OneMedicine Podcast

Rob Lutz 00:02
Hello and welcome to the OneMedicine Podcast with Today's Practitioner. In each episode, we share the expertise of a respected thought leader. Some you'll know, and others you'll probably meet for the first time. We cover topics important to you, always with a focus on improving the health outcomes of the patients you treat, while expanding your understanding of the many healing modalities being used today.

Rob Lutz 00:24
Hi, and welcome to the OneMedicine Podcast. I'm your host, Rob Lutz, and with me today is Angela Pifer, the SIBO guru. Angela, you've been on the show before, and it was an excellent podcast about SIBO. So we're going to talk about some related topics here, of course, and the title of today's podcast is Beyond Bugs: What Chronic Bloating Is Really Telling Us. And before I get into starting to ask a few questions, do you want to just share a little bit more about your background and kind of tee us up for the conversation today?

Angela Pifer 00:54
Sure, sure, sure. I've been a clinician for 20 years, graduate of Bastyr University. I have focused on dysregulated gut symptoms since the beginning. I did a lot of work around emotional eating and IBS initially, and then it felt like about four or five years into my practice that SIBO reared up, and all of a sudden, what we were doing for IBS wasn't quite working as well, and so I shifted gears fairly quick at that point. Been a SIBO-focused clinician for easily 15 of my 20 years in practice. And I have functional medicine certification, and graduated out of Bastyr with a Master's in Nutrition. And I am just a bit of a disruptor in my field. I enjoy that title very much, because I--we're looking at SIBO. I think a lot of people come to me because they're looking for that kill phase. I must have the kill phase. Seven other providers didn't kill it enough. Coming to me for the one kill phase that's going to work, and I always look back at, like, "Well, you've been through seven treatments. It seems that you're getting worse. You're not responding to those treatments. Shall we set that aside for a second and back up and think about what's root cause? How do we reset terrain? How do I stabilize you?" Like, we've got to work more from a foundational perspective than just putting people on another kill phase, especially when we see bloating. Bloating is not always SIBO. In fact, I'm gonna say--go out on a limb here and say--it's rarely SIBO. Not everyone has SIBO. So let's--there's just more to it, right?

Rob Lutz 02:30
Yeah.

Angela Pifer 02:30
So I think as practitioners and providers, we need to step back for a second and maybe let go of that dogma and start to investigate this as it needs to be investigated.

Rob Lutz 02:40
That's great. Well, I think bloating is a really common symptom, right, that a lot of patients come to see a practitioner. And from what I understand, it can be very frustrating trying to solve that for them. Typically, it might be probiotics, digestive enzymes, low-FODMAP. Right?

Angela Pifer 02:57
Or antibiotics.

Rob Lutz 02:59
Yeah, antibiotics.

Angela Pifer 03:00
Or herbal antibiotics are usually, like, out of the gate, what they're going for.

Rob Lutz 03:03
Yeah. But can you just walk us through what are a lot of clinicians missing in this process and when it comes to chronic bloating?

Angela Pifer 03:12
Yeah, absolutely. So I think the biggest thing for me as a provider is that, when you're doing and--I mean, I laid out my business in a way that allows me a lot of time with my patients. I sell programs. I don't do single visits. My onboard session is an hour and a half. I've already reviewed and summarized all their labs for 30 to 60 minutes prior to talking with them. I know that's so different then what a lot of people are doing out there. However, that health history--that 90-minute appointment is all about health history. So I'm trying to figure out, like, when exactly did this start? What was leading up to it the year prior? What can we learn from that? What hits have you taken across your lifetime that might tell us why you're feeling this way right now? And if SIBO, it's a downstream collection of symptoms. Okay, that could still be there. I can work in stabilizing you a bit while I work to figure out what your health history timeline and what your presentation is telling me. So I work a little bit differently that way. Now, when we're looking at all the different ways that we could get to a chronic bloat perspective--presentation in a patient, we've got to think about maybe the upper GI and digestive insufficiencies. Right? Low stomach acid: we're not going to digest protein as well. We're going to get more microbes coming down from the mouth, which is linked tightly with SIBO, can be. Those Proteobacteria coming down from the mouth and gram-negative bacteria coming down and pushing out vermicides in the upper small intestine. We can have low pancreatic enzymes. We're going to get more undigested macronutrients from any downstream bile-flow stagnation, or gallbladder congestion, poor fat digestion, fat fermentation, duodenal enzyme deficiency--that can increase osmotic load and bloating. I think about motility dysfunction. Now, of course, again, we can have some of that motility dysfunction-we are going to have motility dysfunction when we have SIBO. That, there's a slowdown somewhere, but getting to the root of that and figuring out why that's present--we've got to figure that piece out. That's a root cause, but--sorry, that's a foundational root, but then what's the root cause of that. So impaired migrating motor complex, vagal nerve dysfunction, and that's going to lead, again, to low stomach acid. A lot of this can be connected. Mitochondrial insufficiency: you don't have enough energy, you're gonna have a hard time doing everything. If you have low nitric oxide, then that's gonna impair smooth-muscle relaxation. And then for a setup for SIBO, if SIBO, we start to think about post-infectious IBS, and we can run a test looking at anti-vinculin or anti-CdtB, toxin autoimmunity. I think about immune dysregulation, leaky gut, mast cell dysregulation, mast cell priming, local edema from that, and also metabolic endotoxemia, having those LPS antibodies--always are going to have a bloat response with that. You're probably going to bloat around meals, and you can bloat at any time, because you have this toxin being produced in your intestinal tract that your body's trying to deal with. Low secretory IgA: that immunoglobulin that's secreted by the cells that line the GI tract is going to allow then for microbial translocation or colonization. I mentioned mast cell activation, that's a big one. Inflamed lymphatics could be another. Biofilms, I think could also be--definitely may play a role here. I just caution people, because we have very healthy biofilms that are produced as well for our healthy, beneficial flora. Not all biofilms are bad, and when you take a biofilm disruptor, you actually are going to dump a lot more. We have a lot of toxins or heavy metals that get pulled into those biofilms. And so it's, a lot of times people will feel like, "I'm chronic. I'm not getting better. It must be the biofilms. I'll just start taking that." And then they get this massive dump and get flared. So just a little caution around that. Obviously we've got microbial overgrowth. Yes, SIBO can cause bloating. But we also have to think about SIFO, the fungal overgrowth in the small intestine: Candida; parasites; too much ammonia production from too much protein fermentation; pathogens; toxic burden. If you have a mold or mycotoxin issue, you're going to have a stalled digestive tract. That's going to flare everything else up. Pardon me. Heavy metals: you can get damage to your enteric nerves or displaced minerals. Neural inflammation: somebody has been through trauma in their lifetime, past or present, and kind of carrying that with them. That can cause it, because it's going to cause a dorsal vagal freeze. Right? And so, again, the vagus nerve, if that's not working properly, we can't lower inflammation. We can't innervate digestion. We can't send blood flow to the digestive tract. We can't support anything here, because we're pushing it all out, ready to run or fight. Sympathetic dominance: I think we kind of fall in the same space there. If you've got somebody that's really stressed out, and they're not kicking in that parasympathetic piece with the vagus nerve and has low, maybe, heart rate variability, we can watch that. We can start to see that that can be predictive of a motility issue and microbial imbalance issue. If somebody has structural issues, adhesions, ileocecal valve dysfunction, fascia restrictions, lymphatic flow is congested, if people, women who have scarring, men and women. Sorry. Well, it's not all on women, but I was thinking like breast surgery, or any surgeries, if you've got a scar, you're going to prevent lymphatic flow.

Rob Lutz 08:50
Okay.

Angela Pifer 08:51
So something like that could happen as well. Estrogen dominance, hormonal imbalances: that's going to lead to detoxification issues. Cortisol imbalances: that can definitely alter GI motility. I mean, there's so much. Right? And I know, I appreciate very much--I mentioned a couple in there that could connect to SIBO, and definitely do connect with SIBO.

Rob Lutz 09:14
Yeah.

Angela Pifer 09:15
But it is a broad stroke on what can go wrong here, and all I hear is "SIBO, SIBO, SIBO, SIBO, SIBO," to the point where people--the algorithm now has cipro and Bactrim in it, and people are getting dosed with cipro when they go to their doctor and complain of bloating without any testing. "Well, bloating! It must be SIBO. Here's cipro. Hey! Lo and behold! She's way worse." That's crazy, because cipro is just so broad-spectrum, and we have to, we just have to, rethink what we're doing here. That doesn't tell me whether we investigated mold, whether there's a leaky gut issue with metabolic endotoxemia with LPS antibodies. It doesn't tell me, did you look at protozoa? Pathogens? Do they have adhesions? You know, and even if SIBO, what-- how is it set up? That's super-important for us to figure out. If they have a post-infectious IBS presentation where they had a food poisoning event and they got a kick up of that CdtB toxin, and the immune system went after that and starts to produce antibodies against that, they're going to have about 10% of people cross over and start attacking vinculin, and vinculin is going to help connect the migrating motor complex. So you know, basically it's like, you've got this 20 feet of small intestine with this migrating motor complex moving down at, like, these earthworm undulations. And it's like, I walked up and grabbed the rope. You can't go past it. So we get this major slowdown there. Maybe they do need a little bit of support, but have you reset the terrain? Have you treated nerve regeneration? Have you supported them in helping them try to prevent, at all cost, another foodborne illness? Like, how have you reset the terrain to then be able to go and do, "I'm going to do an antibiotic?" Well, the slowdown is still there. So even for people that are getting identified properly, the treatment is still kind of overriding, and we're not stepping back to think about the terrain as much as we need to.

Rob Lutz 11:15
I mean, this is the perfect case for personalized medicine. Right? If you go into a conventional doc, it's like, "Here's your pill, and hopefully it's going to work." You're clearly digging in much, much deeper, really, looking for this root cause and then probably, I'm sure, then coming up with your treatment plan that's very personalized and much better chance of success for that patient. Right?

Angela Pifer 11:35
Yeah.

Rob Lutz 11:35
So we've been talking about chronic bloating, and you've walked us through this full clinical model, which was amazing. What are some early patterns or red flags you see that help you pinpoint which category the patient likely falls into? So you shared a lot, you know. How do you kind of narrow that down? What do you see? What do you look for?

Angela Pifer 11:54
Yeah. I use some questionnaires for it that help me kind of pinpoint patterns, because I'm always looking at symptoms as patterns. One symptom could mean so many different things, so there's a few really foundational symptom trackers that I use and questionnaires that I use that help me look at those patterns. You know, I will say--this happens more often than not. I get a patient who comes to me and says, "Something different than SIBO had happened. I had to take antibiotics, maybe long-term antibiotics, maybe a couple rounds for something, and then within a few months, like, all of this flared up." And now the provider is immediately going to, "Well, now you have SIBO," and I'm like, "Well, how did the multi rounds of antibiotics not address SIBO if SIBO were there?" So on the other side of that, I'm starting to suspect SIFO. I'm starting to suspect a fungal issue happening there, or that they just caused so much dysregulation with the microbes in the intestinal tract by taking that antibiotic, kind of more pathogenic bacteria flare to other--and there's testing that we can do for that. I think about people whose symptoms worsen with fat. We've got to suspect bile stagnation with that, definitely, if somebody is more constipated and bloated. Commonly, we look more at methane or IMO, or "eye-moh," which is a just intense intestinal methane overgrowth. But I also, in my questionnaires and my intake, I'm asking, "How long have you been constipated?" I mean, did this just start six months ago with all of your symptoms? What I see oftentimes is that people have been constipated lifelong, and now they've got other things going on. So how much of that constipation is part of the signaling here? It's just, it's a question I have. "You've always been constipated. I don't like it. I'm going to fix it." But as we're looking right now, "Well, I'm constipated now. I've got this test that says I've got a methane issue." Well, evolutionarily speaking, methane would go up in hunter-gatherers because it's trying to slow the motility down just a little bit, so we actually can access more nutrition from the food that we were putting down--all those roots, tubers, things that were harder to get the nutrition out of. We have studies coming out of Africa showing that people that are more hunter-gatherer there have much, much higher--like high--methane and no constipation to go with it. It's a question. We can't just immediately jump and say, "Ah, constipation. I'm not looking at your past history. I'm just saying constipation immediately. Look at this methane piece." So I think we just--again, we've got to have a broader stroke here. Brain fog, bloating, sugar cravings, I'm looking at fungal, sometimes mitochondrial. I'm always assessing for fatigue. Where's your endurance level? Are you able to get out of bed easily? Do you feel like you have some motivation? You know, where's your endurance piece? Mitochondrial issues often are a root cause. Of course, we got to figure out why they're kind of being knocked down, but not having good energy, not having good nitric oxide, those can be foundational pieces to setting up dysregulation within the gut. Now we have to figure out why they have those two.

Rob Lutz 15:10
How are you testing for that, for the mitochondrial? What's--

Angela Pifer 15:13
Yeah. It's just questions. How are you feeling?

Rob Lutz 15:16
Yeah.

Angela Pifer 15:17
Are you fatigued? I think a lot of people come to me and say, yeah like, "Well, I'm getting, you know, I am 40, so I'm getting more tired." I'm like, "What? Like, why would you be getting more tired at 40? I don't know, that's--I'm not accepting that. Are you sleeping? Let's talk about that first. Are you moving your body? Where's your stress load? Are you sitting all day?" Like, there's lots of questions to go through and try to help figure out, from a lifestyle perspective, what's going on. But we should not be lacking in energy. That's a mitochondrial issue.

Rob Lutz 15:47
Mm hm. And so, we'll not spend too much more time on that. But so, someone that comes in and they're feeling fatigued, you're going to recommend, if they are not exercising, if they're not good sleep hygiene, things like that--those will be things that will, kind of, be your go to. Yeah.

Angela Pifer 16:02
Yes, 100%. If you're not sleeping, I can't fix the gut. If you're in sympathetic dominance, I can't fix the gut. if you're--and no one can fix the gut. If you have mitochondrial insufficiency, and you don't have enough energy, really hard time fixing anything. It just is. Those are just foundational pieces to me. We need those.

Rob Lutz 16:21
Yeah, absolutely. That makes total sense. Okay, so you mentioned SIBO earlier. What is it exactly, and how does it disrupt normal digestion? You can just kind of dive into that for us.

Angela Pifer 16:33
Yeah. It's the chicken and the egg, as we talk about, how does it disrupt normal digestion. Because, to me--and this is from a functional perspective--so people could have adhesions from a surgery. That could cause SIBO. That's a very physical issue. If you think about your 20 feet of small intestine, and part of that's getting tugged on, you're going to create a pocket where things could slow down, motility maybe get stalled. You could have diabetes and nerve, or neuropathy. That can definitely lead to SIBO. So there's a condition underlying that could be stabilized a little more. I'm sure they're being managed for that, but there might be a reason that leads into why they have SIBO, that needs to be more maintenance and stabilized versus we're going to fix this perfectly, because there just might be some other things that we can't get past that way. So from a SIBO perspective, from a functional perspective, I am always thinking, "What's dysregulating the vagus nerve?" Because that is going to allow that translocation of Proteobacteria from the mouth into the upper small intestine, pushing vermicides out. There's lots of different ways that we can get hyper--one thing I didn't mention, hypothyroid, in some of the risk factors, up top, that could lead to bloating. That can definitely slow things down. So from SIBO perspective, it can uncouple bile, it can uncouple B12. I have really not seen anything convincing to tell me that SIBO causes leaky gut. Again, I think SIBO is a much downstream issue and a collection of symptoms. Leaky gut was probably their first--most likely their first. I see a lot of cases where, when I'm testing leaky gut and healing up metabolic endotoxemia, they're 60% better. And we get to regroup at the end of that and say, "Okay, what symptoms do we have now?" Like, it really makes a major difference to the person to not have an inflamed or leaky gut. Shocking, And I'm not going to just nail away at antimicrobials with that. That's a foundational piece we need to correct. Yeah, I think that's the main take-home points, I'd say, on SIBO from a digestive standpoint. I'm more looking at what is interrupting our ability to digest, our ability to clear off the microbes that are coming down from your mouth and sinuses. And sinuses.

Rob Lutz 18:55
What do you mean by clear it out?

Angela Pifer 18:56
And colonizing...

Rob Lutz 18:57
I'm sorry. What do you mean by clear out?

Angela Pifer 19:00
What's that?

Rob Lutz 19:00
The ability to clear out those microbes?

Angela Pifer 19:02
Meaning that you've got stomach acid, and the stomach acid is supposed to be, hit a certain pH, and it's going to break down your food. Chewing, of course, looking and smelling your food, chewing your food until it's liquid. I see people that have--that say that they have--large intact pieces of food, and they're still, well, they're not chewing it well enough. That should never--you should never see that.

Rob Lutz 19:23
Yeah.

Angela Pifer 19:23
Ever, ever, ever. Little particles, maybe, because you're chewing it the best way you can, but not really recognizable pieces. And so, if you don't have good stomach acid, you're not going to clear off these microbes that are coming down. You're not going to clear off things that are accompanying the food that you're eating. Right? And those have the opportunity to colonize, especially what's in our sinuses and what's in our mouth, because we are always swallowing that stuff down, and we do have a little bit of those species in our intestinal tract. And that can get a lot worse if people are on PPIs, or if they have low stomach acid, because their vagus nerve is dysregulated.

Rob Lutz 19:59
Got it. So, for that--we don't need to go into that too much, but you might prescribe something for the vagal nerve, vagus nerve, and then also something to increase stomach acid?

Angela Pifer 20:08
Yeah, I usually start with bitters, bitters with gentian in them. Those are my favorite. And then if tolerated, I'll switch them out to a betaine HCl, sometimes with pepsin, sometimes not. Just depends on the presentation. And then we're working on vagus nerve and that really, that can mean a lot of different things to people. If they're not sleeping and HRV is low, I mean to me, that's just my main target. I've got to get them sleeping, looking top-down, and then figuring out what kind of stress they are under. If it's something where they--I have people that come through, they're, "I am sensitive to everything. I can't even drink water without reacting." I'm just, in my head, thinking about past trauma, maybe, that they've gone through. So we need to be able to kind of meet a person where they're at and give them suggestions to try to soothe and settle their system down, and that might be some somatic work. That might just be sitting on the floor and feeling where your legs are touching the floor, and even like stroking your wrist and looking at your wrist and just being--somatic work is, like, learning how to be in your body. So that might be just, like, there for someone. Another person, if they're sleeping well and HRV is okay, maybe I have them start more of a movement practice. "Are you getting out with your friends? Are you being social? What do you do that brings you joy?" Like we--you know, I'm always looking for different, a little different, approach with everybody, but figuring out how to balance their life a little bit, so their body feels safer in its environment.

Rob Lutz 21:40
Yeah. Yeah.

Angela Pifer 21:40
And then going back to, "What is SIBO?" SIBO is basically an over-colonization of what is coming down from the sinuses and mouth, colonizing the upper small intestine. So we've got Proteobacteria, which are gram-negative bacteria, which, like--things like Escherichia coli and Klebsiella pneumoniae and such. Desulfovibrio, from a hydrogen sulfide perspective, can be anywhere in the intestinal tract. Oftentimes, it's in the large intestine, but it can be anywhere. And then there's just specific, you know, parts per million that we would be reading on a breath test to tell us whether hydrogen is present, methane is present. And then there's only one test that looks at hydrogen sulfide: that would be Commonwealth, I'm not super-fond of that lab. I rarely, rarely ever see a test come out of that lab that doesn't have flat-line methane. Makes no sense to me whatsoever. So I'm not--I don't gravitate towards that. And to me, from a hydrogen sulfide perspective, do you have sulfur smelling gas or stool? Does it burn when you have stool or gas? I'm always asking those questions. You know, do you have a rotten egg smell to that? And so that usually helps me a little bit. If they have that, they've got a sulfate-reducing bacteria issue. They're producing too much sulfur.

Rob Lutz 22:56
Mm hm. Is there a breath test that you use that you feel confident in the results?

Angela Pifer 23:01
Everyone should be running breath tests that go off of QuinTron machines, and Commonwealth does not.

Rob Lutz 23:05
Okay.

Angela Pifer 23:06
Use those. That is what the validation was for the breath testing. I very much prefer Aerodiagnostics. Gary Stapleton is the owner, and I think that they're really doing all of it correctly. They are calibrating correctly and often as they need, because you actually have to calibrate within samples, not over many people's samples--I'm sorry, not over many people's tests that you're running, but actually within the sample collectors that were sent in with a person, you have to calibrate even within that. So they're doing it in a very sensitive way. I like their interpretation. I don't always agree with it, and I've got to make my own decision, but Gary is fantastic. He's a wealth of information. He calls to discuss all cases, like it's, he's--I really like it.

Rob Lutz 23:52
That's great.

Angela Pifer 23:52
I really, really like it, but we've got to be mindful. Studies have shown up to 30% of healthy individuals have positive tests, and at Digestive Disease Week this year, there was a study done that showed up to 68% of people--healthy individuals. So the problem that I have is, when we're looking at breath testing, okay, we only trust it if the person also has chronic symptoms. I have a problem with that.

Rob Lutz 24:22
Yeah.

Angela Pifer 24:23
They're like, "Well, you wouldn't address the healthy individuals," which, of course, you're going to look up from the lab and go, "Oh. Well, you don't have any symptoms, so we're not going to do anything with this."

Rob Lutz 24:30
Right.

Angela Pifer 24:31
But it's, I, it's just--how many people that have chronic symptoms have false positive tests? How do we answer that? I mean, it's got to be 30% doesn't it? I mean, if we're--healthy individuals have 30, I would even say probably more, because there's more going on with the person. Yeah, it's interesting. Also, just for breath testing, I'm not going to ever send someone for a colonoscopy to test for this. But I always ask, "Have you had a colonoscopy? And did they tell you that you have a redundant, loopy or torturous colon?"--meaning that you have a longer anatomical colon than the average person, and if that was present, you can't run the breath test, because they were never tested for a longer anatomical colon. They were never validated for a longer anatomical colon.

Rob Lutz 25:24
Yeah. Yeah. Yeah.

Angela Pifer 25:24
So that's really concerning, right? And so I've had some people, and I just tell them, "Look, you've had five tests. They're all positive. Sometimes you get better with treatment. Sometimes you don't. We're kind of here. I don't know if you have SIBO, because we can't trust this test, because you have a longer or more redundant colon." And think about the prep for the test. Right? We are told to eat a certain diet for 12 hours the prior day. You fast the rest of the day. You wake up; you wait. You should wait an hour before doing anything: no exercise; no smoking; follow the test instructions very, very carefully. And Aerodiagnostics does have patient handouts for that. And I don't care what test you're doing, I'd go off their patient handout.

Rob Lutz 26:07
Yeah.

Angela Pifer 26:07
That's what I do. And then you wait an hour and start the test. Well, you're doing all of that to clear out colonic fermentation, so if you just simply have a longer anatomical colon, you're not going to clear out what you think you're clearing out, and you'll get false positives. We just can't prove it.

Rob Lutz 26:22
That makes sense, yeah. That makes total sense. Okay, you know, a little earlier, you mentioned SIFO. What is the difference between SIBO and SIFO? And why does it matter?

Angela Pifer 26:32
Huge difference. Different target. SIBO is small intestinal bacterial overgrowth. I like calling it small intestinal bowel overgrowth, just because it could be Archaea doing it as well, and they're not bacteria. And then SIFO is small intestine fungal overgrowth. To me, SIFO is probably more insidious. That we have more of a fungal overgrowth in the small intestine is, to me, a very big deal. We can have Candida in the large intestine, but from a presentation, their symptoms--symptom presentation is a bit different. And why SIFO gets so confused with SIBO is because everyone's just stuck on the fact that bloat must equal SIBO. SIFO has more bloating, more chronic bloating. Can still be around food definitely, you know. You're sending food down. If it's going to hit the fungal overgrowth in the small intestine, you're going to get symptoms. So it can have kind of a similar pattern there, but there's a lot more immune dysregulation happening when we've got a SIFO issue. And again, if it's up in the small intestine, it's a bit more insidious to me, and it's a main--that is a main target that I would go after. But you also have to work on immune regulation, the vagus nerve, and figure out what root cause is kind of loading vagus nerve that's allowing this to set up. It's kind of the same.

Rob Lutz 27:51
Similar in a lot of ways.

Angela Pifer 27:52
Underlying piece. Yeah.

Rob Lutz 27:53
Yeah, yeah. Is it harder to treat?

Angela Pifer 27:56
SIFO takes longer to treat than SIBO, for sure. Any fungal protocol is probably going to be three months plus of just continuous treatment. You can't--what I usually do is, depending on the person and what they've tried in the past, and what they're able to handle, I'm picking a blend to treat SIFO. And once they--I'll do a couple things to stabilize and support the protocol that I have them on, and then I will pick a blend of Candida treatment, and they finish up that bottle, they go on to the next. They finish up that bottle, they go on to the next. And it works wonders, because with SIFO, there's quorum sensing with the biofilm. It really is learning as we're trying to kill it, and it can be a lot harder to kill.

Rob Lutz 28:43
I see. Yeah.

Angela Pifer 28:44
And then SIFO, again, when it's forming its robust biofilm, it's underneath the mucus, so it takes longer.

Rob Lutz 28:50
I see. Okay, Methane overgrowth, it's often seen as a constipation bug, but you believe it's more complex than that, right? Can you explain the other side of methane?

Angela Pifer 29:02
Yeah, kind of going back to, there was just that evolutionary perspective that we had. But methane can, it--I mean, it's a hydrogen scavenger, so it can limit proteolytic fermentation, or protein fermentation. I think a real hallmark of SIBO treatment is an immediate "let's drop all carbs," because we don't want to quote, "feed SIBO," or we're trying to calm symptoms down. And our diet is already so heavy-protein, but it's protein, protein, protein, but you get more protein or proteolytic fermentation happening in the large intestine, so you're stepping over the issue in the small intestine. Not getting as much bloating there, because you're dropping stuff, but now you're shifting fermentation, to the large intestine, of protein, and that's going to increase ammonia, which is not good. So it could be compensatory, as it's popping up. The Archaea that produces methane, they're called methanogens as well. It could be compensatory as methane is--sorry, as hydrogen is going up, that methane could come up in it, because it uses four hydrogens to make a methane.

Rob Lutz 30:07
Okay.

Angela Pifer 30:08
And then it can inhibit sulfur--sulfate, pardon me--reducing bacteria, so we could have less hydrogen sulfide. Methane can down-regulate NF-kappa B and cytokines. And I think there's just more to it. It could reflect more microbial stability in a post-inflammatory terrain. So I appreciate very much when people get constipated and methane is present. I'm not saying that's easy. I'm not saying, "Hey, it's compensatory! This is great!" I'm just saying that we have it in our heads, "This bad. Kill it." And there's a reason, perhaps, that it is being altered in the gut, and I think we need to understand that. And I mean, I think about H. pylori this way as well. H pylori present, "It bad. Must kill it," when we've got studies showing that if people have H. pylori just present, not virulence factors, but just present--or maybe you're a carrier--it can help reduce asthma risk, and if I remember correctly, I believe protects against food allergies. I'd have to confirm that one. But there's, "Not always bad! Not always bad!" So again, all we have, if we put our blinders on from a SIBO perspective: "Bloating equals SIBO. Let's do a breath test," even though 30% to maybe 68%, based on this last study of healthy individuals, could have a positive test. If we see methane present, "Must be bad. Kill it. Kill it. Kill it," even though we have evolutionary relationship with this, and also we have people, again, that are more out of Africa, that might have higher methane to begin with. They don't have constipation. What's--we need more studies on that. That's just so interesting to me, so.

Rob Lutz 31:58
Yeah.

Angela Pifer 31:58
And then you go into the algorithm of crazy broad-spectrum antibiotics that are quite newer to the field in the last five plus years, where they moved from, you know, rifaximin, or Xifaxan, that could be combined with neomycin or metronidazole to treat methane, and now we've got Bactrim and cipro on the list. Is the issue with SIBO being recurrent that we didn't have enough heavy-hitting antibiotics to take it out? And that's a question we should all be asking.

Rob Lutz 32:26
Yeah.

Angela Pifer 32:27
And those aren't fixing it. It's still considered recurrent. I mean, if this was just a bacterial issue, and we were like, "Oh, this is an infection; just take this antibiotic," we wouldn't be here talking about this.

Rob Lutz 32:40
Right.

Angela Pifer 32:40
It'd be one and done, but it's not. So there's so much more to it.

Rob Lutz 32:45
So that kind of leads to my next question is, why do so many people relapse after SIBO treatment? Wouldn't you expect them to get better?

Angela Pifer 32:51
Because it's being approached completely wrong.

Rob Lutz 32:53
Yeah.

Angela Pifer 32:54
The SIBO treatment algorithm is causing recurrence. You have people that already have lower diversity in the upper small intestine, that have a Proteobacteria overgrowth in the upper small intestine, and it's just antibiotic, antibiotic, antibiotic. We've got to recorrect what we can. If they're not sleeping well, if they're stressed out, if they have past trauma, if they have fascia issues, if they have adhesions, if they have post-infectious IBS, massive dysbiosis, and more, you're just knocking--knock the bacteria down, the weeds come back. Knock the bacteria down, the resistant weeds come back. Knock the bacteria down, the resistant, resistant weeds come back. It's causing recurrence. And I don't--I feel like it's just we're in this weird bizarro world that even the really alternative providers are like, "Yep, antibiotic. That's the only thing that we can do to treat this SIBO is more and more antibiotics. And my patient is in pain, they're bloated, they're demanding treatment, and I'm going to give them an antibiotic." And I just feel like we're kind of back to where antibiotics were completely, and have been completely, overused forever by mainstream medicine.

Rob Lutz 34:08
Yeah.

Angela Pifer 34:09
And dentistry, massively. And we in this field are just like, "Yep, this is just the way we treat this, and it's really recurrent, so you're going to have to keep using these." What other condition do we do with that? It's really strange. This is so much more functional in nature. So we've got to figure out why they have unresolved motility issues. We have to figure out, do we need to go after biofilm? Is their vagus nerve shut down? Do they have a mold issue? I see it a ton. I see mold a ton with SIBO presentation. And you fix the mold, and SIBO will completely go away on its own most of the time. And I have this lovely woman--that just popped into my head--that I was working with. Massive mold issue at her house. Been through lots of treatments with SIBO. Was getting worse over time. Very healthy with lifestyle, very healthy with food, great life, not a lot of stress in her life. Why is this happening? And she's getting worse and worse. And so when we went through her timeline, trying to figure out and pinpoint--I'm always asking a few questions: Have you ever been bit by a tick? Ever been tested for Lyme, heavy metals, any kind of viral load? And kind of go back through history with that. Any water damage? Any--did your water tank flood? Did your roof leak? Did--when it rained did water come into the house? Does anything smell musty? Is there a humidity issue in your basement? I'm always asking things and, like, you know, sprinkling them throughout to see.

Rob Lutz 35:40
Do you live in New England?

Angela Pifer 35:42
Do you live in Florida? Like, oh no! And it's everywhere. In Florida, it's everywhere. But it's--they are theorizing--or hypothesizing? Theorizing? Hypothesizing?--that it's in 40 to 50% of homes at this point. And I think that's an underestimate with the way that we build homes.

Rob Lutz 36:01
Yeah.

Angela Pifer 36:02
So with all of that, she had a massive mold issue. We figured out they had a big flood, their basement had a big issue, and that the air exchanges were coming up from the basement into the rest of the house. Went through all of that treatment: 100% better; no GI symptoms on the other side. When I go through mold treatment, I'm always working on gut balance on the other side, just because we've done a lot of detox--let's stabilize--but no kill phases whatsoever, of any kind. We get to the very end of our program, and you just like, "Oh my gosh! I'm all better! This is amazing! This is great! This is great!" She reaches out to me about two weeks later, "Are we going to treat, or are we going to test for SIBO again? "And I replied to her, and I said, "Are you having symptoms again?" And she said, "No, no symptoms." I said, "Well, then, why would we test for SIBO?"

Rob Lutz 36:54
Right.

Angela Pifer 36:54
And she said, "Well, to make sure I don't have it anymore." It's just ingrained. It's ingrained in everybody. SIBO, SIBO, SIBO. It's a downstream collection of symptoms. It's a downstream collection of symptoms. We have to back up and say, why are they there? If you have a mold issue, it's going to drive dysregulation with everything--everything!-- and be easily a setup for a mast cell issue, for a dysbiotic presence in the gut, for SIBO, for motility slowdown, for all of it. It's a huge setup for that. Not everybody with a mold issue gets this, but if you have SIBO, it's a really good idea to screen for that, or at least, like, try to, like, look back in your history. Could there have been--like, "Yeah, I lived in two places that had a mold issue. I didn't realize that was an issue now." Let's test for it. Let's test and see how you're testing.

Rob Lutz 37:46
Are they testing--do they test the home and the patient, or just the patient, for the mold?

Angela Pifer 37:50
So I test the person first, and I run a MyMycoLab. People can order that directly from their lab. Wonderful. It's a-it's basically an IgG first page and IgE second page test for a variety of antibodies against a variety of mycotoxins--or for antibodies against a variety of mycotoxins, that's said better. And I love it, because the first page IgG, if that's positive, is going to tell me you've got a present load in your body that your immune system is reacting to, but this could be from a past or current exposure. The IgE panel tells me, if positive, you've got a current load, and you've got a current exposure, at least within the last few months, of some place that you have frequented all the time.

Rob Lutz 38:35
I see.

Angela Pifer 38:35
Right? You can't--it's not like I walk into my grocery store and they've got a mold issue, now I have a mold issue. Like, you had to be in the space for a while, so if that IgE is present, then we test the home. We can do it through swab testing, and we can also look for a mold dog in the area that can come out and sniff and see if they can find it.

Rob Lutz 38:53
Okay.

Angela Pifer 38:53
Which is super cool. It's really a cool advancement in our field right now.

Rob Lutz 38:56
Yeah, nice. Okay, so you also touched on the vagus nerve, which I find fascinating. We probably talked about in our last podcast. It seems to come up in a lot of them these days. How big a role does it play in bloating and gut health overall would you say?

Angela Pifer 39:09
Huge. Huge. And it's the speed forward cycle too, because you've got two vagus nerves that come down. And again, if we think about it, as in terms of 80% of the vagus nerve's function is listening to afferent signals, signals that are coming up from the torso organs, coming--if you've got leaky gut, dysbiosis, imbalanced stuff happening, inflammation, it's all coming up through the vagus nerve and telling the brain, "Oh my God! Look at all that's happening!" And the brain's like, "Oh my God! Slow down the vagus nerve. And I don't want you to calm the system down. We've got a stress fire going on. I don't know what's happening here, but we're going to send a bunch of troops in." And it just cycles. It just cycles that way and gets worse. And then you've got somebody that doesn't feel well. That makes them stressed out, and who wouldn't be stressed out, not feeling well and having to deal with all these symptoms. And then that's going to stall it more. Again, if somebody has past trauma, doesn't feel safe in their environment, they're going to have, be probably more in a free state than an inhibitory state, so we have to really assess for that and try to figure that piece out. But again, vagal tone--I mean, everything that the vagus nerve inhibition is related to, SIBO overlays. SIBO overlays, so poor stomach acid production, digestive enzyme production, pancreatic flow, bile flow, blood flow. You'll get an increase in visceral hypersensitivity. You'll get an increase in IL-1 beta, IL-6, TNF-alpha. IL-6, interleukin-6, chemical messenger, will go on to trigger leaky gut. You'll get ileocecal valve dysfunction. SIBO overlays all of that. So is it SIBO, or is it massive vagus nerve dysregulation that we're going after?

Rob Lutz 41:10
Curious of your opinion, you know, what percentage of patients have some kind of a vagal nerve dysfunction would you say?

Angela Pifer 41:18
If they have chronic digestive symptoms, I would say all of them. It really is that prevalent. And it's just by, again, you hurt.

Rob Lutz 41:27
Yeah.

Angela Pifer 41:28
You don't feel well. I can't just move about my day, eating whatever I want, doing whatever I want. I hurt. I don't feel well. That's a stress. And then, why is that all happening? There's usually underlying reasons.

Rob Lutz 41:41
Yeah.

Angela Pifer 41:42
That's are--also, you know, again, leaky gut, metabolic endotoxemia, what's causing a toxin response to your mitochondria? That can cause stress into itself. That kicks up a lot of oxidative stress in the body. I would say all of them. It's all very, very important for us too.

Rob Lutz 41:58
Yeah, it seems like it's a feedback loop too, because as, you know, someone is feeling stressed, doesn't feel well, they're probably shallow breathing. Deep breathing is a way to kind of bring back some vagal tone. So it does seem like these things kind of get into a loop that we need to disrupt in some way. And the vagal nerve, that seems like something that most people could work on themselves and probably have all sorts of benefits.

Angela Pifer 42:19
Yeah.

Rob Lutz 42:19
Like we're talking about here.

Angela Pifer 42:21
Yeah. I really like Truvaga. It's a handheld microcurrency stimulator.

Rob Lutz 42:26
Yeah, Mm hm.

Angela Pifer 42:27
That's super fantastic. Going for walks, somatic work, you know, again, sitting on a mat, feeling the ground. You can lay in bed, feel your elbows on the mattress. Put your hand over your belly and feel it rise. Focus on how your hand is touching your belly. It's like, just getting back into your body can be very helpful. I didn't--I don't know that I've really found humming or singing helped do anything for the vagus nerve.

Rob Lutz 42:51
It's probably the vibration from humming that's stimulating the vagus nerve. I find just rhythmic breathing, whether, you know, meditating or something like that. And I'll use, on my watch, the mindfulness app. And I won't look at it, but it will track my heart rate variability. If I'm meditating, my heart rate variability goes over 100, whereas if I'm sitting there watching television at night, it might drop down to like 20, because I'm probably shallow breathing and whatever else.

Angela Pifer 43:16
Yeah, agreed.

Rob Lutz 43:17
Okay, what tests help you make sense of the complex bloating cases?

Angela Pifer 43:23
Yeah.

Rob Lutz 43:23
Where are multiple overlapping issues?

Angela Pifer 43:25
I'm always going to run a leaky gut test. I use Vibrant America for that--Vibrant Wellness--always, always, always. And I've always--everyone's like, "Oh, I've got leaky gut." Well, let's test it, because if you--I know how to fix it every time. And if you have metabolic endotoxemia, we have to fix that. We've got to run that again and make sure that's gone. It's a huge issue. So I'm always running that. Probably going to run a stool test, unless they come to me with a really good one. So I'm trying to see actually, what's going on here, and then I use the health history timeline to tell me what else I'm going to test for. Oh, one woman I work with, unfortunately, went through two hurricanes, one each year, one a year after another. We ran a mold test on her. Right? Like, how could you not run a mold test on her? So, so I'm always looking, and tell me how this all got set up, how this all happened. We had a food poisoning event, and three months later, I've got all this onset of symptoms, well, just classic presentation of post-infectious IBS. I'm going to run that test. So it just depends on the presentation and the person.

Rob Lutz 44:28
Yeah.

Angela Pifer 44:29
Yeah. Best way to look at it.

Rob Lutz 44:30
Okay, that makes a lot of sense. Are there ways that clinicians are unintentionally making things worse? I think you touched on it a little bit, like, overusing restricted diets or microbials.

Angela Pifer 44:39
Yeah.

Rob Lutz 44:39
Anything there that you want to remind the listeners?

Angela Pifer 44:42
Thinking every--yeah, absolutely. Thinking all bloat is SIBO, and following the SIBO treatment algorithm. I'll just say it. I don't agree with it. I don't understand it. We should not be using antibiotics for SIBO. We should not be using antibiotics for SIBO. This is not an infection. What are we doing? We need antibiotics. We don't want to build up antibiotic resistance in anybody, at all. So I just feel like that should never, ever be used. We need to be careful with herbal antimicrobials. I mean, even berberine has been shown to drop keystone species, and actually completely eradicate a few species. So we just have to be careful. We have to think about this. "Okay. Have I reset the terrain? Have I gotten a root cause? Have I corrected all of root cause first?" You can stabilize them the entire way through, with whatever they need: maybe more bile support; maybe stomach acid support; getting them working on their vagus nerve; getting them sleeping better; getting them into a movement practice; getting them exercising if they can. There's so many ways that we, like, correct lifestyle and terrain, but if we've done all of that, and they're still dealing with something going on here, yeah, you can go into herbal antibiotics, but just gently, shorter term. Okay, think about restoring and recovering way more than treating, treating, kill, kill. If you think about that, we'll get out of this recurrence loop that we've got a lot of people in right now.

Rob Lutz 46:12
Yeah. I mean, that makes sense, probably for a lot of conditions, to really kind of focus on that foundational piece. That seems like a lot of sense with what you're saying here, with bloating and with SIBO, because you get that foundation strong and resilient, it very likely, in some of the cases you've mentioned, the issues that they were having with SIBO seemed to go away, potentially, or get a lot better, and then, if not, you know where to go at that point.

Angela Pifer 46:34
Yep.

Rob Lutz 46:35
Okay, so what is the future of bloating treatment? Where do you see this headed in five years?

Angela Pifer 46:40
I mean, if we can--yeah, if we can get out of these stupid algorithms, I think that, and go back, and just like, honestly, let go of SIBO. Here I am, SIBO Guru saying, "Let go of SIBO." Because again, I'll get somebody with--I've had people come through with 10 tests, and they're like, "Look, SIBO! Look, SIBO! It's, look! It's SIBO." And I just feel like, okay, maybe you've done that first test and you were going to move through with treatment, and you're doing a second test out to confirm. If you're doing that many tests on a person, it's almost like, "Well, let's just see if this is still here, because I don't know what else to do." I just like--stop over-testing people. It's expensive, and hey, if they have SIBO, if they still have symptoms, you could think that SIBO is probably adding to that. What else is going on? I don't even know that we need to test twice. Right? So I think about it that way, but from a bloating perspective, if we can let go that SIBO is at the root of all bloating. Respectfully, sometimes it is contributing to bloat, 100%, but the vast majority of people, just because they're bloated does not mean they have SIBO. And the second you go, "Oh, SIBO," you're going to stick them in a recurrence pattern most of the time, because now they're going to start chasing it. Right?

Rob Lutz 47:52
And you're not resolving any of those foundational issues.

Angela Pifer 47:54
Not resolving, yeah. So we have to do vagal nerve support, terrain mapping, and figuring out where they need to actually have support with their terrain top-down. Nervous system rehab, that's going to be really a big help there, and sometimes for people, integration of visceral therapies or somatic work, but all the while, that's foundational, all the while learning from the patient and targeting the right test to figure out root cause, to target the right root cause. That's the future of bloating treatment. It's not lack of antibiotics. Yeah.

Rob Lutz 48:31
Yeah, I usually ask as we kind of wrap things up for some pearls, but I think you really just hit it on that last little segment there. You really--is there anything else that you want to share, kind of, to wrap this up for the audience who might be seeing patients that are complaining of bloating, or coming in saying, "I think I've got SIBO," anything that you want to share?

Angela Pifer 48:51
Yeah, I mean, from a bloat perspective, as I'm looking at root cause, sometimes I'll have them try over-the-counter Gas-X. I'll have them try Wonderbelly Bismuth. It's on Amazon. I can get different clues of, okay, if that helped, let's go here. I might have them try some antihistamines, like, kind of just like, sussing out if this is a little MCAS, or mast cell issue, because there's--if we're figuring out how to stabilize them and make them feel better while we're going through all of this work, they'll love you. It makes a huge difference.

Rob Lutz 49:24
Yeah.

Angela Pifer 49:25
But I can get people cooking. They're cooking their food. You know what? When you're bloating a lot, I don't want you eating raw. I want you to slow down your first bite until you have chewed it until it's liquid before swallowing. Simple things like bitters, like, these are just some basic things that we know what to do in the alternative realm, which I even--I hate saying I'm in an alternative realm because I'm not mainstream medicine. But we know what to do with these. We don't immediately think antibiotics. So we--again, if just like, when you catch yourself saying, "Ah, this must be SIBO," set it aside and say, "What if it's not SIBO? What if it's not SIBO?" Right? We've got to look in a different direction, and I think it'll expand us a little bit and make us better providers. And we won't get such narrow blinders on, thinking that every bloat is SIBO, because you can't. I mean, obviously I'm picking up the word SIBO everywhere because of what I do, but every person is talking about this, from a clinician standpoint, maybe not mainstream as much, but it's everywhere. And it's just this immediate, you know, "Oh my gosh; this happens." And it's--yeah, there's, there's lots of other reasons, lots of other reasons. Bloating is not always SIBO.

Rob Lutz 50:41
Well, thank you so much. This was really, really interesting, and I think should be an eye-opener for a lot of the listeners, that this is something that is fairly common, and I think you've given some great guidance on what to think about. I like the foundational aspect of this, looking there first, but I will include some links and notes in the show notes, so folks can reach out to you directly, and then some links to some other articles that you've provided and things that are in the SIBO Resource Center, just that people want to take a look at that too. But anyway, thank you so much. This was really fantastic.

Angela Pifer 51:14
Yeah, you're welcome. Thanks for having me.

Rob Lutz 51:17
You're welcome.

Rob Lutz 51:19
Thanks for listening to the OneMedicine Podcast. I hope you found today's episode interesting and came away with a few insights you can apply to your practice. If you're looking for the show notes, they can be found in the link below. If you want to go deeper on this topic, or anything else, please visit todayspractitioner.com and consider registering for our weekly newsletter as well. Thanks again, and I hope you'll join us next time.