Dr. Nathan Connelly Answers Your Questions on SIBO
Nick: We’re back speaking to Nathan about small intestinal bacterial overgrowth, also known as SIBO. Welcome back, Nathan.
Nathan: Oh, thanks, Nick.
Nick: So what is SIBO?
Nathan: SIBO, or small intestinal bacterial overgrowth, is a condition caused by having too many bacteria in the small bowel, not of any particular type of bacteria, although generally, it’s thought to be the usual Gram-negative bacteria that exist in the colon. But to give an example, we measure the content or the numbers of bacteria in the gut in terms of log species. 10 is one log. 100 is two logs. 1,000 is three logs, et cetera. In the colon, you’re supposed to have nine to 10 logs of bacteria per mL. In the small bowel, in the distal small bowel, it might be six logs or five logs all the way up to the four logs of bacteria in the proximal small bowel, so really very, very few numbers, tens of thousands to hundred thousands times less than exist in the large bowel. And that gradient of bacteria exists for a number of reasons, but it is important in maintaining the ability of the small bowel to do its job, which is to absorb nutrients. So when that balance gets upset or those numbers go up, it causes problems.
Nick: So how is it different to IBS?
Nathan: Well, SIBO is a distinct clinical condition, which is fairly-well understood, and it’s kind of fairly simple. Irritable bowel syndrome is more sort of complicated than that, and it’s considered still be a functional disorder where everything looks normal, but it doesn’t work normal for reasons we don’t quite really understand. SIBO, on the other hand, is kind of a single-word answer versus your Encyclopedia Britannica of answers. And it offers a fairly straightforward way of treating. There’s lots of disagreement about the treatment, but the treatment still is fairly straightforward.
Nathan: The similarities are that the symptoms can be quite similar, so symptoms of altered bowel habits, especially diarrhea, increased frequency of using one’s bowel, abdominal bloating, abdominal cramping, sometimes nausea, sometimes weight loss. These are all symptoms that are in common with most causes of gastrointestinal illness. And SIBO just provides a one-word answer to what on the surface might occur to be a case of irritable bowel syndrome.
Nick: Okay, so it’s not a good thing to have both, but if you have SIBO, it’s better than having IBS?
Nathan: It really depends. I’ll give you an example of this, Nick. People would say, for example, that people with Crohn’s disease, which is an inflammatory condition of the bowel, are much worse off than people with irritable bowel syndrome, but … In many ways they are, because Crohn’s can cause a need for surgery and all the rest of it. But in the end, if you look at the quality of life indicators, and the medical profession’s got lots of way of doing these quality of life questionnaires, people who have got irritable bowel syndrome have just a bad a quality of life as people who have Crohn’s disease.
Nathan: So when you’re weighing up which is the one you’d rather have, I think if you’ve got mild irritable bowel syndrome, it’s better than having severe SIBO. And if you’ve got mild SIBO, it’s better than having severe irritable bowel. I really just think it depends on how badly it affects you and how able you are to access a treatment that works for you. Because just like irritable bowel syndrome is sometimes difficult to treat, sometimes SIBO is difficult to treat. So I don’t really know if one is better than the other.
Nick: Yeah, okay. It probably wasn’t the best question, but I probably wanted to highlight that SIBO sounds less complicated to, I guess, treat than IBS.
Nathan: Well, it’s a lot easier to explain to patients. You know, when I get people who I do on a colonoscopy on for their diarrhea, and maybe they have a family history of Crohn’s disease, I’ll say to them, “Listen, you haven’t got Crohn’s disease.” They’ll say, “Well, is it irritable bowel syndrome?” I say, “Well, probably.” They go, “Thank God for that. I haven’t got Crohn’s disease.”
Nathan: But again, it really depends on the individual and their condition as to who’s worse off. SIBO is easier for a doctor to deal with, because it’s easy to explain to a patient what SIBO is and how you treat it. Irritable bowel syndrome, the first thing you have to get over is explaining to the patient it’s not all in their head, because that’s immediately what the patient will say, “You’re just telling me it’s in my head, Doctor.” So that’s the hardest bit to get over initially with that diagnosis.
Nick: I see. So you’ve mentioned Crohn’s disease. Do we need to sort of define that as well?
Nathan: Well, Crohn’s disease … A lot of people, the listeners, will understand what Crohn’s disease is. It’s an inflammation of the bowel anywhere from the mouth to the bottom end that occurs, again, for reasons we don’t know, but the bowel is actually visibly inflamed and ulcerated. But it causes the same symptoms: diarrhea, abdominal pain. All those symptoms are exactly the same as irritable bowel syndrome.
Nick: I see. So now that we’ve mentioned symptoms, I have a list here, so I’ll just go through them. So we’ve got stomach pain, especially after eating, bloating, cramps, diarrhea, constipation, indigestion, a feeling of fullness, gas, and even weight loss for SIBO.
Nathan: They’re all very common gastrointestinal symptoms, and yes. They’re all symptoms you could find in a patient with SIBO.
Nick: And we’re not really missing anything else, are we?
Nathan: Not really. I would say compared to other patients with … say, if I saw a patient with irritable bowel, the excessive gas, bloating feeling is probably more predominant in SIBO. But the biggest reason to think a patient’s got SIBO is not to do with their symptoms. It’s to do with their past medical history.
Nick: Anything specific you want to mention about that?
Nathan: I’ll get to those in the causes.
Nick: Okay, so we’re about to head into them. Before we do, what are the complications?
Nathan: So, apart from weight loss, which can occur and can be problematic, and possibly I guess, in some cases electrolyte disturbance because of the diarrhea, some of those patients with SIBO do develop nutritional deficiencies, especially B12, and maybe folate deficiency, and maybe sometimes iron deficiency. But they’re probably the major complications. But having SIBO doesn’t seem to predispose patients to cancer or any other kind of complications. It’s more the nutritional ones.
Nick: Okay, so it’s nothing quite serious? It’s more probably just going to annoy you or sort of make each day a little bit harder to get through?
Nathan: Yes, the symptoms of SIBO … Like I said, they’re very similar to irritable bowel syndrome, so it’s kind of like a treatable form of irritable bowel syndrome, an easily treatable form of irritable bowel syndrome. But generally speaking, I mean, a patient out there severely affected by SIBO would disagree with me, but generally speaking, the patients are fairly mild. They present as ambulant patients that would walk in looking quite well, and they’ll walk out looking quite well. They just have these chronic gastrointestinal symptoms which are bothersome and reduce quality of life in most cases.
Nick: Okay, so now that we’ve touched on the complications, let’s go to the causes. What are the causes of SIBO?
Nathan: Well, SIBO can occur, and I’ve seen it occur in people who are perfectly normal who have never had any alteration of their gut anatomy and are perfectly well from that perspective. But the vast majority of patients with SIBO usually have had some previous surgery on their gut. For example, patients who’ve had gastric bypass surgery, if you test them for SIBO, they universally test positive. If there’s a patient who [inaudible 00:08:13] gastric bypass surgery, patients who have had previous excision of parts of their bowel, especially the right bowel, what we call the ileocecal valve is a valve that exists between the small bowel and the large bowel, probably to keep bacteria in the large bowel rather than the small bowel. If you’ve had that valve cut out, which is not uncommon due to cancer, or Crohn’s disease, and sometimes from complicated appendix surgery, then you lose that valve, you lose that barrier, so you tend to lose the gradient of bacteria from the small bowel to the large bowel. So any of those kind of surgeries predispose patients to having SIBO.
Nathan: It can also occur in people who have problems with the way their small bowel works, especially patients with connective tissue diseases like scleroderma. And also, it can be more common in people who take antiacid pills, it’s thought, so proton pump inhibitor therapy. They’re probably the three major risk factors or groups we see at risk for SIBO in the community.
Nick: I see. I did do a little bit of research to try and find out the causes to discuss, and what you’ve just mentioned didn’t sort of come up on my radar. The only thing I can mention is having a weak immune system, but that would open you up to lots of other health problems anyway.
Nathan: Well, the immune system in terms of the gut really acts mostly at the mucosal level, so it’s not the bacteria invading your small bowel and ending up sort of spreading into your body. In terms of the actual bacteria within the gut, that’s not really generally immune-based. What keeps the bacterial numbers down in the small bowel predominantly is flow. You need to have flow of stool through all sections of the bowel. The minute you lose flow, just like a stagnant river, you get buildup of bacteria.
Nathan: For example, people who have had a gastric bypass, they have quite a significant segment of their small bowel that doesn’t contract and doesn’t move, and you tend to get buildup of bacteria in that section. Likewise, people with scleroderma have problems with the way their bowel contracts, and that tends to not move things along properly. So generally speaking, it’s due to having stagnant areas of fecal material within the gastrointestinal tract, particularly the upper gastrointestinal tract that tends to more predispose. And that’s why patients that have SIBO often do have a past history of some form of gastrointestinal surgery.
Nick: I’ve also got something about pH changes in the small bowel?
Nathan: Yes, potentially. And that’s, I guess, partly where your proton pump inhibitor therapy comes in. So people that take PPIs do have altered pH of their stomach, for example. But measuring pH in the small bowel is difficult. The pH in the small bowel is supposed to be slightly alkaline. So patients that have pancreatic problems potentially could have SIBO. But what you’re looking for in general, because I see patients with diarrhea all the time, what you’re looking for in a SIBO patient is any kind of anatomical abnormality that could predispose them to having the condition, which increases their statistical risk, I guess, of having this particular condition. But measuring things like pH and gut immune response are quite difficult.
Nick: I see. So how do you diagnose it?
Nathan: Well, broadly speaking, as in most medical conditions, there are different ways of diagnosing. If you want a test to diagnose it, then hydrogen breath testing or methane breath testing is the way we do it in general. What one does is to have the patient ingest some sugar, which would normally pass into the large bowel and get metabolized to hydrogen or methane, and the methane or hydrogen are absorbed and breathed out.
Nathan: So generally speaking, if you’ve got a normal response to these sugars, the hydrogen level doesn’t go up from anywhere between 90 and 120 minutes. That’s a normal kind of delay that you would expect, because what you’re waiting for is these sugars to get into the colon. The glucose, it shouldn’t really go up at all, because glucose should be absorbed by the proximal bowel before the bacteria even see it, so the glucose ingestion should not cause a hydrogen rise. Lactulose, which is a nonabsorbable sugar, is different, but the hydrogen shouldn’t go up with lactulose until you’re sort of two hours or an hour and a half in.
Nathan: In SIBO, you see this very, very prompt and early rise in hydrogen with either lactulose or glucose, which usually happens in 30 minutes to 45 minutes. The test when it’s positive is pretty striking, and a positive test in my experience is fairly diagnostic of SIBO. So that’s called hydrogen or methane breath testing. It’s a fairly easy test to do. It’s non-invasive. It does suffer a little bit from issues of sensitivity and specificity, i.e. issues with picking up the condition you’re interested in or excluding it when it’s not there, but it’s probably the best test we have.
Nathan: Back in the earlier days, we used to actually try to culture or measure the amount of bacteria based on an aspirate from the duodenum, but that’s a difficult test to perform, and it suffers a lot from reliability issues, so we don’t tend to do that so much anymore. They are inventing some pretty nifty new technologies for looking at these things. There’s a new capsule coming out which can actually measure gas, and pH, and all sorts of things in the small bowel. So I think in the end that for SIBO, that’s the kind of test we’ll be using is a capsule-based test for it, but that’s not commercially available yet, at least not in Australia.
Nick: From the perspective of a patient when they come in to do the hydrogen breath test, you’ve mentioned it’s non-invasive, so it sounds fairly painless?
Nathan: Mm-hmm (affirmative).
Nick: So they’re obviously strapped to some sort of mask, and then they-
Nathan: Not, not at all. Basically, you just do spot hydrogen levels. So we only do hydrogen in our rooms, because the methane testing is a bit more expensive, but basically, you just do spot exhalations of … so it’s a bit like a breathalyzer. You just do a breathalyzer every 15 to 30 minutes, and it measures the hydrogen level. So the worst part about having the test is succumbing to boredom. Generally, one has to sit around for a couple of hours, breathing into this machine every 15 minutes to half an hour, and patients get quite bored. So apart from that, it’s very straightforward.
Nick: All right, so it’s almost similar to sitting in a waiting room?
Nathan: Yes, that’s what the patients do. They sit in the waiting room, doing periodic breathing into this hydrogen machine.
Nick: Okay, so they-
Nathan: You don’t have to do the breath testing. I don’t do it every time. If I’ve got a patient who clearly has a major risk factor for SIBO, and they’ve got symptoms that are typical, I’ll often just give them some antibiotics and see if they get better. If you’re going to treat people continuously for year on year, then at some point, you should do the test in my opinion. Some might disagree with me. Some would disagree that we should treat at all without a test, but that’s the differences in the way that doctors think. But I think as a one-off, treating it initially is not the wrong thing to do, especially if the patient has risk factors.
Nick: Is it a reoccurring problem, or is it something you can cure, or not?
Nathan: It tends to be reoccurring, so if you’ve got an anatomical abnormality that’s causing it, like you’ve had previous bypass surgery, or you’ve got scleroderma, or whatever the reason. Generally, because the reason persists, it’s always at risk of coming back. But what an individual SIBO’s going to do, you don’t really know until you get down the track. And someone can have an exacerbation every five years. That’s not such a big deal. If people are recurrently getting sick with it, then it becomes more difficult.
Nick: How do you treat it?
Nathan: So I treat it with antibiotics. I think they’re the only reliable way of treating the condition, unless of course you can fix the underlying problem, which is unusual to be able to do that. You can’t give someone their ileocecal valve back, and you certainly wouldn’t reverse their bariatric surgery just for SIBO.
Nathan: So basically, the treatment is antibiotic therapy, and there’s multiple different antibiotics that are used. Generally, we try to use antibiotics that aren’t absorbed, because you’re not looking for the antibiotics to work anywhere but within the gut lumen. So antibiotics like Rifaximin, which is probably the gold standard treatment, which is basically an intestinal decontaminant. It doesn’t get absorbed, or at least 97% of it doesn’t get absorbed, so it won’t give you a systemic thrush or any other antibiotic side effects. So Rifaximin is probably first line, and then you’re looking at antibiotics that are variably resorbed.
Nathan: Some older antibiotics like Neomycin used to be gold standard. That can cause hearing problems, so we don’t tend to use it too much. Doxycycline can be quite effective. It’s a very commonly used antibiotic, which is fairly safe to use long-term. Some people use it long-term for acne and other skin conditions, so we can use that one if we need to. They’re probably the three most commonly used antibiotics to treat this particular problem.
Nick: I see, so really, you can’t treat it with alternative medicine or diet changes?
Nathan: Well, you can.
Nick: You can? Okay.
Nathan: You can. So you can use … People think … There is a thing called the SIBO Diet, which the listeners can look up. It basically removes the kind of … It’s kind of similar to a FODMAPS diet in many ways, but the aim is to remove the burden of substances in the diet that are easily fermentable. So it often involves less sugar, less carbohydrate, less of the kind of things that bacteria like to eat, if you like. And in some clients, the diet can help with SIBO. The problem is, of course, tolerability of these diets long-term. And nothing’s free, so obviously if you’re avoiding a lot of carbohydrates, weight loss can be an issue, and managing nutrition can be an issue, and group B vitamins, et cetera. So in my opinion, the diet thing’s not sustainable, whereas the antibiotic thing, if you’re only going to do it for a short period, it’s fairly reasonable.
Nathan: There are also some sort of natural antibiotics, if you like. So naturopaths often have things to offer in terms of SIBO with some of their natural antibiotic preparations that reduce bacterial counts. They’re doing exactly the same thing that the antibiotics are. They’re just doing it in a so-called natural way. But in the end, it’s all achieving the same endpoint.
Nick: And when someone comes in to see you, do they already think they have SIBO, or are they usually thinking they have something else, like irritable bowel syndrome?
Nathan: You get both. So you’ll get patients coming in saying, “Oh, I’ve seen doctors before, and I’ve had a gastroscopy, and a colonoscopy, and they didn’t find anything, and I’ve got diarrhea.” And you take a bit of a history of what’s happened to them in the past, and it’s, “Oh yeah, I had a bypass ten years ago.” The most recent one I had was a fellow who had had his … had extensive surgery for an appendix back when he was like three years old.
Nathan: Ever since then, he’d been intermittently bothered by cramping and diarrhea, and worked out he’d actually had a right hemicolectomy, which is a removal of the ileocecal valve in the small bowel. He hadn’t really told anyone. No one had picked up on this sort of point of history. And I knew he’s had a right hemicolectomy, because that was on his colonoscopy report. There was no ileocecal valve seen. So we gave him some Rifaximin, and basically, within 48 hours, his diarrhea went away. So the response to antibiotic therapy is usually fairly prompt.
Nick: Highlighting that point, if you do have gut-related health problems, diarrhea, cramping, and it’s enough to make your life unpleasant, it’s well worth making sure you sort of communicate your medical history. And it also sounds like if you do go to a GP, they probably won’t be able to diagnose it, in some cases. So obviously, I guess, if you get to a stage where you have seen a GP, and you still have the problem, you’d see a specialist like yourself anyway?
Nathan: Well, sometimes. I mean, obviously some general practitioners are very experienced in dealing with these problems. It’s like all medical problems, and if you’ve seen it once, and you recognize the pattern, generally, you’ll see it again. And the empirical treatment of SIBO, in my mind, is quite straightforward. You give someone antibiotics and see if they get better.
Nathan: And honestly, in my practice, patients with significant irritable bowel syndrome symptoms, antibiotic trials are pretty high up on the list of things to give them. So even patients without a respective of SIBO or a positive breath test often … If you come to me and say, “I get all this cramping, and bloating, and gas, and diarrhea,” and you’ve had the tests done you need to do like excluding Celiac’s, and trials of diet, and all that kind of stuff that we do.
Nathan: If none of that works, then giving the patient a week of Rifaximin and Doxycycline is a reasonable trial, and it separates … If the patients respond, it separates the matters of the antibiotic responsive patient. A big antibiotic responsive is an interesting subset of the irritable bowel group. Some will have SIBO, some will have dysbiosis. It’s a distinct group of IBS patients, again, in my opinion. I don’t know if everyone divides it up the way, but I think most of the irritable bowel syndrome in my practice would see some antibiotics at some point for this reason.
Nick: So both SIBO and IBS, the treatment’s fairly easy? It’s just taking two weeks or a month of antibiotics, and hopefully that offers some relief?
Nathan: Certainly for SIBO. So if I have a patient who’s got SIBO, yes, antibiotics definitely. Irritable bowel syndrome, we’re going to be careful of antibiotic usage. We can’t throw them to everybody. For example, I had a patient the other day who had seen three different gastroenterologists for their diarrhea, and I think got a gastroscopy and colonoscopy at all of them, but in the end, the patient had lactose intolerance. This patient’s not going to get any antibiotics. Sometimes the simplest things are never looked at. So some patients respond very well to dietary intervention in irritable bowel syndrome. There’s no doubt about that. Either lactose removal or other FODMAPS, if it can be done in a sort of sustainable way, does offer some very good symptom control for some patients.
Nathan: Likewise, some patients take medications that cause their symptoms. A classic one is metformin, which is a diabetic drug. So there’s lots of ways of getting this so-called irritable bowel syndrome patient better, so it doesn’t involve seeing a psychologist or taking chronic medication for the problem, so it just depends on the patient. But irritable bowel syndrome is a talk for another day, I guess. But in terms of a SIBO patient, that offers a sort of easier pathway to managing their problem.
Nick: I understand. Okay, I think you’re right. I think maybe our next podcast will be on IBS, and we might also have one on IBD and Crohn’s disease. So there’s a lot of problems that the gut can have. So I guess you’ve got to treat it with some respect, and I guess that means eating a healthy diet?
Nathan: Well, in terms of diet, and diet’s a bit like … I look at diet as being a bit similar to other lifestyle measures like exercise, maintaining a healthy weight, smoking, alcohol intake, illicit drugs, all that kind of stuff, all those things that humans do to themselves. I think with diet, if your diet is poor, and I think we all know generally what a healthy diet is. I don’t want to harp on about that right now. But generally, if your diet is poor, you are increasing your risk of getting medical problems. It’s not guaranteed you are going to get medical problems if you have a bad diet, neither is it guaranteed you won’t have medical problems if you have a very good diet. I’ve seen that on numerous occasions of people being so surprised that they could have Crohn’s, or bowel cancer, or any of these conditions, because their diet is so good. But it’s a definite risk factor that we see for these medical conditions.
Nathan: As an example, there’s been some interesting work done recently on diet and lifestyle and living arrangement for inflammatory bowel disease. And in India, if you live in rural India, and you’re kind of poor, your chances of having IBD, Crohn’s disease, or ulcerative colitis are extraordinarily small. The minute you move to the city and start having a highly processed diet, your risk skyrockets. Which particular part of the diet is still being worked out, but diet is coming through as a major risk factor, not the only risk factor, but a major risk factor for the development of inflammatory bowel disease. And it’s already known that it’s a major risk factor for the development of bowel cancer as well.
Nathan: It’s just not clear yet how we should intervene either on a community level or on an individual level to modify that risk. That’s the challenge, because we don’t really know what particular components of the diet are important yet. But clearly diet is important. I would encourage all the listeners who don’t generally have a very healthy diet try to limit their intake of highly processed foods, try and ingest more fruit and vegetables, have a modest intake of red meat, and of course alcohol in excess is not good either. So I think that those bits of advice are pretty common sense. I think most people would understand them anyway. They innately understand them. But beyond that, what particular parts of the diet are important is not exactly known yet.
Nick: Out of interest, is there any research or evidence in regard to sitting down? So a lot of people will sit down for six to eight hours a day, and is there any evidence that suggests it has a negative impact on … I mean, there’s already evidence that it does impact the body negatively, and it’s now being linked to potentially heart disease, cancer, but is there any evidence in regard to things like inflammatory bowel disease or irritable bowel syndrome?
Nathan: Not that I’ve actually heard, Nick. That doesn’t mean it doesn’t exist. It just means I haven’t heard of it, but we do know that exercise or moving does encourage the gut to move. And in some people, that’s quite extreme. So some people get diarrhea just when they exercise, believe it or not. It’s probably a contributing factor to the emergence of the so-called poo jogger. It might be unavoidable for some people. And I do see patients who come and say this to me, “I don’t get diarrhea unless I exercise.”
Nathan: And clearly exercise promotes colonic motility, so I would suspect that if one doesn’t move at all … and we see this, of course, in hospital patients. Part of the reason they get so constipated is because they lie in bed all day. So I think there’s definitely a link between the two, but how that link sort of statistically or risk factor-wise with particular gut disorders, I don’t think that’s been particularly well looked-at. And you’ve always got to ask yourself the question, is this person inactive because of the condition, or have they got the condition because they’re inactive? It’s always hard to work that causal relationship out. But you can think of numerous theoretical ways in which they could be linked.
Nick: Okay. And I do have one question regarding … I think when people are at work, and they’re in front of a computer, and they are sitting down, and they do need to go to the toilet, often they won’t go straight away, I think. And they’ll try and get whatever they’re working on done before they go to the toilet, so they’re sort of holding in their number two. Is that unwise?
Nathan: Well, that particular phenomenon of putting off bowel actions endlessly probably does lead to an increased risk of a condition called functional obstructive defecation, which is a very common form of constipation, especially in young women. And often young women with this problem will say that they didn’t want to use the toilet at school, for example, what I call “shy poo-ers.” The shy poo-er will put off using the toilet anywhere but at home, and of course when the rectum … which, the job of the rectum is to send stool, store stool, but expect at some point in the near future you’re going to evacuate your bowels. So as that message keeps getting sent to the brain, and the brain keeps suppressing it and saying, “No, not now. No, not now. No, not now.” Eventually, the message gets lost. This is all theoretical, of course. No one knows it for sure, but the message gets lost.
Nathan: And hence the person never feels like they need to go to the toilet, hence they complain of constipation. And a lot of the time, the way to help those patients is through pelvic floor physiotherapy and this thing called balloon retraining, where you actually get the person to be able to sense what it is like again to have distension of the rectum, so they know when they need to go to the toilet. So yeah.
Nathan: There was a study recently performed which suggested that 50% of constipation in young women is due to this phenomenon of obstructive functional defecation. Now putting off going to the toilet is not the only cause of that. There are lots of other causes, anatomical causes, and other kind of functional parts to it. But that putting off of bowel actions too much is not that unusual. There’ll be this … If the mother comes in with the young woman, they’ll say, “Yes, they’ve always had issues going to the toilet all their life.” And you get this sort of history. So yeah, I don’t think putting things off endlessly is a good idea. Same with the bladder. The bladder can suffer from the same problem too.
Nick: I see. Well, it’s been interesting. We’ve talked about poo joggers, and shy pooers, and I’m sure there are other ones we’ll discuss maybe on our next podcast. So I thank you for your time today. Let’s wrap it up.
Nathan: Thanks, Nick.