Small Intestinal Bacterial Overgrowth (SIBO) The Root Cause of Your Gut Symptoms with Craig Strasnick

>> Today on the root cause medicine podcast. >> Irrable bowel syndrome is the world's most common gastrointestinal disorder. It's estimated to affect up to 15 to 20% of the global population. It accounts for greater than 50% of total visits to gastroenterologists in the United States. Obviously symptoms include diarrhea, constipation, it's like bloating, nausea, abdominal pain, dyspepsia, and more. Historically, Irrable bowel syndrome has been what is categorized as a diagnosis of exclusion. So it's taken five to six years on average for a patient to seek and adequately gain a diagnosis of a variable bowel syndrome. Many times that's done empirically using things like the Rome criteria to use a system, a symptom-based approach to diagnosing a patient is having irritable bowel syndrome. So there's nothing totally objective or evidence-based about it. And it's one of the most commonly afflicted diseases and people that are younger than 45 years of age all around the world. So it's a huge clinically unmet need and something that hasn't necessarily been addressed in a way that has been impactful for patients around the country in the world. - Hello, hello, I'm your host, Dr. Kerry Jones. And today, I talk with Craig Strasnik, the co-founder and CEO of Commonwealth Diagnostics, all about small intestinal bacterial overgrowth, known as SIBO, and intestinal methanogen overgrowth, known as IMO. Listen up, is 84% of you with irritable bowel syndrome likely have one of these as a cause? Before we get started, though, I want to talk to you about something that comes up pretty often on this podcast. And that, of course, is lab testing. You see, testing is one essential way to understand the root cause of an illness. If you are an integrative or functional medicine practitioner, chances are you're placing a ton of orders with a ton of different labs. The root cause medicine podcast is created by Roopa Health. Roopa is the best way to order, manage, and track results from over 30 different labs in one single place. Thank goodness. No need to create and log into multiple portals ever again. If you are a practitioner, make sure you go sign up at RoopaHealth.com to create a free account today. Now, let's start this show. Oh, my goodness. Craig, welcome to the root cause medicine podcast. I am so excited to have you on today. It is a pleasure to be here, Karen. Thank you so much for having me. Well, we're going to talk about a really hot topic, SIBO, small intestinal bacterial overgrowth, and others. And I really am thrilled because I get a lot of questions around one IBS, irritable bowel syndrome, but others are writing me DMing me. I get emails of what is the SIBO thing? I think I SIBO or I'm in this Facebook group with thousands of people. Why aren't you talking about SIBO more? And I was like, I got a guy. I got a guy who can come on and talk about it. We would love to talk all about it. That's for sure. I know, I know. All right, well, before we get much further, so everyone listening knows who you are. Give everyone a brief introduction. Who are you? What do you do? What do you stand for? And then we'll jump in. Sure. I appreciate that. My name is Craig Strassnick. I'm a co-founder and the president and CEO of a company called Commonwealth Diagnostics International. We're headquartered here in Salem, Massachusetts, just north of Boston. I personally was raised in a town called Swamps God here on the North Shore, beautiful seaside community, in Northeastern New England, and talked right between Marblehead and Salem and the son of a practicing clinician. So my father was a pharmacist and a psychologist by training before he started his own clinical diagnostics business in the mid-1990s. So I grew up very much understanding and accustomed to the life of practicing clinician who was on call in the middle of the night or having to deal with an emergency case on the weekend. And so my hope and my mission has been to kind of pair my business background. I went to Northeastern University here in Boston and graduated in 2010 with a degree in business with some of the products and services that are well right for introduction to the healthcare community. And take some of that background that I learned growing up and apply that to the business acumen that I garnered during my undergraduate business career. And here we are today with Commonwealth Diagnostics International. And we're very, very proud of it. We've been up and running now for the better part of 10 years and continuing to grow and continuing to shine a light on this area that is IBS and SIBO. - Well, I mean, I have to ask you, how did you go from graduating with a business degree to I'm going to start a company that tests four things like small intestinal bacterial overgrowth and intestinal methanogen overgrowth, et cetera. - Yeah, so that's a phenomenal question. This actually is, I attribute the, our founding of the company and really founding of the idea around hydrogen and methane breath testing that's application for functional GI disturbances to our former lab director, Dr. Lutraficanti. So this gentleman was like a brother to my father. He helped found my father's prior clinical diagnostics company, which was a clinical toxicology and therapeutic drug monitoring company. And Dr. Lou, as we called it, may he rest in peace, he passed away in 2015 of a glioblastone after about 10 months with brain cancer. But he was a mentor to me and like a brother to my father and somebody who, I really credit with teaching me, most everything I know about how to be a practicing clinician and what a practicing clinician really needs from industry to be able to do their job better and provide for the patient a more meaningful and impactful way. And Dr. Lou knew a gentleman by the name of Joe who was just founding a company called Commonwealth Laboratories and they were specializing in specifically an average intestine, but it was all breath-based diagnostics. And my father and I and Dr. Lou, we looked at this opportunity and we talked to Joe and he was basically servicing about 60 or 70 doctors here in the greater New England area. But what we realized was that he could get a test kit to and from the patients of all these providers that he was servicing without those patients have had come to the office in order for them to administer the test and to provide an adequate breath test result. And so we looked at the service model and found that it was a really compelling business case. But then we looked at the unmet need clinically and this is when SIBO and the idea of its relationship to IBS really came into the mainframe for us. And we realized that if we were able to apply hydrogen and methane breath testing in a meaningful and clinical way in the same way that the gentleman Joe was doing for allergy testing to functional GI disturbances and be able to find SIBO in patients without them having to come into a hospital or in patient setting and administer a test over three or four hours to get that test result back to the provider who can then get them on adequate treatment pathway and increased quality of life that much sooner. All of a sudden the business case and the clinical case started to come together really come into focus for us and we started to get really, really excited about it. And so all of this was just really good timing. I was kind of graduating college at the time and it was always the intention for my father nine to take what he had started and the clinical diagnosis space and really expand upon that. And enter commonwealth laboratories and the opportunity to do this together and start something a new with Dr. Liu. - Well, for people who are listening whose head is are now spinning, let's go back to the basics. If somebody listening has no idea what SIBO is or they've heard of it, maybe they saw some stuff on social media as opposed to somebody who was diagnosed in the groups reading up on it, what is SIBO? - Yeah, great question. I would love to start there. Probably should have started there first. So I think the best way to start describing SIBO is really to start with IVS. Irvabales syndrome is the world's most common gastrointestinal disorder. Obvious symptoms include diarrhea, constipation, like bloating, nausea, abdominal pain, dyspepsia and more. Historically irritable health, syndrome has been what is categorized as a diagnosis of exclusion. So it's taken five to six years on average for a patient to seek and adequately gain a diagnosis of Irvabales syndrome. Many times that's done empirically using things like the Rome criteria to use a symptom-based approach to diagnosing a patient as having Irvabales syndrome. If you now look at what SIBO is, a small intestinal bacterial overgrowth. This is something that plays an enormous role in the categorization diagnosis of Irvabales in syndrome patients. So it's estimated that greater than 84% of total IBS patients suffer from SIBO. It's exactly what it sounds like. Small intestinal bacterial overgrowth is an excessive bacteria that's found in the small intestines, one of the most common causes of digestive distress, such as functional bloating, diarrhea, constipation. It's also one of the most common suspected causes of malabsorption disorders. So things like lactose intolerance, fruit dose intolerance, sucrose intolerance, and the demonstrated prevalence in patients fulfilling the diagnostic standard for wrong bore criteria in IBS. Again, it's greater than 84%. So what we like to explain Cibo as is a meaningful way to categorize a sub-segment of the overall irritable bowel syndrome, population in a way that can better target therapy and better target a quality of life for those patients in a far more expedited way. And I'll pause for a minute, Carrie, because I know that intestinal methanogen overgrowth is on the list. Here's what I'll talk about. And I think that's a really important sub-segment of this sub-segment, because there's a distinction with a difference there that matters as well. And I want to go back to the 84 percent. I mean, that's a massive number. I mean, there are a lot of people I know. I've had a lot of patients, friends, neighbors, family who get casually diagnosed with IBS and by casually, I mean, well, you're whatever gas bloating constipation, upset stomach, that it's nothing bad, as in it's not Crohn's, it's an ulcerative colitis, it's not something like celiac. Therefore, it's IBS. Good luck. Try to manage it. Here's Gasex, there are some other medications, et cetera. And people now report IBS casually, oh, yeah, IBS, and blow it off. Yet they are suffering often, they're often, right? It affects the way they're daily living, what they choose to eat. They have to be aware sometimes if they're traveling away from home, et cetera, et cetera. And it drives me nuts when something is considered. It's so common that it becomes normalized when, in fact, it shouldn't be normal. We shouldn't have a irritable bowel syndrome. And then to know that 84% a subset of IBS folks listening, 84% of you probably have SIBO or other things. I just wanted to really hit home on that because you didn't say 8%, you said 84%, and that's a massive number. So I'm glad you said that. Oh, yeah. Oh, yeah. And that's the number that's published in peer reviewed literature going back. I think all the way to early 2000, 2000, the re, I believe, or 2004 in the American Journal of Gastroenterology, but the point you're making, Kerry, is so critically important. I really appreciate you bringing it up. This patient population is a tremendously, and I say this all the time because it's where we at CDI feel the proudest about the work that we do because this patient population is tremendously disenfranchised, but they're just as empowered. Like I mentioned before, on average, an IBS or SIBO patient is seeking care for five to six years before they have actually reached a diagnosis. And many times when they do reach that diagnosis, it's a diagnosis of exclusion. So in other words, they've been poked, they've been prodded, they've been scoped, they've had blood draws, they've had every test under the sun, everything has been ruled out. And then, okay, it's this kind of garbage pale diagnosis of, well, if it's nothing else anatomically and we can't rule anything else in everything else has been ruled out, then we're diagnosing US having irritable bowel syndrome. Well, that's just not enough for these patients. And many times they still, after that on average, five to six years and getting this kind of anecdotal diagnosis feel very much discarded and disregarded. And so if you are experiencing GI disturbances because of some anatomic abnormality, in other words, you don't have inflammation or you don't have a blockage or something where if you get poked or prodder scoped one way or another and you can't see something quantitatively, then many, many times you're just kind of categorize or put into this alternative index of functional GI patients without anything that is objective or quantitative about it where we feel very, very strongly at CDI, we can do a large part in just increasing the quality of life for these patients is giving them something objective, quantifiable seeing levels of hydrogen and where methane go down after a course of antibiotics and correlating that to symptom improvement is going to by default make a patient feel better, but clinically, you're going to see the improved effects of that medication working and you're going to be able to see the effects of it working through the parts per million represented on that breath. So it's just another quantifiable means to be able to diagnose a patient, but then also to be able to manage that patient's disease moving forward and to be able to call it a disease in the first place objectively, it's just as important. So I appreciate you making that point. I think it's a really important one and just putting the patient first is the critical component behind all of this. And you mentioned hydrogen and methanogen and then we had mentioned it earlier in intestinal methanogen overgrowth. Can you explain that for people? I don't think people have heard of that one as much as they've heard of SIBO. Yeah, so intestinal methanogen overgrowth is kind of a new term that's come on the scene as of the last three or four years, but methane has always been a critically important component of the breath testing protocol to be able to quantify GI disturbances, SIBO, lactose, malabsorption, fructose malabsorption, sucrose malabsorption. The distinction with the difference that I would make is how each trace gas kind of correlates to the symptom set of each individual patient case. So hydrogen most predominantly is associated with faster motility, diarrhea, things of the life. Whereas methane has been most recently, anyway, studied and most closely correlated to abdominal distension, bloating, constipation. So what you can see is that in many of these cases of patient has elevated methane on a breath test, then that will correlate to the complaints that they've been having or the history of their management for things like bloating, things like constipation. Well, if you think about the therapeutic indications of being able to distinguish a bacterial overgrowth patient or an intestinal methanogen overgrowth patient, and how to treat that patient accordingly, well, maybe a hydrogen producing SIBO patient should get a course of antibiotics such as refaxement or the like and maybe an intestinal methanogen overgrowth patient should get a course of antibiotics as well, but also some sort of prokinetic, let's say, to increase motility or something else to help regulate or displace the motility in a way that increases or improves their constipation. So what is important also to note is that with hydrogen producing breath test results, you're looking at a microbial over colonization in the small intestine. But intestinal methanogen overgrowth, you're actually looking at non-at-micros, but at RKO. So again, when you look at what the therapeutic indications are there, you want to be able to eradicate the actual colony that is overgrowing in the small intestine. If it's hydrogen producing and you know it's microbes, well, there are therapeutic targets that you can use as interventions to eradicate that bacteria. If it's RKO producing over colonization, then again, they're therapeutic targets to go after that RKO and eradicate it so that it's no longer over colonizing the small bowel. It is just another way to create a more precision-based and personalized approach to diagnosing these functional GI patients that will then allow to create a more precision-based and personalized approach to treating those patients. And I think that is where kind of the next wave of this research in this industry and where ultimately commercial products will go is personalizing the treatment pathways for these CBO and IMO patients. And I definitely want to go back and touch on that because I know it's going to get asked for those who were new, like, people will go, "Where does the hydrogen come from?" Where does the methane gas, where do these gases come from? But as you were saying, it's these colonies, it's small intestinal bacterial overgrowth. And microbes, and they produce, depending what you've got growing, they are what produce the gases. That's exactly right. And there are a multitude of different theories out there as to why these overconocations of microbes or RKO present could be things like a deficient illiocicol valve and colonic bacteria is finding its way back up into the distal region of the small intestine. It could be some sort of migrating motor complex disturbance or motility issue if the pathways are not functioning properly and things are getting flushed out the way they should be, then it could allow an overconocation of microbes and really in a rich community for them to thrive in or for the RKO to thrive in. So we know that the colon is the large bowel is very, very rich with bacteria, much of it, good some of it, not, but we also know that the proximal region of the small intestine should be completely sterile and most all of the entire small intestine down to the distal region should be close to entirely sterile. So anytime you see an elevated level of hydrogen and or methane on a breath test result after ingesting a challenge dose of substrate, depending on which test and what specific category you're looking for, it's a pretty clear indicator that there is something living in your small bowel on that 28 feet or so of small intestine that is thriving in a way that it shouldn't, whether it's a colony of bacteria or colony of archaea, hopefully can be distinguished between whether it's an elevated level of hydrogen or an elevated level of methane on that breath test result. So let's go to the breath test, explain the real simple. So it's not blood test, it's not a saliva test, it's not a poop test. It's a breath test. So explain from start to finish, how does somebody do the breath test? What are they swallowing? What are they doing? Sure. So depending on which test you're taking, so if it's a seabot test, the patient would ingest a challenge dose of what's called either lactulose or glucose substrate, a 25-gram Degram dose of lactolose, which is just a synthetic disaccharide or glucose substrate. And I should mention that prior to the administration of the breath test, the patient will adhere to a specific 24 hour preparation period. So for the first 12 hours of that 24 hour period, they will adhere to a very specific diet, a low carb, low start, low sugar diet, anything that is overly fermentable, they would want to stay away from. And then for the latter portion, latter 12 hours of that 24 hour prep, they would go on a complete fast. So the intention behind that 24 hour prep is to have the gut in its most sterile state possible at the time of test administration. So many times what we recommend to patients or to providers who are kind of educating or coaching their patients along is if you want to use a Thursday night is kind of the entry point to your 24 hour preparatory period. You wake up Friday morning, have a couple of eggs or crispy bacon, something of the like, and some chicken, crispy chicken throughout the day, something like that. Use dinner as your final meal and start the complete fast over that Friday evening into say Saturday morning, wake up on Saturday morning. You administer that challenge dose of substrate again, whether it's the lactose or the glucose, depending on the preference of the ordering provider. That is never anything that CDI recommends or coaches are patients on something that we always leave up to the discretion of the ordering provider or again, if it's a mouse or action test, it would be a lactose substrate that they ingest or if it's a sucrose, fructose test, it would be a sucrose substrate or a fructose substrate that they would ingest. And then they will basically collect breath samples in certain intervals, again, depending on the test over a two or three hour time period. The CBO test is a two and a half hour time frame based on the North American breath testing consensus that was published back in 2015. And the way that that's done is we send individual test tubes and each one of our breath test kits. There's a collection device that's also included in the breath test kit. There are instructions for use and we also have tutorial videos on our website. If patients are a little bit more visual, they can go on our website and follow the tutorial videos. And they'll collect breath test samples in 15 to 20 minute intervals, again, over two to three hour period. They'll then package those samples back up in the bubble wrap bags that we provide. They'll put them back in the same test kit that we have provided them. And we provide a prepaid shipping label via UPS or USPS that will get back to our laboratory within two to three days time. We then analyze those samples using very highly sophisticated and customized gas chromatography analytics here at our our lab in Salem. And we release the results of those tests back to the ordering provider within 24 hours of the time that we receive the samples. And if I'm the practitioner getting the results, what am I looking for on the what when so it's somebody, maybe somebody has with the results, they're listening to this podcast. They actually have breath test results or a practitioner is listening along new to SIBA. What are they looking for? Are they looking for rises, immediate rises, time delay rises because these gases, obviously, you drink the drink, we have to wait and then eventually the gas, right? You know, the gas is formed. Then you breathe it out. Absolutely. So what is it immediate? Is it delayed? That's a great question. So in it differs, I should say based on methane and on hydrogen. So that criteria is all kind of built into the test interpretation that we provide on each result, but relative to base science, a rise of 20 parts per million for hydrogen. And on methane, what you're basically looking for is any presence of methane that is greater than 10 parts per million would be a suspected positive for intestinal methanogen overgrowth. And this was the topic of a lot of discourse during the scientific consensus meeting back in 2015. This was something that that Commonwealth had helped to support and sponsor to get 10 or 12 of the industries raised thought leaders in a room to really talk about and agree on a consensus and guidelines for breath testing and interpretation. Many of the clinicians in the room felt like, look, if methane is present on a breath test report period, it probably should be treated. Methane is not as common, archaea over colonizing in the small bowel is not as common. I can just tell you clinically in the hundreds of thousands of breath tests that we've done over the years, it's not as common. It is very much present, but not nearly as common as elevated levels of hydrogen. So, and again, this kind of goes back to the idea of treating the two differently. They have different ideologies. They're coming from different colonizations and they provide different symptoms sets. So really, they should be treated differently. They should be looked at differently and they should be intervened with differently. So, we're looking at a rise 20 parts per million over baseline for hydrogen at any point in the first two hours of the test to basically possibly identify a small test on bacterial overgrowth patient. And for methane, you're looking at any interval greater than 10 parts per million could be adequately defined as a supported positive for intestinal methanogen overgrowth. This is good to know, I think, with people who do actually have tests. And it happens sometimes people get testing done, and they're working with a practitioner who's new to a subject or new to this area, and they may have said not known the guidelines. And so, if somebody has their own test and they're looking and they do see their results, as you just said, this can be really helpful for them to even look and go either, yep, that's me. That's what my practitioner said. Or I just got my results. This is going to be really helpful for me to talk with my practitioner about this or my practitioner. Maybe just didn't know this information. And this is very fitting with my symptoms. And so I love that I'm all about practical and tactical. And so I love that you're like, look, the methanogens are present. If it's above 10, we've all pretty much got a solid consensus. You should do something about it. And that's easy and straightforward for people to understand when they've got their own test. Of course. And especially when it correlates to patient symptomatology, there is an intervention that a provider is considering already for a patient. And they are a bloated patient or someone with a general distinction or history of constipation complaints, then having elevated level of methan certainly correlates very specifically to that symptomatology. And it would be interesting to see if the intervention or therapy, whatever that may be, whether it's dietary modification, therapeutic, et cetera, that correlates to the diminishing of methan and that patient's breath test. If they come back in 30 or 45 days and have a methan that goes from 12 parts per million to seven. And then in 45 days after that, their methan is at 3. Well, you can pretty well categorize that patient as a successful case if they're also saying that they're less constipated or their abdominal descent just gone down, they're feeling less bloated after meals, et cetera. And by the way, this goes back to it being most important for the patient. You can tell a patient that a therapy is working and they can tell you that they feel better. But if they feel better and you tell them it's working and then you show them a result that quantifiably or quantitatively shows that their levels are going down. Trace gas is being diminished based on the therapy that they've implemented. Their level of confidence is going to skyrocket based on just an anecdotal or hypothetical level of reasoning. And I know that treatment obviously is very personalized and it depends on which gases you have, et cetera. But can you give me sort of an umbrella overlook at treatment? So if somebody's thinking to themselves, is it always antibiotics? Well, I have to change my whole diet. There's obviously a spectrum. Can you kind of just sort of run through high level options, people that might have to know about? Yeah, definitely. I would caveat this first and foremost by saying always talk to your healthcare providers, most important. We leave any and all medical treatment decisions up to the healthcare provider and out their discretion. But there are a host of different therapeutic interventions and therapies that can be implemented, things like refraction like I already mentioned as well as some prognetic and things that deal with motility to speed up or slow down motility depending on what the case may be. But then there are also very specific dietary modifications here for interventions that can be deployed as well, things like the the FODMAPs or the low FODMAPs diet or the specific carbohydrate diet. These are all things that rely very heavily on low fermentable foods, low sugar foods and kind of helping to sterilize the gut or bring it back to a more normalized state. And of course, you know, there's a topic kind of item of the moment is probiotics and even prebiotics and things to directly kind of modulate or or reformulate the gut microbiota and kind of intervene a little bit more directly and what is making up in totality of the microbiome. So there's a whole host of different again dietary and therapeutic interventions and obviously lifestyle management and the like are paired with that and cognitive behavioral therapy and kind of the biopsychosocial holistic approach to functional GI disturbance is something that is getting a lot of peer reviewed attention right now and a lot of different journals and literature that's being published at some of the major industry conferences. So I think this has been area that is only going to broaden. You're going to see more therapies come on the market to kind of intervene with the gut and address some of these functional GI disturbances a little bit more directly. And I hope that some of the data that that we're providing on the diagnostic side will help to guide some of that research and development a little bit more directly. - All right. Well, I have to ask, you know people listening are going, "Why isn't my GI doctor ever brought this up to me?" Or, "Will my GI doctor ever bring this up to me?" And since you are right in the center of it where you work with functional, naturopathic, integrative, and conventional, what do you see? Is this recognized by gastroenterologist, primary care doctors? Is it working in that direction? Is it shunned? - Oh, it's a great question. I would first start by saying if your healthcare provider doesn't know about it, please bring it up to them. I think it is so important to drive awareness and education around this. And it is always a push and pull. Industry is always going to be doing what we can to drive awareness and education at the provider and the patient level. But we need patients educated. We need providers educated. And we need both educating each other in order for this to really, really work. And especially in this day and age where the patient and the consumer are kind of becoming one in the same thing. A lot of services you can get directly to the patient now, a lot of the data you can get directly to the patient now. But ultimately it is up to the discretion again of the provider to oversee and manage the care for that patient. So it needs to be a 360 degree feedback loop between all stakeholders in order for the system to work as it's intended. So that would be just kind of my off the top comment or position statement there. But to your question specifically, Kerry, we do, we work across all medical disciplines, alipathic, integrative, naturopathic, primary care, internal med, specialist, gastroenterologist, et cetera. And what I would say is that it has taken so much more of a main stage today than it did when we were starting the company 10 or 11 years ago. I always kind of equate small intestinal bacteria with an irritable bowel syndrome today to where H. Pylori and peptic ulcers were back in like the late 1970s, early 1980s. Forever there was a gentleman named Dr. Barry Marshall out of Australia who was beating this drum and doing some really profound research saying that an active H. Pylori infection is the reason for peptic ulcers. And for just as many years, the medical community was telling him he was crazy and he was not in that peptic ulcers are a byproduct of stress or some other lifestyle reasoning but that it wasn't H. Pylori and fast-forward 10 or 15 years and all of a sudden Barry Marshall was one the Nobel Prize and it's an absolute no-brainer that H. Pylori, an active H. Pylori infection is the cause of peptic ulcers and there's not a diagnostics company or lab in the world that isn't offering that test as an after-pathogen test. I truly believe that this is what SIBO, IMO, IBS is in 2022. If you talk to 10 practicing gastroenterologists about SIBO, all of them will know what it is. They will all be aware of it. They will be educating on it. I would say less than 50% of them have integrated as a standard of care to their diagnostic. Workup strategy to an early area of indication. I think still the intentions of practicing gastroenterologists are to kind of scope first and rule out first any anatomic abnormalities or anything else before they're ruling in something like irritable bowel syndrome or small intestinal bacterial overgrowth. I would very much caution against that. I am not advocating that you go to a breath test on any patient that presents with a GI disturbance. I think that would be responsible and unreasonable. But I am very much saying that there are cases that don't make sense to me for a practicing gastroenterologist to say scope when potentially a breath test or some other non-invasive means may be more applicable. So for instance, if a 25-year-old female presents with common GI disturbance, maybe as diarrhea, a couple times a week, as an active bloating, et cetera, but is absent alarm signs altogether. She isn't losing a profuse amount of weight. She doesn't have a Londoner's school, et cetera. To scope that patient and go through that invasive means to rule out something like colon cancer, it just isn't based on the data itself is very unreasonable thing to do. It's very, very highly unlikely that a patient like that absent alarm signs has colon cancer. What she may have is irritable bowel syndrome. So if you tell her that, that could help. And she may go to the local Walgreens and get a probiotic or get an over-the-counter medication to help address what she now believes she's been diagnosed as having. But she hasn't seen anything. She hasn't gotten a diagnostic test result to quantify that or justify that for her. And that is tremendously important. And so this is the message that we're trying to educate our providers on whatever their discipline is, whether they're internal medicine or primary care providers, family practitioners, gastroenterologist, naturopaths, integrative medicine, is that the patient wants to know and see what might be going on. And if you don't believe there's a better means of doing so for that patient, and they present as a case that is right for a breath test, please do it because they probably want to know the result. - Yeah, no kidding, no kidding. Well, speaking of, I want to wrap up with carbohydrate malabsorption because that's another breath test. CBO and IMO, CBO being the most well-known, then I would say IMO after I think and carbohydrate malabsorption, we just don't hear a lot about. So let's wrap up talking about that. What is it? What are the symptoms? - Yeah, so this is, it's interesting because the symptoms are the same, I should say that. And this is what is so complex about functional GI or disorders of the gut brain interaction, is that almost all of the symptoms are the same, but there are about 117 and that's not an exaggerated number, different categories of diagnosis that a functional GI patient could be handed. But again, objectively, there is a difference between carbohydrate malabsorption, something like small intestinal bacterial overgrowth or intestinal methanogen overgrowth. So whereas small intestinal bacterial overgrowth is exactly what it sounds like. It's an over colonization of microbes and the small intestine or intestinal methanogen overgrowth is an over colonization of archaea in the small intestine. And it's a quality of bacteria that shouldn't be living there. And those bacterial colonies are excreting hydrogen and/or methane, which is contributing to your overall IBS phenotype. Carbohydrate malabsorption, whether it's lactose, fructose, sucrose, is not an over colonization, but an enzymatic deficiency. So it is the inability of that specific enzyme, whether it's the lactase enzyme, the sucrose enzyme, the fructose enzyme, to adequately hydrolyze that substrate and metabolize it in a way that the body can then normalize and excrete. And by virtue of that inability, the patient would then again excrete elevated levels of hydrogen and/or methane when that substrate interacts with the bacteria or the inability for that enzyme to absorb and allows it to interact with the bacteria and create those elevated levels. We can then quantify that on a breadth test. So again, this goes back to the ability to differentiate between why the patient is feeling the way that they are. And many times, and I don't care if there's a question you may have already been thinking about following up with, but many times when I am explaining the difference between carbohydrate and absorption and SIBO, the following question is, which one do you see providers do first most often? The simple answer is SIBO, is just clinically speaking, we just see SIBO done more often, is just kind of the plain spoken answer. But I also think there's a very practical reason and clinical reason for that. If you are able to adequately rule out an over colonization of micro in the small intestine, then you know that there's nothing necessarily living in the small intestine that shouldn't be there. But you know that you have a test of this patient just administered, you know that they are educated about and they can do again relatively simplistically and again, we try to be cost effective about this too. But to look at some other deficiency outside of an over colonization, a deficient lactase enzyme could have nothing to do with small intestinal bacterial overgrowth, but it could and small intestinal bacterial overgrowth could have nothing to do with carbohydrate and absorption, a deficient lactase enzyme, but it certainly could. So without being too overly ambiguous about it, when I have these conversations with bats and clinicians, they say it's really six, one way, half a dozen, the other, but just because of the practical implications of it, we try to do SIBO first, rule that out, and then we'll do a carbohydrate and absorption test, and secondarily to that if we feel it's necessary in each patient case. - And I'd love to, that you're testing because if the symptoms are the same or very similar, having bacterial overgrowth or colony overgrowth is 180 different than missing an enzyme. So if, and I say this because I see in the groups, I see on social media people go, "I'm pretty sure, I'm pretty sure I SIBO, I have all these symptoms, I'm trying all the quote at home methods to quote, get rid of my SIBO, and it's not working." And yet they may have nothing to do. with getting rid of anything, it's an allack of an enzyme. And you won't know until you test. That is exactly 100% right. And if you're shooting at the wrong target, you're not going to win. Yeah. And it's going to cost you a lot of money. I understand people say, I don't have the budget to do all this testing. I'm like, well, but you are also, as you said, you're constantly shooting in the dark, trying to find treatments that read about groups or read about online for your symptoms. And you've probably spent a lot of money on that. And if it's not working now, it's definitely now, it's the time for testing because it's really figure out what's going to be precision here as opposed to shooting in the dark, especially when the symptoms are the same or so similar. Let's just test and find out. Absolutely. Yeah. There is so much heterogeneity just riddled throughout this disease category that anything that we or anybody else can be doing to personalize it and make it a little bit more precision based is tremendously important. There's no doubt about. Yeah. All right. So as we wrap up, given this is the root cause medicine podcast, we've been talking about all things, SIBO and IMO and carbohydrate malabsorption, give us the top two or three practical tactical things you want everyone to leave with. They don't necessarily have to do, but what do you want people to leave with today? Oh goodness. We talked about a ton of it. And I know I really summarize. I carry I'm very appreciative actually of the opportunity to talk about everything that we have today. I think if I had a narrow down, I think I would go back to the idea of education and understanding that you don't necessarily have to rule 100 different things out in order to rule something in that is very, very meaningful. And again, that's not to say that breath testing in SIBO or IMO is a catch all in any patient that presents with functional GI disturbance. But again, I am saying that it is a very large subsegment of the irritable bowel syndrome population. And by definition, the patient population who either historically has already been diagnosed as having irritable bowel syndrome believes they have irritable bowel syndrome and has gone undiagnosed, they don't understand why. And they shouldn't be discarded, they shouldn't be disregarded. And if SIBO or IMO is the reason why, then they should be given the opportunity to know that. Because even if nothing else, that matters. They can walk away knowing the reason why they feel the way they feel. Because again, just diagnosing a patient as having irritable bowel syndrome is not very satisfying to them. There's not much they can do with that. In fact, to your point, Kerry, it's probably going to be more expensive in burdensome for them because they're going to be chasing the wrong things trying to deal with it. So for the purposes of being clinically reasonable, financially responsible, and just looking out for the patient first and trying to be as objective as possible, I've just practitioners and patients alike to think about the ways to rule in some of the reasons for functional GI disturbatives or disorders of gut brain interaction as opposed to ruling things out first. I love it. I love it. Craig, this has been fantastic. Tell everybody where they can one learn more about SIBO, where they can learn more about commonwealth and the breath test. Because I know people are going to have a lot more follow up questions. Please do. Yeah. No, Kerry, thank you so much again for having me on. Our website is www.comdx.com. So that's C-O-M-M-D like dog x like x-ray.com. That has any and all information you can need about SIBO, hydrogen methane, breath testing, carbohydrate malabsorption, all of our products and services. You can follow us on Facebook, on Twitter, on LinkedIn, on all of our social media. We're kind of constantly and consistently updating and we have a feed on our website as well that posts all of our company updates and content. We're consistently linking to new research nodes and literature in the space. So we try to remain as active as we can in educating and messaging what we're doing in the masses. This is great. And for those who have maybe a GI or primary care doctor that they're working with, you can use this information. Usecomdx.com. Please do. To show them latest research, what's going on, and why you would like to be tested if they're unfamiliar. Just as Craig has said over and over, don't be disregarded. Let's see what we can do because there's a lot you can do. You just have to rule it in, test for it, and then go from there. Well, thank you so much for being on the show today. I really appreciate it. Thank you, Kerry. Oh my goodness. Thank you so much for listening to today's episode. I have one quick favorite ask before you go. If you love today's conversation, would you mind leaving us a review on whatever podcast platform you're listening on right now? My whole goal is education. So positive reviews are actually the number one thing that help new people discover the show. You're amazing. I so appreciate it, and I'll catch you on the next episode.