Episode 61: Must-Know Causes for Refractory SIBO with Dr. Steven Sandberg-Lewis

A huge, constant question we get from clinicians and patients is: what to do about refractory SIBO? Patients want hope, clinicians want to successfully resolve… Listen to my podcast to discover what one of the greatest minds thinks about all this and more.

Dr. Steven Sandberg-Lewis, the co-founder with Dr. Allison Siebecker of the National University of Natural Medicine SIBO Center – one of only four centers in the US dedicated to diagnosis, treatment, education and research, is a longtime naturopathic physician and perennially popular professor of gastroenterology at NUNM. In this NFFM episode, Dr. SSL covers less commonly explored reasons for SIBO, including hiatal hernia syndrome, ileocecal valve syndrome, adhesions & scar tissue and hypochlorhydria. Learn signs/symptoms (often unexpected), diagnosis and treatment for these all-too-often missed underlying issues. FYI – great downloads in the show note too – the “common causes of SIBO” PDF is essential, IMO. Be sure to rate, like, comment, and share our podcasts! Thanks always! ~DrKF

Small intestinal bacterial overgrowth (SIBO) is an underlying cause of symptoms for many patients and can be difficult to treat, with multiple environmental triggers and high rates of relapse. In this podcast, Dr. Fitzgerald talks with gastroenterology professor, Dr. Steven Sandberg-Lewis, who teaches at the National College of Natural Medicine. He is an expert on SIBO and GI physical medicine.

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Dr. Steven Sandberg-Lewis has been a practicing naturopathic physician since his graduation from National University of Natural Medicine (NUNM) in 1978. He has been a professor at NUNM since 1985, teaching a variety of courses but primarily focusing on gastroenterology and GI physical medicine. His gastroenterology specialty student rotations are a unique clinical training at NUNM. In addition to supervising clinical rotations he also maintains a practice at Hive Mind Medicine, in Portland, Oregon.

He is a popular international lecturer at functional medicine seminars, presents webinars and is frequently interviewed on issues of digestive health and disease. He is the author or co-author of several Townsend Letter award-winning articles (Hiatal Hernia Syndrome, Dysbiosis Has a New Name, Small Intestine Bacterial Overgrowth: Common but Overlooked Cause of IBS) and the author of the medical textbook Functional Gastroenterology: Assessing and Addressing the Causes of Functional Digestive Disorders, Second edition, 2017. In 2010 he co-founded the SIBO Center at NUNM which is one of only four centers in the USA for Small Intestine Bacterial Overgrowth diagnosis, treatment, education and research. In 2014 he was named one of the “Top Docs” in Portland monthly magazine’s yearly healthcare issue and in 2015 was inducted into the OANP/NUNM Hall of Fame.

Within gastroenterology, he has special interest and expertise in inflammatory bowel disease (including microscopic colitis), irritable bowel syndrome (including post-infectious IBS), Small Intestine Bacterial Overgrowth (SIBO), hiatal hernia, gastroesophageal and bile reflux (GERD), biliary dyskinesia, and chronic states of nausea and vomiting.

Many of the patients referred to Dr. Sandberg-Lewis have digestive conditions that have defied diagnosis and effective resolution. Often these patients desire naturopathic treatment options in lieu of the courses of treatments they have previously undergone. He understands diseases of the gastrointestinal tract, but also can assess function and often find successful treatments to regain a balance in the digestive system.

Dr. Sandberg-Lewis lives in Portland with his wife, Kayle. His interests include mandolin, guitar and voice; bicycling; writing and lecturing.

Dr. Kara Fitzgerald: Hi everybody. Welcome to New Frontiers in Functional Medicine, where we are interviewing the best minds in functional medicine. And today is no exception. Hey, if you like what you’re hearing, please, please, please leave a review at iTunes. I’d be most grateful.

Alright, today we are talking to my professor actually. One of the most beloved professors at National College of Natural Medicine. So he was my gastroenterology professor back when I was in school, and many of us … let me give you his background. So his name is Dr. Steven Sandberg-Lewis, and we all called him Dr. SSL or SSL in school. You might hear me use that now. But he’s been a long-time naturopathic physician. He graduated on 1978 from National University, my alma mater. And he’s been a professor at NUNM since 1985. And he primarily focuses on gastroenterology and GI physical medicine.

In addition to supervising clinical rotations, I actually got to work with you SSL in clinic rotation, too, and it was such a valuable time for me. He also has a practice at Hive Mind Medicine, in Portland,

Oregon. I think he does … you do some consulting and we could leave your information on our show notes, SSL, for folks who want to reach out to you.

He’s a popular international lecturer in functional medicine seminars and he does lots of webinars. He’s authored or co-authored a number of different articles, and we will link to these on our show notes, because they’re all really clinically useful pieces of content. So one is, Hiatal Hernia Syndrome and Dybiosis Has A New Name: Small Intestinal Bacterial Overgrowth … actually, am I reading these … so Hiatal Hernia Syndrome, that’s one article, right? Dysbiosis Has A New Name, that’s a second article.

Dr. Sandberg-Lewis: Right.

Dr. Kara Fitzgerald: Small Intestinal Bacterial Overgrowth: Common But Overlooked Causes of IBS, that’s a third article. All of them are just good articles to have access to as clinicians. He’s also the author of a medical textbook, again really useful, its second edition was published in 2017. And it’s Functional Gastroenterology: Assessing and Addressing the Causes of Functional Digestive Disorders. He also, in 2010, he co-founded the SIBO Center at NUMN, which is one of only four centers in the US for small intestinal bacterial overgrowth diagnosis, implication, treatment, and research. In 2014, he was named one of the top docs in Portland, not surprising. And in 2015, he was inducted into the NUMN hall of fame. Dr. Steven Sandberg-Lewis, SSL, welcome to New Frontiers.

Dr. Sandberg-Lewis: Thanks. Thanks for having me on.

Dr. Kara Fitzgerald: So, the reason I wanted to ping you, is because well (A) you’ve been practicing naturopathic medicine and focusing on gastroenterology for decades now, and I think … it appears as if we’re hitting some pretty tough guts these days. So I guess, I’m wondering your thoughts. So you wrote the article Dysbiosis Has A New Name. When I was in school, you taught us … we were looking at dysbiosis and gastroenterology. That was the term we used and now we’re calling it SIBO. If I’m not mistaken, it seemed like it was … it seemed like we were turning guts around back then, a little bit more readily than some of the guts we’re seeing today. So my first question is, can you just talk about what you’ve seen over the years in practice?

Dr. Sandberg-Lewis: Yeah. So, I think we’re talking more about small intestinal bacterial overgrowth because it was ignored for a long time. The testing, breath testing for it, and duodenal aspirate culturing that’s available for it has been around since the 1960s and ’70s. But it just kind of languished. And I got re-interested in it around the turn of the century and started playing around with a few cases and test people, and it’s just been in the last ten or eleven years that Allison Siebecker and I have really put a big push into trying to figure out what to do with these people and what are the underlying causes and how can we treat those and not just the symptoms.

So, there’s small intestinal bacterial overgrowth, SIBO, and small intestinal fungal overgrowth, SIFO, and large intestinal bacterial overgrowth, LIBO and the opposite. I mean that’s where you can most commonly use the term dysbiosis. Sometimes you’re missing microbes as well.

Lately, I’ve been finding … I tend to use culture rather than the PCR DNA testing. And lately, I’ve been finding more and more cases where there’s no growth of E. coli and often no growth of enterobacter or lactobacillus as well.

Dr. Kara Fitzgerald: Well, let me…

Dr. Sandberg-Lewis: So either way…

Dr. Kara Fitzgerald: Yeah, I want to just ask you a question. So dysbiosis, the term that we used as naturopathic students or one of them, you would say that’s actually large intestine bacterial overgrowth or undergrowth, did I hear you correctly? What would you say that that means, or is that just an umbrella term for all of what you’ve just described?

Dr. Sandberg-Lewis: Yeah, I think it’s an umbrella term.

Dr. Kara Fitzgerald: Okay.

Dr. Sandberg-Lewis: I think it originally came from Metchnikoff, who loved yogurt and treated things with that…

Dr. Kara Fitzgerald: Right.

Dr. Sandberg-Lewis: … but no, I just kind of think of that as a general term for either missing microbes, under powering of certain key organisms, or overgrowth, and it could be fungus, it could be bacteria. In the future it will also be virus and parasite, but we’re just starting to look at those.

Dr. Kara Fitzgerald: Right. Right. Let me ask you too … yeah, I think that’s a really cool point. There are quite a few viruses hanging out, and likely we’re colonizing parasites too. Why are you opting for culture instead of PCR?

Dr. Sandberg-Lewis: I think it’s because, number one, when I was writing and having some help writing the chapter on lab testing in my book … I think it’s chapter nine, I was looking to see … I hadn’t written about PCR testing at all in the first edition, which came out … I wrote it in 2007. So there wasn’t a whole lot of that around at the time. It was kind of brand new. So I didn’t write about it at all and I wanted to put something in there, in the new edition, because it’s becoming so popular and available.

Dr. Sandberg-Lewis: And there was a whole journal devoted to looking at comparing PCR versus culture, and pretty much the bottom line was, at that time, I think it’s sited in the chapter, but the consensus at that time was that PCR is possibly the best way to test for acute gastroenteritis, because it’s so fast and because it tests so many organisms. And culture is likely best for things that are more chronic.

Dr. Sandberg-Lewis: And I hardly ever treat acutes anymore. I mean, if you have a three- or four- month waiting list, you don’t see acutes very often. You see chronic cases where other docs have been scratching their heads. So that’s what seems to make sense for me.

Dr. Kara Fitzgerald: Okay. Alright, interesting.

Dr. Kara Fitzgerald: Alright, so just coming back to kind of one of the big questions I wanted to talk to you about. You taught us GI physical medicine, and I don’t know if that’s considered by a lot of clinicians, either conventionally trained MDs and DOs transitioning into functional medicine. And maybe even some NDs, this is falling off of our mental plate. And other clinicians coming into the functional medicine, integrated medicine space.

So can you introduce us to GI physical medicine and I know you write about it in your book, but just kind of sum up what you’re doing and what you’re using it for.

Dr. Sandberg-Lewis: Sure. Yeah, so I have a full 20-hour elective that I teach and I taught it up at Bastyr also as a weekend seminar recently, and I taught it in Australia and the Gold Coast in November, as a weekend seminar.

And basically, I see gastroenterology as not just the contents of the gut, the organisms in the gut, the epithelial lining and the blood flow and the prostaglandins and everything … and the enzymes and the acids and bases that are all involved there, but also, there’s a physical medicine … strong physical medicine component.

So for instance, some of the two most well known physical medicine techniques; one is the hiatal hernia syndrome technique. It’s the same for a true sliding hiatal hernia. Either the syndrome which is tested functionally, or the true hiatal hernia, which is seen on imaging. And those techniques have been around.

I learned the chiropractic version of it with a forced pull down, back in 1977 from Dr. Thaler, Ralph

Thaler, and then in … oh what was it? Probably late ’80s, no … late ’80s early 90s, I studied structural integration which is the work of Dr. Ida Rolf and myofascial release, and I thought, well wait a minute.

Why do we have to use this pull down thrust chiropractic type technique? Why can’t I just do it the way I do everything else in structural integration? It’s so effective. And I just adapted it and made a non-forced technique, which seems ridiculously simple and minimal. But it’s elegant and complex at the same time and works very well, takes four to five minutes to do and it’s dramatic in what it changes.

Just yesterday, I had a patient come back. I saw her the first time in July. She had severe reflux and a lot of chest pain and shortness of breath and I did one treatment on her and I just saw her again yesterday. She said, “You know, it’s starting to come back. It’s starting to hurt again. It was doing fantastic. I had no problem at all for five months.” And so we did a second treatment and that’s a really common thing and virtually any doc can do it once you learn it.

Another real … that’s one of the big, greatest hits of GI physical medicine. And there’s also the ileocecal valve syndrome. You know, you can actually check the ileocecal valve with colonoscopy, or with a smart capsule, by checking the pressure or the visual opening or stuck closed type of appearance on colonoscopy. And you can check functionally with other markers. We use the quads as a group. Strength testing left and right. We also use the iliacus left and right. And then there are similar myofascial releases that I worked out and there are lots of other ones available, other people have worked out, that can rebalance it.

We also find that, for instance, a closed ileocecal valve or a hypertonic ileocecal  valve, often has an issues at L3 and C3, so we’ll do some work around the spine.

Dr. Kara Fitzgerald: Can you just give me a … can you describe what kind of clinical presentation is going to clue you in to a functional … to an ileocecal valve syndrome? Or to a lesion there that you need to address. And also the hiatal hernia syndrome, what are you going to be seeing? What is the patient going to be presenting with to clue you in?

Dr. Sandberg-Lewis: It’s actually quite a long list, but I’ll try to tell you the ones I see the most.

Dr. Kara Fitzgerald: Okay.

Dr. Sandberg-Lewis: So one, of course, is right lower quadrant pain. Chronic right lower quadrant pain. Somebody who’s always getting tested to see if their McBurney’s point is positive and if they have acute appendicitis and the doctors just kind of throw their hands up and say, “Uh, I don’t know. I don’t know, eat more fiber. Do something. You don’t have appendicitis.” Right upper quadrant pain may also be the case, and we know there are ascending cecums. Some people their cecum is in their right upper quadrant, about five percent of the population according to one study. So either of those on the right side.

Another is tinnitus. I haven’t seen tinnitus go away when I’ve treated the ileocecal valve, that I’m aware of, but it apparently can be a sign.

Dr. Kara Fitzgerald: Okay.

Dr. Sandberg-Lewis: Another one is people that have sort of a viral syndrome. People who have symptoms like chronic mono, who always feel like they’re achy or sick, or getting sick, but they don’t really get sick. They’re just always that way. And I see that as, kind of as a toxicity sign due to cecal ileal reflux, from the cecum, back through the bowel, then to the ileum causing a toxic response, and perhaps SIBO as well because of the bacterial reflux.

So those are some common ones. Dizziness … that kind of flu like feeling that’s chronic.

Dr. Kara Fitzgerald: A lot of extra intestinal stuff. Like could chase you in different directions. It’s so fascinating. So maybe somebody who’s got … I mean you might be looking for, you know, kind of Epstein-Barr reactivation. Or you might be looking at some of these kind of occult co-infection, and it could actually be ileocecal or ileocecal could be a piece of what needs to be corrected.

Dr. Sandberg-Lewis: Yeah. A big finding that we’re keeping in mind these days is, it’s like the idea of real estate. They talk about location, location, location. That’s really a big part of gastroenterology for me is keeping the bugs where they belong in the right amounts.

Dr. Kara Fitzgerald: Right.

Dr. Sandberg-Lewis: And not having them migrate, or have the stomach migrate into the chest like happens in hiatal hernia. You know, all those kinds of barrier mechanisms.

Dr. Kara Fitzgerald: Yeah. That’s really interesting. Okay, so ileocecal valve syndrome is what you’ve just begun to outline. And again, as Dr. SSL mentioned, will link to his functional, a connection where you can access Functional Gastroenterology, but he covers it there. And maybe if you’re teaching, you know, if you’re going to be teaching a seminar that’s open, you can give us a link and how we might track that down for anybody who wants to jump in and learn it.

Dr. Kara Fitzgerald: So all these extra intestinal symptoms, but also, it could be a cause of really refractory SIBO. What about hiatal hernia syndrome?

Dr. Sandberg-Lewis: What about it in terms of clue like symptoms

Dr. Kara Fitzgerald: Yeah, exactly.

Dr. Sandberg-Lewis: Yeah, so certainly you’ll have people with chronic, unexplained gastric pain.

You’ll have people with nausea. You’ll have people with loss of appetite. If you think about it, if you have a true hiatal hernia, and you have a three centimeter stomach in the chest, and then the rest of the stomach is in the abdomen, often these are people who get full really fast, because that little stomach fills up really fast … just like somebody who has a lap band.

Dr. Kara Fitzgerald: Yes.

Dr. Sandberg-Lewis: And then, just nausea … what other? Oh yes, there’s anxiety. I check everyone who has anxiety for this. It only takes a few minutes to check. And there I think the issue is, if you have a true hiatal hernia and you have your stomach but both above and below … sort of like a dumbbell. You know, you have a portion above, or I guess an hourglass. And we know that when people can’t diaphragmatically breathe, it activates their sympathetic nervous system and they can have quite a bit of anxiety. So I always think of it with anxiety as well, and shortness of breath, and dyspnea on exertion, and reflux. Those are probably some of the big ones.

Dr. Kara Fitzgerald: I guess again, this could be … I mean certainly just in the … I mean a lot of people have hiatal hernias and some are really uneventful and a non-issue, and others become issues significant later on. But it’s another cause for when you’re pulling out all the steps for the good gut protocol and they’re not getting better. And I think the interesting thing you pointed out too SSL, and perhaps you can comment on is, there’s true hiatal hernia and then there’s hiatal hernia syndrome. Can you just distinguish that?

Dr. Sandberg-Lewis: Mm-hmm (affirmative). So, part of it is medical legal, when you’re making a diagnosis. I don’t call it a hiatal hernia unless I have imaging to prove it. If I’m just using functional testing, then I just call it hiatal hernia syndrome, which isn’t a diagnostic code.

Dr. Kara Fitzgerald: Got it.

Dr. Sandberg-Lewis: I think you can use disorder of stomach, other. Or unspecified. But, the other the piece is that according to the literature, if you read, and I hope docs out there will send for the full upper endoscopy report if your patient’s had one or were referred for one. Don’t read the patient report. Get the full report plus the biopsies. And you will hardly ever see anything that says there was a one-centimeter hiatal hernia, because basically, under two centimeters, it’s rarely reported or seen. So there’s a thought that even on upper barium x-rays, if it’s smaller than two centimeters, it may not be seen.

So I think that a lot of these functional ones, these hiatal hernia syndromes are just so small you can’t see them. But it doesn’t matter. As far as I can tell, even just the pressure at the hiatal ring of the fundus of the stomach pushing up against that, can cause similar symptoms. You don’t actually have to have a mediastinal stomach, you know, to have some symptoms. That’s why I check several different ways functionally for that. Cause I don’t want to miss it. It’s a great opportunity.

Dr. Kara Fitzgerald: You have given me some images. Folks, I’ll put them on the show notes … where you’re doing some of these … these GI physical medicine techniques. So you can see what SSL is doing and again, we’ll put as many resources there as possible.

I wanted to also ping you on your approach to the gut-brain axis. I mean stress plays clearly a massive role … and I mean actually, interestingly, you just pointed out this. We tend to think of it, I think … or perhaps my habit is, there’s some cerebral … there’s a life stressor experience and then we see that manifesting in the gut. But you just described hiatal hernia actually causing anxiety and, you know, extensively turning up king of the sympathetic tone.

Dr. Sandberg-Lewis: Yeah.

Dr. Kara Fitzgerald: Can you … yeah, so just turning that around completely. And I guess, you know, we also know of course that microbes can produce all sorts of neuroactive compounds that could probably have a similar influence. But can you just talk about that? You know, just what you’re thinking about with regard to the gut-brain axis and just some of your interventions there beyond addressing a hiatal hernia?

Dr. Sandberg-Lewis: Mm-hmm (affirmative). Yeah and just quickly I would mention, there’s a full a chapter on hiatal hernia syndrome and a full chapter on ileocecal valve syndrome in the second edition of the book, for people who want to read about that more.

In terms of the gut-brain axis, I have thought about it a lot. I’ve lectured on it. I’ve written about it. And I think the important thing is don’t get single minded or fooled into thinking things have to go through the blood brain barrier to effect the brain. Don’t think that all of the emotions and thought processes take place in the brain, because we also of course have the enteric nervous system, which is sometimes called the second brain. And probably each organ … you know, there’s a cardiac brain probably as well that I haven’t studied as much, et cetera, et cetera.

But, the enteric nervous system, that’s where most of this is happening and we don’t talk about gut feelings for nothing. It’s really happening in the gut, so we know that at least 95% of serotonin is produced in the guy. And we know that the gut has it’s own special serotonin receptors that are more predominant. The 5-HT3 and 4 serotonin receptors, where as the brain has more of the ones and twos and higher numbers. But it’s important to realize, you don’t have to travel all the way to the brain to have these effects. But a lot of it does go that way. Short chain fatty acids can pass through. And the bugs in the gut can make neurotransmitters which have their effects peripherally as well.

But really, a lot of what happens with mood, energy, anger or benevolence, really occurs right there in the gut and it has to do with neuropeptides that are produced by the epithelial … actually not by the epithelial cells, but the endocrine like cells … enteroendocrine cells, EECs, that are scattered throughout the gut, that are producing serotonin and vasoactive intestinal peptide and motilin and on and on. CCK, secretin, you know, they’re turning on digestion, but they’re also having other effects. For instance, cholecystokinin, has effects on immunity, local immunity in the gut. And it has effects on satiety and sense of when you’re done eating. There are lots of effects.

So, we don’t have to travel too far out of the gut to see the effects on the entire nervous system. And of course there are more neurons in the gut, or about the same number, as there are in the spinal cord. It’s incredibly neurologically gifted.

Dr. Kara Fitzgerald: So what are some interventions you might think about?

Dr. Sandberg-Lewis: Alright. So first of all, when we talked about location, location, location and numbers, we know that depression and anxiety are linked to bacterial overgrowth in the small bowel. And again, we have bacterial overgrowth … that can occur in the large bowel, but there’s not quite as much absorption there. We know the small intestines designed to absorb everything and take it right to the liver, right? Or through the lymphatics directly into the system.

So definitely you want to check your patients for hiatal hernia syndrome and those kinds of things that can have direct effects on anxiety, but you also want to see if there’s overgrowth. If there’s overgrowth, you’re going to have metabolites that number one, effect digestion … digest away the microvilli and affect the disaccharides and the histamine, diamine oxidase that are produced in the outer little proximal parts … excuse me, distal parts of the microvilli on the brush border. And those, if they’re not there, your patient … I mean you know if your patient has histamine sensitivity, they have a lot of emotional symptoms as well as a lot of very strong physical symptoms.

If your patients are deficient in … if their absorption is effected because of either bacterial overgrowth causing excessive deconjugation and excessive production of secondary bile acids, which bugs like to do to protect themselves, then your ability to digest essential fatty acids and fat soluble vitamins are going to be affected. That’s going to have a lot of effects on the brain and the nervous system and functioning.

So there are a lot of mechanisms. We could go into lots of different mechanisms, but definitely make sure the right bugs are in the right areas at the right amounts, and you don’t have excessive metabolites that put a big drain on the liver and effect absorption, so that you get deficiencies that lead to emotional and mental and cognitive issues.

Dr. Kara Fitzgerald: Are you using … you talk about heart-rate variability. Are you using that  technique with your patients?

Dr. Sandberg-Lewis: I do that to some patients, I’ll use the alpha stim that’s been prescribed for them and I’ll refer for neuro feedback, especially in patients with traumatic brain injury. And that’s a … you know, at our last year’s, in June, SIBO symposium and this year, next weekend … our symposium this year, the whole focus is on underlying causes of bacterial overgrowth. And this year we’re going to do a talk, my wife and I on traumatic brain injury and SIBO. And it’s really a key thing that most doctors don’t get yet. They don’t get that when the brain in shaken and all the networks, the neural networks get reorganized, one of the first things that changes is motility in the gut and the health … the mucous membrane and the epithelial cells and the villi and the microvilli. And that happens within hours and it’s a continuous process. Depending on how things go, it can get worse and worse.

And that can be the beginning of digestive problems, and it doesn’t have to be a month or two months before it can take time, a year or two, until it fully engages and all of a sudden the patient realizes it.

And things like surgeries, endometriosis, appendectomies, and appendicitis and perforated appendix and perforate ulcers, and pancreatitis, can all set up massive adhesion networks between the layers of bowel, that can really effect motility and lead to bacterial overgrowth. And then we also know that food poisoning and traveler’s diarrhea can lead to post-infectious IBS, which is another form of bacterial overgrowth. So we really have to check on the heralding events and not be blind to them put that in history.

Dr. Kara Fitzgerald: You are giving us to post on show notes, the chart of causes, and it’s extremely comprehensive. So folks please download it and think through with your patient cases. Since you threw it out there SSL, I’m really curious to hear what you’re doing with adhesions.

Dr. Sandberg-Lewis: Yeah well, I occasionally will work on an adhesion myself with a patient when I  find one. And what I’ll do is … you can do imaging for adhesions. Often you can actually feel them if you practice. And I teach my students to add two additional things to their abdominal exam to check for adhesions. And really, it does take some months or years of doing it until you get a really good feel for it.

But one thing I do is just kind of spread my two hands out so my fingers create kind of a half circle and my thumbs are on the other side, and just with the umbilicus in the center, I let my fingers kind of sink down into the abdominal tissue slowly. Then I rotate my hands and I just get a sense of how well do those tissues move. Cause we’re looking here for what we call mobility. Mobility is the ability of the organs to move with respect to each other as opposed to motility, which is the internal movement of the bacteria and the food and the stool. So mobility is what we’re checking here.

And then I will, on females, I will put my fingers on … it’s all external exam, but just above the pubic bone. I will put my fingers on either side of the uterus and move it laterally. And if you do that on a regular basis, you’ll find that women that don’t have pelvic adhesions, you can move the uterus all the way to the midline. You can take the lateral border of it and move it all, just about all the way to the midline, both directions. Because you know, those broad ligaments and round ligaments, they’re not real tight. You can’t have a uterus that’s fixed, or else it will rip apart when a woman got pregnant, right? As the uterus grew. So it has to be very mobile.

And when adhesions form after gonorrhea, PID of other types, a ruptured ovarian cyst, appendicitis, especially a perforated appendix, chronic diverticulitis, recurring diverticulitis … any of those kinds of conditions … and endometriosis with monthly bleeding. You’ll find that often, at least one side of the uterus won’t move, hardly at all. And once you’re used to how it normally feels … check young girls that don’t have endometriosis and women that aren’t having those kinds of problems, you’ll really be able to tell the difference. It just feels like it’s locked down, sewed in place, and just won’t move like a normal uterus. And then, I refer to people that do visceral manipulation, do pelvic floor work and can release those adhesions. It takes time.

I learned this kind of palpation from Larry Wurn, who he and his wife developed the Wurn technique, which is a 30 years now, focused practice of physical therapy for releasing abdominal adhesions.

Especially for the small intestine, but also for the whole pelvis and other organs. So that’s what I do with those cases.

Dr. Kara Fitzgerald: So how often are you seeing adhesions that you think are playing a significant role?

Dr. Sandberg–Lewis: Well, I don’t know the percentage. I’d say … let’s see what percentage do I refer for this kind of work? Probably in my practice, it’s close to 20% of the cases and that’s because I see the complex ones that they’ve been looking around for something. But just, definitely think about it, and this is talked about in chapter seven of my book in great detail, but think about it when those conditions have been present.

And definitely a ruptured ovarian … excuse me, a ruptured ectopic pregnancy. That’s like a giant flashing light. There are adhesions folks. You’ve got to deal with them if the digestive problems get worse after that. And again, it could happen over months or even a year or two or three after that.

Dr. Kara Fitzgerald: Yeah. Okay, so it may not appear necessarily related, but it would post date the…

Dr. Sandberg-Lewis: I find a lot of cases where it’s … I tell the patient it’s the perfect storm. So maybe they have a ruptured appendix and they’re starting to have some low-grade symptoms after their appendectomy. And then, they get put on a proton pump inhibitor for reflux or anything else that happens above the umbilicus in standard medicine. And then maybe they get traveler’s diarrhea in Mexico or Costa Rica or India, and then they’re a mess. They’re just really in agony and nobody knows what’s going on with them and they’re just giving them Imodium or some constipation drug and they’re not even functional anymore.

Dr. Kara Fitzgerald: They’re going to be somebody who if they do seek out integrative care, maybe non-responsive, or respond early on and feel great, but they’re recurring, over and over basically. Would you say that’s correct?

Dr. Sandberg-Lewis: Yeah. And these are the cases where a doc will get familiar with treating SIBO, in terms of herbal treatment or elemental diet or rifaximin plus a second antibiotic for constipation. And they’ll treat the patient. The patient feels fantastic while they’ll on the treatment. They feel fantastic for maybe a week or two afterwards, and then it all comes back. And that’s when you really, if you haven’t already done it, you have to go back and take a full history and find out what underlying risk factors are there that are causing rapid relapse.

Dr. Kara Fitzgerald: That’s so interesting. And this could … so, in my practice, I’ve had certainly enough people come to me with SIBO, post-food poisoning or traveler’s diarrhea SIBO. And if they’re still refractory … I mean that can be challenging enough in itself, but we can pull back the layers further and find out there’s a history of endometriosis or any of these other causes that you’re mentioning for adhesions. That’s really interesting to me.

Dr. Sandberg-Lewis: Let me say one more thing. When your history is there with those folks with Post-infectious IBS, and of course you can diagnose that with the antibody blood test for vinculin and cytolethal distending toxin B, those tests are available. The important thing to ask is, when you finished your … some doc gave them rifaximin and they felt amazing. And then you say, “And did they give you a prokinetic to take after that? Patients who have elevated anti-vinculin antibody or anti-CdtB antibody, they are going to be very high risk for rapid relapse because their migrating motor complex is not working properly, due to those antibodies attacking their interstitial cells at the hall that are sort of pacemaker nerve cells for the migrating motor complex. So they need effective prokinetics whether they’re herbal or prescription, or the combination of the two.

Dr. Sandberg-Lewis: And I also tend to treat them for autoimmunity. Try to bring up their T-regs, so  that they have less of that antibody effect. And they’re going to need … you’ve got to tell them they’re going to need prokinetics of one sort or another for possibly three to five years, because that’s how long it takes those antibody levels to come down in the research. Otherwise they’re going to get relapse.

Dr. Kara Fitzgerald: Yeah. Right, right, right. Okay, so I just want to again, you’re giving us a lot of  pearls. You can get anti-CdtB and anti-vinculin antibodies through Common Wealth.

Dr. Sandberg-Lewis: Yes. And then also, Cedar Sinai, they’ve created a lab now that we’re going to learn more about next week at the symposium, but it’s called IBS Smart.

Dr. Kara Fitzgerald: Oh yeah.

Dr. Sandberg-Lewis: So there’s IBS Check and there’s IBS Smart. There’s a third test that Quest does…

Dr. Kara Fitzgerald: That’s right.

Dr. Sandberg-Lewis: … called IBS Detects. I really … nothing against Quest, but I really don’t like their normal range. I find it not very helpful.

Dr. Kara Fitzgerald: Yeah, we were using it here, in practice … we used it a number of times. I don’t think I ever saw a positive.

Dr. Sandberg-Lewis: I have seen two or three positives. I used it during a period of time when IBS Check wasn’t available for a couple of years. But I would more highly recommend IBS Smart which is directly from Dr. Pimentel, or IBS Check which he developed, and then I guess sold to Common Wealth. Those tests I feel like they have a much better normal range, and they even give you the equivocal range, where it’s not quite statistical significance, but they believe high enough that it’s enough to cause changes in migrating motor complex.

Dr. Kara Fitzgerald: Okay, so three to five years. That’s…

Dr. Sandberg-Lewis: Well, that’s the initial research that says that about … if I remember correctly,  about half of the patients, their antibody levels will normalize within three to five years. The other half, they still are high. So I tell them it’s going to be kind of minimum, three to five years that you’re going to be doing this, but it helps to prevent recurrence.

Dr. Kara Fitzgerald: Yeah. Right. Well I think that really, that’s important in managing expectations that once the damage has occurred, the journey may be long … may be actually really long … years long.

Dr. Sandberg-Lewis: Yeah. You want to hear something about prescription prokinetics?

Dr. Kara Fitzgerald: Well I was going to just ask you about prokinetics … What you’re using in this  population? What you like in general? And we might as well just jump over there, and then yeah, go ahead and make a comment on prescription. Yup.

Dr. Sandberg-Lewis: Yeah. So there’s a long list of possible prokinetics that you can use, and on the  prescription side, most of them have serious cardiac side effects that are very likely. The one that does not, that has the lowest, ultra low risk of that, is prucalopride. And until about two months ago, it was not FDA approved, so we would just fax the prescription up to a reputable pharmacy in Canada and they would mail it to our patients.

Dr. Sandberg-Lewis: Other brand names for prucalopride are Resolor and Resotran in Canada, for  transit. And FDA just approved it about two months ago and it’s going to be marketed under the brand name Motegrity.

Dr. Kara Fitzgerald: Right.

Dr. Sandberg-Lewis: Which is a really cool name, and I think it would be fun to have bets about how many times more expensive it would be than the Canadian form.

Dr. Kara Fitzgerald: Yeah. That’s right.

Dr. Sandberg-Lewis: So I don’t know if we’re ever going to use this. We’ll see.

Dr. Kara Fitzgerald: That’s right. It’s a little bit heartbreaking just listening to yeah, then no.

Dr. Sandberg-Lewis: It’s not on the market yet, but they say possibly by June or July.

Dr. Kara Fitzgerald: Well, I’m with you. I just can’t even imagine what they’re going to charge for it.

Dr. Sandberg-Lewis: But that’s my first choice for a prescription prokinetic for patients who have chronic constipation, methane dominant SIBO, because it is at very low doses, it’s usually quite effective. So this one has motilin receptor activity, so migrating motor complex, but it also has serotonin receptor modulation activity, so it can produce a bowel movement in the large intestine. Whereas some prokinetics are really focused more on the stomach emptying, gastric emptying and migrating motor complex, such as very small doses of erythromycin which we sometimes use too. And that’s a great medicine for gastroparesis.

On the other side, the herbal, we tend to use things like Iberogast, the combination liquid from Germany … often very effective and for some patients, can help with constipation and move the large intestine as well, not for all. But it has carminative effects and anti-spasm effects as well, so it can help with symptoms besides motility.

Then we have things like d-limonene. We have our miraculous ginger, which you should think of for your patients that have a lot of nausea and vomiting, as well as motility issues. And motility issues can cause that.

And then we have things, like there’s a new one that has a combination of ginger and artichoke, as an upper GI motility agent. And then, the one company makes a product called MotilPro, which very smart, it’s mostly ginger for the upper GI tract, but then they added 5-HTP, B6 and I think acetyl-L-Carnitine to try to get more activity, parasympathetic activity and serotonin activity for the large gut. So these are all good options.

Dr. Kara Fitzgerald: When are you going botanical versus pharmaceutical? Can you just draw along that line, or does it really just depend on … actually tell me your decision making.

Dr. Sandberg-Lewis: Yeah. Well first of all I’m thinking … like I said, I’m thinking prucalopride when it’s really obstinate constipation. People that say, “I can’t have a bowel movement unless I do something. I take 1200 milligrams of magnesium, I won’t have a bowel movement with out that.” Or, “If I don’t take some kind of polyethylene glycol, MiraLax, two or three doses a day”, or “I have to manually go in and pull it out.” Those kind of cases.

And remember too, there’s rectal dyssynergia, which is an outlet problem. Some people with constipation, the problem is really in their discoordination of their rectal sphincter. It doesn’t relax when they bare down to have a bowel movement. It actually contracts. And that’s another pelvic floor issue that they need physical therapy for, or biofeedback. But those patients especially are often the ones that’ll say, “I have to put my finger in there and pull out the stool because it’s there and it’s driving me crazy, but it won’t come out.”

So, prucalopride especially good for the more serious cases of constipation. Really long term constipation. And what I like to call LLC, or lifelong constipation. You know we see those patients. They were cal carb babies. They had constipation right from the beginning, and here they are as adults, and they’re coming to see you.

Dr. Kara Fitzgerald: You’re going to have to define that. A cal carb baby. Not everybody’s going to know.

Dr. Sandberg-Lewis: Oh, cal carb is a very common polychrest homeopathic remedy that has effects on the kind of … it’s made from calcium carbonate from the inner shell of the … what is that? Not the clam. Anyway … oyster shell.

Dr. Kara Fitzgerald: Oyster.

Dr. Sandberg-Lewis: And they tend to have … these are the kind of babies that only have one bowel movement a week, or two bowel movements a week, and the mom’s are freaked out. The babies are constipated. But they bring in the baby and the baby is smiling and looks right in the eye … stares right in your eye and they seem happy, and they sleep fine. Maybe they’ve got some earaches and some runny noses, but they’re basically pretty healthy and the constipation doesn’t seem to bother them.

As opposed to a patient who has a kind of constipation where they’re straining all the time and if they miss one bowel movement, they want to kill everybody and they’re so uncomfortable. Those are other remedies like Nuxvomica in homeopathy, but cal carb is kind of that pretty healthy, happy baby that doesn’t have bowel movements.

Dr. Kara Fitzgerald: But this is potentially somebody who’s going to have chronic constipation. And so when they come to see you as an adult, you’re thinking prucalopride?

Dr. Sandberg-Lewis: You can treat them homeopathically first, but often I see people who have already seen a bunch of NDs and a bunch of MDs, and they’ve had a lot of really good treatments that haven’t necessarily worked, so it just depends.

Dr. Kara Fitzgerald: So we just have a couple of more minutes. I want to ask you, God, you know I’ve got a lot of questions I could ask you, and I know … you know, I’m sorry folks. I know you’re coming up with questions in your own mind you’re wishing I would ask … the proceedings from the SIBO conferences, from the NUMN conferences you’ve been doing for years with Allison Siebecker … and the folks who are presenting are just the top scientists, but also in the trenches clinicians. Both medical doctors and naturopathic and other types of clinicians as well. So it’s just a fabulous center of excellence. The work you guys are doing there is just so cool to watch…

Dr. Sandberg-Lewis: Thank you.

Dr. Kara Fitzgerald: … it unfold and evolve. And the resources that you’re making available to us has been … it’s a gift. And we refer to them all the time in our practice. But incidentally, people can access the recordings if they can’t make it to the conference, and so all of these things that you’re touching upon … anything that you can give me to put in the show notes for people who want to do a further drill down into what you touched upon today, I would love that.

Dr. Sandberg-Lewis: Yeah, and we could just quickly mention … like I said, next Saturday and Sunday, a week from tomorrow, in Portland at NUMN, is the SIBO Symposium, or S-I-B-O Symposium. And Dr. Pimentel will be there talking about the autoimmune component. His practice partner at Cedar Sinai is going to do an overview of motility through the entire gut and the common motility disorders and how they’re treated.We’re going to talk about traumatic brain injury. Other’s are going to talk about Parkinson’s, cause that’s a very related condition as well. And many other conditions. And then the next month, in April, is the Integrative SIBO Symposium in Seattle, and that has always been a good one too. That’s the third year they’re doing that one.

Dr. Kara Fitzgerald: So if you can’t hop on a plane or drive over to Seattle or Portland to attend, the proceedings are available for purchase?

Dr. Sandberg-Lewis: Yeah, or you can do it as a live webinar kind of thing-

Dr. Kara Fitzgerald: Oh, they’re doing a live stream.

Dr. Sandberg-Lewis: … if you’re into that.

Dr. Kara Fitzgerald: Perfect.

Dr. Sandberg-Lewis: Yeah.

Dr. Kara Fitzgerald: Perfect. Perfect.

Dr. Kara Fitzgerald: Okay, so one final question. There’s been a lot of debate in our space around hypochlorhydria, using HCL. I just wanted to ask … I think Pimentel actually, somebody brought to my attention that he thought HCL could actually be contraindicated in SIBO. I think in some cases it’s absolutely essential, but I guess … I just have a couple of questions. One is, how you identify what you think is likely hypocholhydria, how you’re addressing it, and what role if any do you think it’s playing in SIBO?

Dr. Sandberg-Lewis: Alright. Well I got to say, I’ve got a full chapter on that too in the book. But if you want to get more detail. But we have a Heidelberg machine in our office, and often…

Dr. Kara Fitzgerald: That’s handy.

Dr. Sandberg-Lewis: … we can get one doc in a small state that has a Heidelberg machine, that’s a great thing to have because you can directly measure not just the ambient pH, but the response to a challenge where you neutralize … repeatedly neutralize the stomach acid and see how long it takes to re-acidify. And that can detect what we call a hidden hypochlohydria. So we rely on that quite a bit. We like to know what we’re dealing with. Certainly, you can also … in applied kinesiology, we use strength testing of the pec major clavicular, the PMC. And in applied kinesiology, it’s often discussed that a bilateral weakness of the pec major clavicular is a sign of hypochlohydria, so I’ll take that under advisement when I find it. I test every patient for that.

Dr. Sandberg-Lewis: But then, you can go by symptoms also. The symptoms of course are fascinating and I talk about that in the chapter, but we know you can either have symptoms like reflux, or you can have symptoms more similar to gastroparesis and delayed gastric emptying. A lot of the same symptoms that you have with hiatal hernia syndromes.

Dr. Sandberg-Lewis: So yeah, Heidelberg Test is my only way that I know you can truly test for sure, but you can do a titration therapeutic trial. The main thing about doing any of that and using HCL … if you know your patient has recently or recently enough, had an upper endoscopy and they found erosive esophagitis, not a good idea. First you want to heal things. Or even a … certainly an acute gastritis tends to heal pretty fast, but a chronic gastritis may not do very well with HCL, even though they need it.

Dr. Kara Fitzgerald: Yes.

Dr. Sandberg-Lewis: So, sometimes you have to start with more maybe pancreatic enzymes and things like that. But if you know your patient is achlorhydric or hyperchlorhydric, you’re eventually going to come around to doing something, either stimulating acid with bitters, or if they tolerate vinegar, one or two teaspoons of apple cider vinegar as everybody knows, in water, before meals. Or you’re actually going to give them hydrochloric acid, and it just depends on whether things are healed enough to be able to tolerate that and whether the lower esophageal sphincter has good enough tone to not lead to reflux into the esophagus.

Dr. Kara Fitzgerald: Right. Yeah. Okay. A lot of really useful information. Alright, one final question then we’re gonna just wrap up.

Dr. Sandberg-Lewis: You want me to just say what Pimentel said about it?

Dr. Kara Fitzgerald: Oh yeah, yeah. Go ahead, yeah. Absolutely. I’d like to resolve this, or at least hear it from you.

Dr. Sandberg-Lewis: So he’s just looking at the fact that hydrogen gas, if you’re putting in hydrochloric acid, that’s a source of hydrogen gas as well … say for instance for methane producers to convert into methane. Or just adding to the hydrogen load, if you already have overgrowth of hydrogen producers. And that makes sense chemically, but at the same time, if you have hypochlohydria or achlorhydria, your risk of rapid relapse is very high, because you don’t have that upper gate of the small intestine along with bile salts and pancreatic enzymes, as that stomach acid empties through the pylorus into this small bowel. It really reduces bacterial growth. It keeps it low. Keeps the levels low. So it’s a two edge sword.

Dr. Kara Fitzgerald: Yes. Yes. Hydrogen is pretty dang ubiquitous, so would it actually … would oral  exogenous HCL supplementation really meaningfully contribute to a pool that’s pretty limitless? I guess that was kind of a thought that I had.

Dr. Sandberg-Lewis: Well my feeling is, we have to have HCL.

Dr. Kara Fitzgerald: Yes.

Dr. Sandberg-Lewis: Jonathan Wright wrote the book Why Stomach Acid is Good for You. It’s  essential for so many things. And the idea that you can just let it be deficient … I mean, we need … we’re supposed to have a certain amount of it. So I think it belongs there. It’s part of the ecosystem there.

Dr. Kara Fitzgerald: Yes. Yeah. Absolutely. Well, you taught us … one of the very first steps in an

immune response … killing the organisms that we don’t want around … with stomach acid.

Dr. Kara Fitzgerald: Alright, well listen, it’s been just great talking to you. Thank you so much, and I

appreciate your perspective and just kind of keeping alive some approaches to GI presentations that we’re not routinely thinking about and really getting good outcome. Especially for refractory SIBO cases.

Dr. Kara Fitzgerald: So again folks, go to the show notes and you’ll find a lot of the content and links

and everything that Dr. SSL and I talked about today

Dr. Kara Fitzgerald: So thanks for joining me.

Dr. Sandberg-Lewis: Yeah, thanks for the good work you’re doing, Kara.

Dr. Kara Fitzgerald: Absolutely.

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