 Hello, everyone. Welcome to another episode of Dr. Jill live. So happy to have you here today and excited to introduce our guest. I know it'll be a fascinating conversation on Dr. Jill live. So happy to have you here today and excited to introduce our guest. I know it'll be okay. Sorry about that. They're changing how they do the live. And so I have this echo. So everybody bear with me. We're going to get all settled here again. And hopefully you can hear me online. Put your name and comments in the comment section. I'll be checking in there a little bit where you're from and where you're joining us from. Today I want to introduce a special guest who I haven't known for very long, but we already found out we have something in common. We both come from a farm background. And interestingly, I think that frames not only the work ethic and what we do, but the understanding how the environment and the soils and the gut microbiome really frame our health and our illness and what we see in the clinical practice. So super excited to learn that about you Dr. Derby. Dr. Derby is a board certified colon rectal surgeon who now dedicates a large part of his practice to treating gastrointestinal conditions and from a functional medicine approach. And we're both saying we're eventually trained, but we've really expanded that view of root cause and everything. And functional medicine is my passion as well. He's particularly interested in expertise and gut microbiome, dysbiosis, small and large intestinal bacterial overgrowth, constipation, fecal incontinence and cancer, which is all connected while still performing surgery when necessary. Dr. Derby has been very successful in treating and preventing surgery, treating and preventing surgery for those with ulcerative colitis, Crohn's disease, diverticulitis, gallbladder disease and more, offering anal menometry and biofeedback for incontinence and pelvic floor disorders as well as abdominal massage or abdominal pelvic adhesions. I am absolutely honored and excited to have you here and to talk to you. I love to start with a little bit about your background. How did you go from the farm into medicine and then into colorectal surgery? Tell us a little about your journey and then we'll go to how'd you find functional medicine? Yeah, well, thanks for so much for having me. And I'm super excited to to meet you and talk to you. And so to answer your question, I grew up on working on a farm in Kansas. And I guess my journey started when I had as a little kid, I had an auto immune, a transient autoimmune GI disorder, which required surgical intervention. And that GI surgery that I had was one of my, you know, impotences for, for going into medicine. And, you know, looking back on it, how, you know, I was being set up for, for what I do now was the fact that I did a lot of work on a Kansas wheat farm as a boy. And one of my jobs during wheat harvest was to drive this big wheat truck full of freshly harvested wheat to where we wanted to take it to a grain bin and store it until the market was right for selling it. And so my job was, as a kid, I mean, I didn't even have a driver's license yet. I was 12 or 13 years old. But you know how that works. I do like 12 as well. And I did either like you just drive it over here, the strawberry farm. And I was like, I, because I expect it at that age that you know how to drive. Exactly. Yeah. Yeah. So it was one of those that you had to do it. Yeah. So I would back the truck up to this auger and I would lift the bed of the truck and start emptying out the wheat. But before I started auguring wheat into the grain bin, I turned on this humongous 20 gallon jug of malathion. And it sprayed malathion, which is a pesticide all over this wheat because we wanted to keep the insects out of the wheat. Well, this was, this was hard red winter wheat, which went directly to a flour mill to be processed into flour to become bread. And I can guarantee you that the wheat was never washed because it would ruin it. And so this malathion that I was spraying on there was being also, you know, introduced into people's bread. And so I didn't realize it then. But that was one of the things that really got me thinking. When I became a colon rectal surgeon, I had been practicing for a number of years, and I was seeing more and more and younger and younger patients with surgical GI diseases. So I was cutting out colons and small bowel and all kinds of things. And I said, What, I mean, isn't there something that's causing this? I mean, seeing 30 year old people with colon and rectal cancer, I mean, come on, there's something has to be causing this. And we were seeing the rate of colon rectal cancer, you know, quadruple in people less than 40 years old. And so the big question was, what in the world is causing this? And so that started me on my journey to think, Wow, it's got to be something in our food. And and that also helped me remember back to when I was a kid. And what I did to the wheat that was transformed into flour, which was transformed into people's bread. And so that got me started on this functional medicine journey and, you know, has gotten me ended up to where I am now. So I hope that answers your question. Amazing story. No, because it's so relevant to me to grow on a farm, solve this stuff. And at 25, I got breast cancer. And I have no doubt well water, atrazine, some of these same things contributed. And I don't know if you know my story, and we don't need to talk a lot about it, but just to frame this at 26, right after the chemotherapy, the breast cancer on the treatment, I was diagnosed with Crohn's disease. So no surprise, right? And again, you know how this goes. The doctor said diet has nothing to do with it. He said, you're going to need surgery, you're going to need lifelong immune modulating drugs is incurable. Well, guess what? I didn't need any of that. I'm off meds. I've been I consider myself cured because I have no evidence for 20 years. That's fantastic. Right? So I get this so deeply and I'm so passionate and so excited to have someone like you sitting here. I mean, truly I could almost cry with gratitude to have someone who has that surgical background and understanding but also knows this bigger world because I'm living like proof of the power of diet nutrition, the microbiome, and fixing that. And as you so well know, my story goes with the chemotherapy clearly caused in a permeable gut situation. I have NOD2, which is a high risk gene that causes immune reaction to a neuro microbiome. And so of course, you know the story, but what's powerful is that my story and many of your patients, we can heal without surgery and without drugs. And I never did take I think I took a short course of steroids for a few weeks. And that's the only immune kind of drug I've ever had in my life. So it's pretty amazing that it's possible. Yeah, that's fantastic. And and you know, as you as you're already kind of alluded to, you know, it's all about that gut barrier and how it interacts with your microbiome, how it interacts with your immune system. And yeah, the gut is is the root of all kinds of diseases. And and that's where it really starts. And and you know, that's where it was kind of a really natural transition for me, from going to seeing the the end disease, which is like terrible intestines all riddled with inflammation and strictures and and the whole mass and then, you know, going to the point where I thought that wow, we can actually prevent this from getting to this degree and prevent surgery. And so I still do some surgery, but I'm really have devoted my time to preventing the need for surgery. And it's really been super satisfying for me. Yeah, what a powerful thing, like I said, with your background, because you've seen the physiology, you've seen the anatomy of what happens. And then what you did that not everybody does is ask the question, well, why why? Because for me, too, it's like, when we start to ask the questions, we went into medicine to help people heal, right? And then we go down these paths and similarly forget our beginnings. And the true beginning is like, why does disease happen? What happened here? How can we reverse it? And granted, surgery has its place. It's a lifesaver. But then again, some of these cases. So you mentioned something that I found fascinating. And again, with my knowledge of function, missing that permeability, we call intestinal hyper permeability. It's been called leaky gut in the layman's terms. But for a long time, especially in your field, it was kind of set, you know, there wasn't a lot of respect for that term, or even acknowledgement that it existed. Do you feel like that's shifting a little among your colleagues like analogy, acknowledging that it actually does exist and does contribute to disease? Tell me a little about your journey, because again, that's been a hard sell for conventional medicine with how Yeah, no, I totally am with you there. It was one of those terms that was like, yeah, leaky gut. Yeah, like that right, right, right. But interestingly, when I was a resident in the 90s, you know, I did a lot of work in the trauma ICUs. And we were seeing these people come in with injuries, all they had was a severe close head injury, no abdominal trauma, no other trauma, just a bad knock on the head. And three days later, we they spike a fever, we do blood cultures and their GI bacteria are now in their blood. So we were calling that bacterial translocation. Of course, that's to the nth degree. But what we didn't embrace was the fact that this happens at varying degrees. I mean, obviously, when you're in the intensive care unit, and whole bacteria shows up in your blood, that's kind of the worst possible scenario. But to a lesser degree, that sort of thing is going on in people walking around on the street. But it's more like translocation of bacterial pieces and parts, activating the immune system and causing this inflammatory response. And the whole big picture is what's commonly known as as leaky gut, or what we like to call as increased intestinal permeability, because it sounds more medical. Yeah, exactly. But it's the same idea. And, you know, we were seeing it back then, but we didn't put two and two together. And because we only thought it happened with severely traumatized people. But with lesser traumas, like some of the stuff we're being exposed to in our environment, those things are going on to a lesser degree. And it's kind of like a yes, the same thing's happening, but it's not putting you in the intensive care unit. It's just slowly. And can I use this term is slowly killing you and not quickly like it could happen in the ICU. So inflammation starts and then as you as you know, inflammation is the root of all kinds of evil. And those are the kinds of things that we're seeing as chronic diseases in our society today. And that's what we're kind of out to stop. Yeah, and you mentioned, first of all, love that analogy. And you're right, I've always thought, you know, like same thing as sepsis, not always, but many times in the ICU, someone's severely ill, especially like you said with head trauma, but even post surgical if they're really ill, that sepsis is coming from the gut, it actually literally is. So same as you, I've been like, wait a second, we've known this from residency, we've seen it, it's not new, but we just haven't thought about it in the realm. And I think as our world gets more toxic and as the soils change and the microbiome changes, we're getting more and more changes that affect that permeability, and then cause dumping and immune activation. And we know now that lipopolysaccharide and that endotoxic effect is the root with obesity, diabetes, heart disease, like it's way further than just the gut. Talk a little bit about say someone like myself would come in in their 20s or 30s with Crohn's and maybe they're stable, maybe they're not. Clearly, probably like you, if needed, I use medications to stabilize, but how would you look at them from a functional perspective that might be different from just meds and surgery? Would you look at their gut microbiome? What would you do with a patient with inflammatory bowel in the beginning? Yeah, that's a great question because that's one of the things that I really have focused on. We see a lot of inflammatory bowel disease patients, and what I tell them is that in conventional medicine, they have one tool in the toolbox. And of course, if you've got one tool in the toolbox, if there's a problem, what tool are you going to use? You're going to use the one tool, which is some sort of anti-inflammatory pharmaceutical. And that's all well and good. Those things can be very helpful, but they don't address all of the other needs when it comes to inflammatory bowel disease. So when I see an inflammatory bowel disease patient, whether or not they're on steroids or a biologic or whatever they might be on, I tell them, look, we need to cover all these other bases, which includes, hey, let's look at your microbiome. Let's make sure you don't have pathogenic bacteria that are causing part of your problem. Let's make sure that your commensal bacteria we're working on getting them back into balance because typically in inflammatory bowel disease, the immune system attacks the good bacteria and leaves the bad or the pathogenic bacteria to have their way in a person's gut. So we definitely want to look at the microbiome and there's not a perfect way of doing that just for our listeners, but we take what we can get and that's the best way to do that with the least invasive method is do a comprehensive stool analysis. And that can tell us a lot of things because not only do we want to know about the balance of the good bacteria versus the quote-unquote bad bacteria, but we also want to know how well a person is digesting and absorbing because if they're not digesting and absorbing, then they're going to be losing out nutrients which can make them sicker. They're going to be leaving nutrients in the lumen or the space of the gut, which is just more food for the bad bacteria. And plus undigested food can also cause worsening diarrhea, abdominal pain, bloating, etc. So we look at that. We look at inflammatory markers to make sure that we know what the levels are because we can follow that to see if people's inflammation is getting better. We want to make sure they don't have parasites. It's rare, but every once in a while we see one and it can make a difference in some cases. Then we also want to know, let's say you have good gut bacteria. Well, one of the jobs of good gut bacteria is to make things like short-chain fatty acids. And short-chain fatty acids, of course, are super important to the health of the gut lining. So we want to know what the short-chain fatty acid levels are. And that's a great thing about some of the functional medicine testing is that there's one test that can tell us just about everything that we want to know about what's going on, at least in the colon. And it's not perfect for the small bowel, but it gives us a pretty good idea. And there is no perfect test, so we take the clues, the information, the evidence, and we put it all together. And we come up with a more comprehensive approach to inflammatory bowel disease. And we try to help people. We come alongside them if they want to stay on their biologic or their steroid. We obviously don't want to get them off their steroid because you don't want to be on that long term. But let's say a person wants to stay on their biologic. Well, fine. We'll come in, pull alongside, drive parallel with the conventional medicine approach and help that to work better. If they want to try to get off of their biologic, we can help facilitate that. If they come in and they haven't been on a biologic yet and they're trying to prevent going on one, we can help them do that. So we try to meet them where they are and cover all the bases that conventional medicine really doesn't address, including diet. Like you said, your doctor said, oh yeah, doesn't matter what you eat. Food has no difference. Well, wrong. Right. And it's funny now, I can pull studies at show Crohn's and diet do. For me, back 20 years ago, a specific carbohydrate diet was what I ran into. And for me, it helped. And then Benos, you'll get this. It's funny. I'll just tell you a few of my little things that he helped me to heal all that you just said. So this is clinical case, real life. I had hypochlorhydria, probably from a very young age, zinc deficiency, and pretty severe pancreatic insufficiency. So that was all contributing to overgrowth in the small bowel of both fungus, saccharomyces, survey CI, and bacteria. So I had to treat that CIVO and CIVO, the bacteria and fungal load. I had a little dysbiosis, club C.L.O. was there. And then I had to add back pancreatic enzyme and hydrochloric acid. And then same thing, short chain fatty acids were low. So I took butyrate as a supplement and ate foods with butyrate. But that diet was probably the biggest change because I went from a vegetarian not knowing any better. I was more of a carbitarian and I had gluten in my diet and I have high-risk genes. I was never formally diagnosed with celiac. I may or may not have had it, but either way, the gluten out of my diet made a big difference. So kind of like just what you said, I went through all those in my own body. Now, you mentioned the comprehensive stool. I love that. I do that the same way. Are you doing much breath testing for small intestinal bacterial overgrowth or any thoughts on that? Yeah, in the context of IBD or just really any any patient that comes in with gut issues and symptoms I know just so come with like IBS actually more, right? Yeah, so I mean in IBD studies show that maybe one in five people with IBD also have bacterial overgrowth. But more often the people that I see, you know, are trying to function. They're struggling with bloating every day, bowel movement irregularities. And so yeah, just about every one of those with that scenario is going to get a breath test. And again, breath tests aren't perfect, but breath tests are important because not only does it tell you which gas is being overproduced, but it also can give you an idea how much treatment a person is going to need. So different gases get different treatments. As you know, I'm not telling you anything you don't know, but just for the listener's sake. But you don't know, otherwise you're just guessing. And I can't tell you how many people come into me that have been treated with Zyphaxin or whatever without a breath test. And then we do a breath test and we find out that it was the exact wrong treatment or an incomplete treatment. And so for you listeners out there, and Dr. Jill would agree with me that, you know, you really need to do a breath test so we get more precise of what we're treating if you have SIBO or intestinal methenogen overgrowth or whatever it is. But yes, that's a long answer to your short question. We do a lot of breath testing. We see a lot of SIBO and we offer a more comprehensive approach than standard maybe conventional medicine does, because not only do we treat the bacterial overgrowth, but we also offer kind of a comprehensive approach to try to prevent it from coming back by addressing the root cause and optimizing the microbiome and all those things that are necessary in a comprehensive approach. And I'm sure you see a good bit of that in your practice too. I do. Yeah, I still do a lot of good. So I love what you said because it really is that. And what we see, same thing, a lot of conventional docs might do a breath test or might not and just gives a vaccine. But if you don't address the root cause, which you mentioned, the pancreas, the stomach acid, the motility is huge and then all of those things have to be addressed. And then as you mentioned, most breath tests do both hydrogen and methane. There's newer tests that now just hydrogen sulfide, but those are the big three and super common to have something like the methane and then just like vaccine alone won't treat it. Right. Typically use ice meds as well. But do you use all meds or some herbs or do you use some of both when you're treating SIBO or what's your preference? Yeah, that's why I tell my patients, I say, you know, the great thing about what I do, at least in my opinion, is that we have all options available. So we use pharmaceuticals. I love refaxmen. I think it's just this amazing antibiotic because it's not absorbed to it as, you know, a significant degree. It only works in the gut and the studies show that it actually supports the commensal bacteria while it knocks down the overgrowth, which is just outstanding. Yeah, we didn't have that years ago. Like when I went to medical school, that wasn't it. So it is a very, and I agree with you, I want to say this because a lot of you are free to have antibiotics. I feel very different about refaxmen and I use it just like you frequently because I feel like we get a great result without a lot of harm to the microbiome. Exactly, yeah. And so we have all the pharmaceutical, you know, availability as well as herbal. So I use a lot of herbals. And then we'll do elemental diet. Sometimes it's not, you know, people aren't crazy about it even though some others have said, hey, be more positive about the elemental diet, but I just think of myself trying to do an elemental diet. I would only do it if something else hadn't worked. And so that's what I do for my patients is if I only kind of bring that in as an option, if let's say my herbal protocol or my pharmaceutical protocol hasn't been as effective as I wanted, but also do a hybrid kind of as you were implicating or implying that you can also use a pharmaceutical plus an herbal. And so that's what's so great about what we do is that we've got all the options. Conventional pretty much just does pharmaceutical, naturopaths, well not all of them, but a lot of them just do herbals, you know, nutritional practices just do elemental, but we do all. So I think I couldn't agree more. I love that because often I'll do it and usually the antibiotic is no more than two weeks. So although you did mention allude to you probably like me if the hydrogen's really high, I sometimes go 30 days. I have kind of a cutoff. I'd love to get your opinion. I think around 20 or 30 units of hydrogen, whatever that unit is, is a good, if it's say it's 60, would you go longer than two weeks? Yeah, I'm not opposed to going three weeks with refactionment if the hydrogen's super high. Studies suggest that you can drop it by 30 to 40 points with a two-week course, but I go a lot on how the patient's feeling. So if they hit like 80 or 90 percent improvement in symptoms, then I move on. But if they haven't hit that, I either repeat the breath test or go a little bit longer with the treatment or even sometimes change it up to from a pharmaceutical to an herbal because I kind of say you know what, the pharmaceutical is like a right jab and the herbal's like a left hook. So we're hitting it from both directions and if we hit it from all directions then we'll knock it out. Love it and I couldn't agree more. And often like you said, or sometimes I'll do the antibiotic refactionment plus right after then I'll start an eight-week herbal course or something like that. And like I said, I kind of check them with the patient. What do you prefer? How do we do this? Are you improving? And what's great, fungus and yeast is hard to detect and that can be co-existent. And if that's there, the herbals tend to by far do it a better job because often those herbs, berberine and caprylic acid, oregano, etc, they cover both. And I'm sure you found that as well. Exactly. Yeah, yeah. And there's a, you know, like you say, there's a significant percentage of folks that have those co-existing, both CBO and CFO, which for the listeners is small intestinal fungal overgrowth. And that that can be a bad combination. It can be really tough and it's really hard to nail down CFO. You almost have to go on, you know, just a clinical feeling. But it can get both of them. And so I do like to come back with an herbal protocol, just in case you've got a little bit more bacterial work to do, but still haven't addressed fungus. I love that you mentioned that because that's what I've been talking about for years. Like, I think the suspicion of fungus has to be high because, again, in medical school, we're not, we're almost taught that it doesn't exist except we know better. And even if it's not systemic, you know, sepsis from fungus, it can be there and be very significant in the patient's lives. But like you said, whether it's the antibodies in the blood or the stool test or organic acids, you can do a lot of tests and still not find it. But if there's a massive symptoms I've seen as the yeast, the cravings for sugar, brain fog. It's interesting, yeast produces a product called acetylaldehyde. It's the same thing from alcohol after a hangover. So it's almost like a hungover. And I love that you said that, though, because it is hard to detect. And that's why conventionally we're not taught because it's hard to find. But if you're looking for it, you and I see it all the time. And it is relevant because they don't get better if you just treat the one side and they have both. Exactly. Yeah. And you know, in this day of not doing physical exams, I still think physical exam is important because I can't tell you how many times that just the physical exam itself greatly raised the suspicion of having coexisting CFO or even CFO by itself. And I see some kids and there's a number of times in the recent past where I'm talking to the mom and I'm not thinking, you know, a bacterial overgrowth. And then I examine the child and, you know, tap around on their tummy and there's a good bit of gas in there. And there's some distention that your mother was detect and lo and behold, we do a breath test on this, you know, eight or nine year old. And sure enough, they've got a bacterial overgrowth. So physical exam is an important part. You know, I try to do at least one exam on people and I encourage them to drive to see me if they're coming from long distances. Sometimes that's not possible. But then I say, look, go to your primary care physician and have them lay hands on your belly. So those, you know, it's a, you collect, I tell people I'm kind of like a medical detective. I'm trying to, I'm going to a crime scene, which is the medical condition. I'm trying to gather clues from all these different areas. And then I put all the clues together and kind of come up with a who done it sort of thing. And sometimes fungus is the who done it. Sometimes it's not, but you got to have a high index. I love that you said that because again, it's really, conventionally, we aren't taught to look very far for that. And just very, very specific. I find white coating on the tongue. So if you're listening, look in the mirror, you have a real white white coating on tongue could be fungus. If you're hypothyroid and untreated, that can contribute to SIBO or fungal overgrowth because just that slight bit of decrease of temperature in your body will allow for the proliferation of yeast and fungus and also the motility is lacking and you need good motility in the small bowel to prevent this from happening. I always joke about it like hockey, the Zamboni that goes between the periods on the ice. That's kind of like the migrating motor complex in the gut. And if that's not working, you're going to have this stagnation overgrowth of bacteria or yeast in the gut, which is why you mentioned all these other things that we think about. We talked a little about Crohn's and your approach, which again, look at the microbiome. Is there anything different with ulcerative colitis because they're very similar. They're in the same IBD, but they do present a little differently. Is there anything different you would do with the ulcerative colitis patient versus the Crohn's? Yeah, and ulcerative colitis, I'm always looking for hydrogen sulfide because it's a big player in ulcerative colitis and that's where I think, again, the comprehensive stool analysis comes in because this is the stool analysis is going to tell you about the microbiome mainly of the colon. Let's face it. But I can't tell you how many times that I look at the microbiome of a person who I either suspect has ulcerative colitis or it's been definitively diagnosed and they have an overgrowth of a particular species. It's a sulfate reducing bacteria called desulfobibrio pyger and you know that one on the on the stool analysis and that one really makes hydrogen sulfide and hydrogen sulfide, if it if the concentration is high enough, it is pro inflammatory. It creates inflammation and just with controlling that particular organism when it's overgrown can make a huge difference in you know how the clinical setting of how people are doing and their symptoms. So I definitely always look for that. Don't see it so much in Crohn's but with ulcerative colitis that's a big difference and of course with both Crohn's and you see we're we're instituting you know dietary precautions and sometimes even putting them if they have a flair sometimes even an elemental diet for two or three weeks if they're willing to do that can make a huge difference as well and cooling down that flair and that's been corroborated by a number of clinical studies mainly coming out of Europe. So not so much done. Right and like you said the evidence is actually really good for elemental diets it's just that it's inconvenient to patients they don't always like it so it's not that they don't that they're lacking evidence on that. I love that you mentioned that because it is a great option and for those of you listening there's commercial formulas out there but there's also a couple of like pharmaceutical nutritional companies that make them and there is on the web a naturopath C. Becker who has created a homemade elemental diet so that's a place to look I think it's cboinfo.com or.org. Yeah I think that's ours right. You know Allison probably too. I've been on a few board like listening to some of the people who know a lot more than me on the hydrogen treatments. I'd love to hear your thoughts and I can share some of the things I've heard as far as because I feel like it's a harder thing to treat than the methane or the hydrogen. Any successes on kind of meds or herbs that you use for hydrogen sulfide? Yeah you're right it's a toughie and let's face it we don't have a whole lot of clinical data. It's it's kind of it's kind of one of those things that we've known it's been around but we haven't studied it as much as probably need be and you know there is a hydrogen sulfide study group that is collecting data and the data shows that the clinical scenario is all over the place. It's not just diarrhea but for the ones that I've done like a trio of smart which you know tests all three of the gases that you mentioned and I have a definitive elevation of hydrogen sulfide. The things that I found effective are I have treated it with refaxmen but I add I add bismuth which it's pepto-bismol essentially or you can get a compounded version of bismuth as well which is probably more effective but anyway it's expensive and pepto-bismol is a lot cheaper yeah but the combination of those two I've had success with on the herbal side I've had success with kind of high dose oregano where you really hit it with high doses. Some people don't tolerate that very well so you got to be careful but I have had some success clinical success with that as well so and there are other you know treatments out there you could use the elemental diet I haven't done that yet because in my practice hydrogen sulfide is a is a fraction of hydrogen cebo and intestinal methanogen overgrowth so I don't see it that much but when I do see it those are the things that worked so refaxmen and and pepto-bismol or bismuth and high dose oregano which you're talking you know I use ADP which is an emulsified tablet and so you're talking you know five tablets which is 250 milligrams three times a day which is a ton I mean you you probably smell like a pizza shop you know you know I love that you say that because it's exactly my experience and there are some studies out there with blastocystis which is a protozoa that probably the most common if we do see parasites that's the one that we do and it's that exact brand that was studied and it was three to four three times a day and that was back 10 years ago I used to think that was so high but same as you that stuff is really effective if you go high enough and because it's enteric coated people not always tolerate it but better than at least like the oil if you were doing drops that would be right you would definitely smell like pizza I've heard a little bit about uva ursi and silver I don't use a lot of silver in clinical practice so who knows but the and the uva ursi I sometimes will just add to the regimen I don't feel like alone it's enough but love that you're saying that is bismuth is really a key to I think and interesting if sometimes we'll see on the stool someone who has H pylori then hydrogen cebo and bismuth tends to be real good to prevent bacterial from H H pylori from adhering to the stomach so that's a nice thing if you have two things to be able to use that for both combination this is fantastic so you also talked about motility disorders like constipation what's some other pearls because that's a big deal and I'm sure that you treat a lot of methane cebo that's constipation and that's a root cause but say you've treated methane cebo or you you know having trouble getting that level down what other tips or tricks or things do you do for the chronic constipation so you're saying you you they either don't have methane cebo or you they had it and you treated it it's gone but they still have constipation yeah and maybe just because our listeners maybe don't know this but methane cebo clearly is related to constipation so let's start there what would you do to treat the methane cebo and then if it doesn't resolve what would you do for constipation yeah see see methane all the time and you know one of the things that methane does is causes constipation but it also in my experience causes a lot of neurologic symptoms people are just miserable they have a fair amount of pain usually on the right side not that's not you know hard and fast rule but that's my experience and a lot of them also have coexisting fungal overgrowth because there's some evidence that the fungus and the methane producing organisms kind of have a symbiotic relationship and so whenever I've well to go back to your question um again the methane producing organisms are not technically bacteria they're they're they're more primitive organisms and antibiotics and I'm not telling Dr. Jill anything she doesn't already know I'm telling this for you the listeners out there but antibiotics are designed for bacteria but if we've got a more primitive organism antibiotics will work but you've just got to pound it hard or you know for a hydrogen producing organism you might just have to flick it yeah but with a methane producing organism you got to take a sledge hammer and beat it to death to get rid of it so that's why we use generally use two agents instead of just one and and so we're Faxman plus neomycin those are two pharmaceutical antibiotics or on the herbal side I'll use of like you've already mentioned I'll use a fair amount of berberine or oregano because I can use those in high doses and add allicin to that which is an extract out of garlic and people that have SIBO like garlic you're going to treat me with garlic and I tell them look it it's a it's the antibiotic extract out of garlic it has none of the carbohydrates that cause you know uh gut disruption with with in the presence of SIBO so it's not going to have the same effects and it doesn't make you smell like garlic or anything like that if the if the extract is pure and the one that I use is pure but it's expensive but it works and it'd be better to use something that works and pay a little extra more than get something that doesn't work and and you know then you're in the same place but anyway then I'll also use um combo you know um kind of hybrids so I'll use I just prescribe today for a 19 year old young person um a combination of refaxamen and allicin because I didn't think that they would do well neomycin neomycin can be a little hard to tolerate for some people um but those are my go-tos um and there's other regimens but um you know when you found something that works you want to stick with it and only switch if it's not working and I'm sure that's your experience too yeah I love that and I couldn't agree more everything you said totally would do the same as um and then that constipation you know whether you you've treated the methane SIBO you've looked at things what else do you do for chronic constipation sure yeah um when I'm looking at chronic constipation you know it might there's there's kind of three things to think about um number one uh the colon doesn't propel the waste material along the its path and so we you know we call that um you know dysmotility slow transit constipation or or even uh you know colonic at me um so no motility is one thing and then let's say the motility is fine but everything gets kind of jammed up at the outlet that's called uh you know uh pelvic out pelvic floor disorder or or outlet obstruction so the colon might be working fine but once it gets over to the rectum the muscles of the pelvic floor don't work right and you can't empty so that's a another kind of constipation that needs to be addressed and then the worst is a combination of both of those which would be um bad motility the colon doesn't propel things through but when it finally does get it down there you can't empty it very well and that's a bad combination so let's just say we've done a test and we found out that the colon motility is is um not uh where it should be well that opens a whole can of worms because that could be um a number of different root causes not the least of which is autonomic disorder um vagus nerve dysfunction um you know uh even a intrinsic um dysfunction of the colon excels not um contracting properly so uh it's hard to distinguish between all those so i will um if i'm suspicious of that then i will kind of come at it from all angles i'll i'll do some um you know vagal uh vagus nerve stimulation i'll try to promote motility which we can promote with either pharmaceuticals or herbals um and some pharmaceuticals work great for some people and um some they don't and some herbals work great for people and some they don't so you just got to kind of find which one works um i like um i like ginger based um you know uh prokinetics but some people can't tolerate those from an herbal standpoint i also like pukela pride um which is a pharmaceutical um that's fortunately available once again in the u.s. yeah the past couple of years use a lot um so i'll use that uh you know and i'll use um abdominal massage um you know uh i don't use a whole lot of um say like amethysia uh uh or um true lance or some of those agents because i found that they either give people diarrhea which is just going from out of the frying pan into the fire sort of thing or they work for a little while and then they totally lose their effectiveness and you've got to just keep going through all these different medications and then you're out of uh you know you're out of options so i don't really usually use those too much they can be okay in the short term but um so uh those are kind of the different approaches but then let's say a person has pelvic floor disorder then um uh we'll do anorectal monometry to prove that that their their muscles are not relaxing when they're supposed to relax and they're they're um they're uh relaxing when they're not supposed to relax so they're totally backwards or paradoxical um and that those people will greatly benefit from biofeedback which we do in our office and we do some retraining of the pelvic floor muscles which studies have shown again um that that's a that's a big um a big winner for for um outlet obstruction constipation um and then when you got a combination of the two then uh it makes it more complicated but you do both got it yeah that's super helpful because again this is i think becoming more of more of an issue as we're less mobile or we have more toxic load or more dysbiosis the people who have and again from a toxicity perspective if you're retaining stool you're just a reabsorbing massive amounts of toxins um i want to let you go and honor your time but one last thing i want to talk about and we can make a brief gallbladder disease this is opening a whole can of worms but obviously super common to have issues with the gallbladder and infection inflammation and all that you did mention that sometimes you can prevent um surgery i'm assuming if it's not you know totally inflamed and infected there's just some dysfunction what's some little tips about what do you think about with gallbladder issues and where do you go with that um uh and again i'm maybe opening a can of worms but i'd love to just touch on it briefly yeah um well i'm going to give you my suspicion i would love to do a study sometime and prove it yeah but i think that many gallbladders could be saved if we would control methane producing organisms in the gut because not only does methane slow down the gut but it also slows down gallbladder anything and um for all the people that have their gall bladders out because they they had um gallbladder dyskinesis which means that the gallbladder doesn't squeeze efficiently and empty the the bile out of the gallbladder those people probably had methane and so if somebody comes to me and says a they're they're wanting me to get my gallbladder out because it's not contracting right i said before you do that let's make sure we know your methane status so um that is my first go to if we're trying to save somebody's gallbladder and um so yeah there's other things to do yeah that makes so much sense and and just for the listeners the bile that's produced without produced but stored in the gallbladder and excreted is a sterilization way to help the small bile stay healthy so part of this is actually contributing to the overgrowth of bacteria if your gallbladder is not working it's and from my perspective with mold and toxins it's also storage for cholesterol and toxins and so that a lot happens in the gallbladder that we don't acknowledge it's such a piece of the puzzle um wow this has been absolutely great wealth and knowledge i know people are commenting and already saying they appreciate this um where can people find you and are you taking new patients tell us a little about where to find you yeah um we're taking new patients and you can find me at drjerby that's d r j e r b y dot com perfect and um you know folks are interested they can set up a phone consultation to see if if they feel like our practice is a good fit for them and i i find that to be very helpful um but yeah feel free to check that out and and if you want a phone consultation you can set that up too fantastic um we i am like i said i'm truly honored because i always feel like someone with your expertise and then you've expanded this toolbox you're a rarity and you're a gift because it's so important to give the root cause and yet you know a lot of docs go in straight surgery there's nothing wrong with surgery but i love love love that you've expanded your toolbox and that you've shared your wisdom with us today so thank you so much for coming on yeah thanks so much for having me it's been great