For patients who don’t have stool lab results or cannot do them, how do you suggest we approach [getting] them back to basics with diet?

It depends on the situation. There was a case mentioned earlier where somebody had intolerance to garlic and onions. If somebody has, like, very significant intolerance to FODMAPs, you could potentially presume SIBO and do an empirical protocol with botanicals as well as a dietary intervention and see how they respond. It’s definitely not optimal, but sometimes it’s necessary, and I think if you’re using botanicals, it’s a reasonable approach. I’d be less inclined to suggest that with pharmaceuticals like rifaximin, although there are many studies that have shown that rifaximin, when used empirically in patients with IBS, can produce positive results, and that’s actually true, interestingly enough, even when those patients were tested for SIBO and were negative, rifaximin still had some beneficial effects in the treatment of IBS, and that’s probably because those patients had some other kind of pathogenic or

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infectious influence present. It wasn’t SIBO that the rifaximin was able to help with. We’re always making judgment calls, and we’re always kind of dealing with the difference between the ideal and the actual, and we just have to do the best we can given the resources that the patient has and what’s possible in our practice.