A study of the methodological and clinical validity of the combined lactulose hydrogen breath test with scintigraphic oro‐cecal transit test for diagnosing small intestinal bacterial overgrowth in <scp>IBS</scp> patients

Zhao, Jimeng; Zheng, Xia; Chu, Huimin; Cong, Yanqun; Fried, Michael; Fox, Mark; Dai, Ning

doi:10.1111/nmo.12331

Cited by 55 publications

(66 citation statements)

References 40 publications

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“…Indeed, MRI observations revealed that in about half of the healthy volunteers in whom SIBO was "diagnosed" on the basis of LHBT results were confounded by variation in OCTT and were not due abnormal distribution of bacteria in the small bowel. These data are in agreement with those reported by Yu et al (2) and Zhao et al (8) in IBS patients using combined 99mTc scintigraphy and LHBT , showing that an "abnormal LHBT" using any of the published criteria cannot distinguish rapid OCTT from SIBO (39).…”

Section: Discussionsupporting

confidence: 83%

“…Scintigraphy has good sensitivity and specificity providing similar measurements of OCTT by using both solid and liquid meal (28), but is time consuming, relatively costly, sometimes difficult to interpret due to overlapping loops of small intestine and the caecum, and utilizes ionizing radiations (8,28). MRI was recently applied to evaluate GI structure and function (29)(30)(31) and to detect the presence of gas or liquids and the movement of fluid through the GI tract (32)(33)(34).…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, IBS studies have revealed enteric dysmotility that may cause symptoms either directly as a result of altered OCTT or as a consequence of impaired clearance and overgrowth of colonic bacteria in the small bowel (7). However routine clinical investigations of GI function are not, at present, able to identify the underlying causes of symptoms and disease (8). Moreover, the evaluation of OCTT is controversial due to important problems of the available techniques, such as lactulose hydrogen breath testing (LHBT), sequential scintigraphy with isotope-marked meals, or by magnetic resonance imaging (MRI) (9)(10)(11)(12)(13)(14)(15)(16)(17).…”

Section: Introductionmentioning

confidence: 99%

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Measurement of oro-caecal transit time by magnetic resonance imaging

Savarino¹,

Savarino

Fox

et al. 2015

Eur Radiol

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OBJECTIVES To assess prospectively the agreement of orocaecal transit time (OCTT) measurements by lactulose hydrogen breath test (LHBT) and magnetic resonance imaging (MRI) in healthy subjects. METHODS Volunteers underwent abdominal 1.5-T MRI using axial and coronal single-shot fast-spin-echo T2-weighted sequences, having fasted and after lactulose ingestion (10 g/125 mL). Imaging and H2 excretion gas-chromatography were performed concurrently every 15 min up to 180 min. MR images were analyzed using semiautomatic segmentation to calculate small bowel gas volume (SBGV) and visually to detect bolus arrival in the caecum. Agreement between MRI-and LHBT-OCTT was assessed. RESULTS Twenty-eight subjects (17 men/11 women; mean age ± standard deviation 30 ± 8 years) were evaluated. Two H2 non-producers on LHBT were excluded. OCTT measured by MRI and LHBT was concordant in 18/26 (69 %) subjects (excellent agreement, k = 0.924). Median SBGV was 49.0 mL (interquartile interval 44.1 -51.6 mL). In 8/26 (31 %) subjects, MRI showed that the lactulose bolus was in the terminal ileum and not the caecum when H2E increased on LHBT. Median OCTT measured by MRI was significantly longer than OCTT measured by LHBT [135 min (120 -150 min) vs. 127.5 min (105 -150 min); p = 0.008]. Above baseline levels, correlation between [H2] and SBGV was significant (r = 0.964; p < 0.001). CONCLUSIONS MRI provides valid measurements of OCTT and gas production in the small bowel. KEY POINTS • MRI is a valid technique to measure OCTT. • Excellent agreement between MRI and LHBT was found. • Measuring gas production using MRI may provide evidence of small bowel fermentation. Methods: Volunteers underwent abdominal 1.5-T MRI using axial and coronal single-shot fast-spin-echo T2-weighted sequences in the fasted condition and after lactulose ingestion (10g/125mL). Imaging and H 2 excretion gas-cromatography were performed concurrently every 15 minutes up to 180 minutes. MR images were analyzed using semiautomatic segmentation to calculate small bowel gas volume (SBGV) and visually to detect bolus arrival in the cecum.Agreement between MRI-and LHBT-OCTT was assessed.Results: Twenty-eight subjects (17 males/11 females;mean age±standard deviation 30±8 years) were evaluated. Two H 2 non-producers on LHBT were excluded. OCTT measured by MRI and LHBT was concordant in 18/26 (69%) subjects (excellent agreement,k=0.924). Median SBGV was 49.0 mL (interquartile interval 44.1-51.6 mL). In 8/26 (31%) subjects, MRI showed the lactulose bolus was in the terminal ileum and not the cecum when H 2 E increased on LHBT. Thus, median OCTT measured by MRI was significantly longer than that measured by min)vs.127.5(105-150min);p=0.008]. Above baseline levels, correlation between [H 2 ] and SBGV was significant (r=0.964;p<0.001).Conclusions: MRI provides valid measurements of OCTT and gas production in the small bowel. Keypoints: MRI is a valid technique to measure OCTT.  Excellent agreement between MRI and LHBT was found. Measuring gas production using MRI may pro...

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Section: Discussionsupporting

confidence: 83%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Measurement of oro-caecal transit time by magnetic resonance imaging

Savarino¹,

Savarino

Fox

et al. 2015

Eur Radiol

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“…A causative role of SIBO in IBS has been established by Koch's postulates 27 . Moreover, three recent studies, one from India, 28 one from China, 29 and the most recent one from USA, 30 showed that response of IBS patients with SIBO to treatment with antibiotics is far greater than when antibiotics are used without testing for SIBO. These studies suggest that in future, treatment of IBS patients may see a paradigm shift with a more personalized or individualized approach somewhat similar to several other fields of medicine.…”

Section: Gut Microbiota Dysbiosis In Irritable Bowel Syndromementioning

confidence: 99%

“…However, these may work through different mechanisms in different subtypes of IBS patients. For example, three studies showed that antibiotics are more often effective in patients with IBS‐D with SIBO than those without SIBO 28–30 . In patients with IBS‐C, rifaximin with or without neomycin works primarily by targeting methanogens, which, by producing methane, slow colon transit.…”

Section: Pathophysiology‐directed Treatment For Irritable Bowel Syndromementioning

confidence: 99%

Marshall and Warren Lecture 2019: A paradigm shift in pathophysiological basis of irritable bowel syndrome and its implication on treatment

Ghoshal

2020

J of Gastro and Hepatol

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Irritable bowel syndrome (IBS), a common functional gastrointestinal disorder (FGID), has often been considered rather inappropriately as psychogenic in the past. Though psychological issues are important comorbidities in a proportion of IBS patients, the evidences are far from enough to label this condition as psychogenic only. In the recent past, evidences are emerging that underscores the concept supporting pure psychogenic theory of IBS and suggest this disorder to be rather microorganic. Accordingly, a move of Rome IV Committee attempting to delete the term "functional" and designating these to be disorders of "gut-brain interaction" rather than that of "brain-gut interaction," it emphasizes the importance of the gut over the brain in the pathogenesis. The introduction of the concept of multidimensional clinical profile in Rome IV requires attention to diagnostic category of FGID, overlap, severity, psychological issues, and physiological dysfunction or biomarkers; this attempts to recognize clinical variability and multidimensionality of pathophysiology and management of these disorders. The recognition of the biological factors in the pathogenesis of IBS is a significant paradigm shift in the recent time. This is somewhat similar to the progress in the pathogenesis of peptic ulcer disease from psychological factor to acid to Helicobacter pylori infection. It is expected that in the near future, therapeutic modalities targeting the different pathogenic mechanisms of different subtypes of IBS may bring revolution in management of the disorder.

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Reevaluating our understanding of lactulose breath tests by incorporating hydrogen sulfide measurements

Birg

Lin

2019

JGH Open

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Background and Aim Breath testing has become a commonly used tool in gastroenterology to evaluate changes in the fermentation pattern of the gut microbiome. Currently, hydrogen and methane gas concentrations are measured in breath testing and evaluated against specific cut‐off values for interpretation as normal or abnormal. However, microbial gas kinetics is a complex process that is not currently fully considered when interpreting breath gas results. Gas exchange between hydrogen producers and hydrogen consumers (methanogens and sulfate‐reducing bacteria) is a process whereby hydrogen availability is determined by both its production and removal. Hydrogen sulfide is a crucial gas involved in this process as it is a major hydrogen‐consumptive pathway involved in energy exchange. Methods This is a cross‐sectional study evaluating lactulose breath testing with the inclusion of hydrogen sulfide measurements in patients referred for breath testing for gastrointestinal symptoms of bloating, excessive gas, and/or abdominal pain. Results A total of 159 patients were analyzed between October 2016 and June 2017. Mean hydrogen concentrations with a positive trend through a 3‐h period ( R 2 = 0.97), mean methane concentrations with a positive trend ( R 2 = 0.69), and mean hydrogen sulfide concentrations with a negative trend ( R 2 = −0.71) were observed. Conclusion By incorporating energy exchange in the interpretation of the lactulose breath test, we reevaluated specific breath gas profiles, including those commonly described as “hydrogen nonproducers” and the “double‐peak” phenomenon.

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A study of the methodological and clinical validity of the combined lactulose hydrogen breath test with scintigraphic oro‐cecal transit test for diagnosing small intestinal bacterial overgrowth in IBS patients

Abstract: Combined LHBT/SOCT testing using a H2 5 ppm cutoff may identify a subgroup of IBS patients with SIBO. Pilot data examining the clinical response to rifaximin suggest that this subset of IBS patients may benefit more than those with a normal test.

Cited by 55 publications

References 40 publications

Measurement of oro-caecal transit time by magnetic resonance imaging

Measurement of oro-caecal transit time by magnetic resonance imaging

Marshall and Warren Lecture 2019: A paradigm shift in pathophysiological basis of irritable bowel syndrome and its implication on treatment

Reevaluating our understanding of lactulose breath tests by incorporating hydrogen sulfide measurements

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