from Microba here in Australia, and it's a really great test that also tests for LPs.

 

Nirala Jacobi:

Like I said, histamine also looks at, I think, serotonin and lots of different metabolites. That's really its claim to fame and species count. Right. A lot of labs don't give you how many species of bacteria you have. So this gives you sort of a sliding scale.

 

Nirala Jacobi:

But the three reasons of why histamine is often elevated microbiome production is one, but loss of diamine oxidase is another. And as we know, mass cell migration into this gut wall is another. So there are different reasons why people react to different things. I would say very good.

 

Allison Siebecker:

Yeah, I can say. I would also agree that it's very individual, as I sort of indicated. Sure. You can try the probiotics that they say, oh, no, it's not going to bother anyone with histamine, and then it very well may. But I would say that I have found bifidum species as a pattern.

 

Allison Siebecker:

Some can be better tolerated as a pattern, but not. And it kind of depends on which.

 

Nirala Jacobi:

I find soil-based organisms also very helpful, like very nonreactive in general. And what you're trying to do there is the purpose of that particular bacillus, for example, is to increase key species like faecalibacterium. But in my research about histamine, why do probiotics or why do bacteria produce histamine? Is often to be able to be more acid tolerant. So, whenever acidity increases, which is really interesting because acidity can increase with lactobacillus, it increases lactic acid.

 

Nirala Jacobi:

Then also that may be what you're talking about, why Lactobacillus might be more reactive all of a sudden, other species might increase their histamine production and also other acidity situations. So, it's interesting, it's so much more complex than just taking this probiotic and it'll help you with histamine. It just doesn't work that way. I find.

 

Allison Siebecker:

My little plug is considering chronic sinus infections. Tell us more. It's a personal interest of mine because I've seen my husband suffer with it for so very long. Even in my own self, when I've had sinus infections, I can easily detect I'm having histamine reactions. I'm more sensitive in general to supplements and foods and can't tolerate histamine foods as well.

 

Allison Siebecker:

When the sinus infection is gone, I can tolerate it better. And I think that would go for any infection. I mean, it's inflammatory, it's unbalancing the immune system. Yes. But I have a keen interest in sinus infections that are hidden from view and detection behind compressed walls of the terminates and things.

 

Allison Siebecker:

As I was describing to you. My husband went through a very interesting scan and treatment and procedure with an endoscope in his nose. It's not really an endoscope when it's in your nose, though. A sinuscope. I don't know.

 

Nirala Jacobi:

Yeah, right. Nasoscope.

 

Allison Siebecker:

Nasoscope, where we were able to uncover areas that had been sealed away with infection underneath. So, it's a whole other topic, but it's one that I'm keenly interested in.

 

Nirala Jacobi:

I think I did interview somebody about dental issues and sinus issues because that is absolutely a big driver of hidden chronic illness. Not just gut issues, but chronic fatigue and immunodeficiency issues and stuff like that. I definitely have seen that firsthand and always investigate if there are, especially if there's lots of root canals present, because that can also cause hidden infections in the jaw and then, of course, the whole mold issue in the sinuses and so forth. But, yeah, that sounded really, I'm very happy for your husband to have his life back in a way what sounds like really miraculous, his turnaround.

 

Allison Siebecker:

Yeah, absolutely. I'm thrilled myself, of course.

 

Nirala Jacobi:

Well, Allison, I think we covered a lot of the Sibo imitators and kind of dove into some of these other aspects of what somebody might be going through. And hopefully people will find this helpful because we can all continually learning about other aspects of Sibo. And is it Sibo or not Sibo? So, thank you so much for your time. Do you have any other last minute additional comments to make?

 

Allison Siebecker:

No, no. Just thank you so much for having me back as a guest. It's always so nice to chat.