A New SIBO Test for IBS with Dr. Elroy Vojdani: Rational Wellness Podcast 62
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Dr. Elroy Vojdani speaks about Small Intestinal Bacterial Overgrowth (SIBO) and Irritable Bowel Syndrome (IBS) and a new serum antibody test for SIBO with Dr. Ben Weitz.
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6:07 A 2017 review paper demonstrated that there is a very wide range of patients with IBS who test positive for SIBO on breath test, from 4-78%. I asked Dr. Vojdani why he thought there was such a wide variation in test results? Dr. Vojdani explained that there is no standard definition of what IBS is and the breath test is complicated to perform and requires important pretest procedures in terms of diet and avoidance of certain medications. Also the breath test is a complicated set of procedures to perform and it requires being focused for three hours. And you can use glucose or lactulose as a substrate for the breath test, each of which will give you different results. And there is also controversy as to how to interpret the breath test results among the experts and there are several different consensus reports on how to interpret it. Dr. Vojdani estimated based on the research and his clinical experience that approximately 60% of patients with IBS have SIBO.
10:39 I asked Dr. Vojdani what role stress plays in IBS? Dr. Vojdani does feel that stress plays a big role in many patients with IBS. I pointed out that the small intestine has a lot of serotonin receptors and if you prescribe an SSRI for a patient with IBS to help with stress, that SSRI, by increasing serotonin, may be increasing the motility of the small intestine, thus helping with SIBO. On the other hand, Dr. Pimentel does not think that stress has much to do with IBS and he argues that our flight or fight stress response does not involve suddenly having to go to the bathroom. If you are out on the Savannah trying to run away from a lion, the last thing you’d want to do is to have a bowel movement right then.
14:48 Under normal circumstances the following mechanisms prevent bacteria from migrating back up into the small intestine from the large intestine: 1. Acid production in stomach, 2. Bile secretion into the small intestine from the liver and gall bladder, 3. Pancreatic enzymes, 4. The immune system is centered within the mucosa of the small intestine, 5. Ileocecal valve, 6 Migrating motor complex cleansing waves of peristaltic contractions.
17:55 Dr. Pimentel developed a way to diagnose SIBO with a blood test–a serum that that measures anti-Cytolethal Distending Toxin and anti-Vinculin antibodies. Dr. Pimentel’s concept is that SIBO often starts with a bout of food poisoning that results in a release of Cytolethal Distending Toxin (CDT) from the bacteria that causes food poisoning (often Campylobacter Jejuni). The immune system mounts an attack on the CDT and then via molecular mimicry, the immune system damages structural proteins in the intestinal wall (Vinculin), which affects the nervous system of the small intestine that produce the cleansing waves (the Migrating Motor Complex, aka, MMC). This results in SIBO. What this means is that IBS is essentially an autoimmune disease.
21:50 Elroy and his dad, Dr. Aristo Vojdani, looked at Dr. Pimentel’s research and noted that his test could not help in diagnosing the constipation subtype and even in the diarrhea and mixed subtypes, the sensitivity is only about 60%, which is good but not great. The Vojdani’s also noted that Pimentel’s test only looked at IgG antibodies, while the primary immune complex in the gut is IgA. So they developed their test looking at IgA, IgG, and IgM antibodies to Cytolethal Distending Toxin the sensitivity of the test that the Vojdanis developed for Cyrex Array 22 has a sensitivity of about 88%, based on their validation data.
25:47 Dr. Vojdani explained that if you are positive with their SIBO/IBS antibody test that this indicates an autoimmune subtype of this disease and this indicates that these patients have broken their oral tolerance, which is a major breakdown in the way that their immune system functions. And if you don’t do significant work to restore the oral tolerance in that patient, the patient will never get better or they will get better but they will relapse. In order to restore oral tolerance, Dr. Vojdani suggested that some research shows that high dosages of vitamin A, vitamin D, vitamin K, and probiotics may all help with this. And there’s a lot of really fascinating research being done into the use of helminths as a mechanism to restore oral tolerance. Helminths are the therapeutic use of parasitic worms. Low Dose Immunotherapy also holds some promise as a therapeutic option in restoring oral tolerance.
Dr. Elroy Vojdani is a practicing Functional Medicine doctor in the Brentwood section of West Los Angeles Regenera Medical and can be reached at 424-256-0272. His website is https://www.regeneramedical.com/ The new SIBO antibody test that he developed with his dad, Dr. Aristo Vojdani, is available at Cyrex Labs https://www.joincyrex.com/the-cyrex-system/array-22-irritable-bowel-sibo-screen
Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.
Dr. Weitz: This is Dr. Ben Weitz with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition. From the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube and sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health. Hello, Rational Wellness podcasters. Thank you so much for joining me again today. I’m very excited to be talking to Dr. Elroy Vojdani. And we’re going to talk about irritable bowel syndrome and small intestinal bacterial overgrowth. For those of you who enjoy the Rational Wellness Podcast, please go to iTunes and give us a rating and review so more people can find out about the Rational Wellness Podcast.
So our topic today is about irritable syndrome, irritable bowel disorder, or irritable bowel syndrome. And otherwise known as IBS. And this is the most common gastrointestinal disorder. It occurs in up to 15-20% of the US population. And irritable bowel syndrome is a condition marked by gas, bloating, abdominal discomfort, constipation, diarrhea, alternating one and the other, as well as a range of other symptoms. Traditional medical treatment has been composed of medications for controlling symptoms. IBS is generally being considered to be a stress related condition with no known cause. However, a number of years ago, Dr. Mark Pimentel … This was about 10 or 15 years ago … from Cedars-Sinai became the first one to discover that small intestinal bacterial overgrowth or SIBO is actually the cause of IBS in up to 78% of cases. SIBO consists of bacteria that normally grow in the colon or the large intestine. And then those bacteria start to grow into the small intestine which normally is mostly free of bacteria. The gold standard for diagnosing SIBO is finding more than a small amount of bacteria upon jejunal aspirate. I know that’s a complicated sounding name but what that means is if you were a gastroenterologist and you were doing an endoscopic exam where you stuck a tube down someone’s throat, when you get to the part of the small intestine known as the jejunum, you scoop out some of the liquid and then you analyze it via a culture. And if you find bacteria, more than a small amount, this is a positive indication of bacterial overgrowth. However, this test is very invasive and is not regularly done in clinical practice. It’s basically done in research and by a very small number of clinical gastroenterologists. So Dr. Pimentel developed a breath test using either lactulose or glucose or other substrates for diagnosing small intestinal bacterial overgrowth in which the patient ingests the substrate, the lactulose, which is a fermentable fiber. And then, they blow into these tubes and then the tubes are measured for hydrogen or methane gas. And this is now a very common way for functional medicine practitioners to diagnose small intestinal bacterial overgrowth which often is the cause of IBS.
Dr. Pimentel also developed a serum antibody test. He called it the IBS check test. And now it’s offered by Quest as IBS Detect Test. And it’s done specifically for IBS with diarrhea or IBS mixed. But it’s not indicted for IBS with constipation. Recently, Dr. Elroy Vojdani and his dad, Dr. Aristo Vojdani, developed a new serum antibody test available from Cyrex Labs that’s a number of steps more sophisticated than the IBS Check Test. And this is why I’ve asked Dr. Elroy Vojdani to talk with us today about IBS, SIBO, and the state of testing for this condition.
Let me introduce Dr. Vojdani. He’s the founder of Regenera Medical, a boutique functional medical practice in Los Angeles, California. Dr. Vojdani is the son of Dr. Aristo Vojdani, the father of functional immunology. And he is one of the most important doctors in a functional medicine world and he developed all the testing offered by Cyrex Labs. Elroy began his medical career as an interventional radiologist diagnosing and treating complex late stage cancers and other extremely debilitating diseases. But he really wanted to prevent these chronic conditions so he embraced functional medicine and now he’s in private practice utilizing that paradigm. Dr. Vojdani has also co-authored over 15 articles in scientific literature and continues to be involved in research in autoimmune and other medical conditions. Dr. Vojdani, Elroy, thank you for joining me today.
Dr. Vojdani: Ben, it’s my pleasure. You and I have known each other for a little while now and I’ve always enjoyed our conversations. So it’s great to be here with you.
Dr. Weitz: Good, good, thank you. So irritable bowel syndrome, as you know, is a very common condition. There was a review paper in 2017 that demonstrated that there was a pretty wide range of number of people with IBS who test positive for SIBO. That paper indicated, based on a review of literature, that there was anywhere from 4-78%. In fact, Dr. Pimentel’s paper actually found 84% of patients with IBS testing positive for SIBO. Why do you think there’s such a wide variation in results from these studies? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5347643/
Dr. Vojdani: It’s a really fascinating topic because on one hand, you have IBS which is this collection of clinical symptoms. Very common clinical symptoms. Urgency, constipation, diarrhea, alternating between the two. It’s something that many human beings experience. So IBS is this collection of symptoms. And then, when we talk about SIBO, we’re talking about this specific quantitative and qualitative dysbiosis that you mention where you have an overgrowth of bacteria in the small intestine.
Dr. Weitz: And by the way, can you explain what dysbiosis is?
Dr. Vojdani: Yeah. So dysbiosis is an alteration in some way of the gut microflora, the bacteria, viruses, and parasites that live in a symbiotic relationship with us in our gut. So when we talk about dysbiosis, it’s an alteration either in the number of those bacteria or in the type of those bacteria. And SIBO is actually both, right?
Dr. Weitz: Correct.
Dr. Vojdani: So essentially what was going on in the research world in the last 20 years was that we were discovering that this very common set of symptoms that we call IBS was starting to correlate very often with this type of dysbiosis that we call SIBO. So as you mentioned, the numbers as to the overlap between the clinical condition IBS and the dysbiotic condition, SIBO, were all over the place from as you mentioned 4% all the way to 84%. Some of the reasons for that is that how we classify IBS, there’s a very wide range. There are Rome I-IV criteria. There are other criteria. Outside of Rome criteria. So it depends how you …
Dr. Weitz: The North American consensus.
Dr. Vojdani: Exactly. So we don’t have a firm idea as to what we call IBS. We also have various different ways of detecting SIBO so you can do jejunal aspiration, as you mentioned. You can do breath testing. And in breath testing, there are several different ways you can do that either with glucose or lactulose as you mentioned. And then, there’s different diagnostic criteria for what those results are on the breath test. So basically, we have no standard definition of IBS and we have no standard way to diagnose SIBO. Put that in the mix with a bunch of geographic variations and you get a number that’s all over the map as to where the overlap exists between those two.
Dr. Weitz: I think another factor probably has to do with when you have a test that has to be performed by a patient. They have to follow a very specific dietary regiment for a day. And you know, it’s not easy to follow the specific protocols. The patient has to properly breathe into these tubes. They have to do it every 20 minutes. And this requires being really focused for three hours. And I’m sure that there’s a lot of variation in the way that the test is actually performed.
Dr. Vojdani: Yeah, absolutely. And each individual practitioner has their own unique instructions for their patients as to how to prepare for a breath test. And many have their own unique way of interpreting a breath test. So again, there really is no standard there that exists in how we diagnose SIBO via breath testing. So we get massive variation.
Dr. Weitz: So if you had to guess just from what you know, what would you say percentage of patients who have IBS who actually have SIBO?
Dr. Vojdani: I think it’s closer to the 60% mark personally. That number seems to make sense. IBS, we like to think of it as this one condition and I’m sure as we’re going to continue to talk about, it’s likely a collection of different disease processes that all have very similar manifestations.
Dr. Weitz: Right. What role do you think stress plays in IBS?
Dr. Vojdani: I think stress … Let’s go back in time 25 or 30 years ago when we would talk about IBS and IBS was this condition that we talked about as being entirely genetic and stress as being the only two factors that played a role, right?
Dr. Weitz: Right.
Dr. Vojdani: So we would treat people with some lifestyle intervention. Tell people to avoid spicy food and coffee. And if we were really inclined, maybe we’d prescribe an SSRI or maybe some benzodiazepines to remove the stress component from this disease. It certainly plays a big role. There’s no doubt about it.
Dr. Weitz: And by the way, it’s kind of interesting that if you look at SSRIs, which increase serotonin production, the small intestine actually has a large percentage of serotonin receptors and so if you prescribe an SSRI and you increase serotonin production, you may be increasing the motility of the small intestine. So it may be that those antidepressants were actually having a beneficial effect.
Dr. Vojdani: So interesting, right?
Dr. Weitz: And not just psychological. Yeah.
Dr. Vojdani: We didn’t even know really that there was an enteric nervous system that existed in the gut when we were prescribing SSRIs. And many people do actually respond well to SSRI prescription when you’re trying to treat IBS. So we didn’t know why it worked. We thought we were treating the brain but it turns out there was some treatment to the gut that was going on.
Dr. Weitz: Right, right, right. Now Dr. Pimentel has another take on that whole stress issue. He feels very strongly that stress is not a reasonable explanation for IBS in a lot of cases.
Dr. Vojdani: Yeah. So I think it’s really important to understand that as we’re really learning more about the mechanism in which IBS occurs in individuals that we’re discovering that there’s an autoimmune or auto inflammatory component to this for many people. And when you just zoom out a little bit and maybe talk about IBS and the autoimmune and auto-inflammatory world, it’s really impossible to deny that stress plays some role in the initiation of autoimmune auto-inflammatory disease for people who have the genetic predisposition for it. It’s not a 100% factor the way we talked about it 25 years ago but I think it’s undeniable that it plays a role.
Dr. Weitz: Right. But I remember when we talked to Dr. Pimentel when he attended our meeting. I thought he made a really profound point which is when you look at it evolutionarily, if you’re out in the Savannah trying to run away from a lion and that’s the typical example of somebody who’s under high stress, last thing you’d want to do is having to have a bowel movement right then when you’re trying to run away. It doesn’t seem to make sense that that would be a normal stress response.
Dr. Vojdani: Yeah. I respect Dr. Pimentel a tremendous amount. His research is incredible and he gave a great talk but I think using an analogy in our paleolithic times is very difficult because we’re really seeing this massive epidemic in modern times of autoimmune and auto-inflammatory disease. I think because our lifestyle has migrated so much from where we were a couple thousand years ago and our body, our genetics, our composition, haven’t had a chance to catch up with those very rapid changes. So sure, maybe our stress would have been running away from some type of predator and we wouldn’t want to have a bowel movement while we were doing that back then, but our immune system was also vastly different. Our diet was vastly different. Our responses to these type of things were vastly different. I think when we talk about autoimmune, auto-inflammatory diseases, it’s really important to understand that these are unique things that are popping up in human beings today because of the new world that we’re living in in comparison to what we were in the past.
Dr. Weitz: Sure. So what normally, under normal conditions, keeps the bacteria from the large intestine from growing into the small intestine?
Dr. Vojdani: Yeah, you know, the human body in so many ways is really resilient in preventing these things from happening. And we have tons of mechanisms built into us, physiologic mechanisms, that prevent SIBO from occurring. It begins with gastric acid production in the stomach which helps to sterilize the small intestine as it moves through the small intestine. As it moves through the small intestine, you have bile acid production which through saponification efforts can also destroy bacteria.
Dr. Weitz: So you’re talking about bile that’s secreted by the liver into gallbladder and then released by the gallbladder into the intestine to help us digest fats, right?
Dr. Vojdani: The liver and the gallbladder both secrete directly into the duodenum which is the beginning of the small intestine, right? So if you have bile mixing around in your small intestine, that technically adds to the antimicrobial effect of all these juices that are being produced. You also have enzymes which are being produced by the pancreas and the small intestine which can also break up the surface of these bacteria. We have a very powerful defense mechanism, our army, our immune system, is really centered within the mucosa of our small intestine. So we have this very powerful mucosal immune system that is … We have all these different mechanisms between all the surveying immune cells that are centered within the gut ileum. We have secretory IGA that’s being produced and floating around in the ileum. That’s all designed to prevent us against dysbiotic things like SIBO occurring. And then of course when you talk about the junction between the small intestine and the large intestine, that area between the ileum and the cecum, there’s a valve there. An actual valve that when functioning appropriately acts as a one way valve and prevents things physically from moving back into the small intestine. There’s a lot of things that we’re born with that prevent SIBO from happening which begs the question, why is it happening so much?
Dr. Weitz: Right. You know, Dr. Pimentel’s theory is that it starts with a bout of food poisoning that leads to damage to the migrating motor complex which is nervous system of the small intestine and under normal conditions, another mechanism are these cleansing waves that occur which is when you haven’t eaten for a while and you hear your stomach gurgling, it’s essentially there’s peristaltic wave of contractions that go through your digestive tract that also helps to keep your small intestine clear.
Dr. Vojdani: To the migrating motor complex.
Dr. Weitz: Yes.
Dr. Vojdani: Right, so these forward peristaltic waves that occur in between times of eating predominantly at night also ensure that things move forward.
Dr. Weitz: Right. So I mentioned the antibody test that Dr. Pimentel developed. How effective do you think that test is? Because my experience was I used it not a large number of times but it didn’t seem to be that helpful. It seemed not to be positive in most of the cases of patients that really did seem to have SIBO.
Dr. Vojdani: You mind if I take a step back and kind of explain where Dr. Pimentel came up with the idea to start checking antibodies.
Dr. Weitz: Yeah, let’s do that.
Dr. Vojdani: So there was a ton of research that was being done as to what enteropathogenic bacteria do to survive within animals. And there was research that was being done into E-coli which is a very common pathogen. Clostridium difficile, campylobacter jejuni, and shigella were really the focus of this research the last 20 years or so. And we learned that they have something called bacterial cytolethal distending toxin. Their weapon for, I guess, survival in combating our defenses against them.
Dr. Weitz: Right. And by the way, this is part of a category known as bacterial endotoxins. And bacteria often secrete this and then it creates damage. The endotoxin creates a bunch of damage.
Dr. Vojdani: Exactly. The other example of an endotoxin is lipooligosaccharide or LPS.
Dr. Weitz: Exactly.
Dr. Vojdani: We talk quite a bit in many disease. Right? And we’ve known about LPS for a really long time. I think learning about bacterial cytolethal distending toxin was something relatively new. So several labs including Dr. Pimentel’s lab started doing animal models where they would infect the animals with campylobacter jejuni, one of the enteropathic bacteria, and would observe that after infection, they would develop IBS-D symptoms in that animal model. So they came up with this idea that maybe IBS, at least the D or mixed subtype has a post infectious process. So, they continued to study that and learned that this toxin is way more powerful than we thought it was. It didn’t have just the ability to kill cells. If you think about the name cytolethal distending toxin it’s all about its ability to inject a toxin into a cell and destroy it. But we also learned that our immune response to the toxin begins or initiates an autoimmune cascade that progresses the inflammatory attack even without progressive insertion of the toxin in different cells.
So what does that mean? This bacteria is way smarter than we thought. And infecting an intestine with this bacteria results in symptoms for much longer than a typical disease you should have symptoms, you end up with symptoms for maybe the rest of your life. So that was really, really fascinating research, right? We started to understand that at least a subtype of IBS had this autoimmune mechanism. And that’s because when we … once that cytolethal distending toxin is injected into the epithelial cell, it starts attacking something called the adherence junctions which are basically the cytoskeletal network of our small bowel epithelium. In attacking that, you start releasing new antigens into the bloodstream including the toxin itself and by attacking either the proteins at the adherence junction or attacking the toxins through molecular mimicry, you start attacking adjacent cells that might not be infected with the toxin. And then, you get disruption of the adherence junction and essentially your small bowel epithelium can’t function that way it’s supposed to. So you end up with a lot of these symptoms. And also the migrating motor complex or the enteric nervous system is disrupted in this model as well.
Basically, Dr. Pimentel’s initial research was done in a really large trial. He looked at over 2,000 patients that had IBS subtype D based on Rome III criteria and found that the clinical utility of this test was very useful in separating people who might have diarrhea predominant IBS from IBD, from celiac disease, and from normal controls which is a very typical, difficult, clinical scenario when these people come in the door for the first time, right?
Dr. Weitz: Yes.
Dr. Vojdani: So his research validated the use of an antibody to essentially an IgG only antibody to the cytolethal distending toxin of campylobacter jejuni and then he also looked for IgG antibodies on the vinculin. Found them to have a sensitivity of close to 60% in patients with the D subtype. Somewhere lower than 50%, maybe 45% for the mixed type. And then, the constipation subtype is much lower, maybe 25%. So that was his initial data through his labs, research, and work on this antibody model.
Dr. Weitz: Yeah, it’s kind of ironic because you would think that decreased motility of the intestine would be more associated with constipation but I guess there’s not a strict correlation there.
Dr. Vojdani: Yeah. That’s the really interesting thing about his research. It really only looked like it was going to be valid. And in my opinion, the sensitivity of 60% is good but it’s not great and when you’re trying to develop a clinical marker for a disease, you really hope for much better than a 60% catch rate because you’re a little bit better than flipping a coin which is not fantastic.
Dr. Weitz: Right.
Dr. Vojdani: I think when my dad and I looked at that research and looked at that autoimmune model of this disease, one of the first things that caught our eye was that they’re testing IgG antibodies only in that test. And when you think about the way the immune system works, IgA is no doubt the dominant antibody of the mucosal immune system. So it makes sense that if there were going to be an antibody that were to be formed, IgA would likely to be the most common. IgM can happen in early autoimmune diseases as well. IGG tends to be more chronic and more systemic so it made sense to us that if you were going to detect this, you should look at least at IgA on top of IgG and why not look at IgM as well to try to increase your net of capture because depending on the number of years that that patient has been post infection or post exposure to cytolethal distending toxin, they might have any one of those three antibodies.
So, that’s essentially what we did at Cyrex in developing Array 22 which is what we call generation two of that antibody testing. And in our validation data, essentially we looked at 24 patients, all different types of IBS, basically to serum of 24 patients who show up to a clinician’s office for the first time with IBS. It didn’t matter which subtype. We had a sensitivity of 21 out of 24 were positive. So that’s about 88% or 89%. So much, much higher than what Dr. Pimentel’s data suggests. And our controls in our control group, we only had a positive result in one out of the 24. So our data looks a lot more promising. And I think when you think about the mechanism of this disease, the test makes a lot more sense. https://www.joincyrex.com/the-cyrex-system/array-22-irritable-bowel-sibo-screen
Dr. Weitz: And so your test, as you just mentioned, would also be helpful in diagnosing patients who have IBS/SIBO, with methane, the constipation type.
Dr. Vojdani: Yeah, so the constipation subtype, I will say is likely … Let’s say those three patients out of the 24. I don’t have a breakdown as to their subtype but I would say it’s more likely that the constipation subtype is going to be negative on this test. That comes from my personal clinical experience using it in patients with constipation dominant. That being said, I still find that test to be positive in may 50-60% of those patients. And to me, it’s really, really valuable information because you’re not just learning what does the patient have and giving them a diagnosis and then taking you down treatment road.
You’re also learning that if they have this subtype of this disease, an autoimmune subtype of this disease, that they’ve broken their oral tolerance. That their immune system has a major breakdown in the way that it’s supposed to function. And if you don’t do significant work to restore the oral tolerance in that patient, the patient will never get better. You can eliminate them with whatever protocol you want to. You can put them on any diet you want to for any period of time. One day down the road, they’re going to get the symptoms again because there’s nothing that is resetting where the error in physiology occurs for those patients.
Dr. Weitz: So how is it that you do that?
Dr. Vojdani: Restoring oral tolerance is really challenging. And I just came back … We were just talking before we started the podcast about the annual conference for IFM in Hollywood, Florida which was last week. I just came back. And a very big push at this conference was research designed to do whatever we can to restore oral tolerance. And you have to understand that oral tolerance is something that begins and develops very early in life. This is where our thymus sends out lymphocytes to survey what’s in our body and deciding which of those lymphocytes to eliminate as they might be autoreactive. So that’s essentially what oral tolerance is so that you don’t … you also don’t attack the foods that you eat. You don’t attack your own tissue. And that you don’t have the set of autoimmunity.
Restoring that process, takes a very significant period of time because it takes a very long time to break oral tolerance. But we’re finding that there are a lot of things that we commonly use that really help restore oral tolerance and restore to regulatory cell function which is what we’re trying to do. So high doses of vitamin A. High doses of vitamin D. Vitamin K. Probiotics do this. And then, there’s a lot of really fascinating research being done into the use of helminths as a mechanism to restore oral tolerance or at least to accelerate that.
Dr. Weitz: And by the way, helminths are worms which are being used therapeutically though not yet approved by the FDA here.
Dr. Vojdani: Yeah. Most of the research has been done on whipworms but Dr. Sidney Baker has been using a different type of helminth which is taken from the rat/beetle model which is much, much smaller than whipworms and their lifecycle is much less dependent on an animal that’s similar to us. So it seems like people are having less side effects from it.
And then, of course, there’s a lot of work being done into how do we restore secretory IGA function. Maybe disrupt bio films. Doing whatever we can to reduce the inflammatory attack that’s going on within the immune system so that you give the immune system a breather and a chance to take a break from all the inflammatory insults and reset its oral tolerance essentially.
Dr. Weitz: Now in terms of treating SIBO, you didn’t mention anything about antimicrobials or antibiotics to get rid of the bacteria. Is that part of what you do as well?
Dr. Vojdani: Yeah, so I think antimicrobials whether they’re pharmaceutical or herbal certainly play a tremendous role in eradicating SIBO patients. I’ll tell you my clinical experience. I get patients who have been eradicated once, twice, three times, four times, are getting the issues with the recurrence and then they come into my office which might just be because I’m my dad’s son and there’s a reputation for seeing some complex cases but those are my typical SIBO patients. So really what we try and do in those patients is understand what is continuing to propagate the inflammatory insults. In most cases, the organism that is secreting the bacterial cytolethal distending toxin is long gone. If someone has C-Diff of campylobacter or shigella or e-coli. They tend to know about it.
But it’s really more about understanding do they have leaky gut associated with their SIBO/IBS? Are there significant food immune reactions that are contributing to their inflammatory insults centered in their small intestine preventing the healing? Do they might have other GI organisms that are chronic stealth in nature. Things like giardia, other pathogens that are there that are contributing to this. I tend to look at what other factors … thinking about this as an auto-immunologist, what other factors are contributing to this inflammatory insult against the gut? Why does the patient keep having recurrences? What can we do to restore the immune function and the physiologic function centered within the gut so that these recurrences don’t keep happening. That being said, medications are certainly very helpful for these patients at least to give them some symptomatic relief while they’re doing that work.
Dr. Weitz: Have you looked into low dose immunotherapy?
Dr. Vojdani: Yeah. Low dose immunotherapy, I think, is very, very promising. Particularly there are a lot of practitioners that are doing this. I don’t know for sure that every person is going to respond to it but I think it’s going to be very immune dependent. If you are really in the depths of the fires of a TH1 driven inflammatory autoimmune response, low dose immunotherapy has the potential to make your symptoms worse just because the immune system is so revved up that you can’t reset oral tolerance there. But I think it’s a very promising therapy.
Dr. Weitz: And I think using your test could actually enhance that particular therapy because once you determine which particular bacterial organism it is, you could design the low dose immunotherapy for the campylobacter or the particular bacteria and potentially get their body, their immune system, to be tolerant of it.
Dr. Vojdani: Absolutely. And leaky gut, because of the nature of the relationship between the adherence junctions and the tight junctions, if the adherence junctions are broken, the tight junctions are almost bound to break as well. So the symptoms that we see happening in IBS/SIBO where we have multiple immune reactions likely come from that breakdown of the tight junction. So if you have the breakdown of the tight junctions, you end up with food immune reactions to numerous foods and maybe foods that are on the low FOD map diet or whatever diet you want to put them on. And you end up in this conundrum where you put someone on this diet because you want to help them with the symptomatic relief related to SIBO and it will do that but you’re still propagating an immune reaction to the gut because they’re being continuously supplied with an antigen in high levels that their immune system is reacting to. So that’s where those two things become complimentary and that information is extremely useful, I think, in that situation.
Dr. Weitz: Now are you … do you feel that your antibody test should take the place of the breath test or should be used in conjunction with it?
Dr. Vojdani: I don’t have a very strong opinion one way or the other about the use of breath testing. I think the focus of our work and research was in Functional Medicine we really try to understand root causes. From a cellular level, where are the physiologic breakdowns occurring? So I think what really appealed to us about this initial research and even more so when we did our own research and our own validation in expanding the antibody testing and looking at this autoimmune mechanism more was that you’re really understanding at a cellular level where the disease is propagating. Right? And to me, that’s much more powerful in trying to help this person not have a recurrence five years from when they walk in your door which seems to be a really ongoing problem.
Dr. Weitz: Sure. I totally understand that. But from the small intestinal bacterial overgrowth world, there are sets of paradigms that I know I and other practitioners have been working with so there’s a set of paradigms that seems to work better methane SIBO versus hydrogen SIBO and Pimentel’s about to come out with a new hydrogen sulfite SIBO which and if people already have a whole different set of protocols. So that’s the only issue I have with doing your test is which … It would be nice to also know if it’s methane or hydrogen to utilize some of these protocols that we’ve found a certain amount of efficacy with.
Dr. Vojdani: Yeah, listen every practitioner when it comes into the SIBO world has their own unique way of doing things and I think that’s totally appropriate because every individual that walks in our door is going to be a different version of the disease from the next one that walks in the door. It’s just the way human beings work. And whatever tools you have at your disposal that are getting you results, I’m all for it. I have no issue with that.
Dr. Weitz: Yeah. No, I’m just thinking that I would still probably be inclined to want to do both testing.
Dr. Vojdani: I can see the rationale for that, sure.
Dr. Weitz: Yeah, yeah, yeah. So do you currently treat a lot of patients with IBS and SIBO?
Dr. Vojdani: I do. I do. Yeah. And as I mentioned, I tend to get the patients that …
Dr. Weitz: Are tough cases. Yeah. All different therapies.
Dr. Vojdani: There are some good cases going on in the SIBO world in that more of my western colleagues are becoming fluent in some fashion to the idea that SIBO exists. And they’re ordering breath testing and maybe doing Rifaximin therapy with patients. So a lot of that initial work is being done out there and I’m sure many patients get very significant symptomatic relief from that initial eradication and don’t need further eradication. But I tend to see the patients that have been eradicated a couple of times and are looking for some more complex answers.
Dr. Weitz: Right. Typically, we think of things like well, you’ve killed the bacteria but you haven’t reset the migrating motor complex. So now you need to give them some agents that could reset the migrating motor complex whether that be nutritional or there’s medications and then, sometimes we think well, you haven’t broken up the biofilm. So in addition to doing the antimicrobials, you’ve got to give biofilm agents or you have to do a phase two and rebuild the intestinal wall. And use probiotics and prebiotics and glutamine and things like that.
Dr. Vojdani: Yeah. I think our protocols for SIBO are getting much more complicated these days for a very good reason because it’s a very complicated disease process. Again, I really think of myself as an auto-immunologist so I tend to focus on where the disruption in the immune system is because people who have damaged their enterovenous system and migrating motor complex, if that happens because of exposure to cytolethal distending toxin, and maybe you form antibodies to vinculin, which is part of the adherence junction, those antibodies cross react with your enteric nerve.
So you can give them all the 5HTP, ginger, B6, you want and that might help them get through the current symptoms but if you’re not working on stopping B cells from producing antibodies, they’re going to attack the enteric nervous system, what’s the point?
Dr. Weitz: Yeah, good point. It’s interesting. I could just imagine some pharmaceutical researcher out there right now where there is some very expensive drugs that are typically used for inflammatory bowel disorders. Drugs that cost thousands and thousands of dollars a year and basically are just prescribed for the rest of your life. And I could just see them salivating right now because if IBS is now an autoimmune disease and they could start selling those immune blocking drugs now to not just patients with Crohn’s and ulcerative colitis, but to everybody with IBS. Wow.
Dr. Vojdani: No doubt about it. I think they’re salivating for sure because we know that the epidemic of autoimmune disease in general is blowing up, right? But we’re also starting to discover that so many more diseases at least have an autoimmune component like we were just talking about ankylosed and spondylitis at the conference now understanding that there are target auto-antibodies for ankylosing spondylitis.
So we always knew that was an inflammatory disorder but we never understood that that was an autoimmune disorder. That’s one. We just published one, my dad and I, alone with [inaudible 00:39:40] and published the first of three articles in relationship to Alzheimer’s Disease. It’s in just the recently published June volume of the Journal of Alzheimer’s Disease. It really looks like we’re going to start thinking of Alzheimer’s Disease as an autoimmune disease in the near future too. The implications of that to the pharmaceutical world, I think, are probably huge. But thankfully, you and I are functional medicine doctors and we treat things in very effective and more natural means because when you start modulating entire branches of the immune system, you end up with very significant issues down the road.
Dr. Weitz: Right. Essentially what you’re saying is that we’re trying to reset the immune system. We’re trying to balance it. we’re trying to help re-regulate it. Whereas, the pharmaceutical approach basically is bringing down a hammer on your immune system. Just block a big chunk of your immune system. And of course it doesn’t work.
Dr. Vojdani: Because you might get some symptomatic relief, but your immune system is also responsible for surveying which cells in your body are starting to make genetic changes that are going to predispose them to becoming cancer in the future. So you take a whole arm of your immune system out and you reduce its ability to stop you from having cancer in the future.
Dr. Weitz: Right. Which is why the Functional Medicine approach in the long run is going to end up winning out.
Dr. Vojdani: No doubt about it. So you and I are on the right team.
Dr. Weitz: I’m happy about that, Elroy. Well, thank you so much for joining me today for patients and/or practitioners who would like to get hold of you, what’s the best way for them to contact you?
Dr. Vojdani: So our website is regeneramedical.com. R-E-G-E-N-E-R-A Medical, one word. You can reach our clinic at 424-256-0272.
Dr. Weitz: And you’re available to treat patients in person and also by …
Dr. Vojdani: Yes, we are accepting patients currently. Our office is in Brentwood right on Wilshire and West Gate. Just get in touch with us. Happy to answer any questions.
Dr. Weitz: Sounds good. Excellent, Elroy. Talk to you soon.
Dr. Vojdani: Thanks, Ben. Have a good one.
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