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A hydrogen breath test (or HBT) is used as a diagnostic tool for small intestinal bacterial overgrowth and carbohydrate malabsorption, such as lactose, fructose, and sorbitol malabsorption. The test is simple, non-invasive, and is performed after a short period of fasting (typically 8–12 hours). Even though the test is normally known as a "hydrogen breath test", some physicians may also test for methane in addition to hydrogen.
Many studies have shown that some patients (approximately 35% or more) do not produce hydrogen but actually produce methane. Some patients produce a combination of the two gases. Other patients, who are known as "non-responders", don't produce any gas; it has not yet been determined whether they may actually produce another gas. In addition to hydrogen and methane, some facilities also utilize carbon dioxide (CO2) in the patient's breath to determine if the breath samples that are being analyzed are contaminated (either with room air or bronchial dead space air).
Testing may be administered at hospitals, clinics, physician offices or if the physician/laboratory has the proper equipment and breath collection kit, patients can collect samples at home to then be mailed in for analysis. Conditions Tests vary from country to country, so the following information is provided as a rough guide to typical uses of the hydrogen breath test: Fructose malabsorption – the patient takes a base reading of hydrogen levels in his/her breath.
The patient is then given a small amount of fructose, and then required to take readings every 15, 30 or 60 minutes for two to three hours. The basis of the test is a failure to absorb the given sugar, which is then metabolized by bacteria that give off either hydrogen or methane. Therefore, the more gas that is produced, the less absorption has occurred. If the level of hydrogen rises above 20 ppm (parts per million) over the lowest preceding value within the test period, the patient is typically diagnosed as a fructose malabsorber.
If the patient produces methane then the parts per million for the methane typically rises 12 ppm over the lowest preceding value to be considered positive. If the patient produces both hydrogen and methane then the values are typically added together and the mean of the numbers is used to determine positive results, usually 15 ppm over the lowest preceding value. Lactose malabsorption – the patient takes a base reading of hydrogen levels in his/her breath.
The patient is then given a small amount of pure lactose (typically 20 to 25 g), and then required to take readings every 15, 30 or 60 minutes for two to three hours. If the level of hydrogen rises above 20 ppm (parts per million) over the lowest preceding value within the test period, the patient is typically diagnosed as a lactose malabsorber. If the patient produces methane then the parts per million for the methane typically rises 12 ppm over the lowest preceding value to be considered positive.
 If the patient produces both hydrogen and methane then the values are typically added together and the mean of the numbers is used to determine positive results, usually 15 ppm over the lowest preceding value. Small bowel bacterial overgrowth syndrome (SBBOS) or small intestinal bacterial overgrowth (SIBO) – the patient is either given a challenge dose of glucose, also known as dextrose (75–100 grams), or lactulose (10 grams).
A baseline breath sample is collected, and then additional samples are collected at 15 minute or 20 minute intervals for 3–5 hours. Positive diagnosis for a lactulose SIBO breath test – typically positive if the patient produces approximately 20 ppm of hydrogen and/or methane within the first two hours (indicates bacteria in the small intestine), followed by a much larger peak (colonic response).
This is also known as a biphasic pattern. Lactulose is not absorbed by the digestive system and can help determine distal end bacterial overgrowth, which means the bacteria are lower in the small intestine. Alternative test methods The idea that a SIBO test should be several hours long and that distal overgrowth is important is wrong and is not supported by the scientific literature. The optimal testing is 1 hour.
Small intestinal bacterial overgrowth (SIBO) occurs as a result of excessive numbers of bacteria inhabiting the proximal small intestine. Bacterial concentrations greater than 105 organisms per milliliter is diagnostic for SIBO. We know bacteria are colonizing the proximal and not the distal small intestine for several reasons. First, the gold standard method for detection of SIBO is jejunal aspirates.
 Intestinal fluid of the proximal intestine is sampled, not distal intestinal fluid. Secondly, the consequences of SIBO are the result of competition between bacteria and the human host for ingested nutrients in the intestine. Various functional consequences of bacterial infiltration cause enterocyte damage in the jejunum such as diminished disaccharidase activity, fat malabsorption, decreased amino acid transport and decreased vitamin B12 absorption.
Thus, detection of proximal bacterial overgrowth is critical. The SIBO breath test typically uses a 10 gram oral dose of lactulose for detection of proximal bacterial overgrowth. The best practice is to have breath samples collected at 20, 40, and 60 minutes after dosing. Since SIBO occurs in the proximal intestine, breath samples should be collected only within 1 hour after lactulose ingestion. This truly reflects proximal intestinal bacterial activity, not distal or colonic activity.
The same argument is true if glucose is the substrate. Lactulose is a carbohydrate that is not absorbed by humans. Lactulose is well known to measure oro-cecal transit time. The mean oro-cecal transit time in normal healthy individuals is 70 to 90 minutes. By 90 minutes, at least 50% of individuals would have delivered the lactulose dose to the colon. Approximately 90 to 95% of individuals have colonic bacteria that can metabolize lactulose to hydrogen or methane gas.
Thus, any SIBO breath test that collects longer than 60 minutes may be measuring colonic activity. Diagnostic criteria of 20 ppm hydrogen and/or methane changes within 90 or 120 minutes will have higher positive rates of SIBO but this will reflect colonic activity not jejunal metabolism. A one-hour SIBO breath test avoids false positive results by collecting breath up to 60 minutes. Positive diagnosis for a glucose SIBO breath test – glucose is absorbed by the digestive system so studies have shown it to be harder to diagnose distal end bacterial overgrowth since the glucose typically doesn't reach the colon before being absorbed.
An increase of approximately 12 ppm or more in hydrogen and/or methane during the breath test could conclude bacterial overgrowth. Recent study indicates "The role of testing for SIBO in individuals with suspected IBS remains unclear." The excess hydrogen or methane is assumed to be typically caused by an overgrowth of otherwise normal intestinal bacteria. Other breath tests that can be taken include: sucrose intolerance, d-xylose and sorbitol.
References ^ Simrén M, Stotzer PO (2006). "Use and abuse of hydrogen breath tests". Gut (Review). 55 (3): 297–303. doi:10.1136/gut.2005.075127. PMC 1856094 . PMID 16474100. ^ Rana, Satya Vati; Malik, Aastha (2014-10-01). "Hydrogen Breath Tests in Gastrointestinal Diseases". Indian Journal of Clinical Biochemistry. 29 (4): 398–405. doi:10.1007/s12291-014-0426-4. ISSN 0970-1915. PMC 4175689 .
PMID 25298621. ^ de Lacy Costello BP, Ledochowski M, Ratcliffe NM (2013). "The importance of methane breath testing: a review". J Breath Res (Review). 7 (2): 024001. doi:10.1088/1752-7155/7/2/024001. PMID 23470880. ^ Ghoshal, Uday C. (2011-07-01). "How to interpret hydrogen breath tests". Journal of Neurogastroenterology and Motility. 17 (3): 312–317. doi:10.5056/jnm.2011.17.3.312. ISSN 2093-0887.
PMC 3155069 . PMID 21860825. ^ Deng, Yanyong; Misselwitz, Benjamin; Dai, Ning; Fox, Mark (2015-09-18). "Lactose Intolerance in Adults: Biological Mechanism and Dietary Management". Nutrients. 7 (9): 8020–8035. doi:10.3390/nu7095380. ISSN 2072-6643. PMC 4586575 . PMID 26393648. ^ Däbritz, Jan; Mühlbauer, Michael; Domagk, Dirk; Voos, Nicole; Henneböhl, Geraldine; Siemer, Maria L; Foell, Dirk (2014-02-27).
"Significance of hydrogen breath tests in children with suspected carbohydrate malabsorption". BMC Pediatrics. 14: 59. doi:10.1186/1471-2431-14-59. ISSN 1471-2431. PMC 3975941 . PMID 24575947. ^ a b c d Basilisco, G.; Risicato, R.; Bonazzi, P; Di Sario, A.; Portincasa, P. (2009). "H2-breath testing for evaluation of oro-caecal transit time". Aliment. Pharmacol. Ther. 29: 23–26. ^ a b c d Eisenmann, A.
; Amann, A.; Said, M.; Datta, B.; Ledochowski, M. (2008). "Implementation and interpretation of hydrogen breath tests". J. Breath Res. 2: 1–9. doi:10.1088/1752-7155/2/4/046002. ^ a b c d Simren, M.; Statzer, P-O. (2006). "Use and abuse of hydrogen breath tests". Gut. 55: 297–303. doi:10.1136/gut.2005.075127. PMC 1856094 . PMID 16474100. ^ a b c d Hirakawa, M.; Lida, M.; Kohrogi, N.; et al. (1988).
"Hydrogen breath test assessment of orocecal transit time: Comparison with barium meal study". Am. J. Gastroenterol. 83: 1361–1363. ^ a b c d Bond, J.H.; Levitt, M.D.; Prentiss, R. (1975). "Investigation of small bowel transit time in man utilizing pulmonary hydrogen (H2) measurements". J. Lab. Clin. Med. 85: 546–555. ^ a b c d Ghoshal, U. C. (2011). "How to interpret hydrogen breath tests". J.
Neurogastroenterol. Motil. 17: 312–317. doi:10.5056/jnm.2011.17.3.312. PMC 3155069 . PMID 21860825. ^ Ford, A. C.; Spiegel, B. M.; Talley, N. J.; Moayyedi, P. (August 12, 2009). "Small intestinal bacterial overgrowth in irritable bowel syndrome: systematic review and meta-analysis". Clin. Gastroenterol. Hepatol. 7 (12): 1279–86. doi:10.1016/j.cgh.2009.06.031. PMID 19602448. External links Hydrogen Breath Test information from MedicineNet.
Hydrogen Breath Test information from the University of Michigan Health System Retrieved from "https://en.wikipedia.org/w/index.php?title=Hydrogen_breath_test&oldid=812258774"
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What is the hydrogen breath test? The hydrogen breath test is a test that uses the measurement of hydrogen in the breath to diagnose several conditions that cause gastrointestinal symptoms. In humans, only bacteria - specifically, anaerobic bacteria in the colon - are capable of producing hydrogen. The bacteria produce hydrogen when they are exposed to unabsorbed food, particularly sugars and carbohydrates, but not proteins or fats.
Although limited hydrogen is produced from the small amounts of unabsorbed food that normally reach the colon, large amounts of hydrogen may be produced when there is a problem with the digestion or absorption of food in the small intestine, that allows more unabsorbed food to reach the colon. Large amounts of hydrogen also may be produced when the colon bacteria move back into the small intestine, a condition called bacterial overgrowth of the small bowel.
In this latter instance, the bacteria are exposed to unabsorbed food that has not yet had a chance to completely traverse the small intestine to be fully digested and absorbed. Some of the hydrogen produced by the bacteria, whether in the small intestine or the colon, is absorbed into the blood flowing through the wall of the small intestine and colon. The hydrogen-containing blood travels to the lungs where the hydrogen is released and exhaled in the breath where it can be measured.
When is hydrogen breath testing used? Hydrogen breath testing is used in the diagnosis of three conditions. The first is a condition in which dietary sugars are not digested normally. The most common sugar that is poorly digested is lactose, the sugar in milk. Individuals who are unable to properly digest lactose are referred to as lactose intolerant. Testing also may be used to diagnose problems with the digestion of other sugars such as sucrose, fructose and sorbitol.
The second condition for which hydrogen breath testing is used is for diagnosing bacterial overgrowth of the small bowel, a condition in which larger-than-normal numbers of colonic bacteria are present in the small intestine. The third condition for which hydrogen breath testing is used is for diagnosing rapid passage of food through the small intestine. All three of these conditions may cause abdominal pain, abdominal bloating and distention, flatulence (passing gas in large amounts), and diarrhea.
Tips to Better Manage Your Migraine Start Now How does hydrogen breath testing work? The bacteria in the colon, including the anaerobic bacteria, are able to digest and use sugars and carbohydrates as food. When the anaerobic bacteria digest sugars and carbohydrates, they convert some of the sugars and carbohydrates into gases, most commonly hydrogen. They also may produce and release into the colon other substances, for example, chemicals that cause the colon to secrete water and cause diarrhea.
As previously discussed, some of the hydrogen gas is absorbed by the colon into the blood and is eliminated in the breath where it can be measured. As long as little sugar or carbohydrate reaches the colon, the small amounts of gas and other substances that are produced do not cause a problem. When larger amounts of sugar or carbohydrate reach the colon because they are not digested and absorbed in the small intestine, larger amounts of gas and substances are formed in the colon.
For example, if an individual digests and absorbs the sugar in milk (lactose) normally, then none of the lactose that is given for the lactose hydrogen breath test reaches the colon, and no increase in the concentration of hydrogen in the breath is seen during the breath test. On the other hand, if the individual does not digest and absorb the lactose completely, that is, he or she is lactose intolerant, the lactose travels through the small intestine and enters the colon where the bacteria digest it and produce hydrogen.
An increase in hydrogen in the breath then is seen. Other sugars for which poor digestion can be diagnosed by breath testing include sucrose and fructose (found in corn syrup), and sorbitol (a sugar that is used as a low-calorie sweetener). There are ways other than abnormal digestion of dietary sugars by which the bacteria can cause problems. Unlike in the colon, the number of hydrogen-producing, anaerobic bacteria in the small intestine is small.
If, however, large numbers of hydrogen-producing bacteria move into the small intestine from the colon, a condition called bacterial overgrowth of the small bowel, the bacteria may digest the sugars and carbohydrates before the small bowel has had a chance to digest and absorb them and produce large amounts of hydrogen. Finally, if individuals have abnormally rapid passage of food through the small intestine, there may not be enough time for the small intestine to digest and absorb sugars and carbohydrates.
This results in the entry of larger amounts of sugar and carbohydrate into the colon where the bacteria can digest and convert them to gas. To diagnose bacterial overgrowth and rapid transit through the small intestine, a sugar that is not digested and absorbed by man, such as lactulose, usually is used for the test. In the case of rapid passage through the small intestine, the sugar passes quickly through the small intestine and into the colon so that hydrogen is found in the breath very soon after ingestion of the sugar.
In the case of bacterial overgrowth, production of hydrogen occurs twice during the test. Once as the sugar passes the bacteria in the small intestine and again when the sugar enters the colon. How is hydrogen breath testing performed? Prior to hydrogen breath testing, the patient fasts for at least 12 hours. At the start of the test, the patient blows into and fills a balloon with a breath of air.
The concentration of hydrogen is measured in a sample of breath removed from the balloon. The patient then ingests a small amount of the test sugar (lactose, sucrose, sorbitol, fructose, lactulose, etc. depending on the purpose of the test). Additional samples of breath are collected and analyzed for hydrogen every 15 minutes for up to five hours. How are the results of hydrogen breath testing interpreted? The interpretation of the results of hydrogen breath testing depends on the sugar that is used for testing, and the pattern of hydrogen production after the sugar is ingested.
After ingestion of test doses of the dietary sugars lactose, sucrose, fructose or sorbitol, any production of hydrogen means that there has been a problem with digestion or absorption of the test sugar and that some of the sugar has reached the colon. When rapid intestinal transit is present, the test dose of non-digestible lactulose reaches the colon more quickly than normally, and, therefore, hydrogen is produced by the colonic bacteria soon after the sugar is ingested.
When bacterial overgrowth of the small bowel is present, ingestion of lactulose results in two separate periods during the test in which hydrogen is produced, an earlier period caused by the bacteria in the small intestine and a later one caused by the bacteria in the colon. What are the limitations of hydrogen breath testing? There are several limitations to hydrogen breath testing. For unclear reasons, testing for bacterial overgrowth of the small bowel with lactulose can diagnose only 60% of cases.
(This insensitivity of the test may be due in part to the strict criteria that are used for interpreting a test as abnormal. Less strict criteria may diagnose overgrowth more often.) In addition, with bacterial overgrowth there may be an overlap of the early and later periods of hydrogen production that can be misinterpreted as a single period characteristic of rapid intestinal transit. Finally, some normal individuals may have slow transit through the small intestine making prolonged testing - up to 5 hours - necessary, and many individuals are unwilling to undergo such prolonged testing.
Some individuals do not have bacteria that produce hydrogen, and in these individuals hydrogen breath testing is not possible. Most of these individuals have bacteria that produce a different gas, methane. (There also are individuals who produce both hydrogen and methane.) Methane can be measured in the breath just like hydrogen, and the production of methane can be used for diagnosis in the same way as hydrogen.
There is much less experience with methane, however, and the production of methane is more complex than the production of hydrogen. Therefore, it is not clear if the pattern of methane production after ingestion of sugars can be interpreted in the same way as hydrogen production, particularly for the diagnosis of bacterial overgrowth. A pattern of hydrogen production that is typical for bacterial overgrowth does not necessarily mean that an individual's symptoms are caused by the overgrowth.
For example, there may be anatomic abnormalities of the small intestine such as narrowing or functional abnormalities in the way the muscle of the small intestine works. These abnormalities can cause symptoms of bloating, distention, pain, and diarrhea themselves, but they also can lead to bacterial overgrowth with its similar symptoms. Therefore, it may be an underlying abnormality that is responsible for the symptoms and not the bacterial overgrowth.
The only way to differentiate between the two causes of symptoms-an underlying problem or bacterial overgrowth - is to treat and eradicate the bacteria. If the symptoms disappear, then it is more likely that it is the overgrowth rather than the underlying abnormality that is responsible for the symptoms. Any condition that results in the delivery of undigested or unabsorbed food to the colon may result in abnormal breath tests when dietary sugars are used for testing.
Both pancreatic insufficiency and the condition called celiac sprue can cause abnormal breath tests, in the former instance because pancreatic enzymes that are necessary for the digestion of carbohydrates are missing, and in the latter instance because the lining of the small intestine is destroyed, and digested food cannot be absorbed. It may be necessary to exclude these causes of abnormal breath tests by additional tests-pancreatic function tests and small intestinal biopsy.
Are there other ways in which hydrogen breath testing can be used? Antibiotics are used for treating bacterial overgrowth of the small bowel; however, any one antibiotic may be effective at eliminating the overgrowing bacteria only 50%-60% of the time. Therefore, if symptoms do not disappear in an individual following treatment with antibiotics, it may be useful to repeat the breath test to determine if the antibiotics have eliminated the bacteria.
If not, a different antibiotic or non-antibiotic treatment can be tried. What are the side effects of hydrogen breath testing? The side effects of hydrogen breath testing are exactly what one would expect to see in individuals who poorly digest and absorb sugars and carbohydrates, for example, bloating, distention, pain, and diarrhea. When lactulose is used these symptoms are unlikely to occur or are mild because the dose of lactulose used for testing is small.
What are the alternatives to hydrogen breath testing? For diagnosing lactose intolerance, an alternative procedure to breath testing requires blood samples to be taken after the ingestion of lactose. If the digestion and absorption of lactose is normal, the levels of glucose in the blood should rise. The elevation of blood glucose occurs because the lactose is broken down into its two component sugars, galactose and glucose, as it is absorbed into the blood.
A second alternative is to give a dose of lactose (or other dietary sugar) and observe an individual for symptoms. If the individual is intolerant, bloating, distention, pain, flatulence, and diarrhea are likely to occur. A third alternative is a trial of a diet in which the potentially-offending sugar is strictly eliminated. All of these alternatives, however, have limitations and problems. Bacterial overgrowth can be diagnosed by culturing (growing) the bacteria from a sample of fluid from the small intestine and counting the numbers of colonic bacteria that are present.
This procedure requires a tube to be passed through the nose, throat, esophagus and stomach under X-ray guidance so that fluid can be obtained from the small intestine. It is an uncomfortable and expensive procedure, and most laboratories are not able to accurately culture the samples. Hence, this test is not performed routinely. Medically reviewed by Avrom Simon, MD; Board Certified Preventative Medicine with Subspecialty in Occupational MedicineREFERENCE:"Use and abuse of hydrogen breath tests"National Institutes of Health Reviewed on 9/2/2016 References Medically reviewed by Avrom Simon, MD; Board Certified Preventative Medicine with Subspecialty in Occupational MedicineREFERENCE:"Use and abuse of hydrogen breath tests"National Institutes of Health
Title: Hydrogen Breath Test At Home