Archive for the ‘SIBO’ Category

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The etymology of an orphan

February 26, 2010

Xifaxan and its manufacturer, Salix, has been making news all week. An FDA advisory panel recently recommended the approval of Xifaxan in 550 mg tablets, as an Orphan Drug  for the maintenance of remission of hepatic encephalopathy (HE,) a dangerous result of liver failure.

Xifaxan or Rifaximin, is almost always the front line antibiotic used to eradicate SIBO. According to the literature, it has many advantages over other antibiotics. As a broad-spectrum, non-absorbable antibiotic, it is not absorbed into the bloodstream and it acts against both gram-positive and gram-negative pathogens. In many trials, the administration of Rifaxamin has produced a very low occurrence of side effects and additionally the risk of antibiotic resistance is lower with Rifaxamin than with many other antibiotics. Probably the most unique property of Rifaxamin, and also what makes it most useful to people with SIBO, is its demonstrated efficacy against bloating!  It has also been used to reduce or eliminate cutaneous lesions in Rosacea patients with SIBO.

To be honest I am unclear of the FDA’s recommendation for people with SIBO. If there is an impact, what does the drug’s status as an orphan drug mean for SIBO?

According to Wikipedia, the Orphan Drug Act is “meant to encourage pharmaceutical companies to develop drugs for diseases that have a small market.” That is certainly SIBO!  However, orphan drugs have to treat orphan diseases; conditions that affect fewer than 200,000 people in the United States. I have no idea how many people in the United States suffer from SIBO. During holidays and office birthday parties when I watch everyone eat candy I feel like I may be the only SIBO patient in the nation.

It may not matter whether or not SIBO is an orphan disease. Just a day before the news broke of the FDA recommendation, an article discussing the deliberation noted that Salix is planning to submit a new drug application for Xifaxan this year, specifically for the irritable bowel syndrome indication in the first half of 2010.

 Currently, Xifaxan is prescribed to people with SIBO off-label. The developments of Salix’s new application for Xifaxan for IBS will be of some interest to the SIBO community because if it is approved then Xifaxan could be prescribed specifically for SIBO. Xifaxan has not worked for all of us; I have taken several courses and sometimes it works and sometimes it doesn’t. However, the largest issue with Xifaxan for SIBO is the prohibitively high cost. Most insurance companies just don’t cover drugs when they are used off-label. If Salix’s application is approved, more people with SIBO will at least be able to try Xifaxan. Which, I believe is a good thing. It is interesting to note that there were questions of both efficacy and safety during the HE study, and the SIBO community should be on the lookout to see if these same issues arise during the IBS studies.

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Google Alerts, Twitter Accounts, SIBO Awareness and Internet Friendships!

February 2, 2010

I don’t know what I would do without Google alerts. I was able to watch the Sherlock Holmes trailer the day it was released, although I don’t typically comb the internet for movie news. I kept tabs on my “home” agency, the one where I currently work, where I first worked out of grad school, while I left to trial the private sector.  And I found NonNosher thanks to Google Alerts too! And finding NonNosher’s blog, the Year of Eating Weirdly-Celiac Surprise, could not have come at a better time.

It’s true. I mean, I lived through months and months of mostly the same thing every night – a link here and there to a journal article I’d already read. Or a link to a citation to that same journal article. Or a brand new lit review would come out rehashing all the relevant SIBO literature, which I’d already read. Hooray! Sometimes the link would point to a recent forum post penned by – you guessed it, me! I did learn something completely new from my SIBO Google alerts – apparently SIBO is a very popular nickname!

So, when one day I opened up my Google alert to find mention of NonNoshing and Noragomy (what?) and Celiac disease, I probably didn’t think much at first, but I followed the  link anyway, and what did I see but someone else who used to really enjoy food and eating but now had problems with common, everyday items like fructose and gluten! I read with excitement upon finding my very first SIBO-centric blog besides my own, and I commented immediately. And here we are, about a month later and we’re twittering for SIBO Awareness. That’s right! You may have noticed that my twitter link has changed from my personal account, which is sometimes SIBO-related, to a new one using my blog name. You can find me here: http://twitter.com/GirrlockHolmes

Please follow me and then follow NonNosher, my partner for SIBO Awareness here: http://twitter.com/NonNosher

We want doctors to know how to test for and diagnose SIBO. We want nutritionists to recognize the signs and symtpoms of SIBO and be able to recommend healthy, SIBO-safe food choices. We want SIBO to get the same publicity that Celiac disease and the gluten-free lifestyle have. We want an easier time for the woman or man who wakes up one day and wonders where the bloating and distention or diarrhea and constipation or migratory myalgia or any other more or less common SIBO symtpom are coming from to have a little bit of an easier time on thier way to diagnosis. We want awareness and eventually we want something beyond treatment and recurrance. We want a cure!

NonNosher will probably, much like myself, need a little more than a year to eat weirdly and abstain from cake. Maybe, like me, NonNosher will need a few years. Here’s to a shared campaign and the wonder of the internet for bringing two women in two different states with the same digestive condition together to tweet for more awareness about SIBO!

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Happy New Year Without Cake!

January 1, 2010

Let’s make it a good one. I have a lot of things in mind for how we can do that, but it mostly comes down to talking about what we’re going through, with each other, as loudly as we possibly can. There is so much activity in the yahoo group right now that I can’t keep up with all the posts. Some of us are really suffering right now and some of us are feeling better. I shed a tear for what we are going through a few mornings ago. But if we’re going to be going through it, its best that we’re all talking about it together.

I owe people blog posts and comments and replies to comments and messages and emails. These are coming. Tonight, however, I’m enjoying a healthy chicken dinner and a few hours of Rock Band with my friends. I love New Year’s Eve and New Year’s Day and the chance to start fresh or inject new life into ongoing quests. I didn’t really take time to make resolutions this year but here are a few things I’m thinking I want to do:

Find out how what things I can do to feel great and do everything in my power to do these things the right way

Stand up for inquiry and the questioning of conventional wisdom whenever I can, and be willing to accept conventional wisdom when and if it is actually right!

Continue being an advocate for myself and be an advocate for someone else

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All of the above most likely

November 17, 2009

Does this picture make me tear up (and sob uncontrollably) because

A) I grew up without a mother, who died when I was 10?

B) I’m afraid I’ll never have a child of my own? This used to be totally okay; I even went through the trouble of falling in love with a man who also didn’t want to have kids. I think if I were experiencing anything like what most women go through with their biological clocks I might have died by now, but mine’s ticking a little – I swear I can hear it under a pile of new wave CDs, my undying love for my cats, about 12 months of backlogged student loan payments, several layers of guilt about not being productive enough at work, a few screenplays I never wrote or produced, and that decision I have to make aboutwhat I’m going to wear this weekend to that party that I love.

C) I’m on my 6th round of Xifaxan and they always make me feel a little crazy?

OK Here are my symptoms: Slight irritability. A light feeling of sadness and despair. Light bloating and crampiness.

That’s it. Seriously.

And here’s my theory. Kefir ruined my life. This happened because the housekeeper wave is screwed, and has been since the spring of 2006, if not before. Kefir grains may be full of beneficial bacteria but they tend to deposit all the good stuff in all the wrong places for me. Hence, the last course I took of Xifaxan wasn’t able to help me as much as it normally does. Not because it wasn’t working, but rather because it was working so intensely hard. It was trying to get to the normal bad guys colonizing my small intestine, but it got really busy killing off an entirely new population of friendlies, kefir-y goodness friendlies, meant for my colon, which had taken up residence in my small bowel. This is why I had a CRAZY Herxheimer, which included severe body aches, depression, bloating and distention, headaches, diarrhea, and just loads and loads of misery. But it was all worth it because I got better, right?

WRONG! I pretty much felt only slightly better than before. Which is why I am taking a sixth course. I hold out hope that this time I truly did just need more Xifaxan to completely wipe out the unusually large (even by my dense standards) microbial zoo living in my short gut.

Good things that are happening – I’ve lost a few pounds, finally. I am slightly less tired than before and able to work out (which is why the weight is coming off – god bless you low carb enthusiasts like Taubes but if I don’t move I don’t lose) and I don’t want to spend my entire life under the covers, just some of it.

More to come.

Comments, suggestions?

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More thoughts on kefir and a new Italian SIBO study

October 1, 2009

I’ve taken about an 8-day homemade kefir break and gone back to a more simplistic meat-and-eggs (and cheddar cheese) Atkins-style diet. I no longer feel like a zombie walking around but I’m still very tired. I’m going to start a new batch of kefir tonight (my grains have been sitting in milk for a week) as I just can’t buy into it being a black and white thing – as in kefir is really good or really bad for me….I think I just need to drink a much smaller amount each day.

I’m still having the body aches and pains. I haven’t gotten around to getting back on the VSL. I’ve been taking the peppermint oil and oregano oil again (natural anti-microbials) although this recent thread from some folks in the Rosacea community doesn’t give me much hope that these efforts will assist in bringing any lasting relief.  The bloating was pretty awful yesterday even though I ate above the line all day. I am about to start my cycle so I’m not freaking out about it. I’m even having small amounts of sugar today since the bloating is coming of its own free will. Myperiod = cravings for chocolate. I’m only human.

Still working through some complex thoughts on the constant return of digestive symptoms for those of us who experience great luck with Xifaxan. It really seems to be the norm, not the exception. I found a few old articles that I won’t even bother linking where Pimentel notes that patients can experience symptom relief for around 10 weeks. This is a fair enough number if 1) Xifaxan didn’t cost so much for off-label use and 2) it actually happened for most folks.

So I didn’t find any new research on reoccurance, but I did find a new Italian study on SIBO in children. Enjoy the abstract here.

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RLS/SIBO/celiac connection article

September 4, 2009

The Restless Leg Syndrome, SIBO, Celiac Connection

Interesting yet not completely new idea. Be sure and follow the link to the specialists’ site as well.  

I am waiting for the chronic multi-illness/SIBO connection research to catch up with the digestive-distress caused by SIBO reocurrance research (there isn’t much.) I wonder what happens when antibiotics are administered, say the 3rd or 4th time, but do not fully eradicate the bacteria. Do the non-digestive symptoms return and continue the way that the digestive ones do? And what role can probiotics play in preventing these types of symptoms?

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The antimicrobial properties of kefir, Gulf War Syndrome and gut bacteria, and the effects of high-fat nutrition on gut flora

September 2, 2009

Some interesting and unexpected research finds today:

On kefir, which I am beginning to make in my home

Resoution of Recurrent Clostridium difficile-associated Diarrhea Using Staggered Antibiotic Withdrawal and Kefir

Antimicrobial and healing activity of kefir and kefiran extract

And a few interesting studies recruiting now…

Bacterial Overgrowth Associated With Chronic Multisymptom Illness Complex
Taking the super obvious connection between SIBO and CFS past the obvious and examining the symptoms occurring specifically in Gulf War Syndrome (GWS) patients! Phenomenal!
And…

A controlled feeding experiment

“The purpose of this study is to determine the effect of dietary fat, in standard formulation, on the composition of the human microbiome in a prospective study of normal volunteers. Participants will be randomly assigned to either a high fat or low fat diet for 10 days. The gut microbiome will be phylotyped in fecal samples as well as in bacteria adherent to the colonic mucosa prior to, and during the course of the dietary interventions.”

I’m definitely going to want to follow these two for outcomes.

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I have spent my whole life in ruins because of people who are nice…

September 1, 2009

At present I’m taking a course of Neomycin. This is my first time on an antibiotic that isn’t Xifaxan, and I’m not liking what’s going on with my body. Lots of bloating, popping out of my clothes, abdominal pain and no appetite whatsoever.

The nicest thing anyone could ever say to me when I tell them how bloated and distended I am is “Wow, I see. I’m sorry.” Barring actually agreeing with me, just a simple “That sucks, I’m sorry you’re going through this” would suffice.

Things that aren’t so cool to hear:

No one can tell.

You feel it, but no one can see.

It probably feels worse than it is.

These are all well-meant as the person is trying to assist me in moving past the discomfort and getting on with my life. That’s great. But it just hurts my feelings. IF I’m complaining to you about my bloating and distention, we’re not just acquaintances – we know each other pretty well! so feel free to acknowledge that you sort of know what I look like! I mean, walking around with my gut hanging over my waistline is not really my normal thing; I tend to buy clothes that fit me. This thing takes over my body and blows me a little bit out of proportion. I don’t think I’m gaining the 6 inches each day that I used to before the diagnosis, but it still gets hard to breathe, hard to wear my clothes, and therefore hard to feel comfortable in my own skin. There’s nothing worse than walking around distended and thinking that even your friends think you always look this way. What’s the point of anything? I think I’ll just wear a potato sack to work! Although first I’ll need someone else to clear all these potatoes out of the way…

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The Diet

July 27, 2009

Even though I made promises to update the blog, I’ve failed at many attempts. I’m having a couple of issues.

I prefer discussion over a monologue. Obviously this is why I do tend to give a little more attention to my yahoo group, because we can bounce ideas off one another, and address specific and targeted issues that people are having. Here too, however, I can be slow/late/negligent when it comes to writing and responding to group discussions because Outside of work I spend very little time sitting down. I had a knitting blog once. I used to like movies. But as a cursory glance at this blog will tell you, I am not one of those SIBO’ers who has trouble keeping weight on; quite the opposite, I have trouble losing, and I haven’t lost nearly 40 lbs in the last 2 years or so by blogging or knitting or watching movies. I run, I use the elliptical and crosstrainer, I lift weights, I play wii sports and wii active and I go dancing whenever I can. So blogging is just once thing that’s slipped out of my grasp a little in an effort to hit my weight loss goal (about 10 – 15 more  lbs to go btw. Lastly, I’m learning something about myself lately and it’s that I’m uncomfortable with the amount of knowledge I have about this condition. I have yet to meet/cross paths with anyone who knows more about SIBO than I. Bloggers, forum posters, doctors, you name it. I value expertise very highly and I do not think it comes easily. All this time I have been avoiding telling people how they should deal with their own overgrowth, what they should eat, what they should take, etc. But a few things are becoming clear in my group. There are only a handful but I want to discuss them a post at a time. So for starters, lets talk about diet.

1) A Low carb, high fat diet helps most everyone with SIBO to manage their symptoms and feel a little more normal. The people who aren’t helped by low carb generally fall into two categories: A) People who either think they have issues with fat digestion or people who really have issues with fat digestion and B) People who won’t even bother trying. A group discussion recently brought me enormous frustration when it went something like this:

“I am very sick.” “what’s your diet like?” “I eat pretty much nothing but fruits and oats.” “Try low carb.” “Oh that doesn’t work for me. I need lots of fiber to keep me regular. I put psyllium husks in my fruit smoothie.” “Okay, well maybe you should stop that and try to drop the carbs and up the fat.” “Oh no, I’ve tried a high protein diet before and I have issues with C.””Okay well protein isn’t going to help you go to the bathroom but fat is.” “Oh I can’t eat a high protein diet.”

I haven’t done a ton of research on high protein diets. I eat what some might consider high protein, at between 110 – 150 grams per day. I also run 3 miles a day most days, or go dancing for 3 hours at a time with no breaks. I need the protein I consume. I remember the hair loss that used to occur all the time in my vegan years; I don’t have to deal with that anymore. When you look at my macronutrient breakdown, however, my diet is really high fat. Always my fat intake is at least 60% of my total intake. That leaves less room for protein and even less room for carbs. There are a few reasons for that. First of all, when you have SIBO, fiber becomes fairly indigestible. If you can easily digest fiber, I’ve got news for you – you probably don’t have SIBO. Secondly, most sugars aren’t digestible either, so if you have no sugar, and you have no fiber, all you’re left with is starch. And guess what? While Dr. Pimentel says you can eat all the potatoes, pasta, rice, and bread that you want, (and I hope for your sake he’s right) you may be like me, and those foods may bother you about as much as low GI carbs do. Generally, we with SIBO have two modes of operating – Playing It Safe, and Life Experimentation. Playing it Safe occurs when we feel worst, when we’re trying to figure out what is wrong, when we have an important event coming up and we don’t want to pop out of our party dress or spend the evening in the restroom missing out. Life Experimentation is what we’re doing when we’re not Playing it Safe. Playing it Safe means neither of us are eating rice or oatmeal or buckwheat, if we’re smart. Unless we know for a fact that those foods aren’t feeding the SIBO, and I doubt I can find one person who doesn’t know that. But if you are them, by all means, eat those oats! During Life Experimentation, very few rules apply, except that there is no reason to think you can go overboard on fruit and fiber with no consequence. The important thing, however, is that Life Experimentation gives you something you didn’t have before – knowledge. Of how a food gets on with your digestive tract. During a certain time of the day. During a certain length of time out from your treatment. During your period. All the time. Whatever you can grasp.

High fat and high protein are not the same thing. Okay, now that we are clear there, I will need a person to tell me that they ate a lamb chop cooked in coconut oil (or something less chemically offensive if they are FCI) or a broiled steak or a piece of baked cod and then tell me that they experienced bloating and gas and cramping or some other symptom due to their meal before I will change my tune from the simple gospel that if you have SIBO, meat will not make you sick. I get so tired of reading blog after blog and discussion post after discussion post about people eating ramen noodles while their family dines on turkey or ham. If you have SIBO, there is no mechanism by which the bacteria living in your small bowel can digest or even attempt to digest meat. Meat is probably the safest food you can eat, followed by eggs if you are not allergic (most people aren’t) and dairy if you are not intolerant to that. You can add green veggies to your diet as long as tolerated – the fiber can get you though so be careful with that one.

I have heard a lot of excuses for not going low carb. Especially distubing is the SIBO sufferer who is having trouble keeping weight on; he or she is afraid to eat a low carb diet because then won’t they just lose tons more weight? Maybe I just love food too much, but my answer would be “not if you eat enough of it,” which might be easier to do once you begin to eat food that your body is capable of digesting.

What’s your experience with low carb, high fat? Did it help your SIBO? If not, please share your thoughts and help me understand why I’m being a douche.

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That kid is back on the escalator again!

May 16, 2008

My job is often full of inappropriate people, but then a lot of jobs are. A lot of times it can actually feel like I’m babysitting a bunch of rude children, only I’m not really paying all that much attention to what they spend all day doing. I’ve been chided more than once for taking lots of supplements (so much so that I’ve bought little pill keepers and carted things back and forth instead of keeping my bottles on my desk) and I’ve been asked why I spend so much money on food when people spot me carrying bags in from the local organic market. I’ve been asked point blank why I don’t ever partake in birthday cakes. Because we have about a million birthdays every week here. And apparently some people are offended when everyone on the floor doesn’t participate. Even though I pay into the cake fund each month when asked!

Today I got in the elevator with a gentleman who works here on my floor. He turns to another gentleman in the elevator, a friend of his, and asks, “If you don’t mind me asking, why are you putting on so much weight?”

I was mortified for them both. The poor guy was really embarrassed. He wasn’t really overweight, by the way. The offending man turned towards me and tried to explain himself, but I told him that there wasn’t any explanation in the world that he could offer to get himself out of that one.

Xifaxan has been done for some time now. I’m feeling like my old self again. Still low carb, although my doctor has urged me to test the carby waters, so I do every now and then. I have a wrap, I have a bowl of puffed rice. I always react, only not as badly as before. the discomfort is always there but the bloating just isn’t as bad as it used to be. We are waiting it out and I may undergo a second breath test in July, and respectively a second course of antibiotics. I’m really into the idea of regaining my carb tolerance, but not in order to eat them regularly, because I’d like to get back into deep ketosis. I’ve been playing around with my macronutrient breakdown a little bit this month, going back and forth from high protein to high fat. Again, I have no idea what I’m doing, but high fat does seem to rev up my metabolism a little. I realized today that if I look at weekly or even monthly totals, I’m still losing at a very slow rate, but if I look at the long view, or two months to the day since I started weighing everyday, using a heart rate monitor, and burning more calories but less frequently, I have lost 7 lbs. That’s 3.5 lbs per month – that’s quite fast for me.

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Xifaxan – day nine (or “don’t give it to me – 9×3…you’re out of control, emotional symphony…”)

April 23, 2008

I wish I really knew what I was talking about when it came to nutrition, but I don’t. I only know that I constantly stride the balance between a biologically driven disaster waiting to happen and someone who learns from experience. I think that’s what most of us are. How much we learn varies. How willing to act on what we learn varies even greater. And how lucky we are when it comes to the efficacy of our application is an entirely different story.

Tonight I will take my 27th dose of Xifaxan, bringing my next to last day of the ten day course to a close. Each day has been different. I’ve felt pretty bad almost the whole time – physically and emotionally. Although I ran my first non-stop mile last weekend, my workouts otherwise have been kind of crappy. I’ve lost interest in work. I am generally weepy and tired a lot. I don’t attribute this to Xifaxan on the whole. I’m curious about a whole host of things. I have my period. I’ve been drinking Diet sodas again. Emma says that the effects of aspartame are worse after exercise and I live at the gym these days. I’ve been getting whole caff coffees rather than half caffs. I’ve been eating a ton of protein. And my carbs have been high – in the high 30s to low 40s.

The weight loss is going well. Its slow but not as slow as it had been. I think I’m losing at a pace that I can accept now. It’s for shame that I would be at or around my ideal weight if it had only come off like this from the start. I’ve lingered for a few days at my lowest adult weight ever. I’m looking forward to getting lower. I hope that a weekend in CT won’t ruin things. I don’t plan on eating off diet or anything, its just hard to know what you’re really getting when you are dependent on restaurants and the B&B kitchen.

I’m incredibly thankful that I had a chance to have a breath test and I’m incredibly thankful that I had a chance to take Xifaxan. And I’m pretty terrified that it won’t work. That’s where I am with that.

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How does one shout from the rooftops?

April 16, 2008

On Monday morning I found out that my hydrogen breath test was positive for small intestinal bacterial overgrowth. Today is my second day on 1200 mg of Xifaxan. I am also taking VSL #3. I am trying to keep my regular low-carb diet with minimal lactose. It’s going well. I don’t feel so great. Kind of like a good day pre-low-carb. A bit of gas, especially at the gym. Some pain. Lots of rumbling, but some of it from places that I’ve never really heard rumbling before. I will start my period soon, so the little bit of bloating could be that.

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As I possess my soul in patience and make as little noise as possible…

April 9, 2008

I really didn’t want the hydrogen breath test – getting it approved, taking it, waiting for the results – to be a big deal. I have been disappointed by so many test results before. But I just found out that the doctor has analyzed my test kit, so I’m all ajitters to find out……

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The Hydrogen Breath Test

April 5, 2008

I’ve fasted for tests before but for some reason I awoke ravenously hungry this morning after a 12 hour fast for the Hydrogen breath test. It’s all very complicated – there are two sets of directions instead of just one and I feel like I haven’t prepared well enough. My dear husband studies the instructions like he’s preparing for the SATs, and I mix up the lactulose solution, which is surprisingly clear. We fiddle with the bag and when he thinks he’s figured it out, I start to drink. There isn’t supposed to be a taste to Kristalose, but to me it tastes like diluted sugar water. We start the test at noon.

 

It gets easier as we go as everything is already set up for us. We interrupt Mr. Brett each alarm (spaced 20 minutes apart) and I breathe in a bag. End of story. By 12:30 I want ice cream. By 1PM I really want ice cream. I also have really mild cramping and borborygami that worsens slightly throughout, but is really nothing to write home about. At 2 I am super cranky. I can easily enough blame all of this on drinking the Kristalose, but then we’re really getting into the realm of speculation, considering that I don’t know anything about the nutritional makeup of the stuff. I do have bloating, however, which can’t really be attributed to anything else. I hope it will subside.

As I write this, I have ten minutes left before I breathe into the last tube and that’s it! I can’t wait to have some coffee with cream, and eat breakfast/lunch. Then we’re going to the green market to get lamb steaks from Three Corner Farm and cream from Ronnybrook.

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Yours affectionately

April 4, 2008

Once again I haven’t kept the blog recent. Tomorrow I’ll take the hydrogen breath test for the detection of Small Intestinal Bacterial Overgrowth (SIBO.) I’ll take it at home with my husband helping. We’ll probably watch his anniversary present to me – I finally own the entire Granada television series with Jeremy Brett. If you’re asking which Granada television series with Jeremy Brett, you’re definitely here because of gastrointestinal problems, so you’ll want to read up on tomorrow’s post.
I’m scared of weight gain and cramping due to the test. I’m even more scared of weight gain and cramping all for a negative result. The doctor that I’m currently working with is great – he’s in the Village not too far from my work and he’s already made a lot of really interesting observations and even offered suggestions on the direction to go in once this test is complete.

In other dietary news, the weight loss is once again coming along nicely. Not as fast as I’d like, but I think I must just come to terms with the slow loser that I am. It seems I was pulling off a nice round 1% of my body weight loss per week, but today was an off-day on the scales, which could change everything, or not. Drinking a sugar solution that is sure to give me diarrhea probably won’t help matters.
I’m piloting a new name for the blog, as is obvious from the header. I think it suits – this really is likely to be a year without cake. It’s already April and I haven’t had even one bite. However, dear readers, my identity is sure to remain the same, because it is my business to know what other people don’t know about my stomach.

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