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Implementation and Interpretation of Hydrogen Breath Tests IOP PUBLISHING JOURNAL OF BREATH RESEARCH J. Breath Res. 2 (2008) 046002 (9pp) doi:10.1088/1752-7155/2/4/046002 Implementation and interpretation of hydrogen breath tests Alexander Eisenmann1, Anton Amann2,4, Michael Said3, Bettina Datta1 and Maximilian Ledochowski1,4,5 1 Department of Clinical Nutrition, Medical Hospital of Innsbruck, Austria 2 Department of Anesthesia and General Intensive Care, Medical University of Innsbruck, Austria 3 Department of Medicine, Military Hospital 2, Innsbruck, Austria 4 Breath Research Unit of the Austrian Academy of Sciences, Dammstr 22, 6850 Dornbirn, Austria E-mail: [email protected] Received 29 May 2008, in final form 2 July 2008 Published 24 July 2008 Online at stacks.iop.org/JBR/2/046002 Abstract Hydrogen breath tests are non-invasive and safe diagnostic tools used to investigate functional intestinal disorders. For the diagnosis of fructose or lactose malabsorption as well as for the detection of small intestinal bacterial overgrowth syndrome, hydrogen breath tests are even regarded as gold standard. However, standardization of the testing procedure and the interpretation of the test results are still lacking. In this paper, reliable information on the implementation of the most common hydrogen breath tests and precise guidelines for the interpretation of the test results are presented. (Some figures in this article are in colour only in the electronic version) 1. Introduction sugar molecules, which, as part of a fermentation reaction, are initially broken down into short-chain fatty acids (SCFA), At present, it is known that the exhaled breath of human beings carbon dioxide (CO2) and hydrogen (H2), as illustrated in contains at least 2000 different substances and that, apart from figure 1. breathing, the lung’s further essential function is the excretion A large part of the CO2 remains in the intestines and of volatile substances [1–3]. Hydrogen breath tests are based leads to the symptom of bloating. SCFA generate an osmotic on the physiological fact that healthy humans when fasting and gradient and, by doing so, absorb water into the intestinal at rest do not exhale hydrogen. As hydrogen is only generated lumen, which leads to the symptom of diarrhea. The hydrogen during anaerobic metabolism and the human organism at rest generated in the intestines passes the intestinal wall, ends up in does not have anaerobic metabolism, the hydrogen excreted the bloodstream, is transported to the lungs and excreted as part with the exhaled air must originate from anaerobic bacteria of the exhaled breath. There is strong evidence that the exhaled [4]. The large bowel contains an enormous number of bacteria hydrogen indicates the quantity and the metabolic activity of that are predominantly anaerobes and produce a large quantity anaerobic bacteria in the intestines. Exhaled hydrogen can of hydrogen. It is assumed that the large intestine contains be measured in parts per million (ppm) non-invasively and around 1015 bacteria whilst there is only a very small quantity relatively easily with hand-held breath test devices [9–11]. of anaerobic bacteria in the small intestine [5]. Under normal The time at which the hydrogen concentration rises during a conditions, the bacterial concentration in the small intestine is breath test gives an indication as to the part of the intestines no higher than 102 up to a maximum of 105. If the bacterial where the fermentation takes place [12]. concentration is above 105 bacteria ml−1 of the small intestinal content, a small intestinal bacterial overgrowth syndrome 2. Sample (SIBOS) exists [6–8]. Anaerobic bacteria prefer to metabolize This paper reflects our findings based on a total of N = 3374 5 Correspondence to: Univ.-Doz. Dr Maximilian Ledochowski, Department of Clinical Nutrition, Medical University of Innsbruck, Innrain 66a, A-6020 patients, who visited a doctor’s office for internal medicine in Innsbruck, Austria. Innsbruck, Austria, presenting functional intestinal symptoms. 1752-7155/08/046002+09$30.00 1 © 2008 IOP Publishing Ltd Printed in the UK J. Breath Res. 2 (2008) 046002 A Eisenmann et al Table 1. Contraindications for hydrogen breath tests. Absolute contraindications • Known or suspected hereditary fructose intolerance (CI for fructose load test, sorbitol load test) • Known or suspected (postprandial) hypoglycaemia Relative contraindications • Administration of antibiotics (in the last four weeks) • Colonoscopy (in the last four weeks) • Irrigoscopy (in the last four weeks) • Fluoroscopy of the small bowel according to Sellink (in the last four weeks) • Ileostomy (except for the diagnosis of SIBOS) Figure 1. Fermentation reaction of sugar molecules (lactose) in the intestines as found in lactose malabsorption. the case of hereditary fructose intolerance (HFI), a fructose The data were collected from January 1997 to April 2008. load is strictly contraindicated as it could generate severe The mean age of our patients was 42.9 years (range 3.2–87.5 hypoglycaemia. As the clinical symptoms of HFI and fructose years), including 31.5% (n = 1064) male and 68.5% (n = malabsorption can be very similar, particular care needs to 2310) female subjects. We carried out 1783 fructose, 1590 be taken with regard to children. In such cases, a molecular lactose, 271 lactulose, 200 sorbitol, 14 xylose and 9 xylitol genetic test to establish HFI should always be carried out prior load tests on our patients. The investigation conforms with to a fructose load test. In very rare cases, mainly in compound the principles outlined in the Declaration of Helsinki, and heterozygotic cases where the clinical course of the condition informed written consent was obtained from each participant is not quite severe, it is possible that HFI is not diagnosed until to be included in this analysis. adulthood [14]. Additionally the patient’s current and most recent 3. Preparation for the test medication needs to be documented. Antibiotics continue to distort the test result of the hydrogen breath test to up to Prior to the test, the patient should fast for at least 12 h. During four weeks after they have been discontinued [15]. Therefore, this time, he must not drink anything apart from water. In it is recommended not to carry out the test if this has been the particular, he must be advised to avoid milk and/or fruit juices case. Equally, the taking of laxatives, in particular of lactulose on the day prior to the test. The last meal on the day preceding (Laevolac R ) should be discontinued at least three days prior the test should not be too ample and should ideally not consist to the test. After a colonoscopy the intestinal flora needs up of any fiber. On the day prior to the test, products such as to four weeks to recover. Therefore, hydrogen breath tests onions, leeks, garlic, cabbage, pickled cabbage or beans should should not be carried out before this time has passed. In any be avoided. Twelve hours prior to the test, the patient should case, after a colonoscopy, one has to wait until the patient has stop smoking and chewing gum [13]. If, due to an oversight, had at least three normal bowel movements. The same applies the patient does smoke, it is still possible to conduct the test after the execution of other intestinal examinations where prior at a low basal H2 value (<5 ppm). If, repeatedly, increased ‘bowel cleaning’ has been carried out, such as, for example, basal H2 values are measured in a patient, it is recommended after an irrigoscopy, a Sellink procedure or other bowel tests to measure the exhaled content of carbon monoxide (CO) to [16]. A list of contraindications for hydrogen breath tests is establish whether the patient did smoke shortly before the test. featured in table 1. Apart from vitamins, laxatives and antibiotics, medicines can be taken with pure water on the day of the examination. 3.2. Emergency medication Wearers of dentures must not use an adhesive on the day of the test. The claim that it is contraindicated to brush the Whilst emergencies associated with breath tests tend to be teeth prior to the breath test because most types of toothpaste rare, it is still important to be prepared for all eventualities. contain sorbitol or xylitol is incorrect. In our sample we have If complaints occur, they tend to be migraine attacks, never encountered problems due to patients’ brushing teeth headaches or stomach cramps. However, in rare cases, in the morning. In contrast, when patients fail to brush their patients may experience panic attacks, dizziness, allergy- teeth, increased basal H2 concentrations may occur and even like reactions or tachyarrhythmias. Appropriate emergency distort the test result. Besides, carrying out the test on patients medications should be stocked by a breath test laboratory who did not brush their teeth beforehand is unpleasant for the (antihistamines, cortisone, migraine drugs, spasmolytics, patient and the staff involved. paracetamol etc). 3.1. What must be done prior to starting the breath test? 3.3. Fasting state First of all, it is most important to establish that there are no The fasting state has to be validated. This is usually done by contraindications against the breath test. This applies above all a basal H2 measurement. The basal H2 level should be below to children with suspected hereditary fructose intolerance. In 10 ppm (better <5 ppm). If the basal H2 is 10 ppm or above, the 2 J. Breath Res. 2 (2008) 046002 A Eisenmann et al 30% 27.5% Symptoms during FTT (N=1790) 25.3% 24.0% 25% 20% 15% 12.4% 10.2% 9.7% 10% 6.8% 6.0% 5.9% 5.0% 4.2% 5% 2.8% 1.7% 1.3% 0% chill fatigue nausea bloating diarrhoe diziness belching headache indigestion heartbrun no symptoms miscellaneous hyperperistalsis abdominal pain Figure 2.
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