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Wondering if you have IBS or maybe even SIBO, but a small intestine bacterial overgrowth diet doesn’t help? Most people don’t know that there’s a third type of SIBO called hydrogen sulfide Small Intestine Bacterial Overgrowth that is often missed (I’ve talked about the other two SIBO types here).
Hydrogen sulfide SIBO (or ISO – intestinal sulfide overproduction) is the “new kid on the block” with major implications for the gut-skin connection. Unlike methane or hydrogen SIBO, hydrogen sulfide is a neurotoxin that can produce a wide variety of weird symptoms like bladder irritation, nerve pain, or even fibromyalgia-like pain—yes, it's that sneaky!
What makes it even more complicated is that the type of Small Intestine Bacterial Overgrowth diet changes that will help look vastly different from the typical SIBO diet.
In fact, there’s a high likelihood that if you do a SIBO test, you’ll test negative even though you actually do have hydrogen sulfide Small Intestine Bacterial Overgrowth!
Back by popular demand, Dr. Allison Siebecker joins me to share her clinical expertise and latest research on hydrogen sulfide SIBO.
Dr. Allison Siebecker is a well-known naturopathic doctor and respected expert in SIBO. She was the co-founder and former Medical Director of the SIBO Center for Digestive Health at the National University of Natural Medicine (NUNM) where she has taught Advanced Gastroenterology since 2013. She is the 2021 lifetime achievement award recipient from the GastroANP, and is an award-winning author. Her integrative SIBO protocols have helped thousands worldwide.
She’ll walk us through SIBO testing strategies, unexpected symptoms, and how to treat SIBO with both medications and natural remedies for SIBO.
If you’ve hit a dead end with managing your gut, skin and weird body symptoms, this is one episode you don’t want to miss!
Or, listen on your favorite app: iTunes (Apple Podcasts) | Spotify | Stitcher | TuneIn | Subscribe on Android
In This Episode:
- Why SIBO testing is so bad at picking up hydrogen sulfide small intestine overgrowth
- What’s a “flatline” breath test pattern?
- Hydrogen sulfide SIBO gas – how it can be helpful and harmful
- Surprising hydrogen sulfide SIBO symptoms
- The role of certain bacteria (like Desulfovibrio piger and Fusobacterium varium) in hydrogen sulfide sibo
- Best SIBO test currently available (how reliable is it?)
- Small intestine bacterial overgrowth diet and sulfur food sensitivity
- How to treat SIBO (and natural remedies for hydrogen sulfide SIBO)
Quotes
“Hydrogen sulfide, in some articles, has been theorized to be part of the cause of fibromyalgia.”
“Who would think tingling in your fingers could indicate the form of SIBO?”
Links
Find Dr. Siebecker online
For practitioners: The SIBO Pro Mini Course (SAVE $220)
For practitioners: Check Your Blindspots and Become A Better SIBO Practitioner book
387: Hydrogen Sulfide Small Intestine Bacterial Overgrowth (Diet, Symptoms, SIBO Testing Challenges, Treatments) w/ Dr. Allison Siebecker, ND {FULL TRANSCRIPT}
Jennifer Fugo (00:13.478)
Dr. Siebecker, welcome back to the show!
Allison (00:16.386)
Thank you so much, Jen. I'm so pleased to be here with you again.
Jennifer Fugo (00:20.208)
Well, first of all, we had a fantastic conversation about SIBO about a year ago, which I'll link up in the show notes too, but I thought we could dive a little bit deeper into one particular type of SIBO, specifically called hydrogen sulfide SIBO. That being said, in the event that somebody is like, wait, what is SIBO? There's different types of SIBO. Could we just do a really quick kind of catch-me-up type thing so that way at least people know what we're talking about?
Allison (00:53.536)
Absolutely, yeah. It stands for small intestinal bacterial overgrowth, and it sounds kind of like its name. It's when certain bacteria are overgrown in the small intestine, and actually also the large intestine. We've expanded our definition a little bit, and we have a few types of SIBO.
Jennifer Fugo (01:00.395)
Really?
Allison (01:02.562)
Yeah. So we have three main types of SIBO. There's hydrogen SIBO, methane, and hydrogen sulfide. As you mentioned, we're going to talk all about that today. These are just the gases that certain bacteria make, or microorganisms make. And they correlate with certain symptoms, particularly bowel movement symptoms, in a similar way that irritable bowel syndrome, SIBO is one of the main causes of irritable bowel syndrome or IBS. It's classified by the bowel movements, diarrhea, constipation, or combination of the two. So these different types of SIBO, they kind of correlate in a similar way.
And it used to be, we just thought that sort of all of the bacteria of the small intestine was just too much. And now we know it's very specific organisms for each of those types that are overgrown from the incredible work Dr. Mark Pimentel has been doing. He's our lead researcher in this field. So anyway, this, as I mentioned, is one of the main causes of IBS. It causes those same symptoms, which are abdominal bloating, diarrhea, constipation, or a mix, abdominal pain or discomfort. And there are other symptoms too, but those are sort of the key symptoms. Very, very common worldwide. And just those symptoms and the calling of IBS could be caused by a myriad of things. But what we now know is that this bacterial overgrowth, SIBO, is the predominant underlying cause of IBS.
Jennifer Fugo (02:40.86)
So what you're saying is, if your doctor told you that you have IBS, you shouldn't stop there. You should keep on asking the questions, but what's causing this? Because it could be SIBO.
Allison (02:52.984)
That's right. That's absolutely right. And it's been so helpful for so many people to learn this, to know this, doctors and patients, because we don't just have to stop at managing the symptoms. Now that we know that there's a bacterial overgrowth, we can work at decreasing that. And when we decrease that, it affects all the symptoms. So you don't have to just go in, if you had no idea what was causing it, you'd have to treat constipation separately, bloating separately. So now, and then of course there's the deeper layer, what's causing the overgrowth, right? And if you can get to that, which of course there's a myriad of reasons, well, then you can solve it.
Jennifer Fugo (03:32.764)
That is true. And can I just ask, because you kind of like, I feel like you threw a little nugget in there that I was not anticipating, that SIBO could be also in the large intestine. So I have called that LIBO. I don't know if you call it that.
Allison (03:46.862)
Yeah, we all started calling that a long time ago, we called it LIBO. Well, so here's what happened. The methane type of SIBO, it turns out that it's not actually bacteria that are overgrown, it's another microorganism that are called archaea. And so it just didn't fit the name of bacterial overgrowth. And then we also found out that those organisms, the predominant one is called M. smithii, Methanobrevibacter smithii, that can be overgrown in the large intestine as well. So the small intestine part of that name didn't fit either. So they gave it a new name, which is called intestinal methanogen overgrowth, or IMO for short.
Jennifer Fugo (04:21.252)
[Laughter] IMO.
Allison (04:23.928)
But I still just kind of call it, yeah, IMO, I-M-O, IMO. So I still just call it methane SIBO, or SIBO, because it's hard to change one's language when you've for so long, now, saying it one way.
Jennifer Fugo (04:30.637)
Yeah. That is true.
Allison (04:31.928)
And then the hydrogen sulfide type, it's going to be our topic for today, also got a new name because we have seen that these bacteria overgrow in the large intestine and/or small intestine. So it is now called intestinal sulfide overproduction. And so it's ISO, I-S-O.
Jennifer Fugo (05:04.613)
So many acronyms.
Allison (05:05.654)
Don't worry about it. When you get all these new acronyms, all these names, it's like, it's just a factoid. You could just call it hydrogen sulfide SIBO.
Jennifer Fugo (05:14.416)
So in regards to the three different types of gases, we have this hydrogen sulfide variation. But what makes it so different, or what sets it apart from the other two, which are methane and hydrogen?
Allison (05:29.518)
Yeah, it's really interesting because hydrogen and methane gas is only made by bacteria and archaea, meaning humans don't make it. And so it's a little easier for us to figure this out because when we do a test, a breath test, which is how we test for this, and we measure those gases, we know it's coming from these other organisms. But with hydrogen sulfide, humans make that gas. And actually, so does a certain yeast. But humans make it and it's beneficial for us in the proper amounts, in normal amounts. It's a sort of a reparative substance, it goes in when there's an injury and it helps.
But when it's in a large amount, when it's in an excess amount, it's not good at all. And in fact, it's toxic. It's toxic to our mitochondria and our nerves. So it's a neurotoxin, actually, in large, excess amounts. So when we're doing a breath test, and we now actually have a breath test that can test this gas directly, we didn't used to, it's about the amount. The amount is what matters and we're correlating the amount to too much or not.
But it's good to know this about hydrogen sulfide because so many practitioners, in particular, who like to look up studies get really confused when they start going to the literature to look up hydrogen sulfide. They'll hear something about hydrogen sulfide SIBO, they'll know it's a concern, they'll go look, and they'll start seeing all these articles talking about the benefits of hydrogen sulfide. And it really confuses people. And they're like, why are you calling it bad? Why are you trying to get rid of it? It's because it's the amount. If it's in its normal amounts, it's good. If it's in excess amounts, it's toxic. So that's the situation there.
Jennifer Fugo (07:21.69)
And it sounds like, I like to explain this to clients as the Goldilocks thing. Like we don't want too much porridge, we don't want too little, we need just the right amount for it to be at that therapeutic range. But when it gets overgrown or it's too little, now we could start having issues, right? So I think sometimes it's helpful just to clarify that because like you said, if you just look up, you could go, oh, but it's a ton of benefits. Why would you wanna do this? It's like, well.
Allison (07:51.682)
Yeah, in fact, now that I have a lot, isn't that good, right? But then you just have to go a little farther. And there are articles that discuss this very thing, oh gosh, it's helpful in this amount, it's bad in this amount, you know. So you'll find that there. And one other thing is that it's kind of interesting and helpful to know that hydrogen sulfide gas is actually made out of hydrogen, and so is methane gas. So certain bacteria will make hydrogen gas, and then other bacteria or archaea will take that hydrogen gas and turn it either into methane or hydrogen sulfide. And it's very specialized, these bacteria are generally called sulfide producers or sulfanogens, these bacteria that make hydrogen sulfide.
But something that's interesting is that the bacteria, because you can have all three of these gases at once, the bacteria that make the methane, or actually the archaea, and the ones that make hydrogen sulfide compete with each other. They're competing for that hydrogen because they both need it to do what they need to do. And what the studies show is that if they're both there, the methanogens will win preferentially over the hydrogen sulfide. So it's just an interesting thing. I don't know that that's going to always be the case in all people, but the studies indicate methane will win.
Jennifer Fugo (09:14.64)
So out of curiosity, you mentioned that some bacteria can generate hydrogen sulfide, maybe even a yeast could. Are there certain types of things that you look at, a lot of people who listen to this have maybe done some stool testing themselves or maybe they're thinking about doing it. And I wanna be very clear, a stool test is not indicative of what's happening in your small intestine, because a stool test is a large intestine test. But they might see some of these things that we're discussing on a stool test. So what would be, maybe, are there some specific organisms that you're like, yeah, that's a hydrogen sulfide producer?
Allison (09:58.122)
Yes. And you know, it used to be we would always try to educate people, you can't use a stool test to help you figure out SIBO. But now we know maybe you can, for the methane and hydrogen sulfide type. Some tests are putting in the organisms, they're testing for the organisms that are overgrown. So for hydrogen sulfide, we know that in the small intestine, it's Proteus mirabilis, however you want to say it, Proteus, which actually often causes urinary tract infections. That's the main one for the small intestine.
Jennifer Fugo (10:47.385)
Interesting.
Allison (10:55.406)
Now in the small intestine, there's actually two other ones. Those wouldn't show up in a stool test, but they have very difficult names to pronounce. They start with desulfo, basically.
Jennifer Fugo (10:59.324)
Fair enough. Fair enough.
Allison (11:22.144)
So there's three organisms in the small intestine that seem to be the main ones that are overgrown in hydrogen sulfide SIBO, and two in the large intestine. And the two in the large intestine are Desulfovibrio piger and Fusobacterium varium. So that's what you could look for on a stool test as an indication. Now, what I don't know is, I don't believe the work has been done yet, meaning the studies have been done yet, to figure out what exactly is the amount that is too much. And do we know that yet for a stool test? I don't have that information.
Jennifer Fugo (11:36.614)
So it sounds to me like what you're saying is, though we don't know exactly what the perfect amount is, we don't know what, in our Goldilocks world, we don't know what that middle bowl might exactly look like. But if you have this and you have all of these other symptoms, which we're gonna talk about, clinically you could say, well, this is what it looks like, this is what it sounds like, this is what it feels like, so we're probably gonna say this is probably what's going on. Does that sound fair?
Allison (12:08.152)
I think so, yeah. It's like, this could be an indicator if you're having a stool test. Now, the main test we typically do is a breath test. And that's the one that I would say would probably be the most helpful. And in late 2020, we actually got our first test available that tests directly for hydrogen sulfide. And to my knowledge, there is only one, and that's the Trio-Smart Test, and it tests all three gases. So it's still relatively new, and docs have various opinions about it because it's new and people are still trying to get used to it. But that's a test you can directly, you sample your breath just like you would for a regular SIBO test. The way that works is you drink a sugar substrate first that feeds the bacteria because that's how it works, they make their gas from eating carbohydrates or sugars. Then you sample the gas out by blowing and we can see what's there. So that's one way.
But before we had that test, there was another way we always figured out if people had hydrogen sulfide, and that is a particular pattern on a standard test. What's the difference is the standard test just didn't have hydrogen sulfide, it tested hydrogen and methane. And they come from all sorts of labs, various lab names. And the flatline pattern, you would have to have done a lactulose, lactulose is one of the sugar substances. So you could use glucose, you could use fructose for a SIBO breath test, but you cannot be using glucose, and it's most recommended you use lactulose. Lactulose is a sugar that will stay through, it won't be degraded or absorbed into the body for the whole length of the intestine except by the bacteria that are eating it.
So we need to be able to see what's happening in the large intestine, and we need three hours to do that. So the way to be able to use a flatline test is a lactulose three-hour breath test. So before I just explain that, want to say, and I know this might be technical.
Jennifer Fugo (14:13.19)
That's okay.
Allison (14:27.308)
But the Triio Smart Test is a two-hour test and that's acceptable for hydrogen sulfide, but personally, as a practitioner, I really like to see three hours. And so what I would recommend, and I'll explain why in a second, but I would recommend if you're going to do that test, sample your breath every 22 minutes, just set a timer, instead of every 15 minutes, because this will stretch the test to three hours. And the lab will automatically adjust the lab report. You don't need to communicate with them about this, they're okay with you doing this.
And the reason why is because it isn't just a yes or no test, the SIBO breath test. We use the information to help guide how to treat SIBO in various ways. If you can see how high or how severe the gas goes, this will influence what treatments you pick. And also, it allows you to get a sense of prognosis, basically how many treatment rounds you might need, because it's pretty rare for people to have a one-and-done where, let's say, two weeks of treatment and you're finished. You need to repeat rounds because this is an overgrowth, it's not technically an infection. And we just have to keep going until we can get it down.
Jennifer Fugo (15:17.274)
I just want to double check. You said every 22 minutes?
Allison (15:31.84)
Yeah, because there's nine tubes in there, you can do it every 20 minutes if you want. So anyway, when we see how high the gas is, we also can calculate, we can make a calculation and get a sense of how long the treatment is going to need to be. So it helps us guide our treatment. It's not just yes or no. So this is why we like three hours, particularly for methane, because we can really see things. that are occurring more so than just in the two hours.
But back to the flatline thing, what we're looking for there is that this would be a situation where hydrogen sulfide would be the gas that would be there, but you're not testing for that gas. You're only testing for hydrogen and methane. And so what you wind up seeing is like, nothing. it's a flat line because you're not seeing any gas because it's all hydrogen sulfide, but you haven't tested for that because this test doesn't test for, the original tests just only check for hydrogen and methane. The technology wasn't available. And so it looks flat. But why you need the third hour is because we should always see a rise of hydrogen gas in the third hour, indicating the normal microbiome that's in our large intestine. We should always see a little bit of gas there, that's normal. Once again, it's the amount, we have an amount that's normal and an amount that's too high. And so if you just don't see any and it looks very close to zero, that means that it's been converted to hydrogen sulfide and we just don't see it.
Jennifer Fugo (17:09.628)
See, those are the things that you don't necessarily learn in a book. You had to think about it, and you had to go, why is that like that? And you had to see it again and again, and look at the cases. And this is one of the things, when I think about how people go to ChatGPT and they're like, here's my symptoms, what do I have? And I'm like, it can't replace all of this clinical knowledge and experience and wisdom sometimes, that practitioners can accumulate with experience. So I love this. I mean, some of the stuff, and we'll talk about it at the end because you have practitioner courses, which was like so, so amazing, and we learned so much, the whole team learned so much from you. But this kind of stuff is really helpful for people to get answers. So I wanted to make sure too, before we start talking about how to deal with it and whatnot, just the difference in some of the symptoms that people may experience. Because it is different than just SIBO.
Allison (18:15.222)
Yeah, and I'll tell you something else that's really interesting is we actually found that some of the symptoms I'm going to share with you, that correlate with a flatline test, don't necessarily correlate with just hydrogen sulfide on a Trio-Smart Test. It's very interesting. But before I leave testing, I want to just say something important about a flatline, which is that a flatline doesn't always mean hydrogen sulfide. And something really important to keep in mind is, for instance, if someone's on Ozempic, Mounjaro, Zepound, those GLP-1 medicines, one of things they're doing is slowing stomach emptying. And they can actually slow the substrate that you drank, the lactulose, let's just say, for the test such that it isn't actually being released into the small or large intestine in the timeframe of our test. So it looks like a flatline because no sugar has been there for the bacteria to ferment.
So I just wanted to put the caveat out there that a flatline isn't always hydrogen sulfide, and remember that. And then the other thing would be gastroparesis, which is a condition where the stomach isn't emptying regularly, it's slow. So don't just jump to the conclusion that it's hydrogen sulfide. Check these things first.
Okay, so to the symptoms. We would expect the regular symptoms that I mentioned in SIBO. But when we talk about the bowel movement pattern, like the diarrhea type thing, the diarrhea symptom has been correlated with hydrogen sulfide quite explicitly in studies that have been done on SIBO, hydrogen sulfide SIBO, to the point where they see that the rise of gas correlates directly with the severity of diarrhea. So the higher the gas, the more severe the diarrhea is. Now, this conflicts with what we see clinically a good portion of the time. And we don't have an explanation for it yet, which is that clinically, we very often see constipation with hydrogen sulfide. And I have to say that out of all the hydrogen sulfide patients that I've had, and they were all flatline before this test came in, they all had constipation. Absolutely every single one of my flatline hydrogen sulfide patients had constipation. And then when we even started checking with the Trio-Smart Test, we saw a good, at least 50%, of my colleagues that I spoke to, their patients, 50% of their patients would have constipation. We don't have an explanation, but the way I would say it is, it could be diarrhea or constipation with hydrogen sulfide. So very strange here, how we have a difference between studies and clinical.
Allison (21:05.026)
But the other things the studies have correlated hydrogen sulfide with is the sense of urgency with that diarrhea, acid reflux, and abdominal pain, visceral hypersensitivity basically, and also leaky gut. So those are the key symptoms with SIBO. Now in the literature, we see hydrogen sulfide, maybe even in the large intestine, being correlated with light and noise sensitivity. I can't say I've seen that very often in my patients, but I think that's likely the nerve damage issue there. Bladder irritation. So now I actually want to go into what I saw all the time in my flatline hydrogen sulfide patients.
Jennifer Fugo (21:42.886)
Yeah, please.
Allison (22:01.568)
So I saw so many of these, I started just writing down my patient's symptoms and I saw a pattern. And I've had this pattern validated externally, so it isn't just me. I sent this group of symptoms over to one of the SIBO breath test lab directors and they were able to correlate it with the flatlines that came through their lab. So these symptoms are bladder irritation, like something like we would think of, interstitial cystitis. And it's very common, actually, that I saw that in my patients. And one article did theorize that it's because hydrogen sulfide has an effect on the detrusor muscle of the bladder. Probably again, we're talking here about maybe some of the nerve issues that it could cause, or maybe the mitochondrial issues.
Another one is body pain. And hydrogen sulfide, in some articles, has been theorized to be part of the cause of fibromyalgia. So I know there's a lot of work that's gone on about that, but there could be a relationship there. So this isn't like joint pain, it's more like muscle, soft tissue pain, body pain. I saw that a lot. Very commonly, I would see tingling or numbness in the fingers, hands, toes, or feet. So extremity neuralgia, basically.
Jennifer Fugo (23:04.028)
Can I just ask, do you know, just because when I see that in a client, I'm worried about B12 levels, did you ever correlate that together? Was there any relationship or just it was totally separate?
Allison (23:05.272)
Yeah. Well, something that's really interesting. Now, are you worried about too high or too low?
Jennifer Fugo (23:07.028)
Too low, yeah.
Allison (23:09.272)
That's what I would think. Interestingly, B12, hydroxocobalamin, is a good supplement to take when you have hydrogen sulfide. It can decrease hydrogen sulfide. So people might actually be low in B12 who have hydrogen sulfide. So super good call there, Jen. Yeah, so very, very good there. So that's another one.
Jennifer Fugo (23:29.904)
Wow. Like nerding out. We're being little nerds. We're just like, let's just share all this.
Allison (23:44.302)
And then sometimes these patients would be worse from like an Epsom salt bath, that's magnesium sulfate, or sulfur foods, that sort of thing. Sometimes they would have worse food sensitivities, like they might have histamine and salicylate intolerance. And this sort of goes with the fact that many of these people would feel sicker than another SIBO patient would, than one with hydrogen or methane. And they would sometimes report that they felt toxic. Well, this gas is toxic in large amounts. So they were sort of more sick and toxic. Now, one of the most common symptoms people think of right off the bat, and this is the last one I wanted to mention, is sulfur-smelling gas, like flatulence or belching.
Jennifer Fugo (24:27.449)
Interesting.
Allison (24:41.71)
One would imagine that you would have this with hydrogen sulfide, but I found, at least with my flatline hydrogen sulfide patients, it was rare. So I did not see that very commonly. It sometimes can happen, but it was not like, that's sort of the symptoms you think of first. Like, wouldn't that indicate it?
Jennifer Fugo (24:45.318)
Sure, like that rotten egg-type smell, yeah.
Allison (25:11.573)
Yeah, right. That's exactly it. But no, that was not common. So what I feel like with hydrogen sulfide SIBO is we've got your basic SIBO symptoms, you know, your diarrhea, bloating, pain that you would have with any type of SIBO. And then you've got this other group, the potential for bladder pain, body pain, neuralgia in the extremities, things like that. But what we found when we got the direct Trio-Smart hydrogen sulfide testing is that group of symptoms that correlates with flatline did not correlate with people who were just positive for hydrogen sulfide on Trio-Smart. It only correlated with a flatline. And we don't know why. Maybe they were just more extreme, maybe they're more severe, don't know. But what we do know is when we would treat these flatline hydrogen sulfide patients with the same treatments that we know work for hydrogen sulfide, that we use for when they're positive on the Trio-Smart, they would get better. So it seems to be hydrogen sulfide, but the picture looks a little different than when you just test with Trio-Smart.
Jennifer Fugo (25:58.652)
For anyone who is like, this sounds like a lot of detective work, it is!
Allison (26:03.966)
Oh my gosh, you guys, so let me just tell you, hydrogen sulfide SIBO was just like the problem child because we knew it existed, but we just didn't have any information. We couldn't test it properly, we didn't really know what treated it, we didn't know what organisms were overgrown. I started treating SIBO a long time ago and back then we just didn't have any information. Well, I'm just so grateful that we have more and more information. Now we have the tests, now we know what organisms are overgrown. So it has been a lot of detective work.
Jennifer Fugo (26:31.322)
Yeah, a ton, a ton. And this is what it's like, it's not just looking at a test. I think that's one of the biggest mistakes that most people, they're like, well, I'll just get the test done, but it's not just the test. You have to look at a variety of other factors. And that's why noting down all of, even the things that seem odd, or you're not sure if they're relevant, are really helpful because sometimes oddball symptoms can actually point to something and help determine how to treat SIBO.
Allison (26:59.148)
Right. Like who would think tingling in your fingers could indicate the form of SIBO?
Jennifer Fugo (27:03.962)
I would honestly have never guessed that.
Allison (27:26.744)
Right. And here's the thing, I should have said this right at the beginning. What matters about this, because it is harder to detect, although we do have a test for it now, is that this could be one of the reasons why someone with SIBO or IBS, but let's just say SIBO, who's treated it. who hasn't had good results, this could be a reason why, because they actually had hydrogen sulfide SIBO, maybe along with, and didn't know it, and didn't get the right treatment for it. Or even they might've tested negative on a hydrogen and methane test for SIBO, and doesn't even know what's wrong with them, but they really have hydrogen sulfide SIBO, because they didn't have a, you don't always have a flatline. I mean, we certainly know that. You're only gonna detect, a small amount of people with hydrogen sulfide have a flatline. So you might actually have had SIBO all along and been told you didn't because you only tested for hydrogen and methane.
Jennifer Fugo (28:03.994)
And so what I'm hearing you say is that the treatment options and natural remedies for SIBO for this are possibly different from dealing with hydrogen versus methane.
Allison (28:12.6)
That's right.
Jennifer Fugo (28:21.104)
So when thinking about how to treat SIBO, what are some things, like I know some people are really big with, they like to totally cut as many FODMAPs, especially high FODMAPs, out of their diet as humanly possible. They like to really do a lot of dietary things. Do you think small intestine bacterial overgrowth diet is an option here? Is there a good medication treatment versus a good more like botanical, or herbal options or natural remedies for SIBO? What's been your experience with this?
Allison (28:46.476)
Okay, so let's just start with the small intestine bacterial overgrowth diet, because you brought that up first. What I found with my hydrogen sulfide patients is that there are some who really are sensitive to sulfurous foods, and they really benefit by going on a low-sulfur diet, whereas others really are not intolerant to sulfur foods. So it's really across the spectrum, and it's sort of for each person to figure out. A low-sulfur diet would be going low in like milk, cheese, meats, fish, cruciferous vegetables, also called brassicas, like onions, garlic, and broccoli. And then of course sulfites, like wines have sulfites, dried fruit has sulfites added as preservatives. And you can go on my website, I have a free educational website, SIBOinfo.com. You can go there and I have links to low-sulfur diets, two I really like, underneath resources, diets, and recipes.
But many people with SIBO, as you mentioned, are quite restricted in their diet. They're already going on a SIBO small intestine bacterial overgrowth diet, which is a carbohydrate-reduced diet. And we have many options for that, but many of them are quite restricted. So we only want to add in this extra restriction of these foods if it's actually going to help relieve your symptoms. So it's not like something you rotely need to do, like, bam, you've got hydrogen sulfide, go on a low-sulfur diet. No, you would just check it out and see. And we have studies that support that. Like we have studies that show that cruciferous vegetables really don't contribute much to the making of hydrogen sulfide gas and such in these folks. But then in others they do, right? It's independent, individual. So just check it out and see if it helps you. So that's the dietary front.
By the way, one other thing I just want to mention, it's fascinating, there are some stabilizers and emulsifiers like carrageenan and polysorbate 80 that have been directly linked with increasing hydrogen sulfide. So once again, the importance of trying to avoid processed foods. Polysorbate 80 has been directly shown to increase hydrogen sulfide, like make overproduction of hydrogen sulfide. As well as create leaky gut, and degrade mucus, and do all these crazy things. I mean, it has an effect on the microbiome. That's not good. A negative effect.
Allison (31:11.148)
OK, so that's the SIBO diet piece. Now for our main way we treat SIBO is with antibacterials of some sort. And as you mentioned, we have pharmaceuticals, herbals, and then we have an elemental diet. That's like a medical food product. Let's start with that one. Elemental diet is food broken down into its most elemental components, which for protein is amino acids. And there are several sulfur amino acids like cysteine and methionine. So we were concerned that people with hydrogen sulfide wouldn't be able to do elemental diet because there's sulfur in there, and we were worried it would bother them. Well, what we found over time was that was not the case. And most people with hydrogen sulfide can tolerate the elemental diet. So that is one of the options. Now, will there be people that maybe don't tolerate it? Sure, because there's always people, no matter what type of SIBO they have, that may not tolerate a certain treatment that we give them. So there might be some, but generally that's okay. So that's one.
On the more herbal front, really our two main treatments for hydrogen sulfide are bismuth, which is more of a mineral or a metal, actually a metal, but I'll just lump it in with herbal antibiotics, and high-dose oregano. So those are our two main options that really seem to work for hydrogen sulfide. Bismuth is an antimicrobial. It has the ability to decrease bacteria, but also it binds hydrogen sulfide. So it binds it and take that out of the body. So what is bismuth and where do you get it? Well, everybody knows Pepto-Bismol. So over the counter, you could have that. Pepto-Bismol, no matter what form it's in though, has sugar alcohols in it, even swallowable capsules. Crazy. You know, why do they do that? I could understand it in a chewable to sweeten it, but sugar alcohols can bother people's symptoms. However, there's only a small amount in a little tiny pill, so it might not bother you. But an alternative would be kaopectate, that also is bismuth. And every drugstore has its own generic version of a bismuth. And you need about 2,000 milligrams in a day, so just whatever amount of pills that would equal. That's what the studies show and we show that as well.
Jennifer Fugo (33:27.132)
And you split that over the course of the day.
Allison (33:30.238)
Yeah, three times a day, two times a day. We also have bismuthiol, which Dr. Paul Anderson, wonderful naturopath, created these anti-biofilm formulas that are called bismuthiol formulas. And these also seem to be tolerated well and work for hydrogen sulfide. So he has an over-the-counter one, it's by Priority One, it's called Biofilm Phase-2 Advanced, and he has a prescription version that you can get compounded. You can also get bismuth subnitrate compounded, for practitioners who are listening. And if you want those formulas, just Google Paul Anderson and, what does he call it, Biosolve-PA, and you'll see a PDF for free and you'll you'll get the information. So that's bismuth.
Now, high-dose oregano is very interesting here. Why not regular oregano? Well, what happened was a colleague of mine had a patient who had hydrogen sulfide, and he just decided to do this old protocol that was like sort of like an old chiropractic protocol for Blastocystis hominis parasite of this high-dose oregano, and he did it for his hydrogen sulfide SIBO, on his own, and it worked, and he told us about it. That's how we found out about it. Thank you. And we tried it in other patients and it worked.
So it's the oregano, the particular protocol, is the oregano that's sold by Biotics, that's ADP. ADP, it's like a dry oregano. And it's a lot, it's high dose. So it's five tablets, three times a day for the first week. So that's 15 pills a day. And then it's nine a day, three, three times a day, for the next three weeks, totaling a month. And that works very well. So you could do these by themselves, you could do them together, or you could take them and add them to any other SIBO treatment regimen, any other SIBO herbs, any other antibiotics.
So let me just finish with the antibiotics. What a lot of my colleagues did was they just used what we normally use, rifaximin, neomycin, metronidazole, and they had success. And it turns out in the literature, all of those have been studied for hydrogen sulfide and shown to have effect. However, I had zero effect with any of those.
Jennifer Fugo (35:31.676)
Wow.
Allison (35:51.572)
I never once had them work. Which is why, actually, I went searching to find something else, which is when I found the article on bismuth, began using it, and then began teaching about that. And then of course the oregano came. So those are hit or miss, but what has shown to be even better, more effective, in literature is nitazoxanide, which is known as Alinia. Not so easy to get, can be expensive, but that's studied better than rifaximin for hydrogen sulfide. You could consider using any of these, but I actually would put nitazoxanide a little higher, so almost like bismuth or oregano. If you're going to use rifaximin, consider adding nitazoxanide. If you're going to use neomycin or metronidazole, consider adding nitazoxanide. And there are some other antibiotics that are studied well, but they have a lot more side effects. So I won't mention them.
Jennifer Fugo (36:44.504)
Wow, so interesting. It's just like its own little beast, you know?
Allison (36:49.262)
Each type of SIBO has its own way that it's treated. And do we have time for me to mention a few supportive items?
Jennifer Fugo (36:50.504)
Sure, absolutely.
Allison (36:51.262)
Okay, because I would be remiss if I did not mention molybdenum. Molybdenum is helpful in sulfur detoxification pathways, and it's very helpful for the symptoms, the symptomatic relief, in people who have hydrogen sulfide SIBO. So, typically you take probably around 500 micrograms, maybe as much as a thousand micrograms, in a day, and it's really, really helpful. And we mentioned B12, hydroxocobalamin, and also butyrate. Hydrogen sulfide can decrease butyrate production, and that's a short-chain fatty acid in our large intestines, it's very important for our intestinal health. You could consider supplementing with that. The molybdenum and the B12 are more likely to actually help relieve symptoms, really, really help with that.
And then just a couple others would be GOS. That's a prebiotic, which many people with SIBO are not going to tolerate very well, right?
Jennifer Fugo (37:53.403)
Yeah.
Allison (38:09.538)
Although some people can, you never know. You could try it. If you're ever going to try that, start very slow and low. But in studies, it showed that it decreased Desulfovibrio and increased Bifidus and Lactobacillus. That would be a very good option, good effect on the microbiome there. And also zinc acetate, it showed a five-fold decrease of hydrogen sulfide gas. So those are some things to think about.
Jennifer Fugo (38:19.292)
Interesting. So zinc acetate, as the form of zinc that you would take, as opposed to, I've seen like zinc sulfate, there's zinc picolinate, zinc carnosine.
Allison (38:26.488)
Yes, yes. That was the specific one that was studied showing that it decreased hydrogen sulfide.
Jennifer Fugo (38:36.808)
My gosh, you are such a wealth of knowledge.
Allison (38:39.566)
Thanks, Jen!
Jennifer Fugo (38:42.192)
Like seriously, I mean, I already told you that many times before we even started recording, but I just want everyone to know how much I really appreciate you, your generosity, and also your deep curiosity. Because to be fair, we wouldn't know any of this if it weren't for you, Dr. Pimentel, and anybody else who keeps asking why, and keeps trying things, and wants to have conversations with other people. And is even interested in hearing what's working for somebody and testing it out, and then just being willing to share because not everybody wants to do that. They just want what's the protocol and they move on, even though they don't really understand why it might work, when it might work. You're really digging into things and I love that about the way that you think.
Allison (39:33.656)
Well, thank you. I'll tell you what though. Look, if somebody just wants a protocol, I don't blame them. That's great, so long as it works. But the trouble is, so often, that's not enough. And we need more information because these things don't always work.
Jennifer Fugo (39:45.883)
Yeah, and just one quick question, and I think this might help with the testing. Do you think, and we were talking about this kind of beforehand, looking at the GI tract from the 2,000-foot view, do you think it's a good idea, if somebody suspects they have SIBO, to look at maybe a stool test and a breath test so that you really kind of know what's happening throughout the GI tract rather than just fixating on one section?
Allison (40:20.764)
Oh gosh, yes. I always recommend getting both. That's like pretty much the basic way to start when someone has GI symptoms, get a breath test and a stool test. And then you get, at least you're getting an overall sense of things. There's more that could be done. I mean, you could also get a parasite test, which you and I were talking about before, because not all stool tests are so good at finding parasites. But if you could just start with your basic comprehensive stool test, a functional medicine stool test, and a SIBO breath test.
Jennifer Fugo (40:52.25)
Yeah, that would be a good way to go. Oh my goodness, thank you so much for joining us.
Allison (40:57.836)
You're so welcome. Thanks for having me.
Jennifer Fugo (40:59.25)
So you have, you were sharing, you have your website where people can go and look up information that's more a little patient-oriented, it sounds like.
Allison (41:08.654)
It's doctor and patient. I honestly made it for doctors, believe it or not, but it's for both.
Jennifer Fugo (41:13.518)
Okay, so we'll link up to that and then you also have practitioner courses as well.
Allison (41:14.654)
And patient courses.
Jennifer Fugo (41:16.518)
And patient courses, okay, so we will make sure to link to all of those because I want people to be able to have access to those. If they want to go through them and you're really interested in diving into this, you have these, I mean, I went through the practitioner course, my team did, and we were just like, my gosh, we learned so, so much. So we really appreciate the energy that you have applied to making such a concise resource that really helps troubleshoot because this is not like, you do this one thing, right? Everybody wants the one thing. It's not one thing. There's things to consider.
Allison (41:54.7)
I wish it was.
Jennifer Fugo (41:55.518)
I know, it would make our lives so much easier, right?
Allison (41:56.7)
So much easier. Yes, thank you. I would love anyone who wants to learn more to come to my courses. And of course, I have interaction with my courses, we have Q&As and such. It'd be wonderful to have you.
Jennifer Fugo (42:06.629)
Yeah. And you also have a YouTube channel as well?
Allison (42:12.482)
Yep, I have a YouTube channel, and that's pretty much all I do for social media.
Jennifer Fugo (42:15.31)
Okay, well, we will link to all of that so if people are interested, they can find you. But Allison, thank you so much for your time. I appreciate your dedication to this topic. And of course, I hope you will come back and join us again.
Allison (42:29.75)
Of course! Thank you so much, Jen.
