Do you think the high rate of SIBO recurrence could be due to the fact that because the lactulose breath test runs the risk of false positives and therefore overtreatment, the clinician starts looking for the real underlying root cause, i.e., focuses on SIBO, might miss something else, for example?

Yes. I’m nearly 100 percent certain that’s the case. I think I have increasingly come to see SIBO in many cases as a symptom of a deeper underlying problem and that problem could be heavy metal toxicity, it could be mold- or biotoxin-related illness. It could be some other kind of chronic gut infection that’s been missed, or I think in many cases it could be HPA axis and nervous system dysfunction. We always should remember that the gut is essentially a big bundle of nerves. It’s been referred to as the second brain by some neuroscientists and it’s really now considered to be an extension of the nervous system or even a distinct nervous system in its own right—the enteric nervous system.

When we’re considering gut problems, we always need to think about it from that perspective because if the patient is dealing with a lot of stress, they’re burning the candle at both ends, not getting enough sleep or just dealing with a lot of perceived stress, emotional and psychological stress, that’s going to have a big impact on their gut motility, their gut bacteria and flora, their microbiome, and many other aspects of GI function. But even if the patient is not currently under stress, we know that certain experiences, behaviors, traumas, whether chemical or microbial, emotional, psychological, or physical, like an accident, can imprint powerfully on the nervous system in the concept of neuroplasticity that holds the neurons that fire together and wire together. These really intense traumatic experiences are some kind of ongoing trauma, like an infection can imprint in the nervous system. Even when that trigger is removed, the nervous system still has that pattern. It could be a situation where someone had a gut infection several years ago that created a pattern of dysfunction that includes reduced migrating motor complex function, gas, bloating, diarrhea, or loose stool, or whatever, and then that infection got treated, but the patient still has that pattern in place. Even if you treat the SIBO over and over again, it will just come back because that reduced migrating motor complex function is still there and it’s kind of patterned into the nervous system, and if you don’t deal with that nervous system pattern then it’s not going to be a very successful treatment. Yes, I reject the idea that SIBO just has to become a lifelong, relapsing, remitting condition. I reject the idea that we should just be prescribing antibiotics or herbs to people two or three times a year every year for the rest of their life. I don’t think that makes sense. It’s not really a functional perspective because we’re not really looking for the root cause there. I think we still have a lot to learn and a lot of experimentation to do on the SIBO front.