Amy Nett: The next question from Ariel is, “Under what circumstances in the stomach, large intestine, and/or small intestine, each of the three separate sections, [is] structural functionality rather than dysbiosis the root cause of the pathologies?” And then she goes on to say, “For example, under what circumstances should we consider potential root causes such as inherently weak peristaltic action, structural deformities of the microvilli, [or] lower supply by the body of fiber or other substrate for the microbes to colonize upon within the intestinal mucosa?”
I think what you’re saying [is what] circumstances should we consider the potential root cause such as weak peristalsis or structural deformities. Okay, so you’re saying structural issues rather than microbial imbalances. And so, I would say that it’s difficult to separate those because if you have impaired peristalsis, you’re probably going to have SIBO. And then you’re saying structural deformities of the microvilli, so again, that’s probably going to be, like, a food sensitivity. To some extent, I think when you’re seeing microvillus disruption, you’re probably really thinking about a food sensitivity there. And then you wrote, lower supply by the body of fiber, other substrates for the microbes to colonize, so again, that I would sort of see as “Is there a dietary insufficiency and you’re having [an] inadequate amount of fiber prebiotics that’s getting to the colon?” I think it’s pretty difficult looking at some of the examples you have here to differentiate between structural and functional because I think some of these things, like you mentioned, peristalsis, that’s going to influence the dysbiosis, and certainly we talk about in the setting of the impaired migrating motor complex, often, that starts from food-borne illnesses, certain bacteria that can cause the impaired peristaltic activity.
I would say, when do you start thinking about some of these as more of the root causes? I would say when I’ve been working with someone on treating their dysbiosis, so we’ve done six months of treating small intestinal bacterial overgrowth or dysbiosis that we might see on the stool test and we’re not making a lot of progress, like, we keep seeing the SIBO. That’s when I might start thinking a little bit more about, like, “Oh, okay, is there impaired peristalsis that we need to think about a little bit more?” But even there, what do you want to do for that? Do you want to do a gastric emptying study, which is going to require some radiation exposure? Radionuclide administration. So, even there, I would probably still think about, well, what’s the timing of eating? What are the motility agents that we can use? I’m almost thinking about those, I guess, even initially. If somebody has SIBO, I guess you also want to think about some of those, I guess we’re calling that structural, but I would probably say the peristalsis is still a functional issue, as well.
I mean, I think you’re kind of thinking about them even from the beginning, and then if you have difficulty treating, that’s when you want to get more into do I need to do further testing to look at this functionally in terms of looking at structural deformities of the microvilli. Honestly, I’m not sure if I’ve ever recommended [that] a patient have an upper endoscopy with ]a] small intestinal biopsy just because it’s an invasive procedure. Of course, it’s never benign to put a scope through someone’s intestine, and even though overall it’s fairly safe, you really have to think about, well, there’s a minute minuscule risk of perforation, but it’s not a non-zero probability, and so again, what are we going to do differently? And I would say, knowing that a lot of the impairment to the microvilli is due to dietary factors, sensitivities, etc., and probably going to do that elimination diet anyway. I’m not certain that a small intestinal biopsy is going to change a lot.
I’m just going back to the question to see. I hope that this sort of answers the question, I think just having to think through it as I read it, the ideas that I’m thinking about functional and structural at the same time, but my first approach is going to be a stronger focus on the dysbiosis using antimicrobials, probiotics, [and] prebiotics where appropriate in trying to get the microbiome in a better place with more balance. But if I’m really struggling in terms of getting that patient where I want to see that person, then I might think about going into more of the conventional medicine testing, and again, the one that I have used has been a gastroparesis study, so a gastric emptying study to understand if we need to be a lot more aggressive and think about using prescription medications for motility. I hope that answers [your question.] If not, just send a follow-up and I can clarify.