Unexplained bloating, gas, and pain are common symptoms. If routine tests are negative, such patients are often labeled as irritable bowel syndrome.
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.
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.
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.
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, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Goebel-Stengel M, Stengel A, Schmidtmann M, et al. Unclear abdominal discomfort: pivotal role of carbohydrate malabsorption. J Neurogastroenterol Motil. 2014;20:228–235.
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.
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.
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.
Chang L. Review article: epidemiology and quality of life in functional gastrointestinal disorders. Aliment Pharmacol Ther. 2004;20:31–39.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Biesiekierski JR. Fructose-induced symptoms beyond malabsorption in FGID. United European Gastroenterol J. 2014;2:10–13.
Choi YK, Johlin FC Jr, Summers RW, et al. Fructose intolerance: an under-recognized problem. Am J Gastroenterol. 2003;98:1348–1353.
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.
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.
United States Department of Agriculture. Economic Research Service. Dairy products; Per Capita Availability/dymfg.xls.
Deng Y, Misselwitz B, Dai N, et al. Lactose intolerance in adults: biological mechanism and dietary management. Nutrients. 2015;7:8020–8035.
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.
Vesa TH, Marteau P, Korpela R. Lactose intolerance. J Am Coll Nutr. 2000;19:165S–175S.
Erdogan A, Rao SS, Gulley D, et al. Small intestinal bacterial overgrowth: duodenal aspiration vs glucose breath test. Neurogastroenterol Motil. 2015;27:481–489.
Ghoshal UC, Ghoshal U. Small intestinal bacterial overgrowth and other intestinal disorders. Gastroenterol Clin North Am. 2017;46:103–120.
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.
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.
Montalto M, Gallo A, Ojetti V, et al. Fructose, trehalose and sorbitol malabsorption. Eur Rev Med Pharmacol Sci. 2013;17:26–29.
Misselwitz B, Pohl D, Fruhauf H, et al. Lactose malabsorption and intolerance: pathogenesis, diagnosis and treatment. United Eur Gastroenterol J. 2013;1:151–159.
Rana SV, Malik A. Hydrogen breath tests in gastrointestinal diseases. Indian J Clin Biochem. 2014;29:398–405.
Christman NT, Hamilton LH. A new chromatographic instrument for measuring trace concentrations of breath-hydrogen. J Chromatogr. 1982;229:259–265.
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.
Lacy BE, Mearin F, Chang L, et al. Bowel disorders. Gastroenterology. 2016;150:1393–1407.
Gibson PR. History of the low FODMAP diet. J Gastroenterol Hepatol. 2017;32:5–7.
Srigley JA, Brooks A, Sung M, et al. Inappropriate use of antibiotics and Clostridium difficile infection. Am J Infect Control. 2013;41:1116–1118.
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.
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.
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.
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.
Pimentel M, Gunsalus RP, Rao SS, et al. Methanogens in human health and disease. Am J Gastroenterol. 2012;1:28–33.
Saad RJ, Chey WD. Breath testing for small intestinal bacterial overgrowth: maximizing test accuracy. Clin Gastroenterol Hepatol. 2014;12:1964–1972.
Lin ESK, Pichetshote N, et al. Measurement of hydrogen sulfide during breath testing correlates to patient symptoms. Gastroenterol. 2017;152:S205–S206.
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.
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.
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.
Simren M, Tornblom H, Palsson OS, et al. Management of the multiple symptoms of irritable bowel syndrome. Lancet Gastroenterol Hepatol. 2017;2:112–122.
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.
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.
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.
Conflict of interest
All authors declare no conflict of interest with this article.
The study was approved by the Augusta University Institutional Review Board No. 1114725 and registered at Clinical Trials Gov: NCTO 03261856.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
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
- Small intestinal bacterial overgrowth
- Fructose intolerance
- Lactose intolerance
- Breath test