Breath H2 Concentration Research Articles

Effect of Trimebutine and Rifaximin on Breath Hydrogen and Methane by Glucose Breath Test in Patients With Functional Bloating: A Randomized Double-blind Clinical Trial.

Drugs that stabilize intestinal motility may improve the efficacy of nonabsorbable antibiotics, such as rifaximin, against small intestinal bacterial overgrowth (SIBO). We compared the efficacy of rifaximin alone with that of its combination with trimebutine maleate against SIBO. We performed a randomized double-blind placebo-controlled trial (https://cris.nih.go.kr, no. KCT0004836) that included patients with functional bloating, no constipation, and SIBO using the hydrogen (H2)-methane (CH4) glucose breath test (GBT). Patients were randomized into 2 groups in a 1:1 ratio, namely rifaximin (1200 mg/day) + trimebutine maleate (600 mg/day) group and rifaximin + placebo group, for 2 weeks. Patients completed a symptom questionnaire and underwent a GBT at baseline and at 1 month after treatment withdrawal. The primary outcome was SIBO eradication. The secondary outcomes included changes in the concentrations of exhaled gases, symptoms, and presence of adverse events. The complete eradication rate of SIBO was 35.9% (14/39) in the rifaximin group, and 34.1% (14/41) in the combined group with no significant differences. In both groups, no significant differences were observed in GBT profiles before and after the treatment, respectively. However total breath H2 and CH4 concentration were conspicuously decreased in the combined group after treatment. The combined group exhibited substantial relief of bloating. The adverse events were similar in the 2 groups. While the combination therapy was not superior over rifaximin alone for SIBO eradication, it improves the symptom of bloating with numerically reducing the concentration of breath H2/CH4.

P1754ASSOCIATION OF GUT MICROBIAL FERMENTATION WITH DIARRHEA IN KIDNEY TRANSPLANT RECIPIENTS

Abstract Background and Aims Diarrhea is a common complaint by kidney transplantation recipients (KTR). Metabolic abnormalities and immunosuppressive drugs may cause alterations in the gut microbiome possibly leading to diarrhea. A hydrogen (H2) breath test, reflecting nutrient fermentation, can detect changes in the composition of gut microbiota. In the present study, we studied the association of exhaled H2 with diarrhea in KTR, and investigated its determinants. Method All data were collected from the TransplantLines Biobank Cohort Study (NCT03272841). Living kidney donors were used as healthy controls. Breath H2 concentrations were analysed using solid state-sensor gas-chromatography. The stool water content was measured by faecal dry matter analysis and diarrhea was classified as >80% of water content in stools. Age, sex, body mass index (BMI), diabetes mellitus, eGFR and immunosuppressive medication were tested as potential determinants for H2 using linear multivariable regression. Results We included 424 KTR (mean age 55.4 ± 13.2 years, 39,1% female, transplant vintage 5.5 ± 9.5 years) and 164 healthy controls in this study. Immunosuppressive drugs included tacrolimus (78.5%), mycophenolate mofetil (MMF, 73.3%), cyclosporine (9.0%), and everolimus (2.4%) in various combinations. The median concentration of H2 in exhaled breath was significantly higher among KTR versus healthy controls (11.0 ppm [5.0 - 25.0] vs 9.0 ppm [4.0-22.5] p=0.005). The exhaled H2 was correlated with stool water content (r=0.24, p=0.04), as shown in figure 1. Serum tacrolimus trough levels were associated with exhaled H2 (standardized β=0.14, p=0.01), independent of age, sex, BMI, diabetes mellitus, eGFR and other immunosuppressive medication. In contrast, MMF trough levels were not independently associated with H2 (standardized β=0.07, p=0.21). Conclusion Exhaled H2, a marker of gut fermentation, is higher in KTR compared to healthy controls, and is associated with stool water content. Present results suggest that altered gut microbial fermentation contributes to the occurrence of diarrhea in KTR. Tacrolimus trough level was an independent determinant of H2. These data encourage further studies to validate the association of immunosuppressive drugs, gut microbiota and post-transplant diarrhea.

Altered Gut Microbial Fermentation and Colonization with Methanobrevibacter smithii in Renal Transplant Recipients.

Renal transplant recipients (RTRs) often suffer from posttransplant diarrhea. The observed dysbiosis in RTR may influence the fermentation processes in the gut. In this study, we aimed to investigate whether fermentation differs between RTRs and healthy controls (HCs), by measuring breath H2 and CH4 concentrations. Additionally, we determined the fecal presence of the methanogen Methanobrevibacter smithii (M. smithii), which plays a main role in the process of methanogenesis. Data from the TransplantLines Biobank and Cohort Study (NCT03272841) was used. A total of 142 RTRs and 77 HCs were included. Breath H2 concentrations in RTRs were not significantly different from HCs. Breath CH4 concentrations in RTRs were significantly lower compared with HCs (median [interquartile range (IQR)] 7.5 [3.9–10.6] ppm vs. 16.0 [8.0–45.5] ppm, p < 0.001). M. smithii was less frequently present in the feces of RTRs compared to HCs (28.6% vs. 86.4% resp., p < 0.001). Our findings regarding the altered methanogenesis in the gut of RTRs show similarities with previous results in inflammatory bowel disease patients. These findings provide novel insight into the alterations of fermentation after renal transplantation, which may contribute to understanding the occurrence of posttransplant diarrhea.

Association between increased breath hydrogen methane concentration and prevalence of glucose intolerance in acute pancreatitis

Pancreatic damage, in the form of pancreatitis, intestinal bacteria and glucose imbalance could be interrelated. The aim of this study was to investigate the breath hydrogen (H2) and methane (CH4), which can indicate small intestinal bacterial overgrowth (SIBO) status, and assess the link between SIBO and glucose tolerance in patients with acute pancreatitis (AP). This prospective study enrolled 75 patients who were admitted for AP. A glucose breath test (GBT) which detects breath hydrogen H2 and CH4 for SIBO with an oral glucose tolerance test (OGTT) for 120 min was simultaneously performed to determine SIBO and glucose tolerance. Patient demographic data, laboratory test data, and computed tomography severity index (CTSI) were also evaluated. The levels of total breath H2 and CH4 in patients with AP were significantly higher than those in controls, respectively (p < 0.01). There were no significant differences in the incidence of SIBO between patients with AP and controls. The OGTT indicated that blood glucose levels at 30, 60, 90, and 120 min were higher in SIBO-positive patients than in SIBO-negative patients. No significant differences in CTSI, patient demographic data or laboratory test data were observed between the two groups. Breath H2 and CH4 concentrations are relatively higher in patients with AP, indicating a correlation between high levels of intestinal bacteria and AP. Furthermore, higher breath H2 and CH4 concentrations appear to be associated with oral glucose intolerance, with hyperglycemia occurring in patients with AP.

Impact of 24-h high and low fermentable oligo-, di-, monosaccharide, and polyol diets on markers of exercise-induced gastrointestinal syndrome in response to exertional heat stress.

The study aimed to determine the effects of 24-h high (HFOD) and low (LFOD) fermentable oligo-, di-, monosaccharide, and polyol (FODMAP) diets before exertional heat stress on gastrointestinal integrity, function, and symptoms. Eighteen endurance runners consumed a HFOD and a LFOD (double-blind crossover design) before completing 2 h of running at 60% maximal oxygen uptake in 35 °C ambient temperature. Blood samples were collected before and after exercise to determine plasma cortisol and intestinal fatty acid binding protein (I-FABP) concentrations, and bacterial endotoxin and cytokine profiles. Breath hydrogen (H2) and gastrointestinal symptoms (GIS) were determined pre-exercise, every 15 min during, and in recovery. No differences were observed for plasma cortisol concentration between diets. Plasma I-FABP concentration was lower on HFOD compared with LFOD (p = 0.033). A trend for lower lipopolysaccharide binding protein (p = 0.088), but not plasma soluble CD14 (p = 0.478) and cytokine profile (p > 0.05), responses on HFOD was observed. A greater area under the curve breath H2 concentration (p = 0.031) was observed throughout HFOD (mean and 95% confidence interval: HFOD 2525 (1452-3597) ppm·4 h-1) compared with LFOD (1505 (1031-1978) ppm·4 h-1). HFOD resulted in greater severity of GIS compared with LFOD (pre-exercise, p = 0.017; during, p = 0.035; and total, p = 0.014). A 24-h HFOD before exertional heat stress ameliorates disturbances to epithelial integrity but exacerbates carbohydrate malabsorption and GIS severity in comparison with a LFOD. Novelty Twenty-four-hour high FODMAP diet ameliorated disturbances to gastrointestinal integrity. Twenty-four-hour high FODMAP diet results in greater carbohydrate malabsorption compared with low FODMAP diet. Incidence of GIS during exertional heat stress were pronounced on both low and high FODMAP diets, but greater GIS severity was observed with high FODMAP diet.

Hydrogen-producing milk to prevent reduction in tear stability in persons using visual display terminals

PurposeTo examine the effect of hydrogen (H2)-producing milk, which induces H2 production by intestinal microbiota, on the prevention of dry eye disease. MethodsA randomized, double-blind, placebo-controlled, parallel-group comparative study was conducted in humans. Of 118 candidates aged 20–60 years who were using visual display terminals daily, 54 subjects (mean age, 42.4 years) with mild-to-moderate dry eye symptoms, who were not dry eye patients based on the 2006 Japanese Diagnostic Criteria for Dry Eye, were included in the study. Subjects were assigned to the H2-producing milk group or the placebo group. They were instructed to ingest the assigned test beverage once per day for three consecutive weeks. Breath H2 concentration, fluorescein tear film breakup time (fTBUT), Schirmer's test, 8-OHdG concentration in tears, reported ocular symptoms using the dry eye-related QOL score questionnaire, and the visual analogue scale were assessed at weeks 0 and 3. ResultsChange in fTBUT in the H2-producing milk group was significantly greater than that in the placebo group. A significant decline in fTBUT was observed in the placebo group (p = 0.04), but not the H2-producing group (p = 0.26). This phenomenon was strongly observed in females. We found a positive correlation between the change in fTBUT and net H2 production, and a negative correlation between the change in 8-OHdG concentration and net H2 production in young females. ConclusionsH2-producing milk appeared to retard the decline in tear stability and may prevent short fTBUT-type dry eye by decreasing oxidative stress in the lacrimal functional unit.

Effects of functional milk containing galactooligosaccharide, maltitol, and glucomannan on the production of hydrogen gas in the human intestine

Hydrogen gas (H2) reacts with strong oxidants, and the effectiveness of H2 inhalation or ingestion of H2 water has been demonstrated for many diseases. H2 produced by the intestinal microbiome from indigestible components is the major source of exogenous H2. In this study, we screened a wide variety of indigestible components that induce H2 production by the intestinal microbiome, which exhibits large diversity, and developed a beverage composed of cows’ milk with galactooligosaccharide, maltitol, and glucomannan (H2-producing milk). In clinical trials, the breath H2 concentration of most volunteers was increased by consumption of H2-producing milk 1 (each material: 1%) and H2-producing milk 2 (galactooligosaccharide: 1.5%, maltitol: 1%, and glucomannan: 0.1%). The total range of H2 production (area under the curve) increased and a higher peak concentration was observed compared with consumption of H2 water or pure cows’ milk. Thus, this material may be a desirable functional milk.

Effects of wheat bran extract rich in arabinoxylan oligosaccharides and resistant starch on overnight glucose tolerance and markers of gut fermentation in healthy young adults.

Specific combinations of dietary fiber (DF) have been observed to result in improved glucose tolerance at a subsequent standardized breakfast. Arabinoxylan oligosaccharides (AXOS) are considered as DF with prebiotic potential, but so far no studies have investigated their metabolic effects in humans. This randomized cross-over study evaluated the overnight impact of breads containing AXOS-rich wheat bran extract and resistant starch (RS, Hi-Maize), separately or combined, on glucose tolerance, related metabolic parameters and markers of gut fermentation in healthy subjects. Evening reference and test products were: (1) reference white wheat flour bread (WWB), WWB supplemented with (2) AXOS and RS (WWB+AXOS+RS), (3) an increased content of either AXOS (WWB+hiAXOS) or (4) RS (WWB+hiRS). At the subsequent standardized breakfast, blood was sampled for 3h to monitor glucose, insulin, nonesterified fatty acids, glucagon-like peptide (GLP)-1 and GLP-2. Breath hydrogen (H2) and short chain fatty acids (SCFA) were measured as markers of gut fermentation, and subjective appetite was rated using visual analog scales. Dose-dependent decreases in glucose responses were observed with increased AXOS over the duration of 3h. Insulin sensitivity index was improved in the morning after the WWB+hiAXOS evening meal. An increase in breath H2 concentration and circulating SCFA was observed in the morning after both evening meals containing AXOS. The present study indicates that AXOS have the potential of improving glucose tolerance in an overnight perspective and suggested mechanisms are improved insulin sensitivity and increased gut fermentation.

Sa1338 The Chracteristics of Positivity to Glucose Breath Test in Patients With Cholecystectomy

Objectives: There is a possibility that bacterial overgrowth is associated with postcholecystectomy patients. This study was to evaluate the prevalence and characteristics of small intestinal bacterial overgrowth (SIBO) in patients with intestinal symptoms according to the history of cholecystectomy. Methods: 62 postcholecystectomy patients with intestinal symptoms and 145 functional gastrointestinal disease (FGID) patients, and 30 healthy controls undergoing hydrogen (H2)-methane (CH4) glucose breath test (GBT) were reviewed. The GBT positivity (+) indicating the presence of SIBO, gas types and bowel symptom questionnaire were surveyed. The GBT + were (1) an increase in the breath H2 or CH4 concentration of ≥ 12 ppm over the baseline or (2) a baseline H2 or CH4 concentration of ≥ 15 ppm within 60 min after 50g of glucose load. Results: The GBT +were significantly higher in postcholecystectomy patients (46.8%, 29/62) than those in FGID patients (26.2%, 38/145) (p < 0.01), or those in controls (13.3%, 4/30) (p < 0.01), respectively. Among postcholecystectomy patients, 27 (43.5%), 2 (3.2%), 0 (0%) were in the GBT (H2) +, (CH4) +, (both) + groups, respectively. In the gas types, the GBT (H2) + in postcholecystectomy patients was significantly higher than those in FGID patients (43.5% vs. 20%, p = 0.02). At the single time points of the GBT in postcholecystectomy patients, only the baseline H2 levels were significantly higher in GBT + group than in GBT group, and the GBT + group had higher symptom scores of significance or tendency in abdominal discomfort (p = 0.49), urgency (p = 0.02), bloating (p < 0.01), chest discomfort (p = 0.34), early satiety (p = 0.06) and nausea (p = 0.40) than those of the GBT group. Conclusions: The SIBO with high levels of baseline H2 might be the important etiologic factor of upper intestinal symptoms for postcholecystectomy patients.

Incidence of lactose intolerance in type 2 diabetic patients (1025.1)

Diabetes mellitus is fast‐growing global problem with huge social &amp;amp; health consequences. Diabetic patients generally complain about various gastrointestinal (GI) problems such as flatulence, diarrhea and/or constipation. Lactose intolerance may be one of the reasons of diarrhea and/or flatulence in these patients. Therefore, this study was planned to investigate the incidence of lactose intolerance in diabetic patients and apparently healthy controls. 84 type 2 diabetic patients with age 24‐75years &amp;amp; 80 age and sex matched controls (age range 24‐74 years) were enrolled. Non‐invasive lactose breath test was done after overnight fast. For this, 25g lactose dissolved in 250 ml water was given orally after taking fasting breath H2 and CH4 concentrations. End expiratory breath was collected every 30 minutes up to 4 hrs. Concentration of H2 &amp;amp;/or CH4 was measured by using SC Microlyser. Rise 蠅 20ppm over base line value in H2 and/or CH4 concentration in two consecutive readings was considered as lactose intolerance. Out of 84 diabetic patients, 40 (47.6%) were females and 44 (52.4%) males.While out of 80 healthy controls, 38 (45.2%) were females and 42 (52.5%) males. 56 out of 84 (66.7%) diabetic patients were lactose intolerant, while 28 out of 80 (35%) in controls. This study suggests that lactose intolerance was significantly higher (p&lt;0.0001) in Type 2 diabetic patients as compared to healthy controls.Grant Funding Source: Supported by Indian Council of Medical Research,New Delhi,India

OC-090 Different effects of FODMAP (fermentable oligo-, di-, and mono-saccharides, and polyols) components on small bowel water content: an MRI study

IntroductionA randomised placebo controlled trial (RCT) has shown that FODMAPs exacerbate irritable bowel syndrome (IBS) symptoms in selected patients. FODMAPs are heterogeneous chemically, the major components being fructose and fructans....

PTU-154 Investigation of the optimal duration of the glucose hydrogen methane breath test

IntroductionHistorically, the glucose hydrogen breath test has been popular for diagnosing small intestinal bacterial overgrowth (SIBO). Lately the glucose hydrogen methane breath test has become available. It is non-invasive and...

Lactose Intolerance in Liver Cirrhosis Patients

© 2011, INASL 20 population. Mean age of death being 47.25. Total years lived with disability 311. Considering disability weight of alcoholic cirrhosis as 0.33 and average life expectancy of male Keralites as 72 DALY calculated is 20.95. Conclusion: Alcoholic cirrhosis imparts a huge economic burden on family and society with loss of quality of life and early deaths. Conflict of Interest: None Lactose Intolerance in Liver Cirrhosis Patients SV Rana*, S Sharma*, RK Dhiman**, YK Chawla**, K Singh* Departments of *Gastroenterology and **Hepatology, PGIMER, Chandigarh Background: Malnutrition, characterized by protein and energy deficiency, is considered the most prevalent complication of liver disease. Studies of small bowel mucosa in cirrhosis report a diverse spectrum of histological abnormalities. These include increased mucosal edema, decreased villus to crypt ratio, villus atrophy and decreased total absorptive surface. This may result in decreased lactase activity causing lactose intolerance. Aim: Therefore, this study was planned to evaluate lactose intolerance in patients with liver cirrhosis. Materials and Methods: Lactose intolerance was estimated by using non-invasive lactose hydrogen breath test in 59 patients of liver cirrhosis and 63 ageand sex-matched apparently healthy controls. For lactose hydrogen breath test 25 g lactose dissolved in 250 mL water was given orally to the subjects after taking fasting breath H2 concentration. End expiratory breath was collected every 30 minutes up to 4 hours. H2 concentration was measured by using SC Microlyzer (Quintron, USA). Rise ≥ 20 ppm over baseline value in H2 concentration in two consecutive readings was considered as lactose intolerance. Results: In liver cirrhotic patient, 46 were males and 13 females, while in controls 49 males and 14 females. Out of 59 patients, 27 had viral cirrhosis and 32 had alcoholic cirrhosis. Mean ± SD of age in patients was 45.6 ± 16.4 years and in controls 47.8 ± 15.3 years. Out of 59 patients of liver cirrhosis, 41 (69.5%) were lactose intolerant while in controls 28 (44.4%) out of 63 subjects. The difference was statistically significant (p < 0.01). Lactose intolerance was present in 19 (70.4%) out of 27 viral cirrhosis patients while in 22 (68.75%) out of 32 alcoholic cirrhosis patients. Lactose intolerance was significantly higher in both the groups as compared to control group. Conclusion: This study indicates that lactose intolerance was significantly higher in cirrhotic patients. Conflict of Interest: None Impact of Diabetes Mellitus on the Clinical Outcome of Cirrhosis TM Ramachandran, AR Rajneesh, T Varghese Additional Professor, DM Trainee and Presenting Author, Professor, Department of Gastroenterology, Government Medical College, Calicut, Kerala Objectives: To assess the impact of diabetes mellitus on the natural history, complication rate, hospital admission rate and mortality of cirrhotic patients. Methods: Cirrhotic patients admitted at a tertiary care institution during the period of July 2009 to January 2011 with and without diabetes mellitus were analyzed in a prospective comparative study. The clinical characteristics, various complication rates and hospital admission rates in patients who died as well as survived were analyzed. Pregnant women, Stage IV and V chronic kidney disease, hepatoma and other secondary causes of diabetes were excluded from the study. Results: Of the 199 cirrhotic patients, 106 (53.3%) were diabetic and 93 (46.7%) were non-diabetic. Average age was 57.14 (diabetic) and 53.7 (non-diabetic) years. Mean CTP score was 10 in both groups. Average duration of cirrhosis was 19 months in both groups. Diabetics had a higher prevalence of cryptogenic etiology (p value 0.013) and family history of diabetes (p 0.001). Presentation as acute on chronic liver failure was more in non-diabetic group (p 0.035). Mean albumin value was higher in diabetics (2.72 vs. 2.5; p value 0.017). Number of prior hospital admissions (mean 2.93 vs. 2.17) and number of decompensation episodes (mean 2.96 vs. 2.16) were higher in the diabetic group (p value 0.023). Prevalence of gallstones were common in diabetics (26.41%) compared to non-diabetics (5.37%) (p value 0.001). Frequency of urinary tract infection was higher in the diabetic group (37.7%) vs. non-diabetics (5.3%) (p value 0.001). Frequency of spontaneous bacterial peritonitis was 19.8% (diabetic) and 23.63% (non-diabetics) (p value NS). Frequencies of other infections (pneumonia, tuberculosis, cellulitis, abscess) were also higher in diabetics than non-diabetics. Conclusion: Age, cryptogenic etiology, number of decompensation episodes, number of hospital admissions, serum albumin and gallstones were more in the diabetic group. Urinary tract infection was more common among diabetics whereas spontaneous bacterial peritonitis was present in both groups. Conflict of Interest: None 03_JCEH-Abstract.indd 20 3/18/2011 11:13:04 AM

Impact of Diabetes Mellitus on the Clinical Outcome of Cirrhosis

© 2011, INASL 20 population. Mean age of death being 47.25. Total years lived with disability 311. Considering disability weight of alcoholic cirrhosis as 0.33 and average life expectancy of male Keralites as 72 DALY calculated is 20.95. Conclusion: Alcoholic cirrhosis imparts a huge economic burden on family and society with loss of quality of life and early deaths. Conflict of Interest: None Lactose Intolerance in Liver Cirrhosis Patients SV Rana*, S Sharma*, RK Dhiman**, YK Chawla**, K Singh* Departments of *Gastroenterology and **Hepatology, PGIMER, Chandigarh Background: Malnutrition, characterized by protein and energy deficiency, is considered the most prevalent complication of liver disease. Studies of small bowel mucosa in cirrhosis report a diverse spectrum of histological abnormalities. These include increased mucosal edema, decreased villus to crypt ratio, villus atrophy and decreased total absorptive surface. This may result in decreased lactase activity causing lactose intolerance. Aim: Therefore, this study was planned to evaluate lactose intolerance in patients with liver cirrhosis. Materials and Methods: Lactose intolerance was estimated by using non-invasive lactose hydrogen breath test in 59 patients of liver cirrhosis and 63 ageand sex-matched apparently healthy controls. For lactose hydrogen breath test 25 g lactose dissolved in 250 mL water was given orally to the subjects after taking fasting breath H2 concentration. End expiratory breath was collected every 30 minutes up to 4 hours. H2 concentration was measured by using SC Microlyzer (Quintron, USA). Rise ≥ 20 ppm over baseline value in H2 concentration in two consecutive readings was considered as lactose intolerance. Results: In liver cirrhotic patient, 46 were males and 13 females, while in controls 49 males and 14 females. Out of 59 patients, 27 had viral cirrhosis and 32 had alcoholic cirrhosis. Mean ± SD of age in patients was 45.6 ± 16.4 years and in controls 47.8 ± 15.3 years. Out of 59 patients of liver cirrhosis, 41 (69.5%) were lactose intolerant while in controls 28 (44.4%) out of 63 subjects. The difference was statistically significant (p < 0.01). Lactose intolerance was present in 19 (70.4%) out of 27 viral cirrhosis patients while in 22 (68.75%) out of 32 alcoholic cirrhosis patients. Lactose intolerance was significantly higher in both the groups as compared to control group. Conclusion: This study indicates that lactose intolerance was significantly higher in cirrhotic patients. Conflict of Interest: None Impact of Diabetes Mellitus on the Clinical Outcome of Cirrhosis TM Ramachandran, AR Rajneesh, T Varghese Additional Professor, DM Trainee and Presenting Author, Professor, Department of Gastroenterology, Government Medical College, Calicut, Kerala Objectives: To assess the impact of diabetes mellitus on the natural history, complication rate, hospital admission rate and mortality of cirrhotic patients. Methods: Cirrhotic patients admitted at a tertiary care institution during the period of July 2009 to January 2011 with and without diabetes mellitus were analyzed in a prospective comparative study. The clinical characteristics, various complication rates and hospital admission rates in patients who died as well as survived were analyzed. Pregnant women, Stage IV and V chronic kidney disease, hepatoma and other secondary causes of diabetes were excluded from the study. Results: Of the 199 cirrhotic patients, 106 (53.3%) were diabetic and 93 (46.7%) were non-diabetic. Average age was 57.14 (diabetic) and 53.7 (non-diabetic) years. Mean CTP score was 10 in both groups. Average duration of cirrhosis was 19 months in both groups. Diabetics had a higher prevalence of cryptogenic etiology (p value 0.013) and family history of diabetes (p 0.001). Presentation as acute on chronic liver failure was more in non-diabetic group (p 0.035). Mean albumin value was higher in diabetics (2.72 vs. 2.5; p value 0.017). Number of prior hospital admissions (mean 2.93 vs. 2.17) and number of decompensation episodes (mean 2.96 vs. 2.16) were higher in the diabetic group (p value 0.023). Prevalence of gallstones were common in diabetics (26.41%) compared to non-diabetics (5.37%) (p value 0.001). Frequency of urinary tract infection was higher in the diabetic group (37.7%) vs. non-diabetics (5.3%) (p value 0.001). Frequency of spontaneous bacterial peritonitis was 19.8% (diabetic) and 23.63% (non-diabetics) (p value NS). Frequencies of other infections (pneumonia, tuberculosis, cellulitis, abscess) were also higher in diabetics than non-diabetics. Conclusion: Age, cryptogenic etiology, number of decompensation episodes, number of hospital admissions, serum albumin and gallstones were more in the diabetic group. Urinary tract infection was more common among diabetics whereas spontaneous bacterial peritonitis was present in both groups. Conflict of Interest: None 03_JCEH-Abstract.indd 20 3/18/2011 11:13:04 AM

M1359 Restore: Randomized Evaluation of Endoscopic Suturing Transorally for Anastomotic Outlet Reduction: A Double-Blind, Sham-Controlled Multicenter Study for Treatment of Inadequate Weight Loss or Weight Regain Following Roux-en-Y Gastric Bypass

Background and aims: Roux-en-Y gastric bypass technique (RYGBP) by inducing bacterial stasis could promote small intestinal bacterial overgrowth (SIBO). In a previous study performed in 146 patients with morbid obesity (1) we found an increase in the prevalence of SIBO compared to healthy subjects 17.1% vs.2.5% (p=0.03). The aim of this study was to evaluate prospectively the prevalence of SIBO in a larger population of patients withmorbid obesity, before and after bariatric surgery and its potential effect on vitamin deficiencies after surgery. Patients and methods: from October 2001 to July 2009, a glucose hydrogen (H2) breath test (BT, positive if fasting breath H2 concentration > 20 ppm and or increase > 10 ppm over baseline within the first 2 hours) was proposed to all obese patients referred for bariatric surgery (BMI > 40 kg/m 2 or > 35 in association with comorbidities) before and after bariatric surgery to assess the presence of SIBO. Vitamin levels (B12, B1, PP) were measured while vitamin supplementation was systematically prescribed after RYGBP. Results(mean ± SE, median (IQR) : 378 patients (336 women (88.9%), 39.6± 11.7 yrs, BMI : 45.7±6.3 kg/m 2 ) were included : 357 patients had a preoperative BT that was positive in 55 cases (15.4%), negative in 290 cases (81,2%) and doubtful or uninterpretable in 12 cases (3.4%). Twenty patients had BT after gastric banding [time since surgery 36 months (26-47), weight loss 22.9±14.1 kg] that was negative in 18 cases (90%) and positive in 2 cases (10%) (p = NS compared with preoperative situation). Sixty-five patients had a BT after RYGBP [time since surgery 9.2 months (6.8-23), weight loss 34.4± 11.5 kg] that was negative in 39 cases (60%) and positive in 26 cases (40%) (p<0.001 compared with preoperative situation). After RYGBP the percentage of patients with or without vitamin deficiencies was not different in patients with positive or negative BT (p = NS). Conclusion: in this study with a large number of patients, we confirm the presence of SIBO in 15% of patients with morbid obesity. After gastric banding, there is no increase in this prevalence while after RYGBP it increases to 40% of patients. In patients with systematic vitamin supplementation, a positive BT is not associated with an increase in the frequency of vitamin deficiencies. (1) Sabate et al. Obes Surg 2008 ; 18:371-377

Breath Hydrogen Gas Concentration Linked to Intestinal Gas Distribution and Malabsorption in Patients with Small-bowel Pseudo-obstruction

The patient with colonic obstruction may frequently have bacterial overgrowth and increased breath hydrogen (H2) levels because the bacterium can contact with food residues for longer time. We experienced two cases with intestinal obstruction whose breath H2 concentrations were measured continuously. CASE 1: A 70-year-old woman with small bowel obstruction was treated with a gastric tube. When small bowel gas decreased and colonic gas was demonstrated on the plain abdominal radiograph, the breath H2 concentration increased to 6 ppm and reduced again shortly. CASE 2: A 41-year-old man with functional small bowel obstruction after surgical treatment was treated with intravenous administration of erythromycin. Although the plain abdominal radiograph demonstrated a decrease of small-bowel gas, the breath H2 gas kept the low level. After a clear-liquid meal was supplied, fasting breath H2 concentration increased rapidly to 22 ppm and gradually decreased to 9 ppm despite the fact that the intestinal gas was unchanged on X-ray. A rapid increase of breath H2 concentration may reflect the movement of small bowel contents to the colon in patients with small-bowel pseudo-obstruction or malabsorption following diet progression. Change in breath H2 concentration had a close association with distribution and movement of intestinal gas.

Breath hydrogen and methane levels in a patient with volvulus of the sigmoid colon

Volvulus of the large bowel is the third most common cause of colonic obstruction. A patient with colonic obstruction or delayed small intestinal transit may frequently have bacterial overgrowth and increased breath hydrogen (H2) and/or methane (CH4) excretion because the bacterium can contact with food residues for a longer time. A 39 year old woman attended our hospital with complaints of abdominal pain and distension. This patient's abdominal radiograph showed an inverted U-shaped shadow. The fasting breath CH4 level was 26 ppm. An endoscopic procedure was immediately carried out with suspected sigmoid colon volvulus, and detorsion was achieved. There was resolution of the sigmoid volvulus after colonoscopy, and breath CH4 concentration in the next morning decreased to 10 ppm. A liquid meal was supplied at noon on the second hospital day. The breath CH4 concentration increased markedly to 38 ppm at 18:00 although she had no abdominal symptoms. This value peaked at 42 ppm at 18:00 on the third hospital day and was gradually reduced to 20 ppm the next day. The breath H2 concentration value kept a low level during fasting and increased markedly to 51 ppm the next day after a liquid meal was supplied. The next morning, fasting breath H2 concentration rapidly decreased to 6 ppm. This suggests that changes in breath H2 levels may reflect transient malabsorption after a liquid test meal is supplied. In conclusion, breath H2 and CH4 analysis may be another tool for evaluating the intestinal circumstances.

Diarrhea in Severely Burned Children

Diarrhea is a common problem in critically ill patients. Our patients are fed a high-carbohydrate enteral formula. We hypothesized that diarrhea in our patients may be related to the osmotic effects of unabsorbed carbohydrate in the small intestine and colon. We studied 19 patients, 3 months to 17 years, with burns >40% total body surface area. Each subject was studied weekly for up to 4 weeks postburn. Breath H2 concentration was measured. For the 24-hour period before the breath H2 measurement, the enteral carbohydrate intake, stool volume, and total enteral fluid volume were recorded. At each of several weekly intervals for each subject, the times when stool volume and enteral carbohydrate intake were each maximal were noted. Maximal stool volume ranged from 12 to 69 mL/kg/d. At the time point of maximal carbohydrate intake, diarrhea (stool volume >10 mL/kg/d) occurred in 18 of 19 patients, and maximal stool volume occurred in 10 of 19. Breath H2 concentration (ppm/5% CO2; mean +/- SEM) was 5.5 +/- 3.5 at the time of maximal carbohydrate intake, and was 25 +/- 20 at maximal stool volume. There were no correlations among breath H2 concentration, stool volume, enteral fluid intake, and enteral carbohydrate intake. Almost all the subjects had diarrhea over several weeks postburn. The lack of correlation of either carbohydrate intake or breath H2 with stool volume suggests that diarrhea in these patients may be caused by factors other than carbohydrate malabsorption. These data do not support altering nutrition support because of watery diarrhea.

Diarrhea in Severely Burned Children

Background: Diarrhea is a common problem in critically ill patients. Our patients are fed a high‐carbohydrate enteral formula. We hypothesized that diarrhea in our patients may be related to the osmotic effects of unabsorbed carbohydrate in the small intestine and colon. Methods: We studied 19 patients, 3 months to 17 years, with burns &gt;40% total body surface area. Each subject was studied weekly for up to 4 weeks postburn. Breath H2 concentration was measured. For the 24‐hour period before the breath H2 measurement, the enteral carbohydrate intake, stool volume, and total enteral fluid volume were recorded. At each of several weekly intervals for each subject, the times when stool volume and enteral carbohydrate intake were each maximal were noted. Results: Maximal stool volume ranged from 12 to 69 mL/kg/d. At the time point of maximal carbohydrate intake, diarrhea (stool volume &gt;10 mL/kg/d) occurred in 18 of 19 patients, and maximal stool volume occurred in 10 of 19. Breath H2 concentration (ppm/5% CO2; mean ± SEM) was 5.5 ± 3.5 at the time of maximal carbohydrate intake, and was 25 ± 20 at maximal stool volume. There were no correlations among breath H2 concentration, stool volume, enteral fluid intake, and enteral carbohydrate intake. Conclusions: Almost all the subjects had diarrhea over several weeks postburn. The lack of correlation of either carbohydrate intake or breath H2 with stool volume suggests that diarrhea in these patients may be caused by factors other than carbohydrate malabsorption. These data do not support altering nutrition support because of watery diarrhea.

Efficacy of lactulose plus 13C-acetate breath test in the diagnosis of gastrointestinal motility disorders.

We designed a new method of measuring gastric emptying and orocecal transit time (OCTT) at the same time to assess the influence of gastric emptying upon OCTT. Twenty-five dyspeptic patients (6 men, 19 women) with a mean age of 64.8 years (range, 25-80 years) were studied. The patients received a liquid test meal, containing 100 mg of 13C-acetate and 12g of lactulose, while they were in the sitting position after an overnight fast. Breath samples were collected at 10-min intervals of 120 min and both 13CO2 and hydrogen (H2) levels were measured. Subsequently, H2 concentrations were measured at 30-min intervals, for a total of 240 min. The results of gastric emptying were expressed as the time of peak 13CO2 excretion. OCTT was defined as the period between the ingestion of lactulose and a H2 peak rise of 5 ppm above the baseline value. The onset of H2 enrichment in the breath began at 90-110 min, whereas 13CO2 levels increased from the beginning, with peak enrichment values being reached after 60-80 min. OCTT was related to 13CO2 peak time. In 5 of the 25 patients, H2 breath enrichment in the 10-min sample was more than 5 ppm over the baseline value. All these 5 patients had double or triple peaks in serial breath H2 concentrations. The combination of the lactulose hydrogen breath test (LHBT) with the 13C-acetate breath test, which requires only breath samples, provides us with much information on the gastrointestinal tract; gastric emptying, OCTT, bacterial overgrowth in the small intestine, colonic fermentation, and oropharyngeal flora. The 13C-acetate breath test can be useful as an adjuvant test when LHBT is performed for measuring OCTT.