Small Intestinal Bacterial Overgrowth Syndrome: A Guide for the Appropriate Use of Breath Testing
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INVITED REVIEW
Small Intestinal Bacterial Overgrowth Syndrome: A Guide for the Appropriate Use of Breath Testing Benson T. Massey1 · Arnold Wald2 Received: 18 June 2020 / Accepted: 16 September 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract The increased availability of noninvasive breath tests, each with limitations, has led to widespread testing for small intestinal bacterial overgrowth (SIBO) in patients with non-specific gastrointestinal complaints. The lactulose breath test (LBT) is based upon an incorrect premise and therefore incorrect interpretations which has resulted in the over-diagnosis of SIBO and the excessive use of antibiotics in clinical practice. Despite limitations, the glucose breath test (GBT) should be exclusively employed when considering SIBO in appropriately chosen patients. This review suggests guidelines for the optimal use and appropriate interpretation of the GBT for suspected SIBO. The LBT should be discarded from future use, and the literature based upon the LBT should be discounted accordingly. Keywords Glucose and lactulose breath tests · Hydrogen gas · Methane gas · Small intestinal bacterial overgrowth · Gastrointestinal radionuclide imaging
Introduction The syndrome associated with small intestinal bacterial overgrowth (SIBO) was first characterized over a century ago [1], and by the mid-twentieth century, the ability to treat this syndrome with antibiotics was well recognized [2]. This syndrome was recognized as being a complication arising from a variety of different gastrointestinal disorders and postoperative states. It was understood to be a chronic condition causing considerable morbidity and requiring ongoing treatment if the underlying disease process could not be reversed. Since these initial descriptions, the definition of SIBO has become the subject of much controversy, including what defines the condition, which tests should be used to establish the diagnosis, and what are the appropriate * Arnold Wald [email protected] Benson T. Massey [email protected] 1
Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 900 North 92nd Street, Milwaukee, WI, USA
Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, Madison, WI 53705‑2281, USA
2
treatment options. Initially considered a relatively rare entity with serious metabolic consequences, the number of patients receiving this diagnosis as an explanation for what were previously thought to be functional disorders has grown exponentially in the past few decades. There appear to be several factors driving this growth in the diagnosis of SIBO. The first has been the increased availability of noninvasive and relatively inexpensive breath tests, which has lowered the threshold to test for this condition. Second, such testing has increasingly been employed to evaluate patients who have gastrointestinal symptoms without evidence of having the metabolic derangements and/or underlying condi
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