Prokinetics for SIBO (Interview with Dr. Keller)

Video Transcript

Josh (00:12)

So hey guys this is Josh from SIBO survivor and i’m super excited to be joined by Dr. Melanie Keller today, an awesome SIBO expert and Naturopathic Physician. We’re gonna kind of dive into what is the migrating motor complex and why GI motility has such an impact on SIBO and IBS patients. I think this is one of the topics that a lot of people maybe miss in treatment or just something people don’t understand. So I’m excited to dive into this. Before we get started, just a little quick bio on Dr. Keller. So basically Dr. Keller is a SIBO and IBS treatment expert. She’s had you know rare postgraduate training in SIBO and continues to work with renowned professionals like Dr. Mark Pimentel, Dr. Allison Siebecker and Dr. Steven Sandberg-Lewis and now she has her main practice sibosolution.com so if anyone’s interested in getting help you can always go to her website and reach out there and find her there for more information but I’m so excited to have you and thanks for joining me, Dr. Keller.

Dr. Keller (1:26)

Oh, it’s my pleasure. Thank you for having me.

Migrating Motor Complex Explained

Josh (1:30)

Cool, so just kind of diving into this topic, so I bet a lot of people have heard about the migrating motor complex, that term is thrown around a lot in the community and I just wanted to kind of talk about it and help people understand you know what it is a little bit better. So I guess the first thing is what is it you know what is the migrating motor complex and then we’ll kind of get into more detail.

Dr. Keller (1:57)

Well so the migrating motor complex we’re talking about a certain section of the tube, right? So the tube is starting in our mouth and it’s going to end up at the bottom, right? So there’s a certain section from the stomach through the small intestine where we’re really talking about this migrating motor complex. There’s three phases of it, so I kind of use the example of your mouth and your chewing and your ability to swallow is kind of like you driving out from your home and then the stomach and the small intestine is maybe a lot of people because I’m talking to people in California who understand the 10, the 405 is like getting into traffic, right? And so that’s what we’re basically seeing is that there are certain things that can slow down that action and so one example is someone who is eating all the time or frequently and this was a pretty common thing to be told to do to you know stabilize your blood sugar. For example, eat four to six small meals. Well, that’s one of these things where it kind of just keeps putting cars into traffic. There’s a little traffic lights, right, so it’s like the frequency of you eating or quite frankly even chewing gum can stop this migrating motor complex action that we’re talking about because it’s most active during periods of fasting or most active is when we’re asleep so we’re fasting and we’re sleeping and that’s when the migrating motor complex is moving everything down from the stomach / small intestine into the large intestine where in the morning or when we first have food. So either upon rising or sometime thereafter we’ve put some food in and there’s another response that should let go of what’s been in the large intestine / or the rectum, which is a different mechanism and it’s all about communication in the body.

Josh (3:51)

Definitely, so I guess people are probably wondering why is this important in SIBO and IBS? Like what is the issue, why do we need to do things to help this?

Dr. Keller

Well, we know from Dr. Pimentel’s team that there is an association with if you’ve had a food poisoning or traveler’s diarrhea your body could be reacting to one of the toxins that they leave behind and that can give an immune action to a motor complex nerve. So to me this is an absolutely fantastic discovery that they’ve made and they’ve been able to identify that it’s 99.9 percent sensitive and specific for somebody with IBS-D, but there must be other things that can trigger this as well. So there’s a huge influx of people being mindful of gluten, say for example, or dairy, casein. So there’s little things that could be immune triggers to individuals that we don’t know yet exactly but they could be impacting the body in a unique way that’s also hindering that action but the you know eating frequent meals is one that we really know that’s going to be slowing down that action because that’s where the light switches are in the body.

The Difference Between MMC and Gastrocolic Reflex

Josh (5:10)

Yeah and I guess the other thing that you know I guess for me I was a little bit confused about at the beginning and for a lot of people is what is the difference between the migrating motor complex that’s kind of the term we’re talking about in IBS and SIBO patients and other functions like the gastrocolic reflex or just when people say peristalsis right like what is the difference between these?

Dr. Keller (5:41)

Well that is why there’s the motility experts, okay, so I don’t claim to be a GI motility expert, but I will say from observing at Cedars and from them going through they’re getting referrals right from other Gastroenterologist who say this person is claiming they have a swallowing issue, you know so there’s esophageal mammography and so they’re looking for this being different and electrical and pressure. There’s different reasonings for what could be happening from this part of the tube then there’s different reasonings for the next part of the tube which is the migrating motor complex section and then that gastrocolic reflex is more in the large intestine where we’re looking for does the body receive the information that food has come in? So you can actually get an anal rectal test if you can feel the pressure test like if there’s enough electrical activity. So those are typically that algorithm that they’ll do, if you’re referred to a GI motility specialist, they’re gonna say, okay is there something going on in the esophagus? Of course, it’s based on someone’s symptoms, or is there something where for example they’re not passing stool for days at a time so they want to maybe find out? It’s not very pleasant that you have to find out in the rectum like does my rectum recognize the fullness of stool being there? Is there electrical circuitry that’s saying yep okay light switch on let’s get rid of this and let the sphincters relax, etc. and so those are the things that when they rule those out, which is very common, you say for example I saw that I observed it was just for a week but I could see oh okay so you’ve looked at this we’ve looked at that and now they’re saying the reasoning that it could be SIBO is higher now or at least let’s check for it.

Knowing When to Treat with Prokinetic Agents

Josh (7:25)

Definitely, so I guess, do most SIBO patients have an issue with this and how does someone know if this is an issue, right?

Dr. Keller (7:44)

Yeah, it’s an excellent question because as a naturopath I can’t do these procedures right so I would be referring and have referred to GI motility specialists. So some of you have been out there where you’ve been to the Gastroenterologist and they’ve worked you up and down and they said there’s you know nothing wrong with you and it’s IBS, that means that it’s a diagnosis of exclusion, we couldn’t find any other reasoning, which is again how it’s being you know associated with oh is there something else going on and we might as well run a breast test. They’re pretty familiar with other breath tests, like looking for lactose, looking for fructose, those are pretty common ones and so now it’s not as mainstream as everyone may like it to be but it’s getting there where there’s more acknowledgment from say Gastroenterologist to look with a lactulose breath test, okay, so as a naturopath I may be looking at somebody saying, how many times have you done / how many years have you been doing this and that’s an indicator for me for sure I have the tests that I run but that’s an indicator to me if my test / they haven’t been worked up by a Gastroenterologist they definitely should be because we just want to we want to rule those certain things out.

Josh (9:02)

Yeah, so basically when you go to the Gastroenterologist there are certain tests they can do to figure out if this may be an issue. Like what, would you say in the IBS- SIBO population (it seems to me like this is kind of one of the key factors that a lot of people miss when they do treatment because sometimes people relapse). So what do you see as far as that? Do you see a lot of people who need work on this or help with a natural prokinetic agent or prokinetic drug?

Dr. Keller (9:35)

Sure, so here’s an example what we’re just describing right whether do I need to go and look for it or what if it’s already found then I gotta deal with it. So that’s kind of I see both of that, you know, where I’ll see somebody who is a patient of Dr. Pimentels, they looked at this and they say yes I am aware that I have this situation right that’s unique to them and so we have to treat their likelihood or the relapse potential or their current SIBO a different way, and it’s very interesting because they’re really tuned into it they really know but they’ve also had all the reasoning you know they’re like oh okay this is why I feel this way this is why it’s difficult for example to maybe push or you know eliminate stool fully, instead of that wondering or blaming broccoli, which I always joke.

What Can be Done to Help Motility Issues

Josh (10:30)

Definitely, so I guess that gets me into, you know, what everyone wonders about you know this topic is, what can what can be done to improve motility? Let’s say someone has had the workups and they’re pretty certain that they have an issue moving food and that migrating motor complex wave isn’t functioning correctly so what can someone do?

Dr. Keller (10:56)

Okay well number one and this is what I’ve been into for the last few years and that is I look at an assessment of the stomach, because phase one of the migrating motor complex is emptying of the stomach, which is what Erythromycin is doing okay so let’s say it’s 2015 I’ll just put it that way when I would prescribe Erythromycin is after someone had a negative breath test and or they were reporting 75% or more improvement. Now I will say this wasn’t always necessarily by way of expanding the diet. In my opinion I think it’s a myth that you have to remain on a specific diet for the rest of your life or you are going to relapse. That, I don’t know where that even quite frankly ever came from. However are there certain foods and or awareness or looking at a food guide that could kind of say this is how I manage my likelihood of relapse, okay. So there were certain people who felt that much improvement and they would go on erythromycin and they would do well. They would do Erythromycin for around 90 days, so this is someone who likely maybe hasn’t had a food poisoning and it’s just what they found. This is what took care of it and after even 90 days they can even alternate to every other day and they can eventually come off of this low dose antibiotic that’s not actually acting as an antibiotic, it’s actually just emptying the stomach. Then there were people who that didn’t necessarily work well for them or they kind of teeter-tottered maybe the first couple of days maybe the first couple of weeks and those people may have done better with Resolor (and Resolor or is a 5-HTP 4 agonist which is similar to ginger, i’ll get to that) but this 5-HTP 4 agonist actually helps give multiple migrating motor complex waves. So I forgot to mention that erythromycin it’s just gonna empty the stomach, so we’re just gonna get one wave. Resolor, we’re going to empty the stomach and we’re going to get multiple migrating motor complex waves. So that’s one of the reasons why we actually encourage to take this at night during the time where its most active. So those are the best, our most well known, pharmaceutical medications. Then you can get into botanicals and there are different combinations but I specifically researched heavily the ginger, the chemical constituents in ginger and those mimicked Resolor or 5-HTP 4 antagonists the closest so that’s the reason why I had found it helpful, but some people struggle with ginger they get ginger burps and they just don’t feel so great and some people even you can do like say food sensitivity testing they might even have an immune response to ginger. So those are things that again, it’s based on the individual.

Josh (14:04)

Yeah, really cool so the term used for these things is a prokinetic, is that correct?

Dr. Keller (14:11)

Yes meaning to facilitate movement.

Josh (14:17)

Yeah, kinetics, yeah movement. So yeah very interesting so Resolor, is this correct,  Resolor is the strongest, right, because it has two wave action?

Dr. Keller (14:25)

Yeah, I mean if people want to see it that way it’s just a different mechanism of action, and it’s going to create multiple migrating motor complex waves. So say for example, one milligram of Resolor is maybe where people start or it’s been said, you do this with constipation because people with IBS-D might be really scared to have multiple migrating motor complexes, but sometimes that is the best mechanism for their situation.

Josh (14:57)

Yeah definitely and that leads me to another question here is a lot of times people with diarrhea, right, they’re wondering you know they hear this word prokinetic or you know movement, stimulate things, like its the last thing they want, right, so do you use pro kinetics? Are they used in people with diarrhea and what’s that about?

Dr. Keller (15:20)

Absolutely it’s about education. It’s about explaining it to them. I mean I go through an extensive intake and kind of try to tell somebody the story back. You know, there’s usually examples in their life but it’s me being able to connect the dots for them and say here’s why you’re migrating motor complex area might need some help. I don’t like to say negative words and help them understand why this has nothing to do with the way that it comes out of your body. This is the internal cleaning section that needs help and then they go okay and of course once they can experience not having this stool there, they’re more of a believer as well.

Josh (16:02)

Yeah, exactly so if you get that internal cleaning mechanism working correctly then bacteria won’t build up as much, right, and then they won’t get the gasses that promote diarrhea, is that correct?

Dr. Keller (16:21)

Yeah, exactly, yes.

Josh (16:23)

Because it kind of seems counter-intuitive for a lot of people but it actually helps, right?

Dr. Keller (16:29)

Absolutely, yeah it can be essential, like you’re right you know it’s like well do I need this or how long do I need this that can also be based on the case, for example, someone who has that positive test that we talked about from a food poisoning or travelers diarrhea, I know that they’re now five times more likely more susceptible to another food poisoning and I know that it can be that way for another five to ten years. So I might be saying to them look you might not need this all the time or every night but perhaps there’s going to be times periods of stress where you do notice a shift in your body so you may want to resume that, you know making sure you’re cleaning section is okay.

Knowing How Long to Use Prokinetic Drugs

Josh (17:14)

Yeah, so when people go on prokinetics, how long do they stay on them? Do you try them, then test getting off? How does that work for people?

Dr. Keller (17:26)

Right, which is where I would go back to when I would say our golden rule for 90 days after you got the negative breath test and after feeling 75% or more better, it was when we were waiting for this test, this IBS smart test, specifically, because then we were going to know because we were always asking Dr. Pimentel is that all some people seem like they need to go longer and again when you note someone’s history you kind of understand why that is, you know and some people don’t want to be on a low dose antibiotic for a long-term, so they might rotate them they might rotate different prokinetic options and some people it’s like don’t you ever take my Resolor away.

Meal Spacing and Intermittent Fasting for SIBO

Josh (18:08)
Yeah, yeah, so next next little topic here is fasting, right, you hear a lot of people talking about either you know allowing 4 to 5 hours between meals or even doing intermittent fasting. Do you recommend this and do you think it’s very important to, in people who have this issue?

Dr. Keller (18:34)

I, I’m not opposed. Am I recommending it? No, because there can be some blood sugar issues having a bacterial or fungal overgrowth. You know, so there are some things there where I don’t want somebody about to tip over. I’ve seen it where they’re watching the clock. It’s gotta be four hours or I gotta go five hours and they go hypoglycemic and you know so it’s a little bit of again case-by-case basis. Can it help, can you be mindful of it if you’re a person who snacks a lot? You know, absolutely it’s gonna benefit you to just see, to try to start spacing your meals more, to be mindful of it and usually it’s the gum chewers, but people who chew gum that go wow.

Josh (19:24)

Yeah, so basically if someone doesn’t have blood sugar issues it can help, right? But yeah it’s just important to be careful, right? Because some people do have blood sugar issues and they have to be careful and they have to eat to get enough glucose.

Dr. Keller (19:44)

Right, what concerns me even more, sorry, but is if they’re on berberine and/or cinnamon which also lower blood sugar. You know, so you have to really take everything into account because it could really be affecting someone in a way they don’t necessarily realize and they’re just trying to do the right thing.

Josh (20:01)

Definitely, so last question here, is what do you do when you’re evaluating a patient and how do you how do you make the decision that you think prokinetics are needed? I know we
talked about it a little bit maybe their IBS check test is positive or they show a history of food poisoning. Can we just go over those main factors where someone, this could really be helpful for them?

Dr. Keller (20:32)

Okay, so main factors in this came to mind when you asked about the intermittent fasting. A majority, and this is just what I see, I’m not saying this is everyone just happens to be what presents to me is that these people with a history of intermittent fasting often have constipation. And so to me that relates and I won’t go there too deeply but that goes back to the stomach. That’s another piece where it’s the first part of it and it could be that a stomach is overproducing hydrogen that is feeding the methane, okay? So I’ve just seen clinically that when people look at that stomach and they assess that and address it that they haven’t needed any necessary prokinetic agents, okay? So coming from that – okay we’re not evaluating their stomach we’re or it’s a norm you know everything is functioning there, then it really comes to the individual and of course I’m really encouraging them to have an expanded diet. So if they’re able to have an expanded diet then we’re going to have hopefully minimal prokinetic agents, but I do have a few patients you know there’s always that how much magnesium are you taking and or how much did you not take and how much does say Resolor make up for that magnesium that you’re now trying to back off of? If that makes sense, okay? So I really am shooting for people to have a daily bowel movement, whatever it takes. Most people know what works for them best and yet and then once we’ve established what that is, I would like them to be able to do less. That’s usually the goal and so you could either be bringing pro kinetics on board, so I’ve seen people I’ve been there myself where I’ve been on Erythromycin, Resolor, ginger, spacing, you know? So some people need multiple things and then there are people who actually don’t need anything. So I know that that’s not exactly answering your question as we would like but it really can be based on the situation and your tolerance of either the herb or the drug or your axis, right? So, yeah I’m wanting people to be on fewer things for less amount of time, okay? I don’t like to supplement something forever.

Josh (23:05)

Yeah, definitely and it just shows us it’s a complex issue right, it’s important to work with someone like yourself to figure out the individual case and see what’s going wrong. So that leads me to where can people find you if they need help? I’ve worked with you before, you’re awesome and so what is your site and how can they reach you?

Dr. Keller (23:30)

Yes, my site is sibosolution.com and it’s a new website and you can schedule there to have an introductory 15-minute option for people just to talk about that case a little bit and say does this make sense to you? And that’s usually what people are looking for, it’s just a connection to someone who understands their history.

Josh (24:00)

Well, that was awesome I think people are gonna learn a lot about the migrating motor complex and prokinetics, how they may be a useful piece in their treatment puzzle and thanks so much for coming on to chat Dr. Keller.

See the prokinetics used for IBS and SIBO article for more information on prokinetic agents to help with motility.

Dr. Keller (24:14)

Thank you so much.

Prokinetics for SIBO Interview Summary

  • There are various immune triggers that can cause the migrating motor complex to not function as effectively
  • IBS is just a diagnosis of exclusion
  • It is important to rule things out, which sometimes requires visiting a GI specialist
  • Phase one of the migrating motor complex is the emptying of the stomach. Oftentimes, the pharmaceutical, Erythromycin is often used to help with stomach emptying while Resolor has a 2 phase action.
  • In Dr. Keller’s opinion, it’s a myth that a person has to stay on a specific diet for the rest of their life. However, there are certain foods and triggers that one might have to be more aware of.
  • There are a few options for prokinetics, including but not limited to, Erythromycin, Resolor, 5-HTP, ginger, and other natural products like Iberogast.
  • Prokinetic means to facilitate movement.
  • Prokinetics are even used for patients with diarrhea. Though it may seem counter-intuitive, it is actually quite helpful because it improves the internal cleaning mechanism in your gut, as it prevents gas production that can lead to diarrhea.
  • Prokinetics may be used when needed, such as during a stressful period of time.
  • Spacing meals and/or intermittent can be helpful for some people, but for others could be a problem due to blood sugar issues.
  • Intermittent fasting can sometimes promote constipation.
  • Whatever it takes, it’s important for a person to have a daily bowel movement.
  • The need for a prokinetic is highly individual.