Is your IBS really SIBO?

In this episode Pete speaks with yet another old colleague of his, Tracey Randell, who he fondly refers to as the "SIBO Queen"

Recent evidence suggests that two thirds of people who are diagnosed with IBS, have IBS because they have SIBO.

Given that possibly 20% of the general population are thought to have IBS (meaning it affects roughly 1 in 10 people globally), this is a podcast that could help a huge amount of people. 

Here are some links mentioned in this episode:

https://www.ibsclinics.co.uk/about-us/

https://www.goodreads.com/book/show/53851892-the-devil-in-the-garlic

https://www.siboinfo.com/

Thanks for listening to our podcast and please feel free to get in touch:

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We would love to hear from you!

Transcript

SUMMARY KEYWORDS

SIBO, functional medicine, digestive complaints, gut microbiome, hydrogen breath test, methane production, probiotics, low FODMAP diet, gut motility, ileocecal valve, antibiotics, gut permeability, inflammation, autoimmune link, dietary modifications., SIBO, hydrogen sulfide, methane, antibiotics, FODMAPs diet, sulfur reducing bacteria, intestinal sulfide overproduction, breath test, antimicrobials, MSM, sulfur detox pathways, genetic mutations, toxic environment, sulfur compounds, gut dysbiosis.

SPEAKERS

Peter Williams, Tracey Randall, Speaker 1

Peter Williams  00:02

So welcome to this new functional medicine bite size podcast with another old buddy of mine, Tracy Randall, who I like to call the queen of SIBO. And we will, we will get to that. We'll get to that in a minute. We go back quite a long time, Trace, I think of you as one of those originals that was with that a very original group that were going over to the US, because that's the way it worked at that stage, wasn't it? And we were on our learning, you know, medical journey and functional medicine. And at the time that we were on that learning journey, the only way we could do it was fly out to the US and have a week going through courses, which is where I met you. I cannot remember, but it was, it was definitely at one conference, and I'd probably actually seen you at another one, and just didn't come over and have a conversation with you. So I apologize for that. But do you miss that? Miss those times I sort of do, well,

Tracey Randall  01:03

yes, and actually, I'm doing it all again with a A4M

Peter Williams  01:07

okay, because I think I need to, I need to sort of recapture that and A4M I was looking at on that side. So yeah, I might, I might go and just sort of get that buzz, because it was pretty it was pretty groundbreaking for me. I thought I just felt like, Oh, my God, this is so cool. This is really worth doing, even though the expense, and, you know, the time put it to be able to go and do that was, was was pretty profound. But it was a good time, for

Tracey Randall  01:35

sure. It was a good time. And you're quite right. I was one of the Brit pack because we, we tended, I think, to gravitate towards each other, us Brits, because there always used to be something like 350 Americans in the room and half a dozen Brits. And we would find each other. We would eventually, I remember the awareness of like, oh yeah, there's that. Who's that guy over there? Isn't he a British Yeah, and that's right. And then I think it probably took two of those before we all found each other. And then we became a bit of a pack that hung out together at those conferences, and they and they were great times. And to your point, functional medicine is just the most incredibly exciting thing to be involved in. It was then. It still is now. Hence why I've been hankering after getting that feeling and being back in the room, yeah, watching yet another course, and there's so much great learning out there, but it's all via courses that you do, or via zoom sessions, and it's just not the same as being physically present. No,

Peter Williams  02:33

I don't think, I think that's absolutely key, because it's also about the people that you meet when you're there as well, and the experience of that. So given that you are one of the most experienced, IFM certified practitioners, we can come to you with, you know, and I sometimes give you a shout with regards to particularly difficult digestive patients, because let's have a bit of your background and where you spend most of your time. Because I think obviously we're going to talk about digestive complaints, in particular, SIBO, but why don't you give us your background briefly and then we can sort of start sort of asking you loads of questions and just grabbing all of that expertise from you. Okay,

Tracey Randall  03:16

so I became a nutritionist after 28 years of working in the travel industry, I kind of crossed over. And so I, I, I trained to be a nutritionist in parallel with a a full on sales director role in the travel industry. And then I crossed over to work in the nutrition field when I qualified, which was back in about 2008 and then immediately on qualifying, I discovered Functional Medicine and started going down the path of doing all of the IFM stuff, yeah, and, and so I've been in full time clinical practice for something like 14 years now. Yeah, I chose in those very early days. Well, actually, it kind of happened by accident. I was working for another practitioner who specialized in digestive issues, and I worked a lot with irritable bowel syndrome and inflammatory bowel disease and that kind of thing. And I kind of cut my teeth on that, if you like. And I just loved it. I loved everything to do with the gut, and I loved the fact that it was, you know, the gut I always describe as being the engine room of the body, and that it's fundamental that that works. Otherwise nothing else does. There's no point in tinkering about with hormones or, you know, supporting adrenal function if your gut is disturbed and not functioning properly. So if you can't digest, absorb and assimilate properly, then then nothing else is going to work.

Peter Williams  04:44

Sure, I think that's a really nice way of looking at it. And do you still believe that? I mean asking an expert here that I don't I don't know where the statement ever came from, but all disease begins in the gut. Do you think there's a Do you think there's a good argument for that? 

Tracey Randall  04:59

I can't think of too many conditions that aren't made worse by having poor gut function. And increasingly, diseases that we didn't used to think of as having a gut link is very much coming out now as being gut derived. So I'm thinking about things like Parkinson's. Yeah, totally, for example. Yeah, I'm sure, well, I think we're already doing as functional medicine practitioners, where someone might present with depression and anxiety, and we might start thinking about their gut microflora, the balance of their neurotransmitters, and the influence of what they're eating on on their mental state, you know. So we're already doing that, and we know that there are certain key probiotics that are really good as quelling anti, you know, having anti anxiety, properties that we're utilizing, we're doing that now. So, so I think this is hugely exciting, and I think the interest and the research in the gut microbiome is just exploding at the moment, yeah, and I think, yeah, it continues to be fascinating.

Peter Williams  06:00

And that's definitely one of the areas that I follow most, because I think, you know, there's just such a hotbed of research that keeps coming out. And I don't think we fully understand, Well, we certainly don't fully understand it yet, but I think we're being taken down the pathway where we've got enough information to maybe trial something in clinical practice, and we've got some good sort of data sets that help us so, so it's a it's a guesstimate, but actually quite a lot of the time it works out really well. It's certainly in my in my experience, (yeah, absolutely). So can we talk about this term that is SIBO? Because, as I said to you, I know that. I know you know, if there was a go to person I go to to ask questions on SIBO. You know, I come to you because I can, very occasionally, I'll ring up and, you know, I'm a bit stuck, and need a little bit more advice. Can we just have a breakdown? Because I don't know, so many people actually have SIBO that probably don't recognize it. So can we give it what would be the symptoms that you might think about, and really, what is it? And sort of, and sort of jump into it on that state, yeah,

Tracey Randall  07:09

sure. Okay, so I would describe small intestinal bacterial overgrowth as being a frank overgrowth of bacteria, normal, beneficial, friendly flora, but overgrown in the wrong part of the gut. Okay, so, so I'll explain that. So the gut is basically a big, long tube. It comes in compartments. We have the small intestine or the small bowel. Then there's a valve, and its job, like, like a plumbing valve, is to keep things moving south, stop things back flowing. And then the other side of the valve, obviously, is the large bowel, or the large intestines, we call it. And when we talk about the gut microbiome, and we talk about, oh, it's really important to have trillions of bacteria, really, what we're talking about is having trillions of bacteria in the large bowel. In the small bowel, the environment is very different, or should be very different, because the small bowel has a different function from the large bowel. The small bowel job is to continue the business of digesting your food, and that's fundamentally the difference. And the reason why it's important to note that is that what happens with SIBO is that bacteria overgrow in the upper gut. But the upper gut is not used to hosting such a big population of bacteria. It's not it's not meant to do that. So consequently, the bacteria come into contact with our food, they ferment it and create gasses, and the knock-on effect of that is that the gasses have a bearing on how our gut moves and behaves, and also the bacteria, they degrade brush border enzymes, which means that we fail to digest some of the higher FODMAP foods. So you know, so things like lactose and fructans and galactose, all of those types of high FODMAP carbohydrates, we fail to digest them. The bacteria are voracious. They compete with us for our food. So when someone has had SIBO for a prolonged period of time, we can see diseases associated with malabsorption, maldigestion and deficiency. So we often see things like iron deficiency, B 12 that is unresponsive, you know, so. And additionally, when SIBO has been running for a while, it will also cause our small bowel to become leaky. So we call that leaky gut. And then when the gut becomes too porous, there is free passage of bacterial fragments, or endotoxins, or the posh name is lipopolysaccharide, that is able to traverse through the gut lining into the bloodstream, where, when it hits our circulation, the immune system sees those fragments, creates antibodies to them, and then thereafter, each meal time is a massive inflammatory event. And the inflammation is in response to food particles, but also bacterial fragments as well, you know. And so the person will feel that, because they'll start to have reactions that are systemic. So they'll start to get things like muscle and joint pains, myalgias, that type of thing. Brain fog is another one. When you have a leaky gut, you're you're almost certain to have a leaky blood brain barrier as well, you know, So, so the person that has had SIBO for quite some time will have a very specific set of symptoms, um, fundamentally, lots of bloating, lots of gas, and variable bowel habits. So can be running to the toilet, or can be resolutely bunged up and constipated. Um, so those are the those are kind of the basics of SIBO. Can,

Peter Williams  10:49

can you just take a step back? Can you talk about the importance of borders, because you mentioned two there, leaky gut, which obviously is a border from the outside world inside, and then blood brain barrier. So just the importance of that, because I think also what you were explaining is, with LPS, maybe have a little bit more time on that is it is a molecule that the immune system really doesn't like. And for me, this is part of the, not all of them, but this is what I see quite frequently with depressed patients. That's definitely one of the things. So can you just expand on that? 

Tracey Randall  11:24

Yeah absolutely. So, so just to expand on what a leaky gut is. So it's really important to understand that the cells, the lining of our gut, is one cell thick, and basically the cells of our gut sit together side by side, like my two fists. And if you can imagine that this is a cell and this is a cell, and then in between is something called a tight junction, okay? And then the other side of that, sitting on top of my hands, is, is a mucus layer, okay? That acts as a bit of a buffer, if you like. And that's where a lot of beneficial Flora will hang out. They will exist in a biofilm, in the kind of mucus lining. When bacteria overgrow in the small bowel. What happens is, is that that that barrier layer of biofilm and mucus gets worn away, and then what that what happens is bacteria come into direct contact with the cells of the intestinal lining, and they irritate and aggravate and what happens is, is the tight junctions open, and then that allows food particles from inside the gut and also fragments of the exoskeletons of the bacteria themselves, To travel into basically our mainstream circulation. To your point, you're quite right, that a massive inflammation will ensue as a result of that. And in fact, scientists, when they want to create in a lab rat, they want to give a lab rat a lot of inflammation, because they're testing some kind of theory or some kind of drug, they will inject the rats with lipopolysaccharide, because there's nothing like it for creating this incredibly inflamed state. So, so that same barrier that you have in the gut exists in the blood brain barrier. So the BBB, if you like, exactly the same. It's got the same makeup. It's it's one cell thick. And what can happen there is what goes on in the gut doesn't stay in the gut. It travels outside. So inflammation that is in the circulation very quickly, goes into the brain, and in the brain, what it does is it activates cells called the glial cells, which are special immune cells that have no off switch. So when they become activated and turned on, can't turn themselves off. So we see very often this kind of people that are brain fogged, yeah, because of what's going on in their gut.

Peter Williams  13:48

So I think what you're you're alluding to there is that this is the sort of gut brain systemic axis as well. And this is something where you know, if you've got poor digestion and some of the clear symptoms that you talked about, and you've got brain fog, then we could make a loose theory there that, you know, maybe the gut is more permeable. So can we go through the major so I think there are so many people out there. I mean, as I said to you, I mean not that I'm doing the sort of specializing in digestive aspects. But most people, as I said to, you come to us with some degree of digestive ills or symptoms, and I think probably the majority of the population will have some kind of digestive symptoms going on. Can you give us the here's the things to think about that that are given as an indication that you may probably have SIBO. What would be the, what would be the key things that you would suggest,

Tracey Randall  14:47

okay, the first thing to say is, onset. Okay, so there are different types of SIBO, which I'll, I'll summarize for you in just a second. So the first thing to say is, you know, when we're talking to patients one of the questions that we often ask is, how long have you when was the last time you felt well, yeah, well, I was fine until, yeah, last February, when I went away on a hen weekend and I had a dodgy burger in Benidorm. You know, this is, this is real. What I'm talking about, this is the kind of stuff. Up until then, I'd have no problem with my digestion whatsoever, but I had a dodgy burger. Something really upset me. A few of us were ill, actually, but I, I wasn't as bad as the rest. But, you know, I came home and my tummy was a bit upset, and then it seemed to calm down for a while, and then ever since, I've had, you know, either lots of diarrhea or loose motions, or have been really bloated or constipation. I often find that people send me pictures of bloated tummy. So my laptop is full of bloated tummy pictures for that very reason. So when I'm when I'm asking the questions, and when I'm taking a history, that that moment when everything was fine until, yeah, then normally I'm straight on that, like, tell me what was going on in your life at that point. So if it wasn't a hen weekend, a dodgy burger, it was a protracted, long period of stress, yeah, something catastrophic happened, or trapped in a in a terrible relationship with my boss, with my partner, with friend. You know that that kind of scenario or something like, I had some surgery. I had a problem with a knee. I was put out under anesthesia. I came round, I had I was bunged up and constipated and backed up. Fecal impaction was diagnosed, that existed for 10 days. I've never been right since. So, so that kind of scenario which,

Peter Williams  16:42

which is just, so, you know, I think this is the key thing, isn't it? It's so important to make sure you've done your due diligence with regards to that background. Because usually the aha moment comes there, and then you're, you're on the strategy then, aren't you? You're thinking about, Okay, this starts to make sense now. So, so continue. Brilliant, brilliant bit 

Tracey Randall  17:04

Yeah, what I would say is, because I specialize in irritable bowel syndrome, whatever you come to see me about, I'll probably wind up doing some kind of gut test on you. Yeah, I can always see the I can always see the link. So, so the other onset, the rapid onset, is food poisoning, the classic Delhi Belly type food poisoning. And then I wasn't the same after that kind of scenario. So that's another situation. And then symptoms are either constipation that doesn't respond to anything at all, and I've had a bout of this, men running for bushes on golf courses, where their bowels suddenly let them down, and they get caught short on a golf course. And they have the opposite problem. They have loose motions with extreme urgency. And they, they, gosh, they're, you know, knocked o sideways by what's going on. And they, they all worry about bowel cancer, you know, I've been, I've had all the tests, everything's clear. I've just been told I've just got IBS, you know? So that's another scenario that happens often, is that people will go and see their GP. The GP will refer them on. They end up being scoped, you know, endoscopy, colonoscopies, and just being waved off with a smile. You know, there's nothing wrong. There's nothing in, nothing inflammatory, no cancer, etc,

Peter Williams  18:17

so, and I think this is another key point, because that there's always a conversation that you have to have, and I usually say is because scopes look for big things. And this is not something that you're going to see on the scope. 

Tracey Randall  18:28

It's a functional disorder. It's not a cancer, it's not an inflammatory bowel condition. But you know, for most people, and you know, and 98% of colonoscopies show nothing at all of any consequence, so good

Peter Williams  18:41

But good to have the scope. So I always say, Yeah, I would, yeah. I always not the big thing.

Tracey Randall  18:46

Yeah. I often say, people ask me, oh, you know, I'm booked for an endoscopy, Colonoscopy,  I'm not fancying it much. Do you think I can cancel it because I'm seeing you? And I always say, No, I'd rather that you carried on with that number one. Under the terms of my license to practice, I can't tell you not to that you don't need these things. And I'll also say this to everyone, you will never regret it. If you have the scopes done and nothing is found, then that is a huge weight off your mind. And that in itself, when you're dealing with IBS and the gut brain connection, that's really helpful. And then the other thing is, if something does pop up, you really want to know that you've got something sinister quickly so it can be dealt with, so it doesn't become a bigger issue. So I always go ahead and do the scopes. It's really important 

Peter Williams  19:33

Totally agree on that. So I've got a patient who has these digestive symptoms, one of them, which is significant bloating and significant and/or significant belching as well. Would they be a few? And when would you expect to see that after food or generally? Or is it a mix of everything?

Tracey Randall  19:58

It's a mix of everything. So. So I'll often say to people, so when they write on their form bloating. So I'll say, can you tell me about your bloating? So when you wake up in the morning, do you have a flat stomach? So some people will go, Oh no, I'm already quite bloated. Or other people will say, yes, my tummy is flat. And I'll say, Okay, so do you get progressively more bloated with each meal as the day goes on, and you're really bloated at night and you, you know, you can't wait to put your comfy trousers on and with your elasticated waistband, and they go, oh yeah, that's me. Or, or there's a picture of, no, I'm fine in the morning, generally speaking, but it really kind of kicks in after lunch, and then it's worse after dinner. So, so people's bloating patterns are variable. You made a point about earlier on, about reflux, yeah, reflux is really interesting, because I very much associate that with methane production in the gut. Interesting, yeah, so I It feels to me like methane, because we know it stagnates and constipates the gut. It seems to give almost a retrograde flow with you get a sense that maybe things are running backwards, okay, coming up the pipe that should be going down. And so is that,

Peter Williams  21:05

is that, is that based on your experiences, or is that based on your experiences and where the literature seems to be going?

Tracey Randall  21:11

The literature does back that up with methane being having that stagnation and the reflux link, definitely. I mean, I have to say also that if you're full of hydrogen gas, you're going to reflux as well because of the fact that the gas has got to go somewhere, and Tracy, it's going to be both ends.

Peter Williams  21:27

Can you? So I think what you're trying to say here, aren't you, you're trying to say that gas can go down and gas can go up, and so, can you explain the mechanism? Because this is really, I think this is a really important point, because you'll have people who may get treated for reflux, completely inappropriate treatment, because no one's ever said to them, well, this might be because you've got SIBO, yeah. So, can you just explain that a little bit more and explain the sort of the valves and the sphincters and how it comes back up into the tummy? Yeah?

Tracey Randall  22:00

So, so SIBO is this gross overgrowth of bacteria. The bacteria come into contact with the food, notably what we call FODMAP. So there's basically this classification of carbohydrates that are found in fruit and vegetables, in healthy fruit and vegetables, for the most part, that so can

Peter Williams  22:17

I so just talk about that point, because this is one of the key points, isn't it? Because a lot of these people come in so desperate, because their diets are literally perfect, from a point of view of fruits and vegetables and onions and broccoli and then you go, Ah, okay, so, and that's the reason why that's

Tracey Randall  22:38

That’s a telltale, yeah. And in fact, actually, a group of people I'm seeing a lot of at the moment are the vegans. So people that have basically switched over from their standard UK SAD diet over to being vegan, are expecting to really feel all of the health benefits associated with veganism, but they're not. They're wretched and miserable because of the fact that they're so bloated, distended. Their bowels are misbehaving, they're burping, they're refluxing. They feel horrible. And they say to me, How come that when I used to eat chicken and chips, I didn't have any bloating and I had no problem, yeah, but now that I'm eating my chickpeas and my hummus and my Buddha bowl lunches with all my curly kale and everything else, I am so uncomfortable. I'm racked with abdominal pains all afternoon. And then that that all also gives me the SIBO thing straight away. It's like, okay, that's a FODMAP reaction. And then I go onions and garlic, and I go back through the food diary, and I go, Okay, tell me about this meal. How are you after that one? And then we normally, the pieces start to kind of fall into place, really, very nicely. So

Peter Williams  23:47

what we'll do is we'll put a link to low FODMAPs. So if anyone doesn't know what it is, you can get an idea from that. But again, I mean, I can remember one woman a few years back, and she was she was more about she was trying to lose weight, and she's just sort of so bloated and full and full of water, and just sort of, as I said, she, she took the pictures, you know, she's so desperate. Look at me on this one. Look at me on this one. I'm, you know, I look like eight months pregnant. And then when we sort of discussed to her, Well, you know, listen, sometimes the most health providing foods are the majorthe problem. And we've got to take you through a time frame of where we're probably going to have to get rid of them to give you a bit of, bit of sort of symptom relief. So let's go back, because again, it's just, I mean, there'll be so many people that be like, Oh my god, this is me. This is exactly me.

Tracey Randall  24:38

And it is so many people Pete, that's the thing. If you consider that around 15% of the UK population will go and see their GP at some point and be diagnosed with irritable bowel syndrome, and we know from the research that between 64 and 85% of people that have been diagnosed with IBS have SIBO when they're tested.

Peter Williams  25:00

Yeah, so let's just go through massive that is the numbers. It's probably, it's more than, it's more than two thirds who were diagnosed with IBS have likely got SIBO, which is just unbelievable numbers when you think about it. Yeah.

Tracey Randall  25:16

And a patient that I was with yesterday said she'd been to see the GP, and her GP said she's she had been diagnosed with SIBO, actually, before seeing me by a doctor, actually, in Dubai, believe it or not. And she went to see her GP, and the GP said, Oh, I have heard about SIBO, but it's very rare. Don't get very many people with it. So she said, that's from yesterday. And she said, What do you think? And I said, I think that's completely wrong, absolutely, completely wrong. And I said, you know, I'm afraid that your GP probably trained to be a GP before SIBO was really, very well known about it's really, actually only come to the fore I would say in the last 15 years that it's become much more and actually, it's much more known about in the complementary field, rather than the traditional medicine field.

Peter Williams  26:08

Yeah, and, but again, really strange, because it's the same conversation about, and again, maybe it's a terminology thing, but leaky gut. So I had a guy who had who had leaky gut. He had an iron overload disorder, and his gastroenterologist went like that, there's not, there's no, there's no such thing as leaky gut. And it's like, mate, there are 10s of 1000s of papers on gut permeability. When was the last time you were on PubMed? And I just wonder on that is, I wonder, is that, is that just because, I mean, I don't know, I can't work it out. I mean, maybe that just sort of, that's just down to, well, I did my training 20 years ago. I don't need to do any more. And it's like, I mean, I look at me, and maybe, maybe it's because we are the new field that we're a little bit concerned that we know our stuff, and we're perpetually on PubMed, making sure that we're, we're, we're catching up. I mean, I don't know, but it beggars belief that it's like, what? Okay, well, you know, shall I just send you a page, first page with PubMed? Just put leaky gut in there. And absolutely,

Tracey Randall  27:17

I think, I think what it is we're taught to always be curious, always ask why. And I think that maybe because, as functional medicine practitioners and as nutritionists, we know we're not doctors, we're not permitted to diagnose and we don't. We help to identify biochemical imbalances, and because of that, we always feel, I think, that we've got to back up our arguments and to renew our stuff. Yeah, and that's what pushes us back into the research, because it's like, okay, I want to back up before I'm going to tell Mrs. So and So, that I think that we may need to work in this manner, and that she may have this condition called SIBO, and we need her to get tested to identify it. I need to back up the rationale, and I need to show her where I'm coming from and why this is the case. I also think that when you've been a doctor for quite a while and you are renowned in your field, and you're an expert doing what you're doing, you know, life is super busy for them. They work really mad hours, insane paperwork and lots of bureaucracy and red tape and everything else. I don't know that they have the time always to be curious.

Peter Williams  28:35

Well, I think you're dead, right? I think this comes to an understanding of how complicated, how complicated human health is, and you can spend your whole career in a very tiny field, but there is always so much that you'll go to your grave, never knowing about that tiny field that you can't possibly look elsewhere. That's the way I look at it. I don't think it's I think it's very rare. It's probably just pure ignorance. I think it's more just I'm so on the edge here with general work anyway, I've got no time to even think about anything else. So that that's definitely how I see it. I suppose the problem with that isn't it, is that the internet has just opened a massive pot of good and bad, from a point of view of practitioners are learning about SIBO and again again, I would say, always be cautious about where you get the sources from, from a point of view of who's saying it and you know, and where you've got it from. So can we sort of, so let's assume that we've got a patient that goes that sort of feels like me, and they've come to you, what's the strategy? I mean, of course, it's obviously dependent on individuals. Do you go straight to test or would you recommend doing other things first?

Tracey Randall  29:55

Often, I like to work on an initial session basis. So. So some people will just buy tests on my website, and that's fine, and I will see them with their test results if they want to work with me. That's fine. But my the way that I like to work is for someone to book in and have a consultation. And the reason for the consultation is that I will get them to fill out an exhaustive health questionnaire. You know what functional medicine ones look like? Yeah, absolutely. And a food diary. And then we sit and I'll go through all of the information that I have on the patient in advance, including 45 test results, if they want to send them over. I'll sit have a look through all of those. So, I'll sit down already very much with a sense of an instinct for what might be happening. Yes, exactly, yeah, and then what I'll do is ask questions and go through the questionnaire, clarify that they know what I mean by bloating, that you know constipation means different things to different people. So I want to understand what their understanding is and, and what their experience is and, and I'll work through it like that, but very quickly after working when I've done all of that, I would say, by a third of the way through, I'm already knowing that I really want to test them to find out for sure if there's SIBO. And you might say, Well, if you're that certain, then, because you work in this field, you're probably right. Why would you bother testing? Well, there's still quite a lot of information to get, to be gleaned by the testing process. And the results that you get back, you can tell a lot about someone's SIBO by the pattern of the gasses, how quickly they get bloated in response to the challenge sugar and also testing gives

Peter Williams  31:32

you that more. It gives you objective clarity as well, doesn't it? 

Tracey Randall  31:37

It does. It validates the patient. Yeah, unfortunately, they knew there was something wrong. They've come to see you. This is often the first time that they've come to see someone, like a nutritionist, because before, whenever they've had an illness, the GP has dealt with it, yeah, yeah. And this time, the GP has said, you've just got IBS, you're going have to learn to live with it. So and they've come to you for some other reason, someone's recommended, or they've read something, or they've seen you talk somewhere, and they're in front of you, and so they're feeling a little bit wobbly about, oh, who is this person? What's she going to be talking about? What's she going to tell me is going on?

Peter Williams  32:16

Do you still think that's the case? Because I think there's been certainly in the last five years, and then maybe it's because we're getting older, and, you know, we're a bit sort of older hat on it, and we have a slightly different view, but so many more people are searching the alternatives, and it's, it's more the norm and more accepted. And I think, I think a lot of the medical, the traditional medical communities and consultants that I am speaking to all the time. I think them, it feels like you're, you're on a path now, that's how I feel. I am. It's that, you know, that you're not some fly by, you know, I think

Tracey Randall  32:51

that, I think that mainstream medicine is a lot more respectful of the job that we do these days. So I think that's absolutely fair to say. And I just think, I think there is a lot of people out there that are prepared to take responsibility for their own health totally, you know, and they have a they have a natural they're curious, yeah, and they question, and they ask, Doctor, why aren't you testing me for this. What about this? I do know that some doctors will say, Oh, you've been on Dr Google, you know, have you? And they'll laugh at what someone suggests. But you know, my training, our training, Pete, has always been that if you ask the right questions, and then you sit and listen to the person in front of you, they'll tell you what's wrong. Yeah, totally so. And I think so the person living in their own body knows how their body functions, knows it's off, they’ve read something online, maybe a dubious source, but it resonates for some reason, and they want to explore that area, yeah, I think there's nothing wrong with that. And I think I never have a problem with someone that has read something. I actually quite enjoy the slight challenge, because if they're well read, I'm better read, yeah, they'll start talking about something. Or I read about Dr Mark Pimentel, and he said that, and I go, Oh yeah, that was the interview with such and such and such and such. I know what you're going to say, yeah. In this case, I don't feel this is your problem. I think you're more likely this and you know, and then I'll talk them through why I think it's not applicable, or why I think it is, you know, so but yeah, I think a well informed person in front of you is enormously helpful,

Peter Williams  34:34

as long as they're not so well informed that they're telling you exactly what you should be doing rather than taking your expert advice. I mean, as I said to you, these are that's the only downside I see to some patients, there's so they've already made their mind up about what test you're going to do and what and are. 

Tracey Randall  34:56

That is true, and so the telltale sign is when you get someone's health questionnaire. Yes, and they've hardly ticked any boxes, so they've put their health conditions one and two, and then the boxes that you would normally expect to be ticked in response to those health conditions are not ticked, and it's because they don't want you going off anywhere else, because they just want you to follow their path because, like you said, they've pre-defined that they've got a particular condition, and that's what they want you to so basically confirm for them that the complete

Peter Williams  35:26

The complete value of a questionnaire, because there's so much you can see in the way a patient writes their responses. And, you know, I think invaluable. That's why I love it. You know, it's like a question of you, you're all you're already capable of making that, that psychological picture up about, you know, how are you going to play this over time? So we've got somebody who's coming to you, you've recommended a SIBO test. Can you just give us an idea of what a SIBO test is and how a patient would do? It's a bit of a pain in the ass today, let's face it, but

Tracey Randall  36:00

it's okay. So basically, in order to identify if there's bacterial overgrowth in the small bowel, we use a test called a hydrogen breath test. So what happens is the patient goes on a special diet for 24 hours before the day before, which is basically essentially chicken and rice for most people. So the idea being that it's a it's a diet that's not fermentable, yeah. And then they fast overnight, and then on the morning of the test, they so that the test kit exists of basically about 13 test tubes and kind of a funky thing that looks like a triangular balloon with an arm, with a with a kind of a spout that looks like a Soda Stream, yeah, you know, I mean, yeah, and so. So what they do is they kind of blow into the balloon. There's a little arm where the Soda Stream arm sticks out and and they pierce a test tube, and they blow into it, and they capture their breath. So they do that initially, then they drink a sugar solution, which I normally use lactulose sugar. It's a poorly digested sugar by the human gut, but bacteria adore it. So basically, they drink the sugar solution and then they do a breath sample every 20 minutes for three hours. At the end of the three hour duration, they'll have a load of test tubes that they then package up and send off to the laboratory. The lab, in response to getting all the test tubes, will then perform an analysis of every tube, looking for hydrogen and methane, and they will plot the numbers of the hydrogen molecules and the methane molecules on a graph. So we end up with a little kind of bar graph. And what we're looking for is, we're looking for a response to the lactulose in the first 90 minutes of the test.

Peter Williams  37:49

And why just 90 minutes?  

Tracey Randall  37:51

Well, we used to use Well, we used to use 120 minutes, as you know. So it was thought that it took two hours for the lactulose to move from your basically from your stomach all the way through to your ileocecal valve, which is the valve that links the small bowel and the large bowel. But in more recent times, we feel that lactulose, because it's slower to absorb it can actually result in an over diagnosis of SIBO, seeing SIBO where it's not where actually the lactulose is in the large bowel, and the response that you're seeing is in the large bowel and not in the small bowel, sure. So in the last few years, we've tended to use 90 minutes as a guideline. And I would say, as a practitioner, I do use 90 minutes for the most part. But I also need to listen to my patient, and I need to think about the symptoms. And if someone is actually super bloated at 100 minutes, and they've got a constipation picture, then I might be inclined to think, well, a sluggish bowel. Then maybe it took longer for the lactulose, yeah, move. So, so the breath test results are going to look a bit different and if there is any doubt over whether it's 100 minutes or 90 minutes, or what it is, I sometimes will just sit back and just go, does this look like excessive fermentation? And if it is, well, excessive fermentation is in the small bowel, in the large bowel is it a problem? Yes, the person's bloated, uncomfortable. They've got variable bowel movements, then we proceed accordingly. So SIBO is basically it's a dysbiosis. It's a dysbiosis of the small bowel. We're used to about dysbiosis in the large bowel. So to some extent, it doesn't really matter where the dysbiosis is. You're going to particularly when you're working with herbs, you're going to work with it in the same way, dietary modifications and tactical supplementation for a period of time. Digestive support, probiotics, prebiotics, etc. So, so the approach is, is really very similar. So, so,

Peter Williams  39:53

okay, so what are the primary so before, because before we go on to treatment strategies, um. Which I saw some, some expert who did a SIBO master class for Amrita, I think, last year. So I was, I was reading her notes, and they looked slightly different from a couple of years, but they were actually yours, yeah. So that really nice little master class that you did. So because, again, this is the, I think this is the problem with research, isn't it? It's that it's so fast moving is that I didn't realize that strategies had moved on until I downloaded your master class, because things have shifted, and we can get into that a little bit. But what causes it? So, what are the fundamental causes of SIBO?

Tracey Randall  40:45

Okay, so SIBO is caused by, so for some people, food poisoning. So that's very straightforward. There's an autoimmune link, which is kind of interesting, and it's a rapid onset and there's an autoimmune component, which means that if you have autoimmune type SIBO, you're likely to need to support your gut MMC function, so you need to use prokinetics. Your SIBO is prone to rebounding as well. So

Peter Williams  41:15

so we go back and just expand from that, because I think what's important here, there's going to be a large population who, as I said to you, classic sort of on holiday, had the shits never been the same since may likely the GI tract will never be the same again, because they are creating antibodies against the original poisoning. And you can test for that, can't you? Yeah,

Tracey Randall  41:41

there's actually a test that looks for vinculin antibodies. So basically, there's a, it's very technical term, really, but we call the movement of the small bowel the MMC. So it's a migrating motor complex. And

Peter Williams  41:55

so complex, go on, keep defying it, because, again, it's another key, key point, alright, the migrating

Tracey Randall  42:01

The migrating motor complex is a sweeping wave that normally happens every 90 minutes when the gut is fasted. So, you eat your breakfast at 10 o'clock, your stomach is empty by 12 noon, and then there is this kind of sweeping down motion that is happening in the small bowel, where everything is basically being pushed down to the Iliocecal valve and beyond into the large bowel. And the gut is basically clean, down. Clean. It clean. Yeah, yeah. We're calling, we call it a housekeeper wave, yeah. So that housekeeper wave, the MMC function is created by special cells called the interstitial cells of cajal in the small bowel, and within those within the ICC cells is a little protein called vinculin. And it's that that the immune system confuses with the toxin from the food poisoning bug. And so basically, your own immune system disables MMC function over time. So what that means is is you eat something and your gut doesn't clear down properly. So if you can imagine that, it's a bit like having the kids making their own dinner in the kitchen and not clearing up after them, and then somebody else coming in and making a meal on top. The kitchen gets really, really messy until someone you know finally cracks and clears down. And that's what happens is. And of course, as the gut gets more and more bacterial fragments and food fragments in it, there's more fermentation. The SIBO perpetuates, perpetuates itself. It grows and grows and grows makes the situation worse and so that's what happens. So that's the the food poisoning link, and you can actually test for the antivinculin and anti cddb antibodies as well. Is it called

Peter Williams  43:46

IBS check? Isn't that? What it's called IBS check? That's a test I knew. The other thing about that, I've only ever done this once with one patient. But again, I think again, it was a life changing test because it defined, it defined, I'm not saying it defined it 100% but it defines, most likely why they couldn't get rid of the SIBO. Yeah, absolutely.

Tracey Randall  44:09

It's another test that you do because it validates what you think has been going on. So it's it, this will be very strongly suggested in someone's background and personal history, yeah, but you get it confirmed by the test, does it actually change what you're going to recommend to someone? Not a whole lot. Because the thing with those antibodies are that we don't know how to reduce them, yeah, because antibodies in the body, they diminish over time. But I think we only know that it's time that does that.

Peter Williams  44:36

Yeah. But I think what it does do, though, again, it clarifies the situation. It doesn't change the treatment strategy, but it's an aha moment to say, Jesus, I've been doing this all this time, and, you know, this completely makes sense now.

Tracey Randall  44:51

Or this is me now, and this is, you know, unless I'm careful, SIBO will rebound, yeah, it's also, you could have a discussion then with a GP about. Uh, you know there are, there are medications such as prucalopride, for example, which is a known prokinetic, yeah, with proven efficacy for MMC function that could be requested or trialed for a few months to see if that helps with clearing and keeping SIBO away.

Peter Williams  45:20

And just to confirm what a prokinetic is, it's a drug that allows the sort of the wave, the washing down, to work better, which again, again, can be life changing for certain people, absolutely. Yeah. Okay, so if we could continue with the mechanisms that what else could cause SIBO? 

Tracey Randall  45:43

Okay so anything that SIBO is a disease associated with poor motility, so anything that affects gut motility will potentially enhance your chances of getting SIBO. So that might include, so I touched on this earlier on, maybe a course of NSAIDs. So you've done your knee in and your, you know, your osteopath has said to you, you need to be on NSAID. You take them every four hours. You've got to take them for a month. And what we know about NSAIDs are that they make people bummed up and constipated. They have that effect on, basically stagnating the bowel. Yeah? So I've seen it with that. I've seen it with anesthesia. So someone's some kind of surgery for something and post anesthetic, yeah, that was the problem. I've also seen where someone has had some kind of abdominal surgery for for a unrelating condition, and they wind up with SIBO as a result of that. Then there are people that have maybe had Crohn's disease, where they've had some parts of their bowel removed, or there's been some kind of blind loop surgery. My own mum had some quite radical surgery because she had inflammatory bowel disease years ago, she no longer has an ileocecal valve, so she has a perpetual state of SIBO, where we work to manage the situation with a low FODMAP diet and tactical antibiotics provided by her prescribing GP from time to time. 

Peter Williams  47:17

So because I think this is another important point, isn't it? Can we just talk about the function of the ileocecal valve, and when actually it becomes problematic.

Tracey Randall  47:27

Yeah, so the ileocecal valve is basically a plumbing valve in between the small valve and the large valve. Its job is to stop things backing up or back flowing. For some people, the valve can be faulty. It can be. It can just be that the valve is a different shape or functios slightly oddly, that it's a bit like a swing door that can kind of stick and stay open or stay closed. Or it allows, perhaps it stays open and it allows a reflux of the contents of the large bowel to move back into the small bowel. And the reason why you would do that, why that might happen, would be that the large bowel is teeming full of trillions of bacteria. The small bowel is full of food. So if you're a bacteria, where, where would you want to be? Yeah, yeah, you want to cross through the valve, wouldn't you and be in the small bowel? And we do see a lot of people that have SIBO at the terminal ilium, so the very end of the small bowel. And I And that, I think, is maybe suggestive of an ileocecal valve that's not functioning properly. Yeah. So things can be done about ICV function. You know, you can go and see someone like a chiropractor, an osteopath, they'll show you where your valve is and show you how to massage your abdomen to kind of close it or to feel it. And actually, a lot of people with SIBO, or suspected to have SIBO, they'll often present with a right side of pain, yeah, so they'll say, I've got this funny stabby pain, and they everyone thinks, Oh, it's my liver. It's my kidneys. You know, I've been to see the doctor. Doctor said there's nothing wrong. They might have had an MRI, and everything's kind of clear, but they keep talking about this kind of stabby pain. And I always say to them, oh, is it, you know, if you go, if you can put one finger on the bottom of your rib cage and the other one on the top of your of your hip on your right side. Would you say that it's in the middle of those two points? And they go, yeah, yeah, that's it. You go, Okay, I think that's your valve. That's the ICV. And I think this potentially, and I think what the reason why people feel the stabby pain is that there is a lot of bacterial activity in that area, yeah, for exactly that reason. So that is that for me, is often a real pointer that I look for in someone's picture when I'm considering that they might have SIBO.

Peter Williams  49:48

So we've confirmed SIBO on a test. You don't test everyone, do you, but that you think you'll

Tracey Randall  49:57

be lucky to get through my clinic without being tested for SIBO if I'm honest,

Peter Williams  50:00

right? Okay, fair enough. And then we get to treatment strategy, which, again, was, thank you so much for updating this area, because again, again, I was probably not doing the exact strategy until, until I read your updated stuff. So I'm more updated with that. So can we talk about, what are the strategies?

Tracey Randall  50:24

Yeah, absolutely. So for someone with classic SIBO, so classic SIBO now, so there's been some changes in nomenclature around in the SIBO space. So you and I, back in the day Pete, we used to talk about SIBO methane and SIBO hydrogen. So, and that used to be where SIBO hydrogen was, where you were hydrogen dominant, where you basically your breath test shows more hydrogen anything else, and you might have a tiddly bit of methane, not too much. Your symptoms will be, as you might expect from hydrogen. So hydrogen is high volumes of gasses and a rapid transit time loose motions. That's the picture. So when someone is a classic hydrogen type, they are quite reactive, which is a blessing and a curse. So they're very reactive, meaning that if they don't follow your diet, they'll get punished for it, because they will experience an uptick in symptoms. But equally, if they follow your diet, they will feel very much better very quickly. Can be as fast as within two meals of following a reduced FODMAP diet, a low FODMAP diet, and they will feel like a different person. They'll feel like a million dollars, and you will be a God to them for putting them on down this pathway, from a point of view of how do you address the bacteria? We use antimicrobials. So we use antimicrobials that, antibacterials that are good at basically eradicating the bacteria that overgrow in the upper gut. And if someone is just a classic hydrogen type, they will respond well, if you do a follow up SIBO test, you'll you'll get a very nice negative result, the person will feel quite a lot better. And if that is all that's going wrong with the individual, that will be the last you'll you'll hear of them for sure. Yeah. So the next type of SIBO methane has been renamed. We now call it intestinal methanogen overgrowth, because we came to realize that actually SIBO talks about small intestinal bacterial overgrowth. Methane is not produced by bacteria. It's actually produced by methanogens. And methanogens actually live on the hydrogen made by bacteria in the gut, and they convert the hydrogen into methane, so methane stagnates and slows the bowel down. The person's presentation is a bit different. They're still going to get some bloating, they may get reflux, and they're going to be constipated, for sure. Yeah, lot of people talk about rabbit pellets poos or incomplete evacuation. You know, go to the bathroom three times. I feel like I'm not empty by the time I leave the toilet. Yeah, kind of picture. So constipation doesn't mean only having a bowel movement every every other week. It can mean going every day, but just not fully emptying and having that kind of those dried out little, little, little poops, little pellety poos. So it can be that. So now, with with methane, people tend to be less reactive. So this is a blessing and a curse for different reasons, because it means that if they cheat on their plan, they probably won't feel too much worse. And also that treatment is not so not so dramatic in the fact that they they'll need to work hard on maintaining the dietary approach and taking the supplement regime you're going to recommend for them before they start to feel any better. Often, people will present with or that their test results will show relatively high levels of methane, you know, 30/40, 50 parts per million. And in order for them to feel very much better, they're going to have to get their methane levels, probably sub 10 or even sub five right, to feel very much better. So what that means is, is they need to be on a longer program than people with hydrogen. And you you just keep chipping away. Basically, you just keep on with the with the diet, and I'll talk about the modifications I make to the diet for this. But keep on with the diet. Keep on taking the supplements. And normally what I do to keep people focused is I will re test at intervals so I know fully well if someone's got 100 parts per million of methane on a breath test, they're not going to get a negative result on the first or even the second time that I retest them. But what I'm looking for is progress, because you're because you're in front of me and you're like, I've been on this for two months. It's really boring. I'm really missing out on lots of lovely things. I don't know that I'm any better. I might be a bit less bloated. I. I'm not burping as much, and maybe my bowels are better, but I but it's not gone. And I go, No, okay, but look, here's your follow up test. You've you've done 50% so then that makes you feel better. But

Peter Williams  55:14

this comes down to, I suppose, as I suppose, as I said to you, this is interesting from a conversation of you probably give them here's what's likely to happen, here's the time frame it's going to happen over and it's going to be much longer and much more of a pain in the ass than you ever thought it would ever be. But that is where we're at, and I think again, that is only comes with experience, isn't it, with regards to managing expectations? Yeah, totally, I mean, and I think that's one of the key skills, I think, of being good at anything on this. It's that you have to lay down the law in a really nice way, but you've got to be honest about, here's how this is going to work, and here's the time frame that we've got to work through. And you've got to, you've got to, you've got to knock down the house, build the foundations, and that take, might take months before you see any real change, but then after that, you know you're there. How difficult is that? I mean, I suppose it for me now, it's an easier conversation because we've just been doing it for such a long time. But what are your experiences with patients when you give them that line, or give them that sort of scenario,

Tracey Randall  56:26

if there's someone that has been poorly for a long time has tried lots of stuff already, they will have low expectations of how quickly they're going to recover, and that's helpful, because So then when you say to them, listen, so you've been through this scenario. It's been SIBO methane all along. That's why you haven't seen the improvements, because I don't feel that you have. Well, they've probably not been given the right advice. They've not maintained the program for long enough. They've not they've not been consistent enough with taking their supplements. So these are the reasons why you've not seen the results and to manage your expectations. This is the length of time this is likely to take. So this can take seven or eight months before we're going to reach a point where you're going to be negative, yeah. And and then it's about, it's about stopping boredom. Yeah, so we all have a tendency to eat the same things, day in, day out, and unless we know otherwise, you know, you get stuck in with, Oh, I've got one or two breakfasts I've got, you know, I think the average family eats the same 18 meals or rotation. And I don't think a lot of families, I don't think they've got 18 meals to be on, you know, and people do that, when you put them on the diet, is they go, Oh, okay, so they do all the hard work to start with. They swap over their breakfast. So they've got two new breakfasts. They've got three new lunches and three new dinners. And then, you know, after they've been on a dietary approach for a couple of months, they are really bored, you know, because also their motivation has waned a bit. They've kind of forgotten all the ins and outs of why they came to see you in the first place. Any improvements they've seen. They've just absorbed the improvements without acknowledging Of course, yeah, and that's often why you have to remind them. So you have to say, Well, when I saw you two months ago, you told me that you were experiencing this, and now, now you you know, instead of having a bowel movement every four days, now you're going every day, yeah, that's an improvement, right? And they go, oh, yeah, okay, but you're still bloated, but you're not as bloated as before. You described it before as being a 10 out of 10, and now you're a six out of 10. So there's an improvement. You know, that's why we do those kind of my mind mops, and why we ask people to give us numbers scoring so that can go back to them and say, No, there is improvement. I would encourage you. You know the program is working you you've got to we've got to help you to stay motivated. Let me help you with your diet. Tell me what your problems are. And often it's some kind of event. It's Christmas, it's I'm going away on holiday. I've been invited out. I don't want to be that person in the restaurant that's eating differently from everyone else, how do I manage that situation?

Peter Williams  59:03

How do they manage it? Well,

Tracey Randall  59:05

I had this very, this very same thing happened yesterday with a lovely lady who bought a test kit through my site, and we spoke because she needed some help with her FODMAPs regime. And she said she's going out for lunch today. She said, I'm not going to go. And I said, Why aren't you? And she said, Well,  I'm going out with a group of friends. We had to choose our meals several weeks ago, and it doesn't fit with the FODMAPS. So I said, Well, tell me what you chose. So she said, or, you know, it's carrot and ginger soup. And then I chose the hake, and then there's a vegan pudding, but I don't know what's in it. So I said to her, Okay, so the carrot and ginger soup? Well, carrots fine. Ginger is fine. So I said the problem that there might be with the soup is there might be some onions and garlic in it, but probably not likely to be very much. But I said it's also. Possible. But you know, have you spoken to the restaurant? And she said, No, no, I haven't. I was just not going to go. And I said, Well, in my experience, if you ring the restaurant and you say, Look, I'm terribly sorry, but I'm coming for lunch tomorrow, next week, whenever I've got some problems, I mustn't have onions and garlic, but I can have garlic infused oil, or I can have chives. I said, most enterprising chefs will go not a problem. We haven't got to put those things in your soup. I'll make you a special soup for you. And I said, Your Hake is fine, so. And she said, well, but I don't know what vegetables they are. And I said, Well, you can ask the vegetables, and you can say, could I please have carrots and green beans with my Hake. And, you know, you can have potatoes on the FODMAPs diet. So have some potato as well. And then I said, the vegan pudding. Well, that's not going to have lactose in it, but you probably need to know what's in there. So ask that question as well. But they'll probably do you something else instead, they might do some, you know, some lovely grilled pineapple with some maple syrup or and you can have a a bit of soya ice cream with it, something like that. And that can be your dessert, you know. And so because you might not want the Christmas pudding, or you might not want the vegan option, so it's about giving people these kind of coping strategies. And whilst that sounds very logical to you and I, an awful lot of people are really stumped by these things, because people don't, don't want to make a fuss. Yeah, I don't, oh, I don't want to be different. I don't want to be I don't want to be that person that's awkward.

Peter Williams  1:01:31

So traditionally, we've got treatment strategies that revolve around dietary approaches also revolve around using anti microbials, and that can be a combination of naturals, like stuff like Berberine would be, would be one I would think about, and and some very specific antibiotics, which tend to do a really good job. Rifaximin, is still the main choice, isn't it?

Tracey Randall  1:01:58

Absolutely, I think it's the only antibiotic I would consider. If I agreed,

Peter Williams  1:02:03

I think it's a very localized action. Seems to be pretty, pretty good deal, I would say. So where do this sort of where they suppose the newer stuff comes in, and maybe you can expand on this a bit more, where we're starting to use prebiotics, probiotics and post biotics, which are, again, I pretty much actually let me take a step back, different varieties of probiotics which are, and again, it'd be great if you can expand on all of this, because this was reasonably new To me before I read your course.

Tracey Randall  1:02:40

Yeah, absolutely. So there's now research to substantiate the use of probiotics for the management and treatment of SIBO. Back in the day, Pete, you remember that you and I, you heard me say this actually, that I would never give probiotics when someone was first identified as having SIBO, because SIBO is an overgrowth of bacteria in the upper gut. Why then would you want to add probiotics on top? Because they're friendly flora. SIBO is friendly flora, but just finding itself in the wrong place in the gut, potentially you could make matters worse. Yeah, I think, I think the research has shifted now to say that not all probiotics are created equally, and that there are some very specific single strains that actually have a notable benefit and can be used for the treatment of SIBO. So I actually got invited by Amrita nutrition to talk about this very subject. So I actually did quite a bit of looking into the research. The research is there, but there's not as much of it as you might suppose that there is. But there are some single strains of probiotics, so, so there's one called HN 019, that is in a few products that we use quite often, which is really good from the point of view of helping with gut motility. Our friend saccharomyces boulardii which is a friendly a non-colonizing yeast probiotic is considered to be very benign and helpful from a SIBO standpoint. And then there are some spore-based probiotics. We used to call them soil based, yeah, and they are somewhat helpful for SIBO as well, where I think they help what I haven't seen either in and I've done this with two patients, and I'll explain why not in the two patients that I've done this with, or I have not seen any, any SIBO specialist that has got rid of a pronounced SIBO using probiotics alone, that I'm still waiting to see. So I don't know that we're I don't know whether we're going to see that anytime soon. What I what I have found is that the use of probiotics perhaps as a pre-curser  to antimicrobials, seems to speed up the clearance of SIBO. Interesting that I've done it with, and I've done it a couple of ways where I've done a so I'll often see someone for initial consultation. I get a really strong sense that they've got SIBO. If they're really, really reactive, and they're very, very motivated to get started straight away. I'll put them on the FODMAPs diet, and I'll put them on probiotics, and I'll do the trilogy of the spore based the Saccharomyces boulardii and a lacto bifido blend together, and I get them to do that for the four weeks while we're waiting for SIBO results to come back, and probably the results of a stool test, because I'll often take the advantage of doing a stool test as well, so I can just get a bigger picture of what's happening in the large bowel as well as a small bowel and so. So for a lot of people, they start their journey of resolving their SIBO like that, and then when their results come back and SIBO is confirmed, and there may or may or may not be something significant in the large bowel that we have to address as well. I may maintain them on the probiotics, but just re time the probiotics that they will take them at night time, and we'll take the anti microbials in the daytime, so that they have a chance to kind of take hold and do something useful overnight, or I might give the probiotics a rest, and we might go into an anti-microbial kind of eradication killing phase for a while, and we pop them in again at later on at the end, when SIBO is gone and we're wanting to promote motility, etc. So there's lots of different ways that you can use them. And like I said, there are specific strains that seem to be helpful. Yeah, this area and this kind of triple therapy idea is one that's kind of gaining a bit of momentum at the moment. Yeah,

Peter Williams  1:06:48

I see Ruscio tends to put up quite a lot. He's very keen on the triple probiotic.

Tracey Randall  1:06:56

That is also because he's bought a product out that's got all the three probiotics in it. Not to be cynical but

Peter Williams  1:07:02

yeah, I don't know. Well, hey, listen, I suppose if you know, I think his stuff, he puts out quite good. So

Tracey Randall  1:07:09

he's quite anti-establishment, which is always exciting. When someone challenges the main that's how we learn, isn't it? So when someone says you've been doing it all wrong, we're like, Oh my gosh. But what can I learn from this? Tell me what I'm doing wrong. Tell me what you know. Tell me how to make things better. So

Peter Williams  1:07:26

the other question, listen, I know, I think this is just a super important podcast, because there'll be so many people like that. Holy cow, that's just me. How do I get hold of Tracy or her team? So how long I mean, what's the key here? Is the key that you know, sort of laying out the strategy from the point of view of we probably need to test because we're more accurate, which, again, goes without saying, and the time frame is probably going to be much longer than you ever thought. So again, is it that either the success comes down to a combination of motivated patient, a bit of luck, a bit of getting it right, and then just being as good as you can on a daily basis for quite a long time. Yeah, in a nutshell. So what, what? What? What is the, what is the time frame that you're usually looking at for this? Okay,

Tracey Randall  1:08:19

so I guess I would say what we have to understand about SIBO is, is the reason that we've got SIBO is probably down to our diet and lifestyle, yeah, setting the scene. And then the thing happened, the triggering event that happened for the SIBO to become a thing. Okay? So you can work really hard and get rid of the SIBO, but if you're going to go back to your original diet and lifestyle. Your SIBO is going to rebound within weeks,

Peter Williams  1:08:46

and Tracy, it does, doesn't it? I mean, the patient time

Tracey Randall  1:08:50

and again, absolutely time and again. So people feel really daft the second time around, it's like, it's back. I know it's back. And I go, okay, that's fine. Well, let's test and let's have a look, because it's probably not as bad as it was before, but let's have a look and see, because then we know what we're dealing with, but they but they feel silly because they're like, oh gosh, you know, I kind of went back to doing my normal thing and, you know, drinking too much and eating the wrong things and so

Peter Williams  1:09:16

how many patients then? Because here's something that I've seen time and time, again and again, more related to hydrogen. When you get it right, it's literally game changing in days. And literally after two weeks like that, I'm done, I'm sorted. And you're like, we're not I said honestly, just, I mean, how much of that do you see? Because I see a lot of that. And then they’re back to I've got SIBO again. I'm like, it's because we never even finished the program. We were only just into it.

Tracey Randall  1:09:46

Yeah, I see a lot of, I would say I don't see a lot of people that are pure hydrogen, because I think those types of SIBO are so easy to resolve that they they get resolved by somebody else. So I actually see the tough cases. So I. I see the methane types and I see the hydrogen sulfide types. Often, can we just so I'll come back to that. And then I also the people that have been under treated by mainstream medicine, where they they've gone to a teaching hospital, they've been diagnosed with SIBO, they've been given Rifaximin, and then they've been told to take BSL three and not to retest for a month, and that's the situation. Then they then they retest, and they've either got SIBO or they haven't. And then the hospitals say, well, I can't give any more Rifaxamin. So we see that kind of scenario. And then devastated, you know? And that's when they arrive at your door, and then you've gotta unpick what's gone before explain how the process should have really worked, you know? So that that's the thing with traditionally, the what's happening at the moment is, is that they're they're being diagnosed, okay, they're given an initial round of antibiotics. But I think there's a knowledge gap in the fact that they don't know that Rifaxamin can be repeated and that it's reasonably safe to do so to do that, and they the patients are not really being taught about the FODMAPs diet in any any significant way. So they're very much left to their own devices. So they're making mistakes, so they're not seeing the benefits necessarily. So it's just, it's all not quite good enough, really, in the way that it's working.

Peter Williams  1:11:21

So, and I know you're we're way over time here, but can we just go to hydrogen sulfide? Because, yeah, so

Tracey Randall  1:11:27

it's my, one of my favorite topics. So, so years ago, Pete, you remember me banging on about hydrogen sulfide, like,

Peter Williams  1:11:35

remember we had it, we had a coffee in a local thing, and you were so chuffed about showing me these test results that had a flat line.

Tracey Randall  1:11:43

Yeah. So I basically because I see breath tests a lot, then all of a sudden, I had a succession of 16 SIBO breath tests that came back with a flat line all the way across. And as you know, a healthy person without SIBO, you give them lactulose, you see nothing, nothing, nothing. And then you see, after the ileocecal valve, you see a gradual rise in gasses in response, because that's a normal large bowel flora response to lactulose, which is a yummy sugar that bacteria adore. But when you get a hydrogen sulfide patient, you literally see no gas at all. It's like the gasses have been stolen. All the gasses, all the graph has not been populated, you know. So I got 16 of those in succession. The lab at the time, and I had a bit of a locking of horns over the subject, because I really felt like something was wrong, yeah. So I said, I want you to, you know, I went to the lab, and I said, there's something really odd going on with my patients. I've got all of these kind of quirky results. Is your machine working properly? Has it been calibrated recently? And they were like, how very dare you we’re a lab, we know what we're doing. We suggest that you might want to stop thinking everyone's got SIBO and, you know, look for something else. anyway. So that was exactly what I did, is I looked for something else, and I found in the literature. So straight back in the books, being curious, found the literature that they've starting to talk about a third gas, hydrogen sulfide. And guess what? Hydrogen Sulfide is made from hydrogen by sulfur reducing bacteria. And it was speculated, the article that I read, that some people had a gut that had an overgrowth of sulfur reducing bacteria in it. Fast forward probably 10 years now that's now accepted, yeah, totally accepted, yeah. So now the nomenclature has changed, and now we have ISO, which is intestinal sulfide over production, or H2S SIBO to you and I. So this is absolutely that it's an overgrowth of sulfur reducing bacteria. The sulfur reducing bacteria are taking all of the hydrogen, which is why it doesn't appear on the breath test. Because our breath test at the moment can only show methane, only show methane and hydrogen, they can't show the third gas, which is why it looks so quirky? Yeah, so hydrogen and sulfide, SIBO or ISO, to give it, is new terminology. Is another type of people present, very much like hydrogen dominant. So they have a fast, very reactive response to foods, and also often they are running with things like histamine. So I really think of it as like a kind of, like a hot situation where they've got hydrogen sulfide. They often have histamine reactions as part of the picture. They often are producing noxious, sulfurous flatulence. So eggy farts, to you and I Yeah, and they will tell you about it. They will tell you that they can clear a room if they pass wind in public. So that's a telltale sign. Not everybody does that, but a lot of people do. So that's a kind of a significant finding. The hydrogen sulfide type patient is really interesting. We work with it in a similar fashion using antimicrobials, and with the addition of bismuth, which is able to mop up the hydrogen sulfide. And there's some other quirky bits that I do as well, that I'll support sulfur detox pathways for the individual, and probably also reduce sulfur intake from their diet. Okay, is what I'll do. And then, more recently, and this won't be I haven't spoken about this publicly before, so you won't have heard this. So I'm going to surprise you with this information. So as part of the hydrant sulfide journey, I started to follow the work of Greg Nigh, who is a doctor and a prominent researcher, and he, he's written a book called something like the problems in the garlic or something like that. I'll, I'll get the book reference for you. But anyway, so he, he he speculated, and he was then able to elucidate that. He feels that the sulfur reducing bacteria grow as an adaptation that the that the individual's body is not able to make sulfur compounds, or has an increased need for sulfur compounds and is allowing and encouraging the growth of bacteria that can make hydrogen sulfide in order that the body gets the sulfur that it needs. Okay, so that was the first thing that I read. He then started talking about reducing sulfur from the diet, supporting all the sulfur detox pathways. And I contacted him and said, Do use antimicrobials? And he said, Well, you can, but if you don't change the gut environment so that the sulfur reducing bacteria are discouraged, then the problem will just come back. Yeah, yeah. So we worked with that for a while, and then, more recently than that, I came across an interview that was done with a lady called Dr Janelle. And she her background is that a long time ago, she was working with a dispensing chemist and microbiologist who said that many people with gut dysbiosis need sulfur, and so she started giving people sulfur in the form of MSM, and she has a clinic now that successfully treats all forms of SIBO using MSM and a bit of acacia gum and a bit of digestive support and not too much else interesting. So I just want to tell you that I've just had my I've got two patients that I have put on MSM that have both recovered from their SIBO. One of them was a hydrogen sulfide SIBO. The other one was a mixed type with a reasonable level of methane. And I've got a third lady at the moment that I that is on MSM that is responding well to the treatment. So, so I'm working hard to kind of get my head around why that's working, and what's going on, then what

Peter Williams  1:18:03

do you think is going on? Because is it? Is this going to change all SIBO treatment?

Tracey Randall  1:18:08

I think potentially that that there's a place for it. So my and this is pure speculation, this is my imagination, and probably not too much else, and with some scant facts. So but let me tell you what. Okay, what I think I've seen so, So previously, when I've got other hydrogen sulfide patients, they've had interesting jobs, like two of them have been dentists, right? So what do we know about dentists? We know, don't we that they tend to have high levels of toxins and heavy metals, yeah, because of their occupation, right?

Peter Williams  1:18:40

Yeah, absolutely, yeah. I also

Tracey Randall  1:18:42

think that as as a population, we live in a more toxic environment than ever before, yeah. And what I also know from the numbers of genetic tests that I've done with patients is many, many people have mutations on some of their sulfur pathways. So they have sulfer mutations, they have CBS pathway mutations, which means that they don't handle sulfur compounds well. But that doesn't mean that their body doesn't need the sulfur, and we know and what Greg Nigh was saying was that people that have got these gene mutations, they're the ones that are growing the hydrogen sulfide bacteria, because their body needs the sulfur. So what I'm saying is, is that I'm thinking that toxicity that exists in all of us, to an extent and more in some certain types of people, in certain professions and certain exposures, they might be more likely to grow hydrogen sulfide bacteria, and they're the people that benefit from the sulfur. So it's not about not then, not having sulfur. It's about they need sulfer

Speaker 1  1:19:42

Yeah, that's really interesting. Yeah. So my, my

Tracey Randall  1:19:48

hydrogen sulfide patient that had the flat line SIBO, she was presenting with lots and lots of loose motions, like always in the toilet, you know. And she used to, you know, she used to send me updates from the smallest room in the house, is how she used to head up her emails. And she had a lot of kind of explosive diarrhea most mornings and and she she was histamine, and I think she's mast cell. I told her about this strategy, and she said, I have got nothing to lose. Shot. So she is now. She's been tapering up on the MSM. She's now up to more than 20 grams of sulfur a day, right? And her bowels are fine, fine. They've stopped doing what they're doing. She's got some other health problems going on. She's succumbed to COVID three times in fairly quick succession, and she's mast cell. But whereas previously, I've known her for five or six years and have dealt with her, she had Candida, she had various other bits and bobs, I've known her previously to have a really sensitive constitution when it took nothing at all to knock her gut off of kilter and to put her back into this scenario where she's back having lots of diarrhea. That isn't happening anymore. She's stabilized. So that's her, the second patient. I just had a negative SIBO result done with her. She was a mixed type, some hydrogen, some methane. She'd been on the program for a while. She was doing really, really well. Then she went home for a funeral in Ghana. She ate something dodgy, got food poisoning. We retested her. When she came back, her SIBO had gone through the roof again, and she got really fed up and despondent. She was like, this program is not working. I said it's working. It's working perfectly well. You've got food poisoning, and so now we've got to start again. And she's like, Oh, I just don't know that I've got the heart to go back, you know? So a lot of people go, Oh, but I've worked so hard.

Peter Williams  1:21:42

Yeah. Well, they do, yeah, yeah, absolutely. So

Tracey Randall  1:21:45

I said to her, Look, I'm going to give you some options. So I gave her, she went, I don't want to carry on using the same answer. If I've got to go back to antimicrobials, don't use the same thing. Okay, fine. So I gave you an alternative antimicrobial program, and I also told her about this sulfur initiative as well. And said, maybe you want to try this. And I gave her a link to the podcast. I gave her a link to the book, I'm his. I'm thinking, I think the books down here actually. And I wrote a little paragraph explaining how it's purported to work. And she went away, and after a few days, she came back, and she went, I'm going to do this offer. So what do I buy? So I I'd found some MSM on on a very good online retailer, which I pointed her to, and we started her tapering program. And then I didn't hear from her, and then I got a note last week, and the email was headed up, guess who's SIBO negative? And she had done a follow up SIBO test by the NHS, and it was absolutely negative, completely clear as well.

Peter Williams  1:22:53

Well, that's really interesting. That's really interesting that it might just be, I mean, it's never a combination of one thing, but this might be a real key player in the changing that environment. So would you just, but I know we're way over time here, but do you run stool tests to confirm whether they've got an elevation of sulfur producing okay?

Tracey Randall  1:23:15

Yeah, yeah. So I'm on the lookout for bugs that I know in the right set of circumstances will will make hyrdogen sulfide, yeah, interesting. And there were some tests, some stool tests, that are quite helpful in that regard. Health path, for example, has a they organize their bacteria by gasses,

Peter Williams  1:23:37

right? Okay, that's interesting, yeah. And then the

Tracey Randall  1:23:40

Genova test also will identify Desulviovibrio Vulagris, yeah, but there are, there's actually an awful lot of bacteria that can make sulfur compounds under the right set of circumstances.

Peter Williams  1:23:54

So when you see that your job is not to not to treat those, but to add in more that would be your sort of theory. Okay, that's really interesting.

Tracey Randall  1:24:04

Really interesting. It's really my thing for 2025 is that I really want to go down that pathway. I want to start working with clients that maybe have used antimicrobials and are fed up with them and feel like they have nothing to lose. And we'll give this a go. Well,

Peter Williams  1:24:19

nothing to lose, but so much easier. Yeah, it is. It is because

Tracey Randall  1:24:23

all you do is taper up the sulfur every day. You just take a little bit more, and then you top out at about 30 grams, right? 30 grams of sulfur a day, and you maintain it for eight weeks, yeah. 

Peter Williams  1:24:35

And then that is without any change in the diet. Or would you put them on a low FODMAP?

Tracey Randall  1:24:39

not a low FODMAP diet and not even a low sulfur diet, right? Interesting. So Dr Janelle just talks about, I think, being gluten and dairy free. So obviously dairy is a source of cysteine, which is sulfur. And she just calls it, kind of, she call it sort of like a low allergy diet, but it's really compared to some of the. That we do with people. It's really very straightforward. Well,

Peter Williams  1:25:02

let's face it, low FODMAP, but you know, after that six to eight week time frame becomes potentially problematic from a point of view, the bigger picture, can I, can I ask you to summarize? Let's assume that people are going to listen to this. It's probably going to, you know, it's probably going to go. Well again, what I mean summarize is that when should, when should people think about whether that what would be the key symptoms that you would suggest that people should think about whether they've got SIBO, okay, so let's summarize it.

Tracey Randall  1:25:40

Though, I think, I think it's important to remember that even a healthy gut in someone without irritable bowel syndrome from time to time, can get upset and can be a bit bloaty, and you can be a bit windy for a couple of days. We're coming up to Christmas, and So Christmas is all about brussels sprouts and overeating. And so it would not be unusual for people to feel a bit of digestive distress for a few days following the Christmas period. Oh yeah. But if that hasn't settled by the middle of January, and then it's made you think, hang on a minute. This has been going on for a while. It's just been worse after Christmas. But really, if I think about it, I was bad after that christening in September. I was bad at such and such as party. This has been going on for a while. Then act upon it. You know, you you absolutely can be helped. It's not a walk in the park addressing SIBO, but it's so incredibly important to address it, because SIBO will not resolve itself, left to its own devices. Well, it's been found, and it's been proposed that it's playing a key role in lot of other health conditions which are so much more so much more significant. So things like fibromyalgia, chronic fatigue syndrome, it, you know, predisposes you to COVID susceptibility. It's auto immune. You know, for some it promotes auto immunity for some people. So it's not something that you want to ignore, or you should ignore, but know that it's well within you know, you control what you put on your fork, and ultimately, you can control your health and you can help yourself feel better, but what it isn't, it's not a short fix, and then you can go and eat whatever you want with gay abandon, because for all the reasons that you and I have talked about, the problem will just come back. Yeah. So it's about making meaningful change and realizing that now is the time to be responsible, that your body is telling you that something is adrift and it needs to be addressed, and that now maybe it's time to start looking after yourself.

Peter Williams  1:27:46

All right, awesome. Thank you so much. I think, you know, again, I think this is going to be a key podcast for so many people who it's suddenly going to, you know, the the light bulbs are going to go on, I think on this one, because, I mean, I don't know who probably I mean, as I said to you, you know, nearly two thirds of the population with IBS are going to be SIBO. Have SIBO, so it's going to be a very significant proportion. Tracy, thank you so much for for number one coming on. I know I haven't seen you for a while, so it's good to see you again, but you're just sharing all, just freely sharing all that expertise that you have, we will put, I'll speak to you about it, but you can tell us what we want to put. We'll obviously put your Yep, your place on the case notes, and just really appreciate your time. So thanks so much.

Tracey Randall  1:28:35

My pleasure. Really l