SIBO Restless Leg Syndrome and Rosacea with Dr Leonard Weinstock - Ep 7_en (auto-generated)
[Music] welcome to the healthy gut podcast the place where you can learn how to achieve a happy healthy gut with your host rebecca coombs on today's episode of the healthy gut podcast episode dr weinstock is board certified in gastroenterology and internal medicine he is president of specialists in gastroenterology and the advanced endoscopy center he teaches at barnes jewish hospital and is an associate professor of clinical medicine and surgery at washington university school of medicine dr weinstock is an active lecturer and has published more than book chapters he is an investigator at the sundance research center and has participated in over researching the role and treatment of small intestinal bacterial overgrowth in restless leg syndrome irritable bowel syndrome and rosacea and he joins me on the show today to talk about restless leg syndrome and rosacea particularly in correlation to sibo i myself suffered from restless leg syndrome for years and didn't realize it was all to do with my gut so i hope you enjoy today's show episode dr leonard weinstock welcome to the healthy gut podcast thank you so much becker it's great to have you here i first met you at the sibo symposium this june in portland oregon which was wonderful to hear you speak at the symposium and i was uh really lucky to be able to spend a few minutes chatting to you and also gift you one of my cookbooks which was great and i enjoyed that yeah it's a beautiful cookbook thank you i'd love to to start with your story how did you end up in uh with an interest in gastroenterology um and why you're interested in um sibo in particular well my flight towards gastroenterology started with a strong background in internal medicine i felt that internal medicine just gave somebody a viewpoint of the person as a whole like no other whereas surgery was very limited and pediatrics was their own little thing and gyn was their own thing but internal medicine just covered so much and often brought into these interesting differential diagnosis of patients who have been suffering with conditions for a long time and that's what i found with that there were many people who had unusual disorders and so many of the gastrointestinal disorders were called syndromes and that just really intrigued me because i thought when i went to med school oh everything is a textbook and it's all going to be spelled out well when it comes down to things so many things in gastroenterology are syndromes and they're real mysteries so i like to think of myself as trying to solve mysteries because i've enjoyed uh detective shows and so forth and that was one thing and then the other aspect is you know you do things you do surgical techniques as well so if there's a gastrointestinal bleeding you're not just ordering the test you're actually doing the test so for me that is a combination of the both thinking skills of medicine and the surgical techniques that makes it all happen and i think that anyone that has suffered from gastrointestinal issues can appreciate the detective mode in that often one has to play real detective with uncovering what is going on with them it's so true yeah and talk to me a little bit about what why you uh then also got interested in sibo well sibo uh was fascinating because for years i've been talking to patients about irritable bowel syndrome and so fascinating to me that there could possibly be a condition that really know exactly what's causing it so for the first uh half of my career from 1985 to 2000 it was just a matter of waving my hands and saying oh we think it's a you know reaction to food and your gut is hypersensitive and the nerves therefore are abnormal and there could be stress and all this kind of hand holding and hand waving if you will and then um during that latter part of those 15 years i became interested uh really in motility and irritable bowel syndrome and was asked to be on a support group on an internet support group for irritable bowel syndrome and so i was the pharmacology expert and would give input on that and um on new new new treatments and so forth and somebody asked me well what about the article that came out in 2000 for bacterial overgrowth and the treatment with neomycin and getting better from irritable bowel syndrome and i actually had the american journal gastro on my desk ready to read and i hadn't gotten to it so i immediately turned to the article i said now that is interesting that you could actually get rid of um irritable bowel syndrome with an antibiotic and by doing so it was a real remarkable thought and so i started treating empirically patients for with the antibiotic and seeing some good responses and then there's some written information around that time about doing a breath test and i didn't have access to one but in my office but there was a little hospital that had been doing breath tests for quite some time so i started ordering them and that put some science to what i was doing and so i started treating with neomycin and then later ciprofloxacin and metronidazole and some patients would get a dramatic response nothing else had worked before they'd get a dramatic response they'd relapse they'd retreat them and then they'd wean off their responses and would not uh have the marked improvement that they once did before and so um my interest waned a little bit um but then it was peaked dramatically when uh sofaxin or rifaximin was introduced into our country and then i went to a educational meeting about that and learned about how this drug was not absorbed from the gi tract and it was working mainly on the gut bacteria in the small intestine because of its properties being able to work through bile where the small intestine had bile on the surface and you could get through this bile layer with the antibiotic and it treated many different kinds of bacteria and that the cool thing about it is that it didn't have a resistance factor like other antibiotics it operated in a different way so that was exciting and then at the meeting it was also discussed that it had a role in another condition called fibromyalgia which i think many of your listeners know about or have and that the breath test abnormalities were even greater in the patients with fibromyalgia and so at that time i was taking care of a relative who had post-infectious irritable bowel syndrome and restless leg syndrome and this whole concept of post-infectious uh irritable bowel syndrome came out which we'll talk about later and i asked my cousin whether he had acquired the restless leg syndrome after the irritable bowel started and he did and then i started reading about fibromyalgia and syndrome which is much more than the general population so i started thinking well was there a relationship here could uh if fibro patients had small intestinal bacterial overgrowth or sibo could the um patients with restless leg syndrome have the same and i treated him and he had a dramatic improvement in the restless leg syndrome using the sefaxin and that started my interest in looking at things outside the gut and basically getting back to internal medicine where i had interest in looking at how the body is affected and where does this stimuli come from and so that's that's how i got it got started so um i'm interested to know i think it's fascinating that your journey and interest and and you know what's really interesting is that it's looking at the whole body and and realizing that there are connections between one condition and potentially another i'd love to know what you commonly see in your practice and who are the types of people that you're regularly treating well on the office side of things a gastroenterologist will often treat irritable bowel syndrome and acid reflux disease and crohn's disease and ulcerative colitis those are the top four um causes for unknown causes for pain and bloating that brings things up as well and nausea is a big category of illness and in the morning most cancer neurologists are doing procedures and uh doing colonoscopy and uh looking for polyps and and causes for diarrhea so these are some of the things that a gastro does with respect to who comes in with irritable bowel and what they are like i see more and more of second and third opinions because they're often dismissed and this is one of the things about syndromes and patients that bother me in our society and in the doctor's approaches is that many patients you know come in their condition isn't easily understood it's not like hypertension where you can try one drug or another and you can do one test or another to say which kind of hypertension they have in uh up until recently with both breath testing and a special blood test we haven't been able to dissect uh the patients out from this big pie of irritable bowel syndrome into different spits specific pieces so for instance if i can take a syndrome like irritable bowel syndrome and view it like a pie and slice out a portion who have it due to sibo then i feel okay i can treat these people very specifically if it's gluten sensitivity take out a portion put it aside and work on that with diet and so forth until you get to this idiopathic or conditions of unknown where the same set of symptoms are dealt with by all these people in the syndrome but if we can get out of our global view of irritable bowel syndrome as one unknown and and stop treating them as if there's you know nothing you know specifically wrong with them then we can start getting um ahead in how we treat our patients and i just think that's music to my ears i was one of those patients for years going backwards and forwards to doctors uh complaining of digestive complaints and being diagnosed with you know that that broad sweeping term you have ibs and there's nothing we can do about it just deal with it stop being stressed and be careful with what you eat uh so you know it's it's something i lament on as well that that people unfortunately still today are being given a sweeping diagnosis with not much assistance on what they can do about it i'm really interested to know if there are any figures around you know this this piece of pie whether we there are stats on uh you know how many people with ibs are due to sibo and how many are due to gluten sensitivity or other conditions is there any research around that we can kind of classify that piece of pie yes so if you look at the data for um this new antibody test um because work has been done recently showing that there's an antibody in quite a number of patients with irritable bowel syndrome and co and diarrhea that it is looking like up to 60 of patients with ibs d irritable bowel syndrome with diarrhea have an antibody and this goes back to this whole idea that some of our patients in fact perhaps many of them have post-infectious irritable bowel syndrome so just to put that concept into uh facts it's a seven to thirty percent chance that when you get an infection with a bad bacteria that you'll get post infectious irritable bowel syndrome never had ibs before but then sometime after usually three months or more you'll get irritable bowel syndrome and so um with this antibody testing antivinculin in anti cbt4 there's evidence that these antibodies destroy the myenteric plexus nerves the nerves that are running alongside and into involving the small intestine and if you lose those nerves then you're losing the contractions at night that keep our small bowel clean so if we damage the cells interstitial cells of cahal with this antibody you lose the migrating motor complex the sweeper wave that keeps the small bowel free of bacteria and then you're at risk for getting bacterial overgrowth so studies have been done suggesting by statistics and projection that up to 60 percent of patients have ibs due to this autoimmune condition which is interesting because if you look back at breath test results between 40 and 60 of breath tests were positive in patients with ibs d and so that is sort of a one-to-one correlation there that now makes sense we just had to deal however with the problems of the breath test that it's not very specific and there's a lot of non-believers in the medical profession in the research community because of certain aspects to uh how sensitive it is that it just seems to be too non-specific but with a blood test looking at an antibody that gets to hard data that can be really looked at very clearly um definitely and it's such a shame that here in australia we don't have access to that test yet so hopefully one day soon we are able to to do that test here as well but it is available in america and i i don't know if it's available anywhere else in the world do you know if it's available in any other countries not to my knowledge um in terms of other pieces of that ibs pie um who else makes that pie up what other conditions can cause that yeah so okay so certainly food sensitivities um whether it be specific or non-specific certainly um there are some celiac disease patients that can be uh labeled incorrectly as irritable bowel syndrome because the symptoms are um similar many times but hopefully we've taken them out of that idiopathic pie gluten sensitivity i think fits in it because most in general we don't have any biopsy proof that gluten sensitivity clearly exists now there's some i've seen some electron microscopy where people have gluten sensitivity they don't have celiac disease and yet if you look under this extremely high-powered microscope where you're really only looking at a couple cells at a time it's so high-powered you can see these little vacuoles or little balloons near the lining suggesting that gluten sensitivity is a real disease but at this point i would say two percent of the population has gluten sensitivity and there can be other symptoms that go along with it including headaches and fatigue as well other aspects well i think that the the nerves are abnormal in many patients who have irritable bowel syndrome we do see mast cells mast cells that are deposited in the lining of patients with irritable bowel syndrome and we see other inflammatory cells that come in to the lining so i think there's an inflammatory type irritable bowel syndrome which is where i think some of my patients who have failed many things get better with low dose naltrexone because it reduces inflammation in particular lymphocytes so mast cells i don't think have deserved have received the attention they deserve and there are some nice studies showing that the closer the mast cells to the nerves the more pain a patient would have with irritable bowel syndrome and mast cells release a variety of chemicals like histamine and tyrosine which activate the pain sensory fibers so that may be some of the reasons why we're we have specific food sensitivities especially in irritable bowel syndrome food obviously in your book is well demonstrated plays a big role in sibo in terms of what we're feeding our bacteria okay so if you feed your bacteria that you've gotten excess too much carbohydrates and undigestable sugars they're going to have a feast and cause bloating and gas they are and uncomfort uncomfortable symptoms as well right now uh finally you know i think there are patients where they have these abnormal nerves now are they inflam inflamed or or just abnormal for some other reason perhaps some tract when the grain in the brain gut tract is off off kilter but we have this visceral hypersensitivity at the heart of many patients with irritable bowel syndrome such that you stretch the colon you stretch the small intestine and then you're going to cause problems with pain again that could be going on at the same time bacterial overgrowth is going on so you you increase your gas production you stretch out the small intestine before the gas is able to travel to the colon to be expelled and it takes longer to get absorption of the gas in the small intestine so it stretches out and those nerves get activated and cause problems so it's really a bit like a vicious cycle in that if the gas continues the nerve damage can continue which can lead to more motility issues which kind of keeps going around in circles by the sounds of things yes yes and then of course we step towards well what else do bacteria do and um they cling on to the small intestine lining the small bowel doesn't like it's not used to having bacteria there so it really is not used to have these toxic bacteria clinging on and then a lot of these cells bacterial cells cause damage to the lining of the intestine and increase intestinal permeability so called leaky gut and when that happens then other chemicals food antigens or bacterial byproducts get in there and that stimulates the lymphocytes to ultimately produce inflammatory proteins called cytokines and draw in other inflammatory cells causing inflammation and then that damages the lining of the intestine which then has a vicious cycle of its own becomes leakier more gut toxicity comes in and more inflammation starts and this is where i think the gut starts reaching out to other parts of the body and it may be a lot of what you're going to get is what your biological makeup is so if you've got a certain genetic makeup or phenotype um you're more likely to get one disorder versus another but but i've seen but i've seen you know one of my first patients who came in you know had all the symptoms you know was one after another you know post-infectious irritable bowel syndrome then then restless leg syndrome then fibromyalgia then interstitial cystitis and it's just one after another every two years she got a new syndrome and she actually was able to we were able to reverse virtually all of our problems with antibiotic therapy and then ultimately with naltrexone settling down the inflammation wow that's that's fascinating and so what what is your approach when it comes to when a patient presents for the first time in clinic and they're in a in a bad way um you know what what do you commonly see from someone that is complaining of um irritable bowel syndrome and then how do you approach their treatment so ibs is generally defined as abdominal discomfort three months or more per year with associated changes in the bowel frequency and form and with partial relief of symptoms with elimination and i say that partially because that doesn't really account for all the patients with small bowel symptomatology because those patients are having issues with distension and bloating and ultimately if there's enough acidity that is created by the bacteria it may cause contractions and increase output of fluid and then they get diarrhea or as we've gotten to know over the last making methane they get not only get bloating but they get constipation so my history taking is really important in terms of defining their syndrome seeing how bad their bloating is seeing as if it's visible bloating as opposed to just feeling distended because um if they're not visibly bloated um that somewhat decreases the likelihood of sibo but not entirely and on the vice versa aspect to that abdominal bloating can occur without sibo just because it's a relaxation of the lower abdominal muscles in response to pain and so you relax the muscles that helps alleviate some of the discomfort in general so there's a couple different mechanisms for bloating asking about the type of gas that they have how oatmeal odorous is it are they having any uh passage of the gas chemicals into their mouth with bad breath or chemicals that are actually coming out into the urine those are important questions too then the workup i do is perhaps not you know what everybody does i would say uh we actually do quite a bit of breath testing to get a feel of how severe the abnormality is um if um if we've got a very high peak on the hydrogen those patients can be tough to treat we know that they may need um several courses of therapy or drawn out courses of therapy motility may be a big issue and that's where i'm getting the um the blood test could be helpful that ibs checked the antivan cooling could be helpful although i find that actually to be even more helpful when i've had patients who have been relapses frequent relapses for what i think should have worked to say okay maybe it's not this post-infectious autoimmune disease if it's not what is it so do they have some other disease that is associated with small intestinal bacterial overgrowth such as scleroderma or pseudo obstruction or adhesive disease i'm quite interested the comment you made about that bloating doesn't necessarily mean it's sibo and something that i hear from people quite frequently is that they've they've treated their sibo they've received a negative breath test but they're still bloating and they're and i'm feeling particularly uncomfortable and embarrassed about that because no one wants to look pregnant when they're not man or woman um so what what would be your advice uh to somebody that's listening to this podcast that is still bloating even though they have successfully at this point in time treated sibo well there are there are other causes for it okay um so that's you know something that you need to be uh to think about air swallowing uh gastric outlet obstruction um small bowel adhesions um diseases like pseudo-obstruction although those that is often associated with bacterial overgrowth air swallowing can be a tough one i mean there are people who have nervous habits of taking gulps drinking out of the bottle water and gulping down water with it so that air which is you know a typical atmospheric air does not get absorbed very well by the small intestine so that that's an aspect and then finally irritable bowel syndrome without bacterial overgrowth can be associated with pain and again it could be uh just relaxation of the gut wall to deal with pain it's kind of like undoing your belt buckle when you're uncomfortable it makes a difference it gives more room for the organs to move around hmm definitely and and i'm i'm really interested in this this uh sort of gulping air or drinking from a bottle is that just literally when you're drinking from a water bottle that you can be taking in air or is there something that people are doing specifically when they're drinking that that causes air to uh go in well it's the glug glug when you hear the glove glug glug sound that means air is going in and if it doesn't come out as a belch then it's going to stay in your gut ah okay interesting wow that's that's really interesting and it's something you know i've at times have been known to you know gulp down drinks uh but my mom uh can't she just takes sips and we've always teased her about that but now now i think that's probably a good thing that she's just sipping her her liquid so it's yeah she's prim and proper and and taking sibs and now running around sure it's good and also not potentially swallowing air which is good for her um are digestive disorders and and discomfort on the rise or is it that we're just getting more aware of them i think there are two main factors um number one a lot of people who are sitting at home just dealing with this on their own are becoming aware that there's more reasons to complain they may have better access to health care and so they're bringing to attention to their doctors now [Music] and there's a whole you know series of studies showing that there are many people who have yet undiagnosed untreated irritable bowel syndrome with respect to causality and could there be an increased causation for irritable bowel syndrome if we just take the case of post irritable bowel syndrome there i think are a couple of things number one people are traveling more and they may go to underdeveloped countries or countries where cleanliness and safe water supplies are not at hand and then on the flip side if we're getting more fruits and vegetables from foreign countries then it puts it as us at risk for getting infections um because they're coming in and we're not washing our food as well as we should and i'm interested to know whether once uh once you get some uh food poisoning or or infection from a contaminated food whether that makes you more susceptible to it because i've i've found personally that i've traveled quite extensively as an australian it's almost a rite of passage we leave our country and we go off wandering and so i've traveled through asia south america i lived in the uk for seven years so i traveled throughout europe and and i've been into northern africa i went to egypt and it felt to me that every time i went away from the first time i left australia i would get food poisoning i would always end up with food poisoning and i've picked up parasite infections as well i've done that a couple of times and it and it feels to me that i'm susceptible because nobody else that i'm traveling with seems to get sick like i so is it to have am i now more susceptible because of the infections i've received in the past well perhaps your gut is not yet healed completely it's one possibility that um if you're you don't have an intact bile layer protecting your small intestine and or let's say the mix of bacteria in the colon have been altered by antibiotics or by bacteria shifting things you may not have the protective balance in the small in the colon that you once did putting you at risk for other bacteria coming in and so your immunity may be altered in the setting of sibo said to you know you're at risk for other insults definitely and and i know that i've done all of that travel i've talked about was prior to me discovering i had sibo and then working on healing my gut i haven't left australia since so it will be interesting to see what happens next time i travel after taking a lot of effort to heal the lighting of my gut let's talk about restless leg syndrome i know when i first heard about sibo and i heard that restless leg syndrome was a common symptom i i felt like a hallelujah moment after years of having very annoying restless legs i now had an answer for what had happened and i no longer suffer from it now that i've treated sibo can you talk a little bit about why that occurs and what restless leg syndrome actually is well it's the restless like syndrome is defined as the compelling urge to move your legs while you're awake in the evening getting worse at bedtime with usually in a disagreeable sensation so it could be a creepy crawly feeling a tingling uh an aching and um with that urge to move you'll get temporary relief or if you're walking you get up and walk you can get relief so it makes it difficult for people to get to bed now it may be associated with kicking and jerking in the evening while you're actually sleeping that's periodic motor limb distort disorder so it runs in parallel with it but it doesn't necessarily mean that if you just kick your legs while you're sleeping that means you have restless leg syndrome restless leg syndrome again is dr you're conscious you know people could be on long trips in the car or plane and they just have that itsy feeling they got to get up and walk they just can't keep their legs still so it's very bothersome and it uh it is associated with um significant two significant problems hypertension and stroke there's a higher risk so whether that's through a sympathetic increased sympathetic nerve tone we're not sure but it's so it's not just oh it's a bothersome problem it actually interferes getting to sleep and people can wake up and then they get have it and they can't get back to sleep so it's a real problem but what's fascinating to me is when you look at the condition you've got primary or restless leg syndrome with unknown cause you've got familial restless leg syndrome and then you've got secondary restless leg syndrome and there have been 50 conditions that have been reported to be associated with and or contribute to restless leg syndrome and of which 40 are have you know been looked at to have uh comparison to control groups so there's really very specific uh disorders different gi problems five different rheumatological problems six different metabolic problems four five pulmonary disorders that actually are associated with restless leg syndrome for years uh people have thought well there's not enough iron in the brain and there have been studies looking at that because if the dopamine cells don't have enough iron they don't function well and so that gives rise to this this feeling and um and why it occurs at night we're not 100 sure although there is some um thought that influx of iron occurs more at night in normal people and if you're if you have restless leg syndrome that's not happening but of these 40 conditions 15 have been previously tested on their own for small intestinal bacterial overgrowth and all 15 have had positive tests so like people with irritable bowel syndrome chronic liver disease pulmonary pulmonary problems rheumatological conditions like rheumatoid arthritis have been associated with uh small intestinal bacterial overgrowth um so that really made me um exciting to say okay well maybe it's all about the gut and um the problem is when i started looking at drug studies just aimed at treating the gut only for sibo i get good response but not everybody was responding and and there would be a limitation to how good people got but when i started adding naltrexone to it then i had better improvement and what happened was i started looking at the literature and it turns out one of my research partners in vanderbilt had looked at the amount of endorphins in the brain in patients who had restless leg syndrome and there was less endorphins in the brain and the endorphins protected the dopamine cells in the setting of iron deficiency so now what we're doing is we're treating sibo and giving endorphins to increase uh sorry we're giving low-dose naltrexone to increase endorphins to help get into the brain and protect the brain cells and the dopamine functioning so that's part of it and then finally inflammation and or immunological disorders with these 40 conditions is very common and so we're looking at is there abnormality of the t cells and remember i said at least in the gut we can have abnormal cells and conceivably antibodies can be formed by these t cells um and then perhaps those are attacking the endorphin cells in the brain and contributing towards this so a lot could be going on with restless leg syndrome but with what i can have called sequential treatment um i've gotten very good results we treat the sibo first and then we give the therapy with the ldn afterwards and in terms of one study that i looked at with 40 patients and or moderately better response than they did before treatment so and uh some of these patients who are markedly better were went into complete remission which just generally doesn't happen in treating restless psych syndrome with conventional therapy that's so interesting and well i and i'm i'm kind of also living proof that once you start working on the gut uh restless leg syndrome kind of vanishes it was amazing i used get driven crazy at night with my feet feeling like they were just full of ants and uh and the worst place for me to get restless leg syndrome which i always got was on long-haul flights and i used to fly backwards and forwards between australia and the uk every year so 24 hours of travel and by the end of it i felt like i was ready to rip my feet off i was going crazy and i found actually as well for me that my restless leg syndrome got worse when i was tired which obviously you get very tired on long-haul flights so uh the sign for me that i was getting tired of a day or a night uh was my feet would get very uncomfortable but it's interesting fascinating such fascinating stuff the other condition is rosacea and i'd love to hear a little bit more about what that condition is and its connection to the gut well rosacea has different forms it can involve it generally involves the skin and the face the cheeks the chin nose and forehead and it's reddening flushing bumps with papules or pustules or thickening of the skin but it can also involve the eyes and the area of the eyes that are involved are the lids and the glands that produce the uh mucus and the tears the memobian glands and um it should be considered a syndrome too it's funny that they don't call it rosacea syndrome but it is yet another condition that we don't really know in the majority up until uh uh 2008 so i was reading one of my journals in 2008 and lo and behold there was a study out of italy where they made a correlation of rosacea and sibo and they took 113 consecutive clinic patients and gave him breath tests and 46 of the those patients had a positive lactulose breath test now i'd like to say one thing about breath testing that patients 30 completely healthy volunteers and 10 percent had an abnormal breath test so you know and yet there was no reason expect it no symptoms and so forth so it's not a hundred percent but even if you looked at ten percent positivity of controls versus forty six percent of the rosacea patients that's still very significant and i looked at 63 consecutive patients that came to my clinic for mainly for colonoscopy i'd identify them and said would you like to get a breath test and see if we could treat you a different way and my percentage was about the same two 41 had a breath test that was positive who had rosacea so um in the italian study um they did look at uh age match controls and they had five percent that were um had a positive breath test um so um in their study if the patients had a positive breath test and they were treated with uh rifaximin or sulfaxin um basically for ten days they had a relatively smaller dose than we're currently using now they used 1200 milligrams a day rather than a significant response approximately seventy seventy percent cleared their rosacea completely and twenty one percent had a marked improvement so close to ninety two percent had a dramatic improvement if their breath test normalized so that's pretty exciting and at the same time they compared them to placebo and the placebo patients two out of 20 uh worsened and the rest 18 were unchanged so that's pretty powerful statistics and their gi symptoms got better as well when they looked at patients who did not have a positive test or bacterial overgrowth none of those patients got better and so that's you know pretty good evidence that we have an effective treatment and then i looked at my statistics and basically um 46 of my patients had a cleared or marked response 25 had a moderate response and these are patients at a positive breath test and we're treated and i'm getting similar results in patients who have ocular rosacea um and and a number of the patients i see with ocular rosacea have the disease limited to their eyes but only about 30 percent had a positive breath test in that setting so dermal involvement is a bit more significant and and yet it can play a role in patients who have the uh ocular rosacea where you get dry eyes and um foreign body sensation and redness of the cornea as a secondary phenomenon how interesting and is there do we understand why sibo can lead to or what the correlation is i should say between sibo and rosacea well it hasn't been tested but my feeling is it's related to systemic cytokines namely these chemicals that are triggered by our leaky gut that then travel systemically and if you've got a gene that makes you predisposed to having rosacea then you're going to get your skin activated inflamed and uh affected and i hear from a lot of people that they often have skin complaints uh as well as abdominal or gastrointestinal complaints as well so they very much seem to go hand in hand absolutely yeah absolutely one of the things that i used to be absolutely terrified of when i was quite unwell was that all of this was leading to cancer and and i know i'm not alone in that fear i hear from people all the time saying i'm so scared i'm i'm just waiting for a diagnosis of cancer can i mean are there studies to show that undiagnosed or untreated digestive disorders can then lead to digestive or gastrointestinal cancers or uh or is it us just being a little bit nervous and hypochondriacs well i think you have to look at two things you've got two big organs in your body you've got the small intestine that's 15 feet and you've got the colon that's six feet of intestine and in the colon you've got anywhere between 13 and 100 trillion bacteria in the gut and i think i mean there are some studies to suggest that colon cancer can have a different set of bacteria in the colon that predisposes towards colon cancer so i think if anything is going to increase the risk for cancer it will be an imbalance or what we call dysbiosis in the colon and there are many uh medical conditions ranging from parkinson's disease to diabetes where an imbalance in the gut bacteria are playing a role and mainly in the colon so i think that sibo per se i've not seen research to really support uh risk of cancer in that setting and how do we find out is there a way for us to find out if we have an imbalance in gut bacteria so there are um companies that do analyze the bacteria send a stool sample into a company like genova and then this rocky mountain company there's um i think one other that you can send stool samples in to get a bacterial balance to see what's out of whack to see if you have a narrow group of bacteria that are there as opposed to a wide spectrum of healthy bacteria then the trick is well how do you treat that if you do have that and at this point there's some evidence that the fodmap free diet can swing yourself to a healthier state i think the same could probably be said for a specific carbohydrate diet although i haven't seen evidence of that but i think it's possible and um probiotics may or may not play a significant role just because we're talking about taking in billions of bacteria and that's thrown in a mix of trillions and the degree that um those billions can make a big difference is questionable i think that's not to say that you can't get benefit symptomatic benefit but can you turn your whole gut bacteria around is uncertain so i think changing the food that your bacteria are eating in the colon are probably the best ways to get a healthier mix of bacteria what about fecal metal matter transplants do you well what do you think about that i was going to say that yeah so i mean i think there are some patients who are totally refractory irritable bowel syndrome and and changes in the gut bacteria in the colon have been associated with irritable bowel with diarrhea that that may be a very good future way to change it my only concern is how effective will it be because you know we do these colonoscopies you clean out the colon perfectly and then two days later you're having bowel movements half of which are fecal byproducts so it comes back very rapidly so putting in healthy groups of bacteria it may require treatment after treatment after treatment to possibly to really get a foothold of this new bacteria to overwhelm your unhealthy mix but i think it's possible i think that it's possible that manufacturers of spores capsules with spores of bacteria where you can get anaerobic bacteria into the colon which is really important could be helpful when we're taking probiotics are generally aerobic bacteria so they're maybe not as likely to survive in the colon which is an anaerobic setting um and just uh just going back to sibo i'd love to know whether uh like how often you see success cases with sibo and if you feel that sibo can successfully be treated and kept away for good so is it curable well i think it's highly treatable and some patients can be cured in time and that is a question to be addressed with future studies so if we had a wonderful treatment for let's say the autoimmune aspect to irritable bowel syndrome with this you know endovin coolant then it's been shown that if you can get rid of the um antivan coolant by experimental means the cells that are causing slow motility could get better and that's where i'm hopeful that some of my patients are being treated with naltrexone where there may be lessening of the auto antibody and perhaps with herbal therapies could get better and their nerves could regenerate in time some people who have autoimmune diseases do get better the stimulus to the production of them get better so if we're aggressive in treating the bacteria were aggressive in treating the gut lining disturbance it may lessen the production of those t-cell activities and the antibodies they're producing so uh what percent get better with standard two-week course of antibiotic therapy i say about about eighty percent and then uh other the other 20 you have to retreat retreat and then many of their those get better if they're due to motility disturbance keeping it away by medications such as low-dose erythromycin or sometimes low-dose naltrexone or pucalopride can stimulate the small intestine and keep the bacteria out by keeping the motility going but if a patient comes to me they've had it for 10 years i you know i i say well there is a concern that we're not going to get this into a cure but we can control it the diet i think plays a big role in getting into somebody into remission faster and perhaps keeping them there because let's say you've got a situation where 90 of the bacteria in the small intestine have been killed off but you're feeding it you're feeding them food um sibo uh friendly food if you will um or bacterial friendly food then at some point it's going to tip the scales and the symptoms are going to be active because the the anim the number of bacteria in the gut have overwhelmed what a motility medicine can and in terms of the nutrition component and it's something that i think people get very uh they can they can get quite upset about because food is something that they can control that they're eating it every day do you advise that people do uh remove or or reduce their carbohydrates um when they're treating sibo if they're taking sarah faximum or do you excuse me have them on you know at what would be a standard american or australian diet what's your approach oh no no no i i do a um low fodmap diet no artificial sugars except stevia but no alcohol sugars at all and as low carb as they can deal with especially during the first four weeks of therapy and how long do you have them stay on that diet generally about eight to 12 weeks and then start reintroducing uh foods that they desire but they always stay away from fructose high fructose corn syrup which like gasoline to a fire and so readily available in our processed food correct yeah unfortunately one of the things that i realized as i started to get well well as i as i worked on my health was that there were it was not just the sibo that i needed to address there was other areas in my life and i i saw it as my five key pillars to success when it came to my health my first step was awareness i had to start to get aware of what was happening to me how important do you believe being aware is in a person's journey to health well i think they have to be aware they've got a condition and that they're going to partner with their doctor in terms of getting better so awareness that they're not at fault for this condition i think plays an important role and i really like what you say about partnering with their physician uh it's so important to to find people that you can work with because it's not always a quick fix in terms of in terms of nutrition and we have talked about it a little bit but i know for for myself when i first had to strip out a lot of foods i felt pretty angry about that how what do you see with your patients are they are they happy to eliminate foods or are they often a little bit angry like i was uh they didn't express the anger to me they may think they may do it at home but they don't express the anger to me yes um they just kind of want to know a time zone when am i going to be able to eat pizza you know it's really it comes down to simple things like that and do you feel that people can go back to what they would consider a normal diet of being able to eat a pizza or burgers or fries many many do yeah i would say many many do but um i would say i've got several patients who say i just fell off the bandwagon i had more much more fruit uh and and wine and that triggered a flare so i'll hear that from time to time and that's where they've got they're living well with the of the original bacterial load in their small intestine they feed it then they're in trouble and that's where i think your book i think is very helpful for people who could you know come up with good diets that are healthy um for the long run um definitely i i know for myself that i allow myself little treats here and there but on the whole i feel so much better for eating clean healthy food that i don't really want to go back to the way i ate before and i'm really happy to make food from scratch and you know to know where my food has come from and to really limit the amount of processed food that now is in my diet because i just i feel good for it and if you'd said to me two years ago when i first started this journey into you know getting well with my digestive health if you'd said to me that i'd be really happy to drink alcohol very rarely and not eat much processed food i would have laughed and said sure right okay in another parallel universe maybe but not this one another component that i worked on was movement i i'm one of those people i'm at i'm lying on the couch or i'm running a triathlon and i when i was feeling very unwell my movement suffered i'd been pretty um i've been feeling pretty flat and i just wasn't moving my body do you feel that there's benefit in people moving and that could just be walking or doing yoga or or it could be going and doing a crossfit session um do you see any correlation with your patients in in whether they're being active and moving versus being sedentary excellent question um conceivably uh indirectly in other words if exercise which it does increases colonic activity and then there's less bacteria sitting around in the cecum where uh retroactive movement of the stool up into the electrical valve could put more bacteria there and at risk for ascension into the uh upper small intestine so it's conceivable that that's the factor involved um i haven't actually discussed that with too many of my patients but that's that's very good um plus exercise in general just makes people feel better mm-hmm it does i know when i uh and for me my exercise today these days is walking so i've i've gone away from the really intense exercise and i i am a podcast addict i not only do i do my own podcast but i love listening to others and it's my time out when it's just me myself my podcast the fresh air and i love it i love getting out and walking now fabulous yeah makes me feel great the fourth component that i had to work on was my mindset because i had identified as being a sick person for my entire life because i always had been and i didn't know how to think of myself as a well person i also found that i was pretty negative about things i've already said i was pretty angry about removing foods and feeling really like the world was unfair that i couldn't eat burgers and fries and pizzas so i had to change how i thought about things do you see that with any of your patients in terms of those that start to look at the positives rather than focus on the negatives get well quicker interesting um i haven't evaluated that i certainly recognize seeing patients who get well and feel better psychologically and then there's some evidence that sibo inflammation directly affects the brain in terms of the cosotropine releasing factor which then results in depression and changes in um serotonin in the brain so uh i've seen people come in for follow-ups who have like just their gi symptoms are better they feel lighter on their feet so to speak and they uh their color is better and they just have a much better mood so is it direct or indirect um you know i'm not sure but i think that it can play a big role um in their own mood so sibo itself and the inflammation it's associated with can be associated with a change in their adrenal hypo pituitary adrenal access so it's hypothalamic pituitary adrenal access is all important about fatigue and perhaps if we improve that we get less inflammation less of the bacterial shells coming into our bloodstream that that will help in terms of uh how they feel as opposed to wishing for better health and getting better health yeah sure and the final piece that i had to work on was my lifestyle so i had been chronically stressed i wasn't sleeping well i was getting to bed really late so you know not getting enough hours sleep at night and i needed to readdress some relationships in my life of of people that perhaps weren't um the best influence on me um and so i needed to do that to support my journey to health do you see any correlation between sleep um you know stress levels or even perhaps toxic relationships that people might be experiencing and their ability to manage or work through a condition like sibo well in general with irritable bowel and the abdominal discomfort and the more stress the worse the discomfort so there's definitely a brain gut relationship going from north to south with respect to rest rest is important because during that time you're fasting obviously you're sleeping and you're giving yourself a little more time for whatever migrating motor complex you have or can generate with medicine to get wash the bacteria out um definitely and and i since uh coming through my sibo treatment i now do intermittent fasting so i fast two days a week where i just eat dinner and i feel fantastic for it it really makes me feel really great so um that's been an interesting self-experiment for me hmm yeah yeah interesting yeah it's really interesting it's uh yeah i feel i have so much more energy i feel really positive um and it's for me i feel like on the days where i do eat two or three meals a day uh that i don't have as much energy as i do on the days that i'm fasting so it's been a fascinating personal experiment of one well yeah you've enlightened me and uh on many aspects this evening oh that's great uh dr weinstock it's been an absolute pleasure to have you on the show thanks so much for coming on i have learned a lot and i'm sure my listeners have as well if anybody wants to uh connect with you what's the best place for or how is the best place for them to do that well uh short questions little questions um if let's say they well if they want learn about my research it's all on my email site my website gi doctor.net that's g i d o c o t r dot net doctor.net and then um inquiries uh as long as they're kept simple i can handle some lw gi doctor.net wonderful it's been an absolute pleasure and uh thank you so much for your time today okay have a great day thank you i hope you enjoyed episode 7 of the healthy gut podcast with dr leonard weinstock and if you're anything like me you have just learned an awful lot about restless leg syndrome and rosacea and why they're so connected to the gut if you would like to access these show notes from today's show or get any of the links that we talked about head to thehealthygut.com co forward slash leonard and that's where you'll be able to see a full transcript of the show you'll be able to get all of the links to dr dr leonard weinstock and uh and also look at the show notes as well so that is the healthy gut dot co forward slash leonard now i absolutely love hearing your feedback it just makes me feel so happy to be able to connect with the listeners of the show so do leave us a review and a rating in itunes and it also helps other people find the show the more ratings and reviews we receive the more likely it is that someone who is looking for help around their gut health is going to find the show now if you'd like to connect with us you can do so on all the major social media platforms such as facebook instagram twitter youtube pinterest and google plus and we are the healthy gut on those platforms coming up on next week's show we are joined by angela pifer who is sibo guru and angela and i talk all about the importance of playing your own private investigator when it comes to understanding your own personal health concerns so do join me for episode 8 with angela pifer which is coming up next week [Music] you've been listening to the healthy gut podcast with rebecca coombs to learn more about the healthy gut or the podcast head to the healthy gut dot co forward slash podcast if you would like to help support the continuation of this podcast you can make a contribution at the healthy gut dot co forward slash podcast with thanks to belinda combs for the production editing and original music score of this podcast to hear more of belinda's music head to soundcloud forward slash belinda combs the healthy gut podcast is a production of the healthy gut thanks for listening