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A New IBS SolutionMark Pimentel, MD, Health Point Press, January 2006 ISBN 0977435601Rating:
- This book merits your attention. It could likely explain the cause for your symptomsDr. Mark Pimentel is the Director of the Gastrointestinal Motility Program at Cedars-Sinai Medical Center in Los Angeles, California. The purpose for writing this book was to declare a unifying hypothesis for the cause of IBS. Numerous research studies peformed by Dr. Pimentel, and duplicated by many centers world-wide, point to an overgrowth of bacteria as being the missing link which explains the symptoms felt by 10-20% of the population. He does an admirable job at explaining the background for this new theory, along with treatment options. After reading this book you are more than likely going to want to discuss its findings with your own physician.
 

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The doctor is in Physician offers step-by-step irritable-bowel cure U-Entertainment Welcome to BookTalk, a Daily News feature that includes interviews with authors and offers the option to listen to them simply by calling (818) 788-9722 or (310) 273-1134, and entering a four-digit code. There is no charge to call.This week, we spoke with Dr. Mark Pimentel (2494), director of the Gastrointestinal Motility Program at Cedars-Sinai Medical Center, about his new book, "A New IBS Solution: Bacteria - The Missing Link in Treating Irritable Bowel Syndrome'' (Health Point Press; $19.95).IBS is the most common chronic medical condition in the United States, affecting over 60 million people of all ages and is characterized by abdominal pain, bloating and altered bowel habits. This condition is the second leading cause of missed work days in this country and is more widespread than asthma, depression and diabetes combined.Dr. Pimentel's book offers a revolutionary new treatment protocol for IBS based on years of research findings and clinical trials with thousands of patients. More than 80 percent of his patients who have completed this protocol have been successfully treated and no longer exhibit all of the symptoms associated with IBS.Q: What inspired you to write "A New IBS Solution''?A: The inspiration was provided by my IBS patients. There is an unfortunate stigma attached to the diagnosis of IBS suggesting that symptoms are psychosomatic, or "all in your head.'' For almost two decades, patients have been told that they need to see a psychiatrist instead of a gastroenterologist. Some IBS patients have been given antidepressant medications, which, in fact, do not address the root causes of this condition.Recent studies now prove that, in most cases, IBS is not related to any psychological problem, not even stress. Even with this scientific data, however, it has proven to be very difficult to remove the long-standing stigma that has been associated with IBS. We now have a much better idea of what causes IBS. In this book, I take the reader through the history of IBS and how the new theories of IBS have changed the way we look at this condition.Q: How do doctors diagnose and treat IBS, and how many people in the U.S. are currently affected by this condition?A: IBS is the most common chronic medical condition in the United States. It affects approximately 15 percent to 20 percent of the population; however, the percentage of patients who actually seek medical care is much smaller. It was very common 10 years ago for an IBS patient to be told that there was no known cure for the condition, and they were simply just going to have to "learn to live with it.'' These days, the diagnosis of IBS is more advanced and is being made based on a set of common symptoms, including bloating, diarrhea and/or constipation and abdominal pain. The difficulty with using these symptoms as a diagnostic tool is that there are many other digestive disorders that commonly have the same symptoms. Some degree of testing is required to rule out other conditions. Once this basic testing has been completed and no other causes can be found for the symptoms, the default diagnosis is IBS.Q: You propose that an overgrowth of bacteria in the small intestine might be responsible for the majority of patients with irritable bowel syndrome. How do you diagnose this overgrowth and how do you treat it?A: The easiest way to diagnose the overgrowth of bacteria in the gut is by using a breath test. The specific test I use is called a "lactulose breath test,'' which measures the levels of gases produced by the bacteria in the intestines. Up to 84 percent of patients with IBS will have abnormal test results. Once a patient is diagnosed with bacterial overgrowth, they can effectively be treated using a nonabsorbed antibiotic called rifaximin, in addition to following the detailed eating program described in my book.Q: You mentioned some of your patients have had a "heralding event'' that triggered the start of their IBS. What do you mean by "heralding event''?A: This is a complicated issue that is discussed in greater detail in the book. However, in essence, often IBS patients describe that they had perfectly normal bowel habits until, for example, "the case of food poisoning they had 10 years ago.'' This would be known as the "heralding event'' for their IBS. The book describes how the association between IBS and the patient's "heralding event'' was discovered and how it could lead to bacterial overgrowth, which causes chronic IBS symptoms.Q: Do you believe that stress plays a major role in contributing to IBS symptoms?A: I do not believe that IBS symptoms are caused by stress. However, I do believe that stress can exacerbate the situation, making symptoms worse. There is data to suggest that stress may even increase bacterial levels in the gut. IBS patients often tell me that they feel worse when stressed but are still symptomatic when not stressed.Q: Is there any message you would like readers get from your book?A: Initially, it was not my intention to write a book about IBS. In truth, I am more interested in the scientific aspects - the research and treatment of this condition. However, I believe that patients would be better served by reading about the history of IBS, learning about my new protocol and renewing their hope of recovery from this disabling condition.The ways in which IBS affects the quality of life for those who suffer from its symptoms is best summarized by the following examples: The 20-year-old college student who is skipping classes due to frequent visits to the bathroom; the business traveler who won't eat before or during any of his flights since he experiences discomfort and profound bloating; the musician who is worried she may not make it through her concert performance due to bouts of diarrhea.Lastly, this book is written for the 15 percent of people driving the Los Angeles freeways every day who just may not make it all the way home and are forced to take a rapid detour or suffer the consequences. There really is hope - and you, too, can regain your life.---BookTalk is produced by David Knight. Questions may be sent to him at BookTalk, P.O. Box 57785, Sherman Oaks, CA 91413, or via e-mail at booktalk###sbcglobal.net. Amy Mathews also contributed to this story.
 

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I just received this book and read it in a single weekend. Needless to say, I have yet to put his recommendations to the test, but he makes a very convincing case for what he believes is the source of our troubles. I'm especially impressed with how he unifies several theories about IBS into one explanation. It seemed unlikely to me that anyone could do that--especially in a mere 156 pages. As I discussed the contents of this book with my spouse, we'd find ourselves frequently saying "That might explain why..." I intend to find a doctor to help me through these recommendations ASAP and I will certainly report back to the group when I've managed to do that.
 

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Good Morning!I will be ordering Dr. Pimentel's book to give it a read. I am interested in his findings and recommendations. These findings resonate with my own research into GERD. In my book, Heartburn Cured, I provide convincing evidence that bacterial overgrowth of the small intestine is the root cause of GERD - and I do believe IBS and most other intestinal maladies. I have a question about Dr. Pimentel's approach that perhaps someone can answer. Is the original breath test done with glucose of lactulose? I have heard both, but want to clarify. If it is glucose, that makes sense, because glucose is readily absorbed in the jejunum and hence would only be metabolized by bacteria if they had overgrown to occupy this region of the small intestine. Lactulose, on the other had would give a positive breath test with even healthy people because it is not absorbed. I would presume glucose is being used. A second point I want to make is that my approach does not use antibiotics as I consider that approach a second choice by far. My strategy employs the glycemic index to control this overgrowth. Monomeric sugars like glucose / dextrose are absorbed very efficiently and will be less likely to feed the gut microbes. Fiber is more friendly for GERD (perhaps less so for IBS) as well, because even though broken down by gut microbes more than previously thought, it happens mostly in the lower intestines. The starch is the real culprit and perpetuates the overgrowth the most.This way of controlling SIBO is the healthiest and most sustainable in my opinion. If you receive antibiotic treatment for a fixed duration, forgetting about the risk of superinfection with resistant and potentially pathogenic microbes, what is to stop the re-emergence of SIBO once the treatment is stopped? If your diet still contains too many starchy carbs, the condition will likely return. I would appreciate the thoughts of others that have first hand knowledge of this approach or who have tried it.Thanks,Norm Robillard Ph.D.HeartburnCured.com
 

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I can answer your breath test question by paraphasing the book:The three common ways of performing breath tests as a way of diagnosing bacterial overgrowth are Xylose, glucose, and lactulose.The test principally used at Cedars-Sinai is the lactulose breath test since lactulose, a synthetic sugar similar to what you would find in sugar-free gum is not absorbed by the body and is therefore calorie-free.Lactulose is able to travel all the way through the small intestine which is 15 feet long while glucose is completely absorbed within the first one or two feet of the GI tract. Xylose is less absorbable than glucose but is unreliable in detecting bacteria since it has varing absorption rates.Since the body doesn't "eat" the lactulose, the bacteria has a chance to digest it and, as a result, produces different gases as a by-product like hydrogen and methane. In the case of glucose, if the body absorbs it before it reaches the bacteria, then the bacteria never has a chance to "eat" it and, therefore, gases can never be emitted and detected in the breath leading to an unreliable breath test. The LHBT will not come back positive if the patient does not have bacteria in the small intestine to "eat" up the lactulose. Keep in mind that, over a three-hour period, breath samples are collected every 15 minutes so if the breath test comes back positive within 2 hours then that indicates that the bacteria is residing in the small intestine. It's normal for a positive breath reading after 2 hours since by then the lactulose syrup will have reached the large intestine where everybody has bacteria. I think you were hung up on the misconception that only one reading was taken for the breathtest but actually it's every 15 minutes for 3 hours. Yes, the last reading would be positive for everyone.Hope this helps.Right now, Dr. Pimental recommends either antibiotics or semi-fasting with Vivonex for 2 weeks. On a side note, my GERD was cured by just quitting coffee. No more purple pill for me!
 

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My doctor's visit to discuss the Pimental book was a little disappointing in that he had not read the book. I was a little suprised since his office uses the Quintron SC. He did agree to schedule a breath test, but seemed doubtful that it could be treated even if we got a positive result. I too am curious about the sugars used. In my case I'm having the lactulose test, but why wouldn't they use fructose since that's what I have the most trouble with?
 

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I think the reason for the use of lactolose is that since it isn't absorbed by anybody you get to see what the bacteria are doing without any variation from the human.Fructose would mostly be used to diagnose if you have fructose intolerance (don't absorb it properly) so that would vary from person to person how the numbers went. You don't have to calibrate it for SIBO based on whether someone is intolerant or not, if that makes any sense?K.
 

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Actually K, it does make sense to me, but it still leaves me with some questions. Let's say (for example) that I am fructose "intolerant." Does that necessarily mean that I just don't absorb it or could it also mean that a particular set of the 400 bacteria in my gut have overgrown and thrive on it? If it does mean that I just don't absorb it as well as I should, then why not? I only know that fructose is absorbed best with glucose, but other than that I'm not sure what the mechanism for absorbtion is. I don't think there's an enzyme in the gut for it.Thanks again,Steve
 

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Good morning,Your comments are well put. Any carbs that are not absorbed due to intollerance, overconsumption (what Heartburn Cured is all about)or any malidy that affects both carb breakdown or absorption for that matter will feed gut microbes and potentially (because of gut immunity, and other mechanisms that try to keep the bacteria from overgrowing)cause overgrowth. PPIs can contribute as well by limiting stomach acid production.But I would think that using glucose (doesn't need any breakdown and is absorbed efficiently) would be the best test for true overgrowth. Lactulose, since it is not broken down or absorbed by humans, should always give rise to a positive breath test unless hydrogen is not absorbed into the blood stream further along in the intestine where bacteria normal reside in healthy people.I need to get this book to see what Dr. Pimental says, but in the mean time, any thoughts on this are appreciated.Thanks,Norm RobillardAuthor of Heartburn Cured
 

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Lactulose is only considered positive if it gives two peaks--the first when SI bacteria encounter the carb, and the second when colonic bacteria encounter it.Glucose would only provide one peak in both healthy and SIBO individuals. Because glucose is absorbed through the first 1/3 of the SI, by the time the chyme reaches the colon, all the glucose will either be absorbed or fermented by SI bacteria, leaving none to be fermeted by colonic bacteria in either healthy or SIBO individuals. Furthermore, with individuals with bacterial overgrowth, a single peak in their breath test may also be indicative of glucose malabsorption symdrome, causing the glucose to be transferred to the colon unabsorbed, and leading to colonic bacterial fermentation. It is impossible to distinguish between the two.Therefore, glucose cannot conclusively prove bacterial overgrowth in the small bowel. Normal individuals would show no peaks, but those who do have higher hydrogen content may have other conditions.Lactulose, however, is not absorbed and will always show at least 1 peak (in normal individuals who transfer the carb to the colon unabsorbed where bacteria ferment it and produce hydrogen) but a maximum of two peaks (in SIBO, where SI bacteria begin to ferment it first in the small bowel, and also later with colonic bacteria).With lactulose, since the small intestine does not normally absorb the sugar, there is no risk of other conditions being implicated along with SIBO.
 

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Steve, it is that you don't absorb it and thus it feeds the bacteria. Fructose is not the easiest sugar for anyone, but some people absorb it worse than others. Even normal people absorb it best when it is in the proper ratio with glucose. Some people do not absorb it well even then. It is an active transport across the gut wall into your blood. If your transport molecules aren't working quite right you won't absorb it properly.You just do not have the mechanics. And you get serious gas from it no matter where it finds the bacteria. Even when there is totally normal small intestinal numbers excess fructose hitting the normal level of bacteria in the colon will make you very uncomfortable.K.
 

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Thanks again for your help.Ok, so if I take the lactulose hydrogen (and methane) test and it comes back negative, but I KNOW I have a serious problem with fructose, does that mean I'm essentially stuck? I mean other than avoiding fructose which I do to the best of my ability, is that all that can be done? For right now? I've often considered taking L. Reuteri since there are claims that it helps develop epithelial cells which I thought might help me absorb the fructose. All of the supplements I see contain corn in some form.Best wishes,Steve
 

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Well the probiotics may help as well as they generally do not produce gas from the carbs you eat.I do not have any specific carb issues beyond standard issue human and probiotics dropped me from like 30+ farts a day to virually none. The fart frequency was before, during and after IBS so for me it was an independant issue. IBS just made them harder to hold in.I don't know if the methane vs hydrogen would have any effect on which antibiotics to use, but they are from differnet classes of bacteria. I think most of the antibiotics used tend to be on the broad-spectrum end of things so it might not matter. I think it is more of when you get peaks not which gasses you have.K.
 

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Steve One thing in Pimentels book of interest is that he says probiotics may aggravate the problem of SIBO since youre just adding more bacteria to the gut which may migrate to the small intestine.Type of bacteria may not matter, they still cause a problem.My daughter has always had a problem with probiotics they always made her feel worse.Hoping this is a clue..She was told she was fructose intolerant.Had lactulose breath test one day.High hydrogen but only 1 peak.It was done as a baseline.Then the fructose next day which was positive.Cutting out fructose has not "cured"her.Pimentel says fructose breath test will be positive if there is bacterial overgrowth,so now going down that path.Hope this helps you Gilly
 

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FYI"Harris and colleagues[41] presented a retrospective chart review assessing the presence of GI symptoms, in particular those associated with IBS, in patients referred for glucose hydrogen breath tests for SIBO. They predicted that lactulose breath testing overpredicted the actual prevalence of SIBO in IBS. Glucose hydrogen breath testing has a sensitivity of 75% for SIBO[42] compared with the sensitivity of 39% with lactulose breath testing for the "double-peak" phenomenon characteristic of SIBO.[43]"http://ibsgroup.org/eve/forums/a/tpc/f/71210261/m/187100912
 

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Gilly,What you’re saying makes sense to me. I see no reason why the bacteria supplied in probiotics would not have the same effect. These organisms also prefer carbohydrates for fuel and would tend to contribute to the problem. Limiting the carbs is the approach I prefer for limiting / controlling bacterial overgrowth in the small intestine.Eric,Great comments. This rational is more consistent with my own theory on acid reflux. I will check out the refs.Norm RobillardAuthor of Heartburn Cured
 

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Dr Norm Yes low carbs and certain sugars does seem the way to go,but unfortunately it is difficult,boring, antisocial etc etc My daughter has modified her diet a lot and it has helped quite a bit.Luckily heartburn is one thing she hasnt got.Touch wood!Eric Do you mean that glucose is a more accurate test?Gilly
 

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Hey Eric--or anyone else: do you know of any place that gives the glucose test for SIBO, especially anyone on the web? Given the false positives from lactulose, I am interested...They don't do the SIBO breath test at all at our stodgy local teaching hospital, and my only alternative was Great Smokies, which is the lactulose. Rather not take all those antibiotics if I don't have it [that was what got me here in the first place! Grr. ]
 

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I have made some comments about Pimentel's book elsewhere on the forum but perhaps this is where I should have made them.First, it appears that the probability of success is higher with the Vivonex Plus Elemental diet for 2 or 3 weeks, according to Pimentel's data, than with antibiotics. What is unclear is whether the Vivonex needs to be followed up with Zelnorm or Erythromycin (50 mg/day at bedtime) to regularize the "cleansing wave" motility of the small intestine. Yet his protocol emphasizes Xifaxan and Neomycin and de-emphasizes the Elemental Diet. Given the data, the misery that IBS causes for so many, and the easy availability of Vivonex, I wonder why Vivonex would not be given primary place in the protocol and Xifaxan/Neomycin given less emphasis.Second, I wonder why there are significant discrepancies between Pimentel's dietary recommendations and those of Elaine Gottschall of the Specific Carbohydrate Diet fame. One example, Pimentel tells us to avoid cheese, because of its lactose content. Gottschall tells us that almost all cheeses have no lactose. Gottschall has a theory to distinguish good from bad carbs: whether or not they are monosaccharides. Pimentel tells us to avoid "high residue" carbs. What constitutes "high residue" appears to be empirically determined. This doesn't make Gottschall right and Pimentel wrong. I just wonder whether each substance that Pimentel has labeled "high residue" was actually determined empirically to be problematic for IBSers.
 

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I have read the book and this is the very first thing I have read that matches what I have been trying to tell my doctor for over a year!I am very skeptical of any new findings but this is the only thing that matches every problem/symptom I have to a Tee.Im trying to find one of the breath machines but the company will not realease any info to me as to who has one.Does anyone know if anyone in the dallas fort worth area of Texas has one of these machines?
 
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