Perspectives in clinical gastroenterology and hepatology
Breath Testing for Small Intestinal Bacterial Overgrowth: Maximizing Test Accuracy

https://doi.org/10.1016/j.cgh.2013.09.055Get rights and content

The diagnosis of small intestinal bacterial overgrowth (SIBO) has increased considerably owing to a growing recognition of its association with common bowel symptoms including chronic diarrhea, bloating, abdominal distention, and the irritable bowel syndrome. Ideally, an accurate and objective diagnosis of SIBO should be established before initiating antibiotic treatment. Unfortunately, no perfect test exists for the diagnosis of SIBO. The current gold standard, small-bowel aspiration and quantitative culture, is limited by its high cost, invasive nature, lack of standardization, sampling error, and need for dedicated infrastructure. Although not without shortcomings, hydrogen breath testing provides the simplest noninvasive and widely available diagnostic modality for suspected SIBO. Carbohydrates such as lactulose and glucose are the most widely used substrates in hydrogen breath testing, with glucose arguably providing greater testing accuracy. Lactose, fructose, and sorbitol should not be used as substrates in the assessment of suspected SIBO. The measurement of methane in addition to hydrogen can increase the sensitivity of breath testing for SIBO. Diagnostic accuracy of hydrogen breath testing in SIBO can be maximized by careful patient selection for testing, proper test preparation, and standardization of test performance as well as test interpretation.

Section snippets

Pathophysiology of Small Intestinal Bacterial Overgrowth

Several key mechanisms play a role in preventing bacteria overgrowth in the proximal gut including gastric acid; the migrating motor complex; integrity of the intestinal mucosa; the gut immune system; enzymatic activities of intestinal, pancreatic, and biliary secretions; direct effects of commensal bacterial within the small bowel; and the physical barrier created by the ileocecal valve.7 A number of conditions capable of adversely affecting one or more of these protective mechanisms have been

Small-Bowel Aspiration and Quantitative Culture

Small-bowel aspiration for quantitative culture traditionally has been regarded as the gold standard for the diagnosis of SIBO. Because it is imperative not to contaminate the sample, aspiration is performed either through an endoscopically or fluoroscopically confirmed guidewire-placed sterile catheter.33, 34 It is also important that the specimen be transferred promptly to the appropriate laboratory for culturing under aerobic and anaerobic conditions. However, small bowel culturing

Concluding Remarks

There remains a need for a gold standard test for SIBO. The invasive nature of testing, lack of standardization, sampling error, the need for dedicated infrastructure, and high cost cast doubt on the legitimacy of small-bowel aspiration and quantitative culture as a gold standard. Breath testing provides a solution to some of the practical issues that detract from aspiration and quantitative culture, but suffers from its own limitations. Proper patient selection, test preparation, standardized

References (78)

  • L. Lombardo et al.

    Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy

    Clin Gastroenterol Hepatol

    (2010)
  • B. Braden

    Methods and functions: breath tests

    Best Pract Res Clin Gastroenterol

    (2009)
  • R.J. Saad et al.

    Breath tests for gastrointestinal disease: the real deal or just a lot of hot air?

    Gastroenterology

    (2007)
  • C.E. King et al.

    Detection of small intestine bacterial overgrowth by means of a 14C-D-xylose breath test

    Gastroenterology

    (1979)
  • C.E. King et al.

    Comparison of the 1-gram [14C]xylose, 10-gram lactulose-H2, and 80-gram glucose-H2 breath tests in patients with small intestine bacterial overgrowth

    Gastroenterology

    (1986)
  • M.D. Levitt et al.

    Volume, composition, and source of intestinal gas

    Gastroenterology

    (1970)
  • N.T. Christman et al.

    A new chromatographic instrument for measuring trace concentrations of breath-hydrogen

    J Chromatogr

    (1982)
  • M.D. Levitt et al.

    Stability of human methanogenic flora over 35 years and a review of insights obtained from breath methane measurements

    Clin Gastroenterol Hepatol

    (2006)
  • J. Romagnuolo et al.

    Using breath tests wisely in a gastroenterology practice: an evidence-based review of indications and pitfalls in interpretation

    Am J Gastroenterol

    (2002)
  • G.R. Corazza et al.

    The diagnosis of small bowel bacterial overgrowth. Reliability of jejunal culture and inadequacy of breath hydrogen testing

    Gastroenterology

    (1990)
  • G. Metz et al.

    Breath-hydrogen test for small-intestinal bacterial colonisation

    Lancet

    (1976)
  • T.M. Bauer et al.

    Diagnosis of small intestinal bacterial overgrowth in patients with cirrhosis of the liver: poor performance of the glucose breath hydrogen test

    J Hepatol

    (2000)
  • W.H. Barker et al.

    Macrocytic anemia in association with intestinal strictures and anastomosis

    Bull Johns Hopkins Hospital

    (1939)
  • S.V. Rana et al.

    Small intestinal bacterial overgrowth

    Scand J Gastroenterol

    (2008)
  • M. Majewski et al.

    Results of small intestinal bacterial overgrowth testing in irritable bowel syndrome patients: clinical profiles and effects of antibiotic trial

    Adv Med Sci

    (2007)
  • E.D. Shah et al.

    Abnormal breath testing in IBS: a meta-analysis

    Dig Dis Sci

    (2010)
  • R.S. Choung et al.

    Clinical predictors of small intestinal bacterial overgrowth by duodenal aspirate culture

    Aliment Pharmacol Ther

    (2011)
  • C.N. Paik et al.

    The role of small intestinal bacterial overgrowth in postgastrectomy patients

    Neurogastroenterol Motil

    (2011)
  • P. Petrone et al.

    Small intestinal bacterial overgrowth in patients with lower gastrointestinal symptoms and a history of previous abdominal surgery

    Arch Surg

    (2011)
  • J.D. Machado et al.

    Intestinal bacterial overgrowth after Roux-en-Y gastric bypass

    Obes Surg

    (2008)
  • E. Pyleris et al.

    The prevalence of overgrowth by aerobic bacteria in the small intestine by small bowel culture: relationship with irritable bowel syndrome

    Dig Dis Sci

    (2012)
  • V. Ojetti et al.

    Small bowel bacterial overgrowth and type 1 diabetes

    Eur Rev Med Pharmacol Sci

    (2009)
  • I. Marie et al.

    Small intestinal bacterial overgrowth in systemic sclerosis

    Rheumatology (Oxford)

    (2009)
  • A. Parodi et al.

    Small intestinal bacterial overgrowth in patients suffering from scleroderma: clinical effectiveness of its eradication

    Am J Gastroenterol

    (2008)
  • A. Rubio-Tapia et al.

    Prevalence of small intestine bacterial overgrowth diagnosed by quantitative culture of intestinal aspirate in celiac disease

    J Clin Gastroenterol

    (2009)
  • U.C. Ghoshal et al.

    Partially responsive celiac disease resulting from small intestinal bacterial overgrowth and lactose intolerance

    BMC Gastroenterol

    (2004)
  • T. Matsumoto et al.

    Breath hydrogen test using water-diluted lactulose in patients with gastrointestinal amyloidosis

    Dig Dis Sci

    (1991)
  • E.C. Ebert

    The thyroid and the gut

    J Clin Gastroenterol

    (2010)
  • N.S. George et al.

    Small intestinal bacterial overgrowth in gastroparesis

    Dig Dis Sci

    (2012)
  • Cited by (0)

    This article has an accompanying continuing medical education activity on page e119. Learning Objective–At the end of this activity, the successful learner will be able to understand measures to improve the diagnostic accuracy of breath testing for suspected small intestinal bacterial overgrowth.

    Conflicts of interest The authors disclose no conflicts.

    View full text