Hydrogen Breath Test Research Articles

Efficacy of the use of the synbiotic Maxibalance in the complex therapy of the small intestine bacterial overgrowth syndrome in patients with irritable bowel syndrome with diarrhea

Aim. To evaluate the effectiveness of Maxibalance in the complex therapy of the small intestine bacterial overgrowth syndrome (SIBOS) in patients with irritable bowel syndrome (IBS) with diarrhea using a hydrogen breath test with glucose.
 Materials and methods. 66 patients with PCOS with diarrhea were examined, 30 patients made up the control group. The diagnosis of PCOS was determined according to the Rome IV criteria (2016). The diagnosis of SNBR was confirmed using the hydrogen breath test (HBT) with glucose. Medical treatment of patients in both groups included the use of antispasmodics, rifaximin. To the patients of the first group, the synbiotic Maxibalance was added to the treatment. Outpatient observation of patients lasted 8 weeks.
 The results. After the end of the course of treatment, 4 weeks (1 month) later, the patients underwent a repeated VDT with glucose in order to control the effectiveness of the treatment, which showed a negative result of SNBR in 77% of patients. Patients also reported a significant improvement in the condition and reduction of IBS symptoms after a course of treatment with the addition of the synbiotic Maxibalance to the therapy.
 Conclusions. The data obtained from the study indicate that the small intestine bacterial overgrowth syndrome is present in more than half of patients diagnosed with IBS with diarrhea, and therefore it should be suspected in this category of patients. The use of complex therapy of SIBOS in patients with IBS with diarrhea, including non-absorbable broad-spectrum antibiotics such as rifaximin and probiotics Maxibalance is a safe and effective approach to the treatment of IBD, helps to normalize and reduce symptoms of heart failure in patients with IBS with diarrhea and improving well-being.

Management of a Female Patient with Irritable Bowel Syndrome and Somatoform Disorder

Aim: to demonstrate the management of a patient with somatization disorder and irritable bowel syndrome.Key points. A 41-yo female patient was admitted with complains of spastic lower abdomen pain, hard stool once every 1–2 days under laxative treatment (macrogol), bloating, anxiety, waiting for confirmation of a life threatening illness, internal stress, difficulty in falling asleep, shallow sleep. Has a long history of disease, characterized by the appearance of a variety of somatic symptoms (headache, tachycardia, joint pain, stool disorders, abdominal pain, etc.) during periods of emotional tension, lack of data suggesting organic disease. No abnormal changes were detected in examination at the clinic (complete blood count, serum chemistry tests, urinalysis or fecal tests, hydrogen and methane breath tests with lactulose, abdominal ultrasound, esophagogastroduodenoscopy, colonoscopy). With the prior agreement of patient, she was consulted by a psychiatrist and diagnosed with somatization disorder and mild anxiety disorder. On discharge from hospital recommended cognitive-behavioral therapy, continue taking macrogol, as well as treatment with Kolofort. After 3 months of complex treatment, there was a significant decrease in the severity of both the symptoms of irritable bowel syndrome and anxiety disorder.Conclusion. For patients whose complaints meet the diagnostic criteria for IBS, a two-stage differential diagnosis may be justified: at the first stage, differentiation of IBS and organic diseases of the gastrointestinal tract is carried out; at the second stage - IBS and somatization disorder. Kolofort can be the drug of choice both in patients with IBS and the pharmacological part of therapy in patients with somatization disorder.

Impact of Saccharomyces boulardii CNCM I-745 on Bacterial Overgrowth and Composition of Intestinal Microbiota in Diarrhea-Predominant Irritable Bowel Syndrome Patients: Results of a Randomized Pilot Study

Background: Small intestinal bacterial overgrowth (SIBO) is associated with diarrhea-predominant irritable bowel syndrome (IBS-D). Probiotics like Saccharomyces boulardii CNCM I-745 (Sb) may be efficacious in balancing the microbiota. This randomized open label study assessed the effect of Sb in patients with bacterial overgrowth associated with IBS-D and its impact on the intestinal microbiota. Methods: Patients were randomized to receive Sb + dietary advice (Sb + DA) or dietary advice (DA) only for 15 days. SIBO was assessed by the lactulose hydrogen breath test (LHBT). Symptoms were assessed with the IBS Symptom Severity Scale (IBS-SSS) and stool consistency with the Bristol Stool Form Scale. Microbiota and mycobiota were analyzed by 16S rDNA and ITS2. Results: 54 patients were included, among whom 48 (27 Sb + DA, 21 DA) were evaluated. Decrease of hydrogen excretion was slightly higher in Sb + DA group, 41% versus 29% in DA group, and IBS-SSS total score were reduced by −134 and −93, respectively. The proportion of patients with diarrhea was lower in the Sb + DA group than in the DA group (25.9% compared to 47.6%). Bacterial and fungal microbiota showed that Sb treatment was associated with several modifications. Interestingly, F. prausnitzii was more abundant in Sb-treated patients with marked clinical improvement. The safety of S. boulardii CNCM I-745 was excellent. Conclusions: In patients with SIBO, S. boulardii CNCM I-745 associated with dietary advice reduced bacterial overgrowth and improved digestive symptoms while restoring the intestinal microbiota. The increased abundance of F. prausnitzii coupled with symptom improvement merits further research.

The incidence of adult type hypolactasia in patients with irritable bowel syndrome

The incidence of lactose intolerance in irritable bowel syndrome (IBS) varies in the literature (27-72%). Primary adult lactase deficiency (adult type hypolactasia) is the most common type of primary enzyme deficiency. Complaints related to lactose intolerance may overlap with the symptoms of IBS. To assess the prevalence of primary hypolactasia in patients with IBS. The study included 56 patients with IBS diagnosed based on the Rome III criteria and 23 healthy people. All study participants completed a questionnaire on IBS symptoms and lactose intolerance, and they underwent a hydrogen breath test (HBT) with lactose. In the group of patients with positive results of HBT, the polymorphism C/T -13910 and G/A -22018 in the promoter of the LCT gene encoding lactase was determined. Lactase deficiency was diagnosed in HBT in 34 (60.7%) patients with IBS and in the control group - in 10 (43.5%). Primary adult type hypolactasia was confirmed in 78.9% (n = 30; 79.3% in the study group; 77.8% in the control group). There were no statistically significant differences in the occurrence of LCT gene polymorphisms in particular IBS subtypes. Adult type hypolactasia was significantly more common in patients with severe than moderate and mild enzyme deficiency in HBT (p < 0.05). The incidence of lactase deficiency in IBS patients is not different from that found in healthy subjects. Nevertheless, irrespective of the IBS subtype, lactose intolerance may pose additional issues in patients with IBS and requires the targeted treatment.

Prevalence of small intestinal bacterial overgrowth in patients with gastroparesis: a systematic review and meta-analysis.

We performed a systematic review and meta-analysis to identify the prevalence of small intestinal bacterial overgrowth (SIBO) in patients with gastroparesis. Several studies have suggested an association between SIBO and gastroparesis, which is characterized by delayed gastric emptying in the absence of mechanical obstruction. A comprehensive search was performed using MEDLINE, EMBASE, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) through January, 2022 for randomized controlled trials and observational studies reporting the prevalence of SIBO in gastroparesis. Pooled prevalence was estimated using a random effects model. Heterogeneity was assessed by using the inconsistency index (I2). Among the 976 articles identified, 43 studies were selected for full text review. Six studies, with 385 patients, were deemed eligible for inclusion, with a perfect agreement between investigators (kappa=1.0). Overall, 379 patients were diagnosed with gastroparesis by gastric emptying scintigraphy and six were diagnosed with a wireless motility capsule. The pooled prevalence of SIBO was 41% (95% confidence interval 0.23-0.58). SIBO was diagnosed using jejunal aspirate cultures (N=15, 8.4%), lactulose breath test (N=80, 44.7%), glucose breath test (N=30, 16.8%), D-xylose breath test (N=52, 29.1%), and hydrogen breath test (N=2, 1.1%). Heterogeneity was significant and noted to be high at 91%. Only one study reported SIBO diagnosis in controls, therefore no pooled odds ratio was calculated. SIBO was present in almost half of the patients with gastroparesis. Future studies should examine and identify the association between SIBO and gastroparesis.

Exhaled Hydrogen after Lactulose Hydrogen Breath Test in Patient with Duodenal Ulcer Disease-A Pilot Study for Helicobacter-pylori-Associated Gastroduodenal Disease.

The precipitating mechanism(s) from the inactive to the active stage of duodenal ulcer disease (DU) is unclear. It has been shown that hydrogen gas from colonic fermentation provides an important energy source for Helicobacter pylori (Hp) colonization. The lactulose hydrogen breath test (LHBT) is a useful tool to assess the small intestinal and/or colon fermentation. This study examines the association(s) between the status of gastroduodenal disease and the result of a lactulose hydrogen breath test (LHBT). We enrolled Hp-positive active duodenal ulcer (aDU) patients, inactive DU (iDU) patients and patients with a positive Hp infection without structural gastroduodenal lesion, i.e., simple gastritis (SG Hp+). The patients with simple gastritis without Hp infection (SG Hp-) served as controls. Histological examinations of the gastric mucosa and lactulose hydrogen breath test (LHBT) were performed. SG Hp+ patients tend to have advanced gastritis (pangastritis or corpus-predominant gastritis) compared with SG Hp- patients (7/29 vs. 0/14, p = 0.08). More iDU patients had advanced gastritis than either the SG Hp+ (7/9 vs. 7/29, p = 0.006) or aDU patients (7/9 vs. 6/24, p = 0.013). In comparison with the aDU patients, the iDU patients were also older (52.1 ± 12.6 vs. 42.2 ± 11.9 years, p = 0.02) and had a lower mean area under the curve value of the LHBT(AUC) (209.1 ± 86.0 vs. 421.9 ± 70.9, p = 0.023). aDU patients with a positive Hp infection have a lower grade of gastric mucosa damage than iDU patients and tend to have a higher level of exhaled hydrogen after LHBT.

Management of Adult Patients with Gastrointestinal Symptoms from Food Hypersensitivity-Narrative Review.

The incidence of food hypersensitivity has increased dramatically over the years not only among children but also in adults. Adult patients are usually less suspected of food hypersensitivity symptoms since food allergies are more typical for small children, with a tendency to outgrow the condition. The aim of this article is to increase awareness of hypersensitivity to food symptoms and their diagnosis and treatment possibilities among gastroenterologists and other health care professionals dealing with this type of patient. Symptoms of many gastrointestinal disorders, especially functional, may be driven by different types of mechanisms, and food intolerance or allergy should be considered as a potential cause. This article presents the current understanding of the epidemiology, diagnosis and treatment of immune- and non-immune-mediated food-induced diseases. Diagnosis of food hypersensitivity is based mainly on medical history, different types of sensitivity tests, e.g., hydrogen breath test, specific IgE (sIgE) serum concentration, tissue eosinophil count, skin tests and oral food challenges considered as a "gold standard" for food allergy. Elimination diet and pharmacologic treatment for allergy symptoms are first-line therapies. Eosinophilic gastrointestinal diseases are often caused by non-IgE-mediated food allergies, require endoscopic biopsy samples to confirm diagnosis and proper elimination diet often combined with steroids or proton pump inhibitor agents for treatment. Mast cell activation syndrome (MCAS) derives from pathologic reaction of mast cells with increased tryptase serum level as a marker. Symptoms may occur in the digestive, respiratory, skin, neurologic and cardiovascular system. Treatment is based on histamine type 1, type 2 (H1, H2) receptor antagonists and other mast cell stabilizing agents. Carbohydrate intolerances are the most common type of food hypersensitivity in adult patients, and an elimination diet is effective for reducing symptoms. Food additives hypersensitivity remains difficult to diagnose, but use of a diet low in chemical substances alleviates symptoms and helps to diagnose the triggering factors.

Association of serotonin transporter promoter polymorphism (5-HTTLPR) with orocecal transit time in irritable bowel syndrome.

Irritable bowel syndrome (IBS) is a multifactorial disorder with altered intestinal motility, secretion, and sensation. Serotonin (5-HT) stimulates gut motility and alters serotonin signaling that may lead to both intestinal and extraintestinal symptoms in IBS. The aim of this study was to examine the association of serotonin transporter gene promoter polymorphism (5-HTTLPR) in IBS with orocecal transit time (OCTT) measured by lactulose hydrogen breath test. This prospective case-control study included 151 IBS patients (mean±SD 37.4±11.6 years, median 36, range 19-68). Ninety-two patients were diarrhea-predominant IBS (D-IBS), 44 constipation-predominant IBS (C-IBS), 15 alternating diarrhea and constipation IBS (M-IBS), and 100 healthy controls (mean±SD 37.2±11.4 years, median 36, range 20-64 years). 5-HTTLPR gene polymorphism was studied by polymerase chain reaction-based method. 5-HT levels were measured by enzyme-linked immunosorbent assay (ELISA). Orocecal transit time (OCTT) was measured by a non-invasive lactulose hydrogen breath test. OCTT was also compared with respect to 5-HTTLPR genotypes in differentIBS phenotypes. Serum serotonin levels were significantly higher in overall IBS patients (152±77 ng/mL, p<0.001), D-IBS (184±76 ng/mL, p<0.001), compared to healthy controls (129±56 ng/mL). There was no difference in 5-HT levels between C-IBS (124±53 ng/mL) and controls. In the case of M-IBS, 5-HT levels were (88±49 ng/mL p<0.05) significantly lower than that of controls. OCTT was significantly shorter in D-IBS patients (95±36 min) as compared to controls (112±41 min). In contrast, C-IBS showed significantly prolonged OCTT (136±54 min). There was a significant difference in OCTT between D-IBS and C-IBS patients (p<0.001). There was no significant association found between OCTT and 5-HTTLPR. Serum serotonin concentrations were increased in D-IBS compared to controls and C-IBS. OCTT was shorter in D-IBS and delayed in C-IBS patients. There was no association of 5-HTLPR polymorphism with OCTT.

Effects of α-D-glucans with alternating 1,3/1,6 α-D-glucopyranosyl linkages on postprandial glycemic response in healthy subjects

Slowly digestible carbohydrates have been demonstrated to be beneficial for the management of postprandial glycemic response both in individuals with diabetes mellitus as well as in the general population. The objective of this study was to evaluate the glycemic response and digestibility of a novel carbohydrate with 1,3 and 1,6 α-D-glucopyranosyl linkage pattern and with two different degrees of polymerization (DP). In a double blind, randomized, controlled, cross-over trial, participants consumed either an acute dose of 33 g of an a-D-glucan with average DP of 10 (alternan saccharide 10 [AS10]), an a-D-glucan with an average DP of 15 (alternan saccharide 15 [AS15]), or glucose syrup (as reference). The primary endpoint was the 3 h incremental area under the curve (3h-iAUC) for glycemic response, measured with a continuous glucose monitoring device. While AS10 resulted in a non-significant reduction in 3h-iAUC (-13%, p = 0.368), AS15 reduced 3h-iAUC by 33% compared to glucose syrup (p = 0.010). All test carbohydrates were fully digested, as demonstrated by breath hydrogen testing. These findings support the hypothesis that DP in combination with the glycosidic linkage pattern can affect glycemic response of carbohydrates. The significant reduction in glycemic response observed for AS15 is indicative of a slowly digestible carbohydrate that could be useful in glycemic management.

Low-FODMAP Diet for the Management of Irritable Bowel Syndrome in Remission of IBD.

Approximately 30% of patients with quiescent inflammatory bowel disease (IBD) meet the diagnostic criteria for irritable bowel syndrome (IBS). The aim of this study was to evaluate the effectiveness of a low-FODMAP diet in patients who meet the diagnostic criteria for IBS whilst in IBD remission. A total of 200 patients in remission of IBD were included in the study. Sixty-five of these patients (32.5%) were diagnosed with IBS according to the R4DQ. On the patients who met the IBS diagnostic criteria, anthropometric measurements, laboratory tests and lactulose hydrogen breath tests were performed. A low-FODMAP diet was introduced for 6 weeks. Of the 59 patients with IBS diagnosed at baseline for whom data were collected at the end of follow-up, after the low-FODMAP intervention IBS-like symptoms were not present in 66.1% (n = 39) (95% CI (53.4%; 76.9%)). The difference between the two groups (with SIBO at baseline (33 of 48 patients) and without SIBO at baseline (6 of 11 patients)) in the low-FODMAP diet's effectiveness was not statistically significant (p = 0.586). The low-FODMAP diet improved the gut symptoms of flatulence and diarrhea. It had no effect on the occurrence of constipation. In IBD patients in remission who meet the IBS criteria, the dietary intervention of a low-FODMAP diet is effective for a reduction in IBS-like symptoms, regardless of the coexistence of bacterial overgrowth.

Altered gut microbiota in patients with small intestinal bacterial overgrowth.

Small intestinal bacterial overgrowth (SIBO) is diagnosed by using quantitative culture of duodenal aspirates and/or a hydrogen breath test. However, few studies have analyzed bacterial microbiota in Japanese patients with SIBO. Twenty-four patients with any abdominal symptoms and suspected SIBO were enrolled. Quantitative culture of duodenal aspirates and a glucose hydrogen breath test were performed on the same day. SIBO was diagnosed based on a bacterial count≥103 CFU/mL or a rise in the hydrogen breath level of ≥20ppm. The composition of the duodenal microbiota was analyzed by 16S rRNA gene sequencing. Small intestinal bacterial overgrowth was diagnosed in 17 of the 24 patients (71%). The positive rates for the hydrogen breath test and quantitative culture of duodenal aspirates were 50% and 62%, respectively. Patients with SIBO showed significantly reduced α-diversity compared with non-SIBO patients, and analysis of β-diversity revealed significantly different distributions between SIBO and non-SIBO patients. In addition, the intestinal microbiome in SIBO patients was characterized by increased relative abundance of Streptococcus and decreased relative abundance of Bacteroides compared with non-SIBO patients. Duodenal dysbiosis was identified in patients with SIBO and may play a role in the pathophysiology of SIBO.

Small Intestinal Bacterial Overgrowth in Patients with Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass

BackgroundSmall intestinal bacterial overgrowth (SIBO) is defined as an excessive growth and/or changed composition of bacteria in the small bowel. Obese patients are at increased risk of SIBO and related complications. The purpose of this study is to evaluate the incidence of SIBO after bariatric bypass procedures, connection between SIBO, symptoms, comorbidities, and liver pathology.MethodsPatients underwent a hydrogen breath test with glucose substrate (25 g/200 ml of water). The demographic, anthropometric data, comorbidities, and symptoms were analysed with a questionnaire. In 45 patients, the NAFLD Activity Score was evaluated in liver biopsies.ResultsGlucose breath test was positive in 24/56 (43%) of patients and was associated with higher frequency of defecation (p = 0.022), lactose intolerance (p = 0.047), scleroderma (p = 0.042), irritable bowel syndrome (p = 0.018), and diabetes (p = 0.002). Mean NAFLD Activity Score in SIBO patients (n = 18) was 3.33 and 3.00 in non-SIBO patients (n = 27). In SIBO-positive cohort of patients, a statistically important trend in difference between NAS and difference to range value anti-Xa 4 h after subtherapeutic dose application was calculated.ConclusionsThe incidence of SIBO after bariatric surgery bypass procedures is alarmingly high (43%). The results of our study conclude that diagnosis cannot be set based on specific symptom and SIBO is related to reduced response to the application of LMWH. Mandatory SIBO screening and appropriate treatment would affect the clinical outcome of the underlying disease, improve it significantly, and prevent the development of its complications.Graphical abstract

S1582 Abnormal Glucose Breath Test Does Not Correlate With Patient’s Self-Reported Symptoms and Their Severity

Introduction: Glucose Hydrogen Breath Testing (GBT) is commonly used for diagnosing Small Intestinal Bacterial Overgrowth (SIBO). However, patients present with clinical symptoms (sx) and their predictive value for a positive (pos) GBT remains unclear. AIM: To assess the prevalence of self-reported GI sx profiles in adults with unexplained upper GI symptoms and correlate this with GBT. Methods: We retrospectively analyzed all adult patients presenting to a single medical center from 6/20 –12/21 for GBT. A pos GBT for SIBO was defined by the North American Consensus (≥20 ppm H2 increase over basal within 90 minutes (mins) and/or ≥10 ppm CH4 at any time). Pts completed a GI questionnaire assessing 17 key sxs: regurgitation (RG), chest pain (CP), heartburn (HB), belch (BH), abdominal pain (AP), bloating (BT), gas (GS), nausea (NA), vomit (VT), abdominal cramps (AC), indigestion (ID), distension (DN), fullness (FL), early satiety (ES), diarrhea (DR), constipation (CN), and fatigue (FT). Sxs measured by frequency (None, < 1/week (wk), 1/wk, ≥ 1/wk), intensity (None, Mild, Moderate, Severe), and duration (None, < 10 mins, 10 – 30 mins, ≥ 30 mins). Sub-groups, GERD, Dyspeptic, and IBS were constructed assessing the mean summation scores for Frequency, Intensity, and Duration between negative (neg) and pos GBTs. Univariate analysis and logistic regression analysis was performed. A P-value of < 0.05 was considered statistically significant. Results: We evaluated 184 pts, mean age of 51.7 (18 – 85), 78.3% female, 82.8% Caucasian, and mean BMI of 27.2. No significant differences were seen between GI sx frequency and intensity categories for pts with GBT neg and pos groups. A trend for a higher percentage of pos GBT pts reporting FL (P=0.09) and DR (P=0.07) in sx duration categories of 10 -30 mins (FL: 30.8% vs 27.5%; DR: 31.8% vs 23.4%) and ≥ 30 mins (FL: 51.3% vs 41.3%; DR: 37.2% vs 22.1%) was noted. Regression analysis showed a trend toward a pos GBT for VT frequency of Less than 1/wk: (P = 0.07; OR = 2.99; 95% CI: 0.91, 9.83) and NA intensity of Severe: (P = 0.09; OR = 2.24; 95% CI: 0.86, 5.84). No differences were seen between the GERD, Dyspeptic, and IBS sub-groups (Figure). Conclusion: The pre-test predictability of GI symptoms as it relates to a pos or neg GBT is poor. The yield for a pos GBT varies between 31%-55% and depends on age. In routine practice, when the index of clinical suspicion is high for SIBO, clinicians should consider objective testing with GBT rather than empiric antibiotic treatment.Figure 1.: (Left) Mean Summation Scores for Self-Reported Frequency, Intensity, and Duration Responses to GI Symptoms Relative to the Gastroesophageal Reflux Disease (GERD), Dyspeptic, and irritable bowel syndrome (IBS) Groups. (Right) Prevalence of Positive Glucose Breath Test (GBT) Among Age Cohorts and Glucose Breath Test Measurements

Benefits of Flavored Lactose-Free Milk for Korean Adults with Lactose Intolerance.

Although lactose-free dairy products for the clinical management of lactose intolerance (LI) are widely available, scientific evidence on their efficacy is still lacking. This study comparatively analyzed the efficacy of flavored lactose-free milk (LFM) and whole milk (WM) in reducing symptoms in South Korean adults with LI. This prospective study was conducted in adults suspected of LI. All screened participants underwent the hydrogen breath test (HBT) using 570 mL of chocolate-flavored WM (20 g of lactose) and responded to a symptom questionnaire. LI was confirmed when the ΔH2 peak exceeded 16 ppm above baseline values and with the occurrence of symptoms after WM consumption. The participants who were diagnosed with LI underwent the HBT again with 570 mL of chocolate-flavored LFM (0 g of lactose), followed by the symptom questionnaire survey after 1 week. After excluding 40 participants who did not meet the diagnostic criteria for LI and 2 who were lost to follow-up, a total of 28 lactose-intolerant individuals were enrolled in the study. The ΔH2 values in the first HBT were significantly higher than those in the second HBT (33.3 ± 21.6 ppm vs. 8.6 ± 6.3 ppm, P < .001). Similarly, there was a significant reduction in the total symptom score in the second HBT (4.18 ± 1.51 vs. 0.61 ± 0.98, P < .001). Flavored LFM is well tolerated in South Korean adults diagnosed with LI based on the HBT and symptom questionnaire results. Therefore, LFM may be a viable alternative to WM.

Antimicrobial treatment improves tryptophan metabolism and mood of patients with small intestinal bacterial overgrowth

BackgroundOptimal composition of intestinal bacteria is an essential condition for good health. Excessive growth of these bacteria can cause various ailments. The aim of this study was to assess the mental state and gastrointestinal complaints of patients with small intestinal bacterial overgrowth (SIBO) in relation to tryptophan metabolism and rifaximin treatment.Methods120 subjects, aged 23–61 years, were enrolled in the study, and divided into 3 groups, 40 individuals each: healthy subjects (Controls), patients with SIBO and chronic diarrhea (SIBO-D), and with chronic constipation (SIBO-C). The lactulose hydrogen breath test (LHBT) was performed to diagnose SIBO. The mental state of patients was assessed using the Hamilton Anxiety Rating Scale (HAM-A), and the Hamilton Depression Rating Scale (HAM-D). L-tryptophan (TRP) and its metabolites: 5-hydroxyindoleacetic acid (5-HIAA), kynurenine (KYN), xanthurenic acid (XA) and quinolinic acid (QA) were measured in urine by liquid-chromatography-tandem mass spectrometry and related to creatinine level. Patients with SIBO were recommended to take rifaximin for 10 days at daily dose 1200 mg, and this cycle was repeated in subsequent two months.ResultsMild and moderate anxiety, as well as mild depression were diagnosed in all SIBO patients. Changes in TRP metabolism were also observed in these patients. Specifically, an increase in the activity of the serotonin pathway of TRP metabolism in the group SIBO-D was observed. The SIBO-C patients showed an increase in the concentration of KYN, XA and QA. 5-HIAA/TRP and KYN/TRP ratios significantly decreased in group SIBO-D, and KYN and QA levels decreased in group SIBO-C after treatment with rifaximin. The levels of anxiety and depression decreased in both groups.ConclusionRifaximin treatment of SIBO patients ameliorated their mood disorders and gastrointestinal aliments underlined by changes in tryptophan metabolism.Trial registration Retrospectively registered (if applicable).

P27 Challenging management of GI complications in Systemic Sclerosis

Introduction/BackgroundSystemic sclerosis is a chronic, progressive, multisystemic autoimmune disease in which there is excessive collagen deposition in the dermis and internal organs. It is commonly categorized into limited cutaneous or diffuse cutaneous systemic sclerosis. In more than 80% of patients there is GI involvement. Gut complications can impair oral intake, absorption and even faecal continence, and consequently can have severe adverse effect on quality of life. With disease progression, management of GI symptoms may become more of a challenge. We present a challenging case of SSs with esophageal involvement along with severe regurgitation who eventually responded to a specific prokinetic.Description/Method70 y/o female initially presented to gastroenterology clinic in 2013 due to dysphagia to solids and was found to have benign fibrotic oesophageal stricture for which she had therapeutic dilatation, (normal biopsy result). Subsequently, she had barium swallow which showed severe regurgitation. Manometry confirmed severely hypo-contractile oesophagus thus she was referred to rheumatology for suspected connective tissue disorder.On initial review, she did not describe typical inflammatory symptoms, scleroderma, sclerodactyly, Raynaud’s phenomenon, digital ulcers, calcinosis, telangiectasia or any other connective tissue features but was diagnosed with limited cutaneous systemic sclerosis due to ANA & anti-centromere antibody positivity, severe oesophageal dysmotility and diagnosis of mild pulmonary hypertension (on right heart catheter studies).Her main disabling SSs symptom was refractory belching, intermittent dysphagia and reflux disease resulting in poor oral intake and resultant malnutrition. She had 4-week trial of antibiotics to treat for presumptive small intestine bacterial overgrowth (SIBO) due to persistent belching but had no evident improvement. She had multiple endoscopies which only showed grade B oesophagitis due to which she remained on high dose PPI (Omeprazole 40mg BD) but showed no recurrent stricture. She was also given dual therapy with Ranitidine 150mg bd but derived no benefit.In Rheumatology clinic she was started on erythromycin 250 mg BD as a pro-kinetic and in liquid form for better tolerability (due to the dysphagia) with gradual but significant improvement of her upper GI symptoms. Switching liquid form to tablets/capsule form via GP resulted in worsening symptoms so was switched back to liquid form. GI symptoms worsened again in 2017 and impression was tachyphylaxis to erythromycin. She was started on trial of another pro-kinetic (metoclopramide) but symptoms continued worsening. In view of this she was started back on liquid erythromycin and her symptoms gradually improved again and has remained stable since.Discussion/ResultsSystemic sclerosis (SSc) is an incurable connective tissue disorder. It is estimated that approximately 90% of patients with SSc have some form of oesophageal involvement. For first three years, this patient’s main symptoms were her upper GI tract issues with reflux and oesophageal dysmotility causing delayed gastric emptying.Considering the severity of her GI symptoms, it was of great importance for her to maintain a regular follow up with gastroenterology team for a regular review of symptoms and repeat investigations as needed such as multiple repeat UGI endoscopy to ensure no recurrence of oesophageal stricture, monitoring of GORD, and hydrogen breath testing.We recommend for patients with severe oesophageal dysmotility to be started on prokinetics early to control GI symptoms and have minimal impact of these on quality of life. Liquid preparation has shown a significant improvement in symptoms in our patient as compared to tablet or capsule form which actually worsened the symptoms.Key learning points/ConclusionDysphagia can be a presenting symptom of systemic sclerosis in some cases. Upper gastro-intestinal symptoms can be severe with significant effect on quality of life.Management of these symptoms can be challenging and may require a combination of treatments.Pro-kinetics mainly erythromycin can have a major positive impact in controlling GI symptoms,Liquid form had better outcome in this case as compared to tablet or capsule form.Poor control of GI symptoms can result in significant malnutrition which is associated with more aggressive disease progression, so GI symptoms management plays a key role in disease control.

Cost-Benefit Analysis of Hydrogen Breath Test–Directed Rifaximin for Treatment of Diarrhea-Predominant Irritable Bowel Syndrome

Rifaximin is a Food and Drug Administration–approved, nonabsorbable antibiotic to treat diarrhea-predominant irritable bowel syndrome (IBS-D). Because of its pricing, access is often limited by step therapy requirements, meaning that insurers frequently require patients to have failed 1 or several empiric IBS-D treatments before rifaximin can be used.1 Unfortunately, rifaximin is the only Food and Drug Administration–approved IBS-D therapy that conceptually treats IBS-D mediated by small intestinal bacterial overgrowth (SIBO).

Glucose substrate in the hydrogen breath test for gut microbiota determination: A recommended noninvasive test.

Intestinal dysbiosis and small intestinal bacterial overgrowth (SIBO) are common in patients with liver cirrhosis. Existing studies have not explored the association between gut dysbiosis and SIBO. We propose some suggestions for the authors’ experimental methods and concepts, and we hope these suggestions can be adopted. The hydrogen breath test is worthy of recommendation due to its high accuracy and convenient operation. We suggest changing the substrate of the hydrogen breath test from lactulose to glucose to improve the accuracy of each parameter. SIBO is a small subset of gut dysbiosis, and we propose clarifying the concept of both. SIBO may be caused by liver cirrhosis or one of the pathogeneses of gastrointestinal diseases. Therefore, interference from other gastrointestinal diseases should be excluded from this study.

Supervised Machine Learning for Predicting Carbohydrate Malabsorptions Using Hydrogen Breath Tests

Abstract Introduction: Carbohydrate malabsorptions symptoms include intestinal fluid retention, causing diarrhea and abdominal distention. The aim of this work is to create a machine learning model that predicts carbohydrate malabsorption using H2 measurements from lactose and fructose tolerance tests. Methods: We compare the predictive ability of popular classifiers with classifiers that are specifically designed for time series data. Our approach was implemented using sklearn and sktime Python machine learning libraries. Results: The highest predictive ability for the fructose dataset was achieved using a Random Forest Classifier (balanced accuracy = 0.91). In contrast, the highest predictive ability (balanced accuracy = 0.81) for the lactose dataset was obtained using an IndividualTDE time classifier. Conclusion: Our results indicate a high predictive ability for distinguishing between carbohydrate malabsorptions. However, the detection of SIBO is challenging but adapted time classifier models could reach higher performances compared to standard methods. Our results could establish the basis of an expert system for diagnosing carbohydrate malabsorptions and SIBO, respectively.

Small intestinal bacterial overgrowth - small intestine, big struggle

The gut microbiota plays an important role in the proper functioning of the human body. The microbes present in the intestines are important for the correct functioning of the digestive tract as well as other, often distant, organs of the human body. Unfavorable conditions may lead to an imbalance of intestinal microorganisms, leading to unfavorable consequences.&#x0D; Under physiological conditions, the large intestine is inhabited by a significant amount of bacteria, while the small intestine contains only a small amount of them. The appearance of pathological conditions in the gastrointestinal tract may lead to the colonization of the small intestine by an excessive amount of bacteria, which, in combination with gastrointestinal symptoms, is called small intestinal bacterial overgrowth. The most common symptoms associated with this disease are abdominal pain, diarrhea, and gas.&#x0D; It is difficult to diagnose this disease due to the lack of specific symptoms and imperfect diagnostic methods. The highest quality test is the microbiological test, however, due to the invasiveness of the method and the difficulties with precise collection of the material, less invasive tests are used, primarily the hydrogen breath test.&#x0D; The mainstay of treatment of bacterial overgrowth is antibiotic therapy, which aims to reduce the amount of bacteria to the extent that the patient does not feel the disease. It is also important to eat a diet rich in fiber and low in fermenting oligo-, di- and monosaccharides and polyols.&#x0D; Patients with the small intestinal bacterial overgrowth rarely develop symptoms of a severe course of the disease, however, due to the unpleasant symptoms and relatively easy treatment methods, the disease should be included in the differential diagnosis in people with risk factors and present symptoms.