Abstract
Background
Duodenal aspiration (DA) and lactulose breath tests (LBT) are commonly performed to diagnose small intestinal bacterial overgrowth (SIBO). There are no data directly comparing these tests.
Aims
To investigate the agreement between DA and LBT for the diagnosis of SIBO.
Methods
A retrospective cohort study of adult patients who underwent a LBT and a DA at a tertiary care center over 9 years was assembled. LBT was considered positive if the hydrogen baseline or peak change measurement was ≥ 20 ppm, and/or if the methane baseline or peak change was ≥ 10 ppm. DA was considered positive if > 100,000 cfu/mL of gram-negative flora was identified on culture, and contaminated if > 100,000 cfu/mL of gram-positive flora was identified.
Results
A total of 106 patients were evaluated; 81 (76.4%) were female; the mean age was 53.4 ± 15.9 years. 21 patients (19.8%) had evidence of contamination on DA. 14 (16.5%) patients had a positive DA result. Patients with diabetes mellitus and those with PPI use were more likely to have a positive DA (94.4% vs. 71.4%, p = 0.007; 62% vs. 28.6%, p = 0.021, respectively). 33 (31.1%) patients had a positive LBT. Patients with a history of small bowel resection were more likely to have a positive LBT (12.1% vs. 1.4%, p = 0.016). DA and LBT results agreed in 54 patients (63.5%; kappa = − 0.02), indicating poor agreement.
Conclusions
The agreement between LBT and DA in evaluation for SIBO was poor. LBT may be favorable to DA, as LBT is safer, cheaper, and less likely to yield a contaminant result.
Similar content being viewed by others
References
Adike A, DiBaise JK. Small intestinal bacterial overgrowth: nutritional implications, diagnosis, and management. Gastroenterol Clin North Am. 2018;47:193–208.
Jacobs C, Coss Adame E, Attaluri A, Valestin J, Rao SSC. Dysmotility and proton pump inhibitor use are independent risk factors for small intestinal bacterial and/or fungal overgrowth. Aliment Pharmacol Ther. 2013;37:1103–1111.
Rao SSC, Bhagatwala J. Small intestinal bacterial overgrowth: clinical features and therapeutic management. Clin Transl Gastroenterol. 2019;10:e00078.
Hamilton I, Worsley BW, Cobden I, Cooke EM, Shoesmith JG, Axon AT. Simultaneous culture of saliva and jejunal aspirate in the investigation of small bowel bacterial overgrowth. Gut. 1982;23:847–853.
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.
Mattsson J, Minaya MT, Monegro M, et al. Outcome of breath tests in adult patients with suspected small intestinal bacterial overgrowth. Gastroenterol Hepatol Bed Bench. 2017;10:168–172.
Erdogan A, Rao SSC, Gulley D, et al. Small intestinal bacterial overgrowth: duodenal aspiration vs glucose breath test. Neurogastroenterol Motil. 2015;27:481–489.
Giamarellos-Bourboulis EJ, Pyleris E, Barbatzas C, Pistiki A, Pimentel M. Small intestinal bacterial overgrowth is associated with irritable bowel syndrome and is independent of proton pump inhibitor usage. BMC Gastroenterol. 2016;16:67.
Corazza GR, Menozzi MG, Strocchi A, et al. The diagnosis of small bowel bacterial overgrowth. Reliability of jejunal culture and inadequacy of breath hydrogen testing. Gastroenterology. 1990;98:302–309.
Khoshini R, Khoshini R, Dai S-C, Lezcano S, Pimentel M, et al. A systematic review of diagnostic tests for small intestinal bacterial overgrowth. Dig Dis Sci. 2008;53:1443–1454.
Pimentel M, Saad RJ, Long MD, Rao SSC. ACG clinical guideline: small intestinal bacterial overgrowth. Am J Gastroenterol. 2020;115:165–178.
Pyleris E, Giamarellos-Bourboulis EJ, Tzivras D, Koussoulas V, Barbatzas C, Pimentel M. The prevalence of overgrowth by aerobic bacteria in the small intestine by small bowel culture: relationship with irritable bowel syndrome. Dig Dis Sci. 2012;57:1321–1329.
Franco DL, Disbrow MB, Kahn A, et al. Duodenal aspirates for small intestine bacterial overgrowth: yield, PPIs, and outcomes after treatment at a Tertiary Academic Medical Center. Gastroenterol Res Pract. 2015;2015:971582.
Ratuapli SK, Ellington TG, O’Neill M-T, et al. Proton pump inhibitor therapy use does not predispose to small intestinal bacterial overgrowth. Am J Gastroenterol. 2012;107:730–735.
Su T, Lai S, Lee A, He X, Chen S. Meta-analysis: proton pump inhibitors moderately increase the risk of small intestinal bacterial overgrowth. J Gastroenterol. 2018;53:27–36.
Quigley EMM. The spectrum of small intestinal bacterial overgrowth (SIBO). Curr Gastroenterol Rep. 2019;21:3.
Gabbard SL, Lacy BE, Levine GM, Crowell MD. The impact of alcohol consumption and cholecystectomy on small intestinal bacterial overgrowth. Dig Dis Sci. 2014;59:638–644.
Sung HJ, Paik C-N, Chung WC, Lee K-M, Yang J-M, Choi M-G. Small intestinal bacterial overgrowth diagnosed by glucose hydrogen breath test in post-cholecystectomy patients. J Neurogastroenterol Motil. 2015;21:545–551.
Author information
Authors and Affiliations
Contributions
All authors participated in the design, research, literature review, writing and editing of this manuscript. No assistance, financial or otherwise, was provided for the production of this manuscript.
Corresponding author
Ethics declarations
Conflict of interest
DC: no disclosures; BEL: consultant for Ironwood, Urovant, Salix, Viver; JW: no disclosures.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Cangemi, D.J., Lacy, B.E. & Wise, J. Diagnosing Small Intestinal Bacterial Overgrowth: A Comparison of Lactulose Breath Tests to Small Bowel Aspirates. Dig Dis Sci 66, 2042–2050 (2021). https://doi.org/10.1007/s10620-020-06484-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10620-020-06484-z