IBS patients

Breath Test to Detect IBS Masqueraders

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Sometimes a ‘diagnosis of exclusion’ doesn’t exclude everything.

  • by Shawn Khodadadian MD

In my practice, I deal with many patients whose lives are affected on a daily basis by symptoms of functional bowel disorders. They suffer from gas, bloating, and other bothersome symptoms that interfere with everyday life.

They often undergo procedures to rule out conditions such as peptic ulcer disease, colitis, and other conditions. Many of them are diagnosed with irritable bowel syndrome (IBS).

These patients are placed on severely restrictive diets by healthcare professionals or even well-intentioned, but misinformed friends and family. For example, the common practice of restricting dairy products in nonlactose intolerant patients can be unnecessarily restrictive. These additional — and sometimes unwarranted — restrictions can make adequate diet selection difficult.

In patients who do not have celiac disease, sensitivity to gluten may still exist. But ruling out other testable and common intolerances (such as lactose or fructose) and small intestinal bacterial overgrowth may be a good idea before long-term gluten restriction in these patients.

I have found that offering my patients hydrogen breath testing can be valuable in helping us diagnose on two fronts: overlooked intolerances to lactose or fructose, as well as small intestinal bacterial overgrowth.

There is a growing body of literature highlighting symptoms that may be attributable to poor absorption of short chain sugars. Fermentable oligo-, di-, and monosaccharides, and polyols (FODMAPs) may trigger gastrointestinal symptoms in IBS patients, and adherence to these diets has been associated with symptoms improvement.

Small intestinal bacterial overgrowth is a condition characterized by excessive growth of small intestinal bacteria and can be associated with inflammation and nutrient malabsorption. Patients may have symptoms such as bloating, dyspepsia, abdominal discomfort, and diarrhea, which may be mistakenly labeled as irritable bowel syndrome. This is important for treatment: bacterial overgrowth may respond to a short course of antibiotics rather than long-term management of uncomfortable symptoms.

Breath testing measures the hydrogen and methane gas produced by bacteria in the small intestine that has diffused into the blood and then lungs for expiration. During a breath test, patients are asked to give a baseline breath sample and then ingest a substance such as lactose, fructose, or lactulose. Subsequent breath samples are then taken to determine if these substances were adequately digested or if there may be an overgrowth of small intestinal bacteria.

We have found these tests to be quite useful in treating patients with gas and bloating and IBS. They allow us to place patients on accurate and specific diet plans. Our patients are very appreciative of being able to identify which foods cause their adverse symptoms, which subsequently leads to a more free diet.

We have found that many of our patients who had previously been told to restrict lactose and fructose may in fact not have issues with digesting these substances and can expand their already restricted diets. This extra piece of information can make a difference for patients and can be as simple as taking a breath.

Probiotics, Prebiotics, and Synbiotics for Irritable Bowel Syndrome

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In a meta-analysis, probiotics conferred some benefit, but the number needed to treat was 7.

Some patients with irritable bowel syndrome (IBS) use probiotic therapy — ingestion of live or attenuated microorganisms — either on their own or as recommended by clinicians. Alternatives to probiotics include prebiotics (nondigestible food ingredients that stimulate growth or activity of intestinal bacteria) and synbiotics (combinations of prebiotics and probiotics). In this meta-analysis, researchers examined the efficacy of these substances in patients with IBS or chronic idiopathic constipation.

For IBS, the proportion of patients with overall improvement in symptoms was significantly higher with probiotics than with placebo (44% vs. 27%) in 23 trials; seven patients had to be treated to benefit one patient. Synbiotics (2 trials) were of no clear benefit, and no trials of prebiotics were eligible for inclusion. For chronic idiopathic constipation, stool frequency increased from baseline with probiotics (3 trials) and with synbiotics (2 trials) but not with prebiotics (1 trial).

Comment

Probiotic therapy appears to be worthwhile for a minority of IBS patients. However, we don’t know whether responses persist long term, because most studies lasted only a few weeks or months. Moreover, the bacterial strains used in these studies were quite heterogeneous. For patients with chronic idiopathic constipation, probiotics and synbiotics might be beneficial, but they require further study. Although probiotics generally are considered to be safe, data are sparse on long-term use and use by immunocompromised patients.