GENERAL CONSIDERATIONS FOR BREATH TESTING
Small intestinal bacterial overgrowth (SIBO) is a heterogeneous syndrome characterized by an increase in the number and/or the presence of atypical microbiota in the small intestine. Genova's SIBO breath test relies on measurement of gases produced by microbiota in the intestine - hydrogen (H2) and methane (CH4) - following ingestion of lactulose in a fasting state.
A normal transit time of lactulose (10 g) in healthy fasting patients from the mouth to the junction between the small and large intestine (oro-cecal transit time, or OCTT) is approximately 90 minutes. In general, transit times have been found to vary in humans. Given such findings, transit time should be taken into consideration when interpreting breath testing.
To preclude elevated breath levels of hydrogen and methane prior to the ingestion of lactulose (at baseline), impeccable patient preparation and sample collection are imperative. Falsely elevated findings may result from incomplete avoidance of high-fiber foods, residual fiber in the intestine due to delayed transit time, residual oropharyngeal (mouth and throat) bacteria, exposure to tobacco smoke, or napping during collection.
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EVALUATION FOR HYDROGEN (H2)
In healthy humans, hydrogen gas is exclusively produced by intestinal bacteria - primarily a result of carbohydrate fermentation by anaerobic bacteria in the colon. In SIBO, fermentation of the malabsorbed lactulose substrate by bacteria residing in the small intestine results in elevated concentration of exhaled hydrogen (H2).
- The hydrogen result is the difference between the baseline hydrogen (S1) and the highest hydrogen finding among S2, S3, S4 or S5. The result does not take into account actual collection times. It is expected that the patient followed recommended collection times.
- A rise of H2 of ≥20 ppm over baseline in those samples collected after 90 minutes maybe positive for SIBO in patients with slower transit time or constipation.
- ELEVATED BASELINE - The clinical significance of elevated baseline H2 levels in patients reporting adherence to fasting and dietary guidelines is not known. In a symptomatic patient, some clinical groups with expertise in SIBO management may consider an elevated hydrogen baseline a positive test.
- Approximately 8 to 27% of individuals do not produce H2 due to the presence of methanogenic microbiota which consume hydrogen molecules to produce methane gas. As a result, low H2 findings through all time points in a symptomatic patient may reflect a false negative result. In this instance, clinical attention should be shifted to evaluation of CH4.
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References:
Rezaie A, Buresi M, Lembo A, et al. Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus. The American journal of gastroenterology. May 2017;112(5):775-784. [L]
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A rise of H2 of > 20 ppm over baseline in the first 90 minutes of testing is positive for SIBO.
An increase in hydrogen (H2) of more than 20 parts per million (ppm) on a Small Intestinal Bacterial Overgrowth (SIBO) breath test typically indicates a positive result for SIBO. The test works by measuring the levels of hydrogen and methane in the breath after the ingestion of a sugar solution (usually lactulose or glucose). Bacteria in the small intestine ferment these sugars, producing hydrogen and/or methane as byproducts, which are then absorbed into the bloodstream and exhaled in the breath.
Here’s what an increase in hydrogen of more than 20 ppm generally signifies:
Presence of Excess Bacteria in the Small Intestine: Normally, the small intestine has relatively few bacteria. A significant increase in hydrogen suggests that bacteria are present in higher-than-normal numbers, fermenting the ingested sugar and producing hydrogen gas.
Positive Diagnosis for SIBO: A rise in hydrogen levels by more than 20 ppm from baseline values typically confirms a diagnosis of SIBO, according to most medical guidelines.
Symptom Correlation: Patients with SIBO often experience symptoms such as bloating, abdominal pain, diarrhea, and/or constipation. The increase in hydrogen is indicative of bacterial overgrowth that correlates with these gastrointestinal symptoms.
It is important to consider other factors such as the specific protocol followed during the test, the patient’s preparation, and baseline hydrogen levels to accurately interpret the results. Consulting a healthcare professional is crucial for a comprehensive assessment and appropriate treatment plan.
When both H2 and CH4 are present, treatment may require more than one antimicrobial agent. Patients who received a combination of rifaximin and neomycin showed a higher rate of methane eradication on breath testing compared to patients who received either rifaximin or neomycin alone. There was also a better clinical response with the combination therapy.
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Potential treatment options:
Treatment options for Small Intestinal Bacterial Overgrowth (SIBO) typically include a combination of dietary modifications, antibiotics, probiotics, and sometimes other supportive measures. Here are the common treatment options:
1. Antibiotics
Rifaximin is the most commonly prescribed antibiotic for SIBO. It is poorly absorbed in the gut, making it effective at targeting bacteria in the small intestine with fewer systemic side effects. Other antibiotics that might be used include:
2. Dietary Changes
3. Probiotics
Probiotics can help restore a healthy balance of gut bacteria. Commonly used strains include:
4. Herbal Antimicrobials
Herbal treatments can be effective for some patients, either alone or in combination with other treatments. Common herbal antimicrobials include:
5. Prokinetics
Prokinetic agents can help improve motility in the gastrointestinal tract, reducing the risk of bacterial overgrowth. Examples include:
6. Supportive Treatments
7. Addressing Underlying Conditions
Treating underlying conditions that may contribute to SIBO, such as:
8. Lifestyle Modifications
Follow-up and Monitoring
Regular follow-up with a healthcare provider is important to monitor symptoms, ensure treatment effectiveness, and adjust the treatment plan as necessary. In some cases, repeat breath tests may be conducted to assess the eradication of bacterial overgrowth.
Consulting with Healthcare Professionals
It's crucial to work closely with healthcare providers, including gastroenterologists and dietitians, to develop and follow an individualized treatment plan tailored to the specific needs and underlying conditions of the patient.
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