Skip to main content

Advertisement

SpringerLink
Log in

Diagnostic Utility of Carbohydrate Breath Tests for SIBO, Fructose, and Lactose Intolerance

  • Original Article
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Background

Unexplained bloating, gas, and pain are common symptoms. If routine tests are negative, such patients are often labeled as irritable bowel syndrome.

Aims

To determine the diagnostic utility of breath tests that assess for small intestinal bacterial overgrowth (SIBO), fructose or lactose intolerance, and the predictive value of symptoms.

Methods

Patients with gas, bloating, diarrhea, abdominal pain (≥ 6 months), and negative endoscopy and radiology tests were assessed with symptom questionnaires, glucose (75 g), fructose (25 g), or lactose (25 g) breath tests. Breath tests were categorized as positive when H2 (≥ 20 ppm) or CH4 (≥ 15 ppm) increased above baseline values or as hypersensitive when symptoms changed significantly without rise in H2/CH4 or as negative.

Results

1230 patients (females = 878) underwent 2236 breath tests. The prevalence of SIBO was 33% (294/883), fructose intolerance was 34% (262/763), and lactose intolerance was 44% (260/590). Hypersensitivity was found in 16% and 9%, respectively, during fructose and lactose breath tests. Although gas (89%), abdominal pain (82%), and bloating (82%) were highly prevalent, pretest symptoms or their severity did not predict an abnormal breath test, but symptoms during the breath test facilitated diagnosis of SIBO, fructose, and lactose intolerance and hypersensitivity.

Conclusions

Approximately 45% of patients with unexplained gas and bloating had SIBO, fructose, or lactose intolerance; another 9–16% had visceral hypersensitivity. Pretest symptoms were poor predictors, but symptoms during the breath tests were useful. Breath tests are safe, provide significant diagnostic yield, and could be useful in routine gastroenterology practice.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Goebel-Stengel M, Stengel A, Schmidtmann M, et al. Unclear abdominal discomfort: pivotal role of carbohydrate malabsorption. J Neurogastroenterol Motil. 2014;20:228–235.

    PubMed  PubMed Central  Google Scholar 

  2. Ringel Y, Williams RE, Kalilani L, et al. Prevalence, characteristics, and impact of bloating symptoms in patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. 2009;7:68–72.

    PubMed  Google Scholar 

  3. Fedewa A, Rao SS. Dietary fructose intolerance, fructan intolerance and FODMAPs. Curr Gastroenterol Rep. 2014;16:1–13. https://doi.org/10.1007/s11894-013-0370-0.

    Article  Google Scholar 

  4. Fernandez-Banares F, Esteve-Pardo M, de Leon R, et al. Sugar malabsorption in functional bowel disease: clinical implications. Am J Gastroenterol. 1993;88:2044–2050.

    PubMed  CAS  Google Scholar 

  5. Chang L. Review article: epidemiology and quality of life in functional gastrointestinal disorders. Aliment Pharmacol Ther. 2004;20:31–39.

    PubMed  CAS  Google Scholar 

  6. Drossman DA, Morris CB, Schneck S, et al. International survey of patients with IBS: symptom features and their severity, health status, treatments, and risk taking to achieve clinical benefit. J Clin Gastroenterol. 2009;43:541–550.

    PubMed  PubMed Central  Google Scholar 

  7. Chang L, Toner BB, Fukudo S, et al. Gender, age, society, culture, and the patient’s perspective in the functional gastrointestinal disorders. Gastroenterology. 2006;130:1435–1446.

    PubMed  Google Scholar 

  8. Riveros MJ, Parada A, Pettinelli P. Fructose consumption and its health implications; fructose malabsorption and nonalcoholic fatty liver disease. Nutr Hosp. 2014;29:491–499.

    PubMed  CAS  Google Scholar 

  9. Vos MB, Kimmons JE, Gillespie C, et al. Dietary fructose consumption among US children and adults: the Third National Health and Nutrition Examination Survey. Medscape J Med. 2008;10:160.

    PubMed  PubMed Central  Google Scholar 

  10. Bray GA. Energy and fructose from beverages sweetened with sugar or high-fructose corn syrup pose a health risk for some people. Adv Nutr. 2013;4:220–225.

    PubMed  PubMed Central  CAS  Google Scholar 

  11. Rao SS, Attaluri A, Anderson L, et al. Ability of the normal human small intestine to absorb fructose: evaluation by breath testing. Clin Gastroenterol Hepatol. 2007;5:959–963.

    PubMed  PubMed Central  CAS  Google Scholar 

  12. United States Department of Agriculture. Economic Research Service. (2017). Source: USDA, Economic Research Source, Food Availability Data. https://www.ers.usda.gov/data-products/chart_gallery/gallery/chart-detail/?chartld=85059.

  13. Wasserman D, Hoekstra JH, Tolia V, et al. Molecular analysis of the fructose transporter gene (GLUT5) in isolated fructose malabsorption. J Clin Invest. 1996;98:2398–2402.

    PubMed  PubMed Central  CAS  Google Scholar 

  14. Corpe CP, Bovelander FJ, Hoekstra JH, et al. The small intestinal fructose transporters: site of dietary perception and evidence for diurnal and fructose sensitive control elements. Biochim Biophys Acta. 1998;1402:229–238.

    PubMed  CAS  Google Scholar 

  15. Biesiekierski JR. Fructose-induced symptoms beyond malabsorption in FGID. United European Gastroenterol J. 2014;2:10–13.

    PubMed  PubMed Central  Google Scholar 

  16. Choi YK, Johlin FC Jr, Summers RW, et al. Fructose intolerance: an under-recognized problem. Am J Gastroenterol. 2003;98:1348–1353.

    PubMed  CAS  Google Scholar 

  17. Choi YK, Kraft N, Zimmerman B, et al. Fructose intolerance in IBS and utility of fructose-restricted diet. J Clin Gastroenterol. 2008;42:233–238.

    PubMed  CAS  Google Scholar 

  18. Di Rienzo T, D’Angelo G, D’Aversa F, et al. Lactose intolerance: from diagnosis to correct management. Eur Rev Med Pharmacol Sci. 2013;17:18–25.

    PubMed  Google Scholar 

  19. United States Department of Agriculture. Economic Research Service. Dairy products; Per Capita Availability/dymfg.xls.

  20. Deng Y, Misselwitz B, Dai N, et al. Lactose intolerance in adults: biological mechanism and dietary management. Nutrients. 2015;7:8020–8035.

    PubMed  PubMed Central  CAS  Google Scholar 

  21. Scrimshaw NS, Murray EB. The acceptability of milk and milk products in populations with a high prevalence of lactose intolerance. Am J Clin Nutr. 1988;48:1079–1159.

    PubMed  CAS  Google Scholar 

  22. Vesa TH, Marteau P, Korpela R. Lactose intolerance. J Am Coll Nutr. 2000;19:165S–175S.

    PubMed  CAS  Google Scholar 

  23. Erdogan A, Rao SS, Gulley D, et al. Small intestinal bacterial overgrowth: duodenal aspiration vs glucose breath test. Neurogastroenterol Motil. 2015;27:481–489.

    PubMed  CAS  Google Scholar 

  24. Ghoshal UC, Ghoshal U. Small intestinal bacterial overgrowth and other intestinal disorders. Gastroenterol Clin North Am. 2017;46:103–120.

    PubMed  Google Scholar 

  25. Rezaie A, Pimentel M, Rao SS. How to test and treat small intestinal bacterial overgrowth: an evidence-based approach. Curr Gastroenterol Rep. 2016;18:8.

    PubMed  Google Scholar 

  26. Rezaie A, Buresi M, Lembo A, et al. Hydrogen and methane-based breath testing in gastrointestinal disorders: the North American consensus. Am J Gastroenterol. 2017;112:775–784.

    PubMed  PubMed Central  CAS  Google Scholar 

  27. Montalto M, Gallo A, Ojetti V, et al. Fructose, trehalose and sorbitol malabsorption. Eur Rev Med Pharmacol Sci. 2013;17:26–29.

    PubMed  Google Scholar 

  28. Misselwitz B, Pohl D, Fruhauf H, et al. Lactose malabsorption and intolerance: pathogenesis, diagnosis and treatment. United Eur Gastroenterol J. 2013;1:151–159.

    Google Scholar 

  29. Rana SV, Malik A. Hydrogen breath tests in gastrointestinal diseases. Indian J Clin Biochem. 2014;29:398–405.

    PubMed  PubMed Central  CAS  Google Scholar 

  30. Christman NT, Hamilton LH. A new chromatographic instrument for measuring trace concentrations of breath-hydrogen. J Chromatogr. 1982;229:259–265.

    PubMed  CAS  Google Scholar 

  31. Gasbarrini A, Corazza GR, Gasbarrini G, et al. Methodology and indications of H2-breath testing in gastrointestinal diseases: the Rome Consensus Conference. Aliment Pharmacol Ther. 2009;29:1–49.

    PubMed  Google Scholar 

  32. Lacy BE, Mearin F, Chang L, et al. Bowel disorders. Gastroenterology. 2016;150:1393–1407.

    Google Scholar 

  33. Gibson PR. History of the low FODMAP diet. J Gastroenterol Hepatol. 2017;32:5–7.

    PubMed  CAS  Google Scholar 

  34. Srigley JA, Brooks A, Sung M, et al. Inappropriate use of antibiotics and Clostridium difficile infection. Am J Infect Control. 2013;41:1116–1118.

    PubMed  Google Scholar 

  35. Sloan TJ, Jalanka J, Major GAD, et al. A low FODMAP diet is associated with changes in the microbiota and reduction in breath hydrogen but not colonic volume in healthy subjects. PLoS ONE. 2018;13:e0201410.

    PubMed  PubMed Central  Google Scholar 

  36. Rao SS, Yu S, Fedewa A. Systematic review: dietary fibre and FODMAP-restricted diet in the management of constipation and irritable bowel syndrome. Aliment Pharmacol Ther. 2015;41:1256–1270.

    PubMed  CAS  Google Scholar 

  37. Eswaran S. Low FODMAP in 2017: lessons learned from clinical trials and mechanistic studies. Neurogastroenterol Motil. 2017;29:e13055. https://doi.org/10.1111/nmo.13055.

    Article  Google Scholar 

  38. Dionne J, Ford AC, Yuan Y, et al. A systematic review and meta-analysis evaluating the efficacy of a gluten-free diet and alow FODMAPs diet in treating symptoms of irritable bowel syndrome. Am J Gastroenterol. 2018;113:1290–1300.

    PubMed  CAS  Google Scholar 

  39. Pimentel M, Gunsalus RP, Rao SS, et al. Methanogens in human health and disease. Am J Gastroenterol. 2012;1:28–33.

    CAS  Google Scholar 

  40. Saad RJ, Chey WD. Breath testing for small intestinal bacterial overgrowth: maximizing test accuracy. Clin Gastroenterol Hepatol. 2014;12:1964–1972.

    PubMed  Google Scholar 

  41. Lin ESK, Pichetshote N, et al. Measurement of hydrogen sulfide during breath testing correlates to patient symptoms. Gastroenterol. 2017;152:S205–S206.

    Google Scholar 

  42. Singer-Englar T, Rezaie A, Gupta K, et al. Competitive hydrogen gas utilization by methane- and hydrogen sulfide-producing microorganisms and associated symptoms: results of a novel 4-gas breath test machine. Gastroenterology. 2018;154:S-47.

    Google Scholar 

  43. Zhu Y, Zheng X, Cong Y, et al. Bloating and distention in irritable bowel syndrome: the role of gas production and visceral sensation after lactose ingestion in a population with lactase deficiency. Am J Gastroenterol. 2013;108:1516–1525.

    PubMed  CAS  Google Scholar 

  44. Dainese R, Casellas F, Marine-Barjoan E, et al. Perception of lactose intolerance in irritable bowel syndrome patients. Eur J Gastroenterol Hepatol. 2014;26:1167–1175.

    PubMed  Google Scholar 

  45. Simren M, Tornblom H, Palsson OS, et al. Management of the multiple symptoms of irritable bowel syndrome. Lancet Gastroenterol Hepatol. 2017;2:112–122.

    PubMed  Google Scholar 

  46. Lin EC, Massey BT. Scintigraphy demonstrates high rate of false-positive results from glucose breath tests for small bowel bacterial overgrowth. Clin Gastroenterol Hepatol. 2016;14:203–208.

    PubMed  Google Scholar 

  47. Kee WJ, Seo M, Cho YH, et al. Prevalence of fructose malabsorption in patients with irritable bowel syndrome after excluding small intestinal bacterial overgrowth. J Neurogastroenterol Motil. 2018;24:307–316.

    Google Scholar 

Download references

Acknowledgments

We thank Mrs. Helen Smith for the excellent secretarial assistance, and Mrs. Collier Badger, Mrs. Arie Mack and Mrs. Michelle Jackson for assistance with the breath tests. Dr. Rao was supported by NIH 5R21 DK104127-02 and U-34, DK109191-02.

Author information

Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Department of Medicine, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA

    Mercedes Amieva-Balmori, Enrique Coss-Adame, Nikilesh S. Rao, Brisa M. Dávalos-Pantoja & Satish S. C. Rao

  2. Universidad Veracruzana, Veracruz, Mexico

    Mercedes Amieva-Balmori

  3. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico

    Enrique Coss-Adame

Authors
  1. Mercedes Amieva-Balmori
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Enrique Coss-Adame
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nikilesh S. Rao
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Brisa M. Dávalos-Pantoja
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Satish S. C. Rao
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

SSCR was involved in study concept, patient recruitment, analysis of breath test, overall supervision, manuscript writing, IRB submission. MA-B helped in data analysis, data interpretation, manuscript writing. EC-A contributed to data analysis, data interpretation, IRB, statistical analysis. NR helped in data entry. BMD contributed to data entry.

Corresponding author

Correspondence to Satish S. C. Rao.

Ethics declarations

Conflict of interest

All authors declare no conflict of interest with this article.

Ethical approval

The study was approved by the Augusta University Institutional Review Board No. 1114725 and registered at Clinical Trials Gov: NCTO 03261856.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Amieva-Balmori, M., Coss-Adame, E., Rao, N.S. et al. Diagnostic Utility of Carbohydrate Breath Tests for SIBO, Fructose, and Lactose Intolerance. Dig Dis Sci 65, 1405–1413 (2020). https://doi.org/10.1007/s10620-019-05889-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-019-05889-9

Keywords

Search

Navigation