Impact of Oral-Cecal Transit Time on the Interpretation of Breath Tests After RYGB: A Personalized Approach to the Diagnosis of SIBO

Abstract

Introduction: Traditionally, small intestinal bacterial overgrowth (SIBO) is diagnosed when there is an early peak in breath hydrogen or methane. Given unclear intestinal transit time in Roux-en-Y gastric bypass (RYGB) patients, it is unknown if the traditional approach at diagnosing SIBO is adequate in this patient population. This study aims to assess oral-cecal transit time (OCTT) and its impact on the interpretation of breath tests in the diagnosis of SIBO in patients with RYGB. Methods: This study consisted of prospectively collected cohort of RYGB patients who underwent testing for SIBO using lactulose breath test (LBT) with or without small bowel follow-through (SBFT) to assess OCTT. Outcomes of SIBO test based on LBT alone versus LBT with OCTT were compared using a Chi-squared test. Results: 151 RYGB patients underwent LBT to assess for SIBO. Sixty-two of the 151 patients (41.1%) underwent SBFT to assess OCTT in addition to LBT. Median OCTT was 60 minutes. Of these, 59.7% had OCTT shorter than 90 minutes. Based on LBT alone, 36/62 patients (58.1%) were classified as positive SIBO. When LBT results were combined with OCTT, 26/36 patients (72.2%) had hydrogen or methane rise within OCTT, suggesting 27.8 % false positive rate. Patients with true positive SIBO based on LBT and OCTT had a higher response rate to antibiotics compared to those with false positive SIBO (78.3% vs 33.3%, p=0.03). Conclusion: A personalized approach of combining LBT with SBFT to assess OCTT may improve the accuracy of SIBO testing and enhance clinical outcomes in patients with RYGB.