Breath Test or Duodenal Aspirate for Small Intestinal Bacterial Overgrowth: Still No Breath of Fresh Air
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EDITORIAL
Breath Test or Duodenal Aspirate for Small Intestinal Bacterial Overgrowth: Still No Breath of Fresh Air Eric D. Shah1
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Small intestinal bacterial overgrowth (SIBO) was originally defined by a pathologic increase in bacterial colonization (as determined by culture methods) in the small intestine, which was historically considered a ‘sterile’ organ [1]. The concept of SIBO originated from studies on patients with postsurgical Billroth II anatomy resulting from stasis of bacteria within the postsurgical blind loop. More recently, SIBO has been associated with symptoms and pathophysiology of irritable bowel syndrome (IBS) [2]. Targeting IBS with rifaximin (or with other antibiotics as an off-label indication) improves global IBS symptoms, based on the presence of SIBO as one of several mechanisms which underlie this complex disorder [3, 4]. Toward developing a better understanding of the strengths and limitations of available SIBO tests, Cangemi et al. in this issue of Digestive Diseases and Sciences retrospectively analyzed 9 years of pooled diagnostic test findings from a quaternary referral center (Mayo Clinic, Jacksonville, Florida) among patients who underwent the two most common diagnostic evaluations for SIBO: breath testing, and duodenal aspirates obtained during a routine upper endoscopy [5]. The primary finding of their study was a significant discrepancy between duodenal aspirate and breath testing results (with disagreement in 37.6% of cases, κ statistic = − 0.02). Considering technical limitations of SIBO testing, the authors conclude that breath testing is more likely the preferred routine option to evaluate for SIBO in clinical practice as a noninvasive, low-cost test. Breath testing is an ambulatory procedure performed either in-office or at-home through one of several commercial laboratories. The concept of breath testing is based on * Eric D. Shah [email protected] 1
Center for Gastrointestinal Motility, Esophageal, and Swallowing Disorders, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
the exhalation of gases produced solely by the intestinal flora (and not elsewhere in the human body) following ingestion of a carbohydrate substrate. Based on breath testing, SIBO is defined by the rise in ≥ 20 parts-per-million of hydrogen compared to baseline within 90 min of substrate ingestion as a surrogate for orocecal transit time [6]. Although diagnostic cutoffs improve the practical ease of test interpretation in broader practice, the diagnostic accuracy of breath testing may be limited by differences between breath test findings and orocecal transit confirmed using concurrent scintigraphy, which may affect the interpretable utility of a single cutoff in certain patient populations [7]. Clinicians must also consider differences in test findings based on the two recommended substrates: glucose is less sensitive and more specific, possi
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