How to Overcome Inflammatory Bowel Disease

In this episode of Functional Medicine Research, I interview naturopathic physician Dr. Ilana Gurevich on overcoming inflammatory bowel disease.  We had a deep discussion about testing and treatment options for inflammatory bowel diseases including Crohn’s disease and ulcerative colitis.  We covered diagnostic testing, the pros and cons of stool test markers, probiotics, fiber, digestive enzymes and hydrochloric acid, gut healing nutrients, diets like the Specific Carbohydrate Diet, helminths, and much more.  It was a pleasure to have Dr. Gurevich’s expertise on inflammatory bowel disease.

How to Overcome Inflammatory Bowel Disease

Below is a transcript on How to Overcome Inflammatory Bowel Disease with Dr. Ilana Gurevich

Dr. Hedberg: Well, welcome everyone to “Functional Medicine Research” I’m Dr. Hedberg, really looking forward to my conversation today with Dr. Ilana Gurevich. She is a naturopathic physician and acupuncturist. She graduated from the National University of Natural Medicine in 2007, with her doctorate in naturopathic medicine, and in 2008, with her masters of Oriental medicine. She is currently co-owner of two large integrated medical clinics, one in Northwest Portland and one in Northeast Portland.

She runs a very busy practice specializing in treating inflammatory bowel disease, which we’ll be talking about today, as well as IBS, SIBO and other functional GI disorders. She lectures extensively and teaches about both conventional and natural treatments for gastrointestinal conditions, including inflammatory bowel disease, SIBO, and IBS. She’s one of the foremost experts on the intersection of IBD and IBS and how treating one resolves the other. Dr. Gurevich also acts as a mentor in the naturopathic community, educating and consulting with physicians about GI disorders. She supervises residents and consults with doctors about their most difficult GI cases. She was nominated as one of Portland’s top docs by the Portland Monthly in 2014, 2016 and 2020. So Dr. Gurevich, thanks for coming on the show.

Dr. Gurevich: Thank you so much for having me.

Dr. Hedberg: Yeah. So this is gonna be really interesting. I’ve heard you talk before and I wanted to have you on because you’re extremely a research-based, you know, scientifically sound. And of course, you have tremendous experience in inflammatory bowel and SIBO and IBS. So why don’t we just lay some groundwork? And if you could just talk a little bit about what have you found to be the real causes, the triggers of inflammatory bowel in your patients?

Dr. Gurevich: You know, it is such a multifactorial disease. So with inflammatory bowel disease, there are these two peaks of when people generally get diagnosed. The first is, you know, adolescence, right around puberty to like the mid-30s or 40s. And then the second is menopause, andropause in your 60s, 70s, 80s. And those patients tend to get found a lot just on their basic screening colonoscopy.

And so, you know, because there are these bi-modal peaks of diagnosis, it really makes me think that one of the issues is hormonal changes that happen. And, you know, we’re learning more and more recently about how hormones affect the GI, mainly using the estrobolome as an example, and then how the estrobolome affects how you conjugate or process your hormones. And so there’s definitely a hormonal component.

Research is also exceptionally clear that diet is a huge component. You know, in parts of the world where they don’t really see inflammatory bowel disease like Africa, like Asia, when people from those countries move to a Western civilization, they start getting diagnosed with inflammatory bowel disease equal to people of the West, which means that the way that we’re eating is definitively changing our microbiome, which is then causing onset of inflammatory bowel disease.

What’s interesting is the opposite now is also happening as we introduce the Western diet into more diverse countries that in the past were, you know, utilizing their own natural forms of eating as opposed to processed food. Now, those countries are seeing an upsurge in inflammatory bowel disease. And so the microbiome and us killing the microbiome or shunting it is definitely causing lots of changes that then upregulate the immune response in the intestine that’s causing the onset of inflammatory bowel disease.

And then there’s always the mental, emotional component. You know, the majority of your neuro-transmitters from your GI, from your brain are made in your GI and so the higher stress, the higher depression, the higher changes that happen. Then there’s also an upregulation, not so much with diagnosis, but definitely with flares of disease. So I have a fair amount of patients, you know, I’ve been at this a while, and so patients are with me for a long time and we’ll have them super, super well-controlled, and then they’ll go through like one of the most stressful events of their lives and then all of a sudden, they’ll go into yet another flare. So that’s another thing.

And then my big thing is I will…it’s pretty well-documented that antibiotics and certain antibiotics in particular will cause onset of an inflammatory bowel disease flare. And so antibiotics is the fourth big pillar that I’m always educating patients about. You know, my rule of thumb is you get an antibiotic if you go into the hospital. And if not, we have ways to treat you. And generally, using all of the natural tools that we have, I can get you out of whatever you need the antibiotic for so that you don’t need an antibiotic so you won’t go into a flare because I have just seen it so many times when they have an abscess or they need dental work or something like that and they end up getting a flare because of the antibiotics.

Dr. Hedberg: Yeah. I see that as well, emotional traumas triggering autoimmunity. And you mentioned moving from certain countries into the West. Do you think that, you know, things like intestinal parasites or just hygiene in general has any connection with that?

Dr. Gurevich: I really do. And I really, really do, especially because I’m looking at some of the research that we’ve done, that we’ve seen recently with helminths there’s that one study that was done, I wanna feel like 10 years ago that was done in Argentina. Do you know the study I’m talking about?

Dr. Hedberg: I do.

Dr. Gurevich: Okay. So he was an MS doctor. And so when their entire economic system collapsed, so did a lot of their sewage system and stuff like that. And people used to come in with helminths that they were finding and all of a sudden, their MS was going into remission. And so, yeah, I definitely, you know, there’s this whole theory called this old friend theory, which is we evolved with these parasites, protozoa and worms. And because of that, when our immune system is targeted at those parasites, protozoa and worms, it’s not likely to target us. And I also wanna say, I have also seen the opposite be true, which is parasites, protozoa and worms could also be causing dysfunction because they are pathogenic species. And so I’ve definitely seen both happen.

Dr. Hedberg: And have you seen viruses as a player? This is a, you know, one of the real areas that I focus on and I’m interested in things like Epstein-Barr and other viruses like that. Have you seen that as well?

Dr. Gurevich: You know, I think just because of how hyper specialized my practice is, I don’t focus on it as much. I’m also in a relatively large integrative clinic. So if people are coming in with that chronic-infection-like picture, then generally, I’ll refer them over to one of my more infectious-disease-specialized colleagues. And so, you know, I feel like when we’re talking about when patients are having both going on, and their GI is, you know, they’re not in a flare, I usually take a back seat and let one of my colleagues really manage the infectious disease aspect of it.

Dr. Hedberg: Excellent. It sounds like you have a really great team where you work, so…

Dr. Gurevich: I’m exceptionally fortunate.

Dr. Hedberg: Yeah. So once you’ve established that someone has inflammatory bowel, let’s talk a little bit about lab testing. I know you’ve done tremendous research on this, and I’m going to assume that you’re gonna be doing stool testing on a lot of these patients and some of these markers are somewhat questionable. So why don’t we just talk about some of these starting with pancreatic elastase? Have you found that that is a good marker, a good test?

Dr. Gurevich: So when you were talking about working up in inflammatory bowel disease patient, you are, you know, where I usually start with is, I usually start with actually not specialty labs, but just the regular standard Quest lab labs. And if it’s an ulcerative colitis patient, I’m always, before I start any treatment, I’m always gonna get a baseline.

And the baseline for UC that’s been most validated is a fecal calprotectin or a stool calprotectin. This is a stool test that I will say, I don’t trust specialty labs. I’ve seen their values go up and down. And I have a theory about it. I don’t know if my theory is correct. And so I’ll always run a calprotectin through one of the standard labs. It’s looking for white blood cells within the intestine.

When you have white blood cells in the intestine that means there’s an inflammatory response. The number, depending on how high that calprotectin is, that tells us how much of a flare they’re in. And it’s something like 96% predictive for equal to a colonoscopy. So that’s a really good test for the large intestine. It’s less so a good test for the small intestine. Efficacy of calprotectin for the small bowel is somewhere between 30% and 90% effective, depending on what study you look at.

And so what I’ve done recently is I’ve pivoted away from stool testing for small bowel Crohn’s patients to a blood test that’s put out by Prometheus Labs. Prometheus is the company that came up with a blood test to differentiate Crohn’s disease versus ulcerative colitis. And I have no financial…I’m not tied in financially at all with them, but it’s a remarkably good test. It’s called a Crohn’s Monitr score and you use it. It has 12 different biomarkers looking at the 5 different causes of inflammatory bowel disease, so mucosal healing, platelet aggregation, inflammatory markers, immune system regulation, and I can’t remember the fifth area.

And so that blood test comes up with a number and that number tells you how well-controlled they are or how much of a flare they’re in. And so the first thing that I’ll do is I’ll start there. And then from that test, from one of those two tests, it gives me a clue of how aggressively I have to treat. And then the other thing that I do is I go back and I rerun these tests every four weeks to three months, because I don’t have the luxury of having the huge clinical trials that tell me about, you know, this biologic agent or this immunosuppressant and how effective it is. So I have to be constantly checking my work to make sure it’s working.

Dr. Hedberg: Yeah. Calprotectin, I have…

Dr. Gurevich: That’s where I start, after that’s depending on how that number comes back at… Oh, sorry, go ahead.

Dr. Hedberg: Oh, no. I was just going to say that a calprotectin is one of those markers on some of the specialty labs that sometimes just kind of a head scratcher. It doesn’t really seem to correlate well with the patient.

Dr. Gurevich: So my theory with that is, you know, when I’m running a calprotectin through any of the standard labs, they are taking that sample. That sample is just used for that one test and they are immediately freezing it. And then from…I’m on the West coast. So we sent all of our samples down to California and then they’ll process it there. Specialty labs, you can’t freeze the sample. And the reason for that is because they’re monitoring so many other things from that one sample. And so I think that might be one of the reasons why you’re getting not accurate results.

However, the literature does say that calprotectin should be a very stable test. And so the only thing I’ve noticed is exactly what you were saying, which is when you have a calprotectin from a specialty lab, those markers are sometimes you’re super elevated. And then I’ll always retest with a stable lab and then that elevation is gone. So I just personally don’t trust, even my favorite specialty lab stool test, I just don’t trust the calprotectin on there.

Dr. Hedberg: Okay. And some of the other markers, I also think might be somewhat questionable, like beta glucuronidase and secretory IGA. And I also just, you know, some of these markers, you just have to ask yourself, are these really gonna change how I treat the patient? That’s how I look at testing. How do you see those markers?

Dr. Gurevich: So I feel like a highly questionable makes them seem like they have any kind of accuracy and they just don’t. Beta glucuronidase is such a variable marker, which means that if you’re male, it’s different than if you’re a female, that’s different than if you’re pregnant. And it changes if you had lots of vegetables three days before you ran a test and it changes again, if you had lots of protein, and it changes again, if you’re overweight. It’s such an unstable marker. I really, I don’t know why it’s in every single one of the panels. That confuses me because, literally, it has no validation at all behind it.

Secretory IGA is a tricky one because secretory IGA has value that, you know, 75% of your secretory IGA should be bound. It should be bound to parts of the microbiome that are healthy physiologically, and that’s kind of how the immune system modulates because, you know, there’s so many trillion bacteria in the microbiome, in the large bowel. The immune system will bind the ones that are healthy or that are, you know, probiotics and then it’ll know which ones to attack. So depending on how much of your secretory IGA is bound or free. If most of it is bound, that means it’s good. You know, the body’s doing a really good job regulating. If most of it is free, that means the body’s under attack and trying to get rid of some kind of species.

My fundamental issue with the secretory IGA test is when I started doing all of the literature searching on what they’re running, none of the functional labs knew if they were running a free or a bound. And so I don’t know what it’s telling me. I think that it would have validity if they knew what they were measuring, but if I don’t know what they’re measuring and they don’t know what they’re measuring, then I can’t put any clout into the result that I’m getting.

Dr. Hedberg: And the first one I asked you about was pancreatic elastase. Do you have any thoughts on that test?

Dr. Gurevich: That is an extraordinarily, well-validated test, so really, really well-validated. I’m gonna say this off the top of my head, which means it might be slightly wrong, but they, basically, the way that that test was validated was using the gold standard, which is they give you an endoscopy and then they give you an IV of secretin I think. Yeah, I think they give you secretin and they measure the amount of elastase that’s coming out of the pancreas in the top of the large intestine.

So basically, elastase is I think 96% validated to be equal to the amount of enzymes that come up on that more barbaric test that nobody’s gonna do. It is extremely useful to rule in or out pancreatic insufficiency. And when we’re talking about both IBS and IBD, pancreatic insufficiency can be playing a role in both of them and could be one of the reasons why patients are suffering from chronic diarrhea.

It’s exceptionally easy to rule in and out. You can use a specialty lab or you can use a standard lab. A fecal elastase one is that stool tests that you run through a standard lab. And it will tell us that they have enough enzymes being secreted or they don’t. And then there are naturopathic supplements or pharmaceutical drugs that are used to very effectively treat it. And then you also go by looking at the underlying cause.

Dr. Hedberg: So the lab, you know, it has a cutoff of 200, at least on the specialty lab that I use. And, you know what I’ll read, some practitioners will say, well, you know, sub optimal is less than 400 and then the lab says suboptimal is less than 500. Is there a particular number that you’re looking for?

Dr. Gurevich: My cutoff is usually 500. There’s a couple of studies that said that optimal function is right around 500. But, you know, depending on how low, it warrants what kind of treatment I’m gonna go forward with. You know, am I gonna go forward with pushing a little bit more of a pharmaceutical model that has significantly higher doses of lipase, amylase and protease as compared to a supplement, which might have lower doses?

Dr. Hedberg: Right. I’m blanking on the name of that medication.

Dr. Gurevich: There are two, one of them is called Creon and the other one is Zenpep, they’re basically exactly the same thing.

Dr. Hedberg: Right. Right. And then there’s two companies that have a pancreatic enzyme formula that I’ll use, you know, pretty high doses. Are you using those mainly or the medications?

Dr. Gurevich: Am I allowed to say brands?

Dr. Hedberg: Oh, yeah.

Dr. Gurevich: Okay. So yes, Pure Encapsulations and Vital Nutrients, both have an equivalent of Creon. They’re using, I think it’s two pills gets you 24,000 lipase, I think. And I am using both of those really successfully. It’s expensive, but it’s cleaner. So, you know as a fact that the Creon and Zenpep have a ton of, you know, it’s a pharmaceutical, so they’re gonna put unnecessary additives in there. You don’t get those additives in the Pure Encapsulations for sure or the Vital Nutrients. It’s exactly the same strength. But then, you know, it depends on how poor their pancreatic, their exocrine pancreas function is, because depending how poor it is, the supplements just might get cost preventative.

Dr. Hedberg: Yeah. If it’s below 200, I’m using 4 capsules per meal of the Vital Nutrients. Have you seen the need to go higher like six?

Dr. Gurevich: Yep. I go higher.

Dr. Hedberg: Up to six.

Dr. Gurevich: And, you know, the Creon puts…has this really great algorithm out like that looks at weight. So basically, they come up with therapeutic dose based on your weight. And so I mean, I feel like sometimes, if I’m needing to peak somebody out, it could be 8 to 12 per meal, and then it becomes significant cost prohibitive to use the supplement.

Dr. Hedberg: Have you, I mean, have you found that using betaine HCL can potentially offset some of that? I know some practitioners are using upwards of 5,000, 6,000 milligrams of betaine HCL per meal. I don’t really see that many that can handle that much. It’s usually much lower than that. Are you using much betaine HCL in your practice?

Dr. Gurevich: So I did for a long time. There is absolutely no literature on using hydrochloric acid. And I feel like 50% of patients do really, really well with it and notice a huge difference like that is the thing. And 50% of patients, you go higher and higher and higher, and they never noticed anything. So I don’t use it as much as I used to. I will sometimes prime the pump using apple cider vinegar. And I also really, really like digestive, you know, digestive bitters, like getting bitters from the liquor store and mixing them with some water while you’re cooking, because I also find that that kind of stuff primes the pump.

And then, you know, I feel like part of the issue that we have with humanity right now is we’ve forgotten how to live like humans and we’ve forgotten how to prioritize the needs of our nervous systems. And so, you know, just basic lifestyle medicine, when you’re reminding people to relax, to not be in a hurry, to not eat while working, to be mindful of their eating, like all of that stuff has kind of gone by the wayside in the last 50 years as we’ve become more technological. And that kind of stuff is a really simple way to improve function as well.

Dr. Hedberg: Right. Exactly. Yeah. I’m also a big fan of bitters. So probiotics, I wanna ask you a few questions about those because in the IBD patients I’ve seen, it just seems like the spores tend to be the ones that have to be the most cautious with, whereas the lacto bifido and Saccharomyces, some people do have issues with those, but I just seem to see more issues with spores specifically for IBD. Are you seeing that as well? Or are you seeing a completely different…?

Dr. Gurevich: No. I am super cautious with spores because there was a couple of studies that said that spores upregulate the Th17 autoimmune cytokines within the body. So I am super cautious. I’m not saying I won’t do it, but I’m definitely cautious. For Crohn’s disease, the only probiotic that’s been well validated is Saccharomyces boulardii. And by well-validated, I think there’s two studies that showed efficacy with a higher dose Saccharomyces boulardii than like, so about 15 to 20 billion CFU per day.

With ulcerative colitis, class one probiotics have been very well-validated, especially the studies using VSL or Visbiome. So it’s a multi-strain, class one probiotic. At high doses, somewhere between 112 to 900 billion, that’s been shown to really be efficacious for ulcerative colitis, less so for Crohn’s.

In fact, I just recently was doing a lit search again on probiotics and Crohn’s disease and I couldn’t. Every study was like, “We tested it for inflammatory bowel disease. It showed efficacy for ulcerative colitis, no efficacy seen for Crohn’s.” So for Crohn’s, I’m mainly starting with SacBoulardii for those patients. And then spores, I mean, I feel like if I have them pretty well stable and they’re a little teeter-tottering, not with their calprotectin or Crohn’s monitor scores, but just with their symptoms, I might start a spore at that point. But I’m definitely very, very slow and very cautious with it. So I totally agree.

Dr. Hedberg: And other than probiotics for gut repair, you know, there’s so many to choose from, many products out there. Are you using, do you like to use single things, you know, herbals, or are there any blends that you like to use? I’m just talking specifically about a lot of these herbs and supplements, compounds that are designed for repair of the gut barrier and reducing inflammation.

Dr. Gurevich: Yes. I’m using both singles and blends. Glutamine for a Crohn’s disease, especially small bowel Crohn’s, glutamine is my go-to. The problem I think with glutamine is you have to use it in a really, really high doses. So for an average 120 to 150-pound patients, you’re talking about 27 grams of glutamine per day is what the studies have shown to be efficacious. So I love that. I’m using recently, I’ve been using a lot of quercetin and resveratrol, and that I feel like for intestinal permeability is working magically.

I also think that I, you know, because of all the research that’s been coming out about COVID, and especially a lot of that research out of China, I started using it as part of my viral prevention protocol, and then I’ll really upregulate those doses for if somebody gets sick with a virus, any URI or any you know, flus, any URIs or anything like that, and I’m noticing quercetin doing really, really good work, both on intestinal permeability in the GI and on supporting the immune system. And there’s really good research on quercetin following traumatic brain injuries because it does cross the blood brain barrier. And so quercetin has become one of my…I now have a small love affair with quercetin.

And then zinc, for ulcerative colitis, zinc carnosine, and for esophagitis or very high Crohn’s disease of the esophagus or the stomach, zinc carnosine I think is working phenomenally. There’s some really interesting studies with zinc carnosine during treatment of radiation. So, you know, stomach cancer, esophageal cancer, where they’re irradiating, zinc carnosine not only prevents ulcers from forming to significant degrees in those patients, but also significantly speeds up recovery time. And so my thought is, if it is working that well for a patient who’s being irradiated, I think it works really well to heal up the mucosa of the upper GI. And if you do rectal administration of the intestine, just because it really just feeds the enterocytes and feeds the cells and really just replenish them.

Dr. Hedberg: And there are a few immunoglobulin products out there that most of them are IgG. I’ve been using and getting good results with IgY, which is relatively new. It’s called IgY Max.

Dr. Gurevich: Who makes it?

Dr. Hedberg: Moss Nutrition carries IgY. It’s from hyper-immunized chicken eggs. And as long as they don’t have an egg sensitivity, it works really well. Are you using any immunoglobulins?

Dr. Gurevich: Yeah, I am. I am mainly using the ones out of… I’m using Mega IgG from Microbiome Labs. I’m using their spores also. And yes, I mean serum bovine immunoglobulins, which that’s not what the one that you’re using, that is the one that I’m using, is extremely well-validated in the literature for a very, very long time. I think the studies go back to even like the 1970s, there’s some studies using serum bovine immunoglobulins and the colostrum from there.

I do feel like, so the way that I think about them is whenever patients go traveling abroad, especially, I’d like to put them on a, you know, GI preventative protocol so they end up not getting foodborne illness. And Mega IgG is part of that foodborne protocol, just because it really, you know, supports the immune system.

And then, if I’m having patients who are chronic, you know, I have a lot of patients who have this overlay between having bacterial overgrowth in the small bowel and Crohn’s disease, which makes perfect sense considering the anatomy changes that come with Crohn’s disease are the perfect, perfect storm to set up a bacterial overgrowth situation in the small bowel. And so I’ll use serum bovine immunoglobulins on those patients because I don’t necessarily want them on herbs forever, or sometimes, we’d just rotate through antimicrobials. And so I’m putting IgG products into that category.

Dr. Hedberg: Okay. And what about fibers? So there’s so many fibers to choose from, and I mean, the research, at least that I’ve read is somewhat okay as far as fiber goes. There’s Acacia, flax, psyllium, lot of different types out there. Do you use any fibers with your IBD patients?

Dr. Gurevich: Yes and no. So, you know, it’s really the dietary studies on inflammatory bowel disease are really interesting because there’s a lot of studies on using Specific Carbohydrate Diet, which is a Paleo-like, specific monounsaturated diet. You know, you’re really trying to take out most of the fibers. You know, in the beginning process of these diets, if you eat vegetables, they’re cooked, there’s no seeds, there’s no skins. There’s, I mean, you’re trying to cook down the fiber. And some patients do great on that diet. And some patients do crap on it.

And then there’s this other diet called the semi-vegetarian Crohn’s diet, which is done out, taken out of Japan, where it’s the exact opposite diet. It is basically a macrobiotic diet. And some patients do great on it, and some patients do crap. And so the reality is, I don’t think, I think that really, it just comes down to what the patient’s gonna tolerate. I’ll usually listen to the history and figure out if this is more of a vegetarian-oriented person and what their diet is like, and try to put it. If they’re more that orientation, then I’m gonna try to give them the semi-vegetarian diet, which has, you know, lots of brown rice, lots of miso, lots of vegetables and then animal protein once every two weeks or so. Or if they feel like they can’t tolerate vegetables and they’re in that camp, then I’m more likely to start the Specific Carbohydrate Diet with them.

Dr. Hedberg: Yeah, it’s so interesting because, you know, the diets couldn’t be more different and, and there’s, you know, this recent emergence of the carnivore diet and you know, you read some anecdotal reports of the carnivore working really well for inflammatory bowel, but then you have the, you know, the macrobiotic-like diet that you were just talking about. Do you have any theories on why one will work better for the individual?

Dr. Gurevich: Yeah. You know, the best thing that I can come up with is everybody has their own microbiome. At the moment, what we don’t know about the microbiome is significantly more than what we know. And you kind of just have to cater to what you have going on. I have a patient that I just saw this week and she was a vegetarian her whole life and then she got really, really bad ulcerative colitis.

And so she started doing all the internet searches and she got on the Specific Carbohydrate Diet and she went into such a flare. So I mean, like, I think we just ran labs and her ferritin was a seven, which was up from when we ran a couple of months ago when he was a two, you know, just bleeding profusely. And then she was like, “You know, what am I doing?” And so she was like, “I’m gonna go back to how I used to eat when I was younger,” which was a macrobiotic diet. And it completely got here out of the flare.

Like my theory with her is her microbiome was not set up to digest that type of protein, you know. But another patient, you know, completely can go into remission just with a Specific Carbohydrate Diet. And then there’s lots of patients who diet definitely is a big role of treating inflammatory bowel disease. But anybody who treats it knows that diet is not everything.

Dr. Hedberg: Right. Have you used the GAPS diet at all? I have to say I haven’t used that in practice. I know it’s very similar to the SCD, but not identical .

Dr. Gurevich: So I have some patients who prefer it, it’s really dairy heavy. You know, Specific Carbohydrate Diet has some dairy, but GAPS has a lot of dairy. All of those diets, I mean, it takes a certain type of patience, you know, somebody who really is diligent to be able to maintain it.

Dr. Hedberg: Exactly. Yeah. Just sourcing everything and making sure it’s local and organic and all those kinds of things.  So what about prebiotics? What have you found in the literature regarding prebiotics, and do you use those much with your patients with IBD?

Dr. Gurevich: So it’s again a yes and a no. I think prebiotics are kind of vital. I’ve been playing around recently with Dr. Ruscio’s protocol using all three classes of probiotics simultaneously or even ordering E-coli nissle from Canada and using all four classes simultaneously. And it’s been interesting. I don’t think it’s ubiquitously effective, but I do think that there is a subset of people that it really is stabilizing their GI. And one of the ways that I rationalize putting people on that expensive of a protocol is because I’ll, you know, ramp up the class ones and the class twos and class threes and fours. And then I’ll put in a prebiotic and I’ll have them on all four simultaneously with a prebiotic, because the reality is probiotics are kind of like air conditioning.

You know what I mean? Like they’re effective and they’re effective, especially when you’re taking them. But if you take them, there’s a high likelihood that you’re gonna backdrop. And what makes prebiotics different is they give you that stability. So you’re introducing this new microbiome into the small and large intestine, and then you give them prebiotic, so it feeds the microbiome so they can actually build a house and stay for a while. And so that’s where I’m using a lot of prebiotics. And then, you know, prebiotics are also fibers and fibers come from vegetables. And if they tolerate vegetables, then that’s my favorite place to get their prebiotics from.

Dr. Hedberg: The last area I wanted to ask you about was the interplay among IBD, IBS and SIBO. You have a lot of experience and knowledge about that. Is there anything you wanted to say about how those tie together and how you might approach one versus the other, if there’s a connection with those and IBD?

Dr. Gurevich: I think that nobody can argue it anymore. There was such a large connection. So, you know, Crohn’s is the easy one to talk about because it’s kind of obvious. You know, a lot of Crohn’s patients will get a luminal thickening and inflammation. That decreases the motility. The motility within the small intestine is one of the protective mechanisms of how we prevent bacterial overgrowth. You know, if we can get that migrating motor complex to continually wash the small intestine, bacteria can’t grow there, right? And then we can keep the ecosystem in harmony.

As you get transluminal thickening inflammation or fistulas. And what are fistulas? Fistulas are super highways that introduce bacteria from one part of the intestine to a different part. And the thing about the small bowel, if we’re talking about an enteroenteric fistula, which is a fistula from small bowel to small bowel, it’s like the microbiome is like a neighborhood. It’s like, you know, I live in Northeast, which is a very different neighborhood than Southeast. It’s got different people, different bacteria. And so when you introduce the bacteria from one part of the small bowel to a different part, then obviously, you end up with bacterial overgrowth.

So as far as Crohn’s, Crohn’s is kind of the perfect storm…say, that when I started learning, I started learning about SIBO in 2011. At that point, learning about SIBO fundamentally changed the entire way that I treat inflammatory bowel disease, especially Crohn’s disease. Because a lot of times, you’ll have these patients who feel terrible and so the gastro then increases their biologic and then the biologic doesn’t work. And so then they switched their biologic. And then, you know, there’s only a series of classes of biologics that you can get through and what’s happening is they’re treating them, but they’re treating the wrong thing because the problem is the bacterial overgrowth and that’s why the patient feels so bad.

And so when you prioritize treatment of the bacterial overgrowth in the small intestine, that actually can correct the inflammatory bowel disease, and sometimes it can get them out of a flare. This has been documented in the literature. When they talk about it there, they’re talking about what the best time to work a patient up for SIBO is if they’re inflammatory markers look normal. So it looks like they’re under good control, but their symptoms are not good.

I feel, I find that the opposite is true. You know, a lot of patients who wanna A, come and work with a naturopathic physician and B, wanna wait the amount of time that it takes to get in, they’re very motivated to not, you know, go on a drug routes or to not increase the amount of pharmaceuticals that they’re on. And so those patients are very motivated to let me work them up for SIBO first and go after treatment.

The other benefit about treating SIBO is that, you know, a lot of the herbs that we use to treat also…it’s like a double good thing. You know, you’re really, you’re getting rid of pathogenic flora, but you’re also healing up of the intestinal permeability and the inflammation in the small bowel, which has been really well-documented, which is usually why, or often why I’d like to treat my inflammatory bowel disease patients with an herbal treatment, as opposed to with a pharmaceutical treatment.

Dr. Hedberg: I don’t really do much SIBO, breath testing anymore. I did for a while and then just kind of figured out how to work with people clinically. Do you like to test people upfront for that with most people or are you doing some empirical work first?

Dr. Gurevich: I am still on the testing front and I know that I think we’re probably a dying breed. So the reason for that is because, you know, I really like to see if I’m on the right track or not. And so there’s a couple of things that I find very useful out of the SIBO test…know how high their numbers are. If I’m having patients come back, especially with methanes that are through the roof, 60s, 80s, 100s, my thought process for those patients are probably SIBO isn’t your primary issue. There’s probably some kind of GI pathogen that’s in there, most likely parasite, protozoa or worm that’s causing this amount of microbiome changes. So that’s really helpful for me.

The SIBO testing, the other reason why I like it is because I feel like I have a clear understanding of what treatment is gonna get me the biggest success. So, you know, depending on how high their hydrogens or methanes are, how many treatments of herbs or pharmaceuticals or elemental diet I’m gonna need to bring them down. And so that’s helpful and that’s a good way for me to kind of talk the patient through what their next couple months are gonna look like.

And then I also like to, you know, I run a task, we see where the numbers are. We go with treatment and then I follow the 85% rule. If you’re 85% better, I don’t need to retest you. But if not, I’d like to touch base.

And, you know, I have this patient, really interesting patient. She’s a microscopic colitis patient and the worst diarrhea. I have tried everything with her, just terrible, terrible diarrhea. You know, we’ve tried protozoan, parasites, and now we tried SIBO. She also has bile acid diarrhea. And for some reason she developed tolerance…route. I think her hydrogen were in the 60s. And what happened is we ran the SIBO test because she didn’t really get better. And the SIBO test didn’t change at all.

And then I was like, “Oh, well, that kind of makes sense in hindsight, because you’ve got bile acid diarrhea and Xifaxan is a drug that requires the bile to activate the function of that medication. And it has to be reabsorbed by the bottom of the small intestine.” And so, because I had that second SIBO test with no change, I was able to clinically kind of decipher out, “Oh, I think we need to be treating your bile acid diarrhea while we’re giving you the medication for the SIBO” and that to give her better efficacy.

Dr. Hedberg: Yeah. I can certainly understand that it’s sometimes, you know, it can be, you know, third-party data can be motivating for certain patients. And then, you know, so in other cases we do have to be careful with a label. But I think that in a practice like yours, where you’re seeing very, very serious cases, you’re probably more like a last resort with many people. I can see how that would be extremely valuable.

Dr. Gurevich: I do think that is why my perspective is skewed the way it is. I totally, I had a patient come in this week who I was the first person she’s ever seen for abdominal pain. I was like, “What?” Like, I mean, I didn’t even know what to say. I didn’t like it. I didn’t even know where to start. It was so simple. So I do I fully agree with you. I do think because of how specialized my practice is, I feel like I’m playing by a different set of rules a little bit than somebody who’s treating more broad spectrum clientele.

Dr. Hedberg: Right. Exactly. Okay. Well, this has been really excellent. You’ve created a course for inflammatory bowel disease. Can you tell us about that?

Dr. Gurevich: I could, can I say one more thing about inflammatory bowel disease?

Dr. Hedberg: Oh, yeah. Sure.

Dr. Gurevich: So I feel like my mission, especially because I work with alternative providers, is just to do a little three-minute education on biologic medications. And in particular, the desire for alternative medicine providers to take patients off of their biologic medications. So at the moment we’ve got five, we introduced a new five different biologic medication mechanism of action groups. You know, there’s a TNF alpha, there’s a monoclonal antibody inhibitors. There’s the JAK B inhibitors are the new ones that just came out. And there is often this desire for alternative medicine doctors to get confused and think their goal is to take the patient off of the biologic medication. And I really just wanna give a warning to functional medicine providers and naturopathic providers because the biologic medication is not our enemy.

We know that the biologic medication has side effects, but it has significantly less side effects than the immunosuppressants and then the steroids. The other thing is because it’s a biologic medication, the body has an ability to develop antibodies and make antibodies against that medication, which means that then that whole drug class goes out the window. And so the education that I always wanna give doctors is the goal is not to get people off of the biologic. The goal is to get them stable. Lots of these patients are gonna fail their biologics either way, without you taking them off of it. Lots of these patients still need a lot of GI support and help even on the biologic.

So my piece of education, my warning really is if a patient is stable on a biologic, don’t touch it. That biologic is giving them some stability and the side effects are not as significant as the side effects would be if you pulled them off the biologic, they got sick again and they can’t get stabilized.

And so that’s always when I’m trying to remind them functional medicine providers, because there is this war a little bit of, you know, the more natural way of doing things versus the pharmaceutical way of doing things. And it’s always been my experience that if you can find a pharmaceutical that people tolerate well, that doesn’t have a ton of side effects, that isn’t making them broke and you can supplement it with all of the other tools that we have in our tool belt, which is so vast, patients get the best care and then they’re also not at war with their naturopathic versus their gastro. And so that’s always what I wanna tell people. So I feel like I always want to say that because there is this desire for our cohort to do that and I think that it’s a dangerous desire.

Dr. Hedberg: Absolutely.

Dr. Gurevich: But yes, I did put together a very, very extensively long inflammatory bowel disease course. It’s nine and a half hours on Western treatments, drugs, epidemiology of inflammatory bowel disease. Plus it also has naturopathic treatments. I do a whole section on ozone, which is one of my favorite ways to treat many inflammatory bowel disease patients. Rectally, it works phenomenally.

I also did a whole talk on bile acid diarrhea and exocrine pancreas insufficiency. It is approved, I think, through next March for naturopathic credits for the entire country and Canada. And you can find it, if you go to my website, my website is and you can find the link to the class there.

The nice thing about the class online is, as everybody knows at this point, I talk very, very fast. And whenever I lecture at a conference, I always need four times as many slides as everybody else because I talk so fast. So there’s a ton of information in there, but you can watch me at half speed, which maybe will help with the anxiety that I bring in just by talking so fast all the time.

Dr. Hedberg: Well, I think that it’s not necessarily talking fast. It’s being concise, which is actually a real gift. And so, I think that’s a good thing. I will link to the course. If you go to and search for inflammatory bowel or Dr. Gurevich, I’ll have a full transcript of this interview today, and there’ll be links to Dr. Gurevich’s website and her course. If you know anyone with an inflammatory bowel, she’s definitely someone that you wanna look for. Anything else you wanted to mention, Dr. Gurevich?

Dr. Gurevich: No, you know, I feel extremely fortunate to have found the profession that I have because it is so rewarding to be able to sit with patients and really, you know, just go through the process and bear witness to what they’re going through and just try to help and advise them. It is, you know, naturopathic medicine is exceptionally well-suited for helping and treating the intestine and the whole person. And I’m exceptionally fortunate to live in a time where people have access to that care in a way that they never did in history. And so I just feel very, very fortunate to do what I get to do on a daily basis.

Dr. Hedberg: Well said. I feel the same way. So, well, thanks for tuning in everyone. Go to for the transcript. This is Dr. Hedberg, and I will talk to you at the next show. Take care.

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