|
1
|
Alegre E, Sandúa A, Calleja S, Deza S, González Á. Modification of baseline status to improve breath tests performance. Sci Rep 2022; 12:9752. [PMID: 35697832 PMCID: PMC9192647 DOI: 10.1038/s41598-022-14210-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 06/02/2022] [Indexed: 11/20/2022] Open
Abstract
Breath tests used to evaluate carbohydrates malabsorption require baseline H2 and CH4 levels as low as possible. Test cancellation is recommended when exceeding certain cut-offs (H2 ≥ 20 ppm and CH4 ≥ 10 ppm). Although following preparation protocols, many patients have baseline levels above those cut-offs. We investigated if light walking can reduce baseline H2 and CH4 levels. We retrospectively analyzed baseline H2 and CH4 levels from 1552 breath tests. Baseline levels (B1), especially in H2, were lower when obtained at later hours of the day. In those with baseline levels above cut-off, re-sampling (B2) after light walking for one hour, decreased H2 levels 8 ppm (Q1-Q3: 1-18 ppm), and 2 ppm (Q1-Q3: 0-3 ppm) for CH4. Consequently, 40% of tests with elevated B1 levels, presented B2 levels below mentioned cut-offs. Ten percent of tests considered negative when using B1 for calculations, turned positive when using B2 instead. All positive tests when using B1 values, remained elevated when using B2. Re-sampling after light walking for one hour could allow test performance in those with previous elevated baseline levels, avoiding diagnosis delays. Using the second sample for delta calculations identifies positive patients for malabsorption that would have been considered negative.
Collapse
Affiliation(s)
- Estibaliz Alegre
- Clínica Universidad de Navarra (Service of Biochemistry), Av. Pío XII 36, 31008, Pamplona, Spain.
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain.
| | - Amaia Sandúa
- Clínica Universidad de Navarra (Service of Biochemistry), Av. Pío XII 36, 31008, Pamplona, Spain
| | - Sofía Calleja
- Clínica Universidad de Navarra (Service of Biochemistry), Av. Pío XII 36, 31008, Pamplona, Spain
| | - Sara Deza
- Clínica Universidad de Navarra (Service of Biochemistry), Av. Pío XII 36, 31008, Pamplona, Spain
| | - Álvaro González
- Clínica Universidad de Navarra (Service of Biochemistry), Av. Pío XII 36, 31008, Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| |
Collapse
|
|
2
|
Leszkowicz J, Plata-Nazar K, Szlagatys-Sidorkiewicz A. Can Lactose Intolerance Be a Cause of Constipation? A Narrative Review. Nutrients 2022; 14:1785. [PMID: 35565753 PMCID: PMC9105309 DOI: 10.3390/nu14091785] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 11/16/2022] Open
Abstract
Lactose intolerance and constipation are common in children and impact everyday life, not only for patients but also their families. Both conditions can be comorbid with other diseases or form a part of their clinical presentation, but constipation is not usually associated with lactose intolerance. The typical symptoms of lactose intolerance include abdominal pain, bloating, flatus, diarrhoea, borborygmi, and less frequently nausea and vomiting. In approximately 30% of cases, constipation can be a symptom of lactose intolerance. Constipation is characterized by infrequent bowel movements, hard and/or large stools, painful defecation, and faecal incontinence, and is often accompanied by abdominal pain. This paper provides a narrative review on lactose intolerance, its epidemiology, pathogenesis, the correlation between lactose intolerance and constipation in children, and potential mechanisms of such association.
Collapse
Affiliation(s)
- Julia Leszkowicz
- Department of Paediatrics, Gastroenterology, Allergology and Paediatric Nutrition, Faculty of Medicine, Medical University of Gdańsk, Nowe Ogrody 1-6, 80-803 Gdańsk, Poland; (K.P.-N.); (A.S.-S.)
| | | | | |
Collapse
|
|
3
|
Hammer HF, Fox MR, Keller J, Salvatore S, Basilisco G, Hammer J, Lopetuso L, Benninga M, Borrelli O, Dumitrascu D, Hauser B, Herszenyi L, Nakov R, Pohl D, Thapar N, Sonyi M, European H 2‐CH 4‐breath test group. European guideline on indications, performance, and clinical impact of hydrogen and methane breath tests in adult and pediatric patients: European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Neurogastroenterology and Motility, and European Society for Paediatric Gastroenterology Hepatology and Nutrition consensus. United European Gastroenterol J 2022; 10:15-40. [PMID: 34431620 PMCID: PMC8830282 DOI: 10.1002/ueg2.12133] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Measurement of breath hydrogen (H2 ) and methane (CH4 ) excretion after ingestion of test-carbohydrates is used for different diagnostic purposes. There is a lack of standardization among centers performing these tests and this, together with recent technical developments and evidence from clinical studies, highlight the need for a European guideline. METHODS This consensus-based clinical practice guideline defines the clinical indications, performance, and interpretation of H2 -CH4 -breath tests in adult and pediatric patients. A balance between scientific evidence and clinical experience was achieved by a Delphi consensus that involved 44 experts from 18 European countries. Eighty eight statements and recommendations were drafted based on a review of the literature. Consensus (≥80% agreement) was reached for 82. Quality of evidence was evaluated using validated criteria. RESULTS The guideline incorporates new insights into the role of symptom assessment to diagnose carbohydrate (e.g., lactose) intolerances and recommends that breath tests for carbohydrate malabsorption require additional validated concurrent symptom evaluation to establish carbohydrate intolerance. Regarding the use of breath tests for the evaluation of oro-cecal transit time and suspected small bowel bacterial overgrowth, this guideline highlights confounding factors associated with the interpretation of H2 -CH4 -breath tests in these indications and recommends approaches to mitigate these issues. CONCLUSION This clinical practice guideline should facilitate pan-European harmonization of diagnostic approaches to symptoms and disorders, which are very common in specialist and primary care gastroenterology practice, both in adult and pediatric patients. In addition, it identifies areas of future research needs to clarify diagnostic and therapeutic approaches.
Collapse
Affiliation(s)
- Heinz F. Hammer
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMedical UniversityGrazAustria
| | - Mark R. Fox
- Centre for Integrative GastroenterologyDigestive Function: BaselLaboratory and Clinic for Motility Disorders and Functional Gastrointestinal DiseasesKlinik ArlesheimArlesheimSwitzerland
- Division of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
| | - Jutta Keller
- Department of Internal MedicineIsraelitic HospitalAcademic Hospital of the University of HamburgHamburgGermany
| | - Silvia Salvatore
- Pediatric DepartmentHospital “F. Del Ponte”University of InsubriaVareseItaly
| | - Guido Basilisco
- Gastroenterology and Endoscopy UnitFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanoItaly
| | - Johann Hammer
- Department of Gastroenterology and HepatologyUniversity Hospital of Internal Medicine 3Medical University of ViennaViennaAustria
| | - Loris Lopetuso
- UOC Medicina Interna e GastroenterologiaDipartimento di Scienze Mediche e ChirurgicheFondazione Policlinico Universitario A. Gemelli IRCCSRomeItalia
- Department of Medicine and Ageing Sciences“G. d'Annunzio” University of Chieti‐PescaraChietiItaly
| | - Marc Benninga
- Department of Pediatric Gastroenterology, Hepatology and NutritionEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Osvaldo Borrelli
- UCL Great Ormond Street Institute of Child Health and Department of GastroenterologyNeurogastroenterology and MotilityGreat Ormond Street HospitalLondonUK
| | - Dan Dumitrascu
- Department of GastroenterologyClinica Medicala 2Cluj‐NapocaRomania
| | - Bruno Hauser
- Department of Paediatric Gastroenterology, Hepatology and NutritionKidZ Health Castle UZ BrusselBrusselsBelgium
| | - Laszlo Herszenyi
- Department of GastroenterologyMedical CentreHungarian Defence ForcesBudapestHungary
| | - Radislav Nakov
- Clinic of GastroenterologyTsaritsa Yoanna University HospitalMedical University of SofiaSofiaBulgaria
| | - Daniel Pohl
- Division of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
| | - Nikhil Thapar
- UCL Great Ormond Street Institute of Child Health and Department of GastroenterologyNeurogastroenterology and MotilityGreat Ormond Street HospitalLondonUK
- Gastroenterology, Hepatology and Liver TransplantQueensland Children's HospitalBrisbaneAustralia
| | - Marc Sonyi
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMedical UniversityGrazAustria
- Clinic for General Medicine, Gastroenterology, and Infectious DiseasesAugustinerinnen HospitalCologneGermany
| | | |
Collapse
|
|
4
|
Hammer K, Hasanagic H, Memaran N, Huber WD, Hammer J. Relevance of Methane and Carbon Dioxide Evaluation in Breath Tests for Carbohydrate Malabsorption in a Paediatric Cohort. J Pediatr Gastroenterol Nutr 2021; 72:e71-e77. [PMID: 33560761 DOI: 10.1097/mpg.0000000000003004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The relevance of methane measurement in breath tests for the detection of carbohydrate malabsorption in children is controversial. The need for correction for poor sample collection is disputed. We evaluated the relevance of methane/CO2 measurements for the diagnosis of paediatric carbohydrate malabsorption. METHODS A total of 132 breath tests (fructose: n = 54; lactose: n = 78) were performed in 91 children/adolescents with functional abdominal complaints. Breath samples were collected and analysed for hydrogen, methane, and CO2. Malabsorption was defined by a net increase over baseline of ≥20 parts per million (ppm) for hydrogen, ≥5 to ≥12 ppm for methane, and ≥10 to ≥15 ppm for hydrogen-plus-methane. The diagnosis was made before and after the use of a CO2-based correction factor (5.5% as the numerator). Hydrogen-based test results were compared with results obtained with other cut-off values. RESULTS Fifty-eight positive tests were obtained by hydrogen measurement (without CO2 correction). The addition of methane measurements did not significantly influence the test results (P > 0.05). Only under the use of extraordinary cut-offs (combined hydrogen-plus-methane smaller than ≥18 ppm) did the rate of malabsorbers increase significantly (P < 0.05). After CO2 correction, hydrogen ≥20 ppm was detected in 4 additional patients, but 1 patient lost the hydrogen-based diagnosis of malabsorption (Cohen kappa = 0.92). CONCLUSIONS Methane measurement did not significantly affect the detection rate of carbohydrate malabsorbers in children/adolescents with functional abdominal complaints when established cut-offs are used. The use of CO2 correction altered the diagnosis of malabsorption in a minority of patients but did not significantly alter overall test results.
Collapse
Affiliation(s)
| | - Hana Hasanagic
- Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin 3; Medical University of Vienna, Austria
| | - Nima Memaran
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hanover, Germany
| | - Wolf-Dietrich Huber
- Klinische Abteilung für Pädiatrische Nephrologie und Gastroenterologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medical University of Vienna, Austria
| | - Johann Hammer
- Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin 3; Medical University of Vienna, Austria
| |
Collapse
|
|
5
|
Leis R, de Castro MJ, de Lamas C, Picáns R, Couce ML. Effects of Prebiotic and Probiotic Supplementation on Lactase Deficiency and Lactose Intolerance: A Systematic Review of Controlled Trials. Nutrients 2020; 12:E1487. [PMID: 32443748 PMCID: PMC7284493 DOI: 10.3390/nu12051487] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023] Open
Abstract
Lactose intolerance (LI) is characterized by the presence of primarily gastrointestinal clinical signs resulting from colonic fermentation of lactose, the absorption of which is impaired due to a deficiency in the lactase enzyme. These clinical signs can be modified by several factors, including lactose dose, residual lactase expression, concurrent ingestion of other dietary components, gut-transit time, and enteric microbiome composition. In many of individuals with lactose malabsorption, clinical signs may be absent after consumption of normal amounts of milk or, in particular, dairy products (yogurt and cheese), which contain lactose partially digested by live bacteria. The intestinal microbiota can be modulated by biotic supplementation, which may alleviate the signs and symptoms of LI. This systematic review summarizes the available evidence on the influence of prebiotics and probiotics on lactase deficiency and LI. The literature search was conducted using the MEDLINE (via PUBMED) and SCOPUS databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and included randomized controlled trials. For each study selected, the risk of bias was assessed following the Cochrane Collaboration methodology. Our findings showed varying degrees of efficacy but an overall positive relationship between probiotics and LI in relation to specific strains and concentrations. Limitations regarding the wide heterogeneity between the studies included in this review should be taken into account. Only one study examined the benefits of prebiotic supplementation and LI. So further clinical trials are needed in order to gather more evidence.
Collapse
Affiliation(s)
- Rosaura Leis
- Department of Pediatrics, University Clinical Hospital of Santiago de Compostela, 15704 Santiago de Compostela, Spain; (M.-J.d.C.); (R.P.); (M.L.C.)
- IDIS-Health Research Institute of Santiago de Compostela, 15704 Santiago de Compostela, Spain
- CIBEROBN, Instituto Salud Carlos III, 28029 Madrid, Spain
- Facultad de Medicina, Departamento de Pediatría, Universidad de Santiago de Compostela, 15704 Santiago de Compostela, Spain;
| | - María-José de Castro
- Department of Pediatrics, University Clinical Hospital of Santiago de Compostela, 15704 Santiago de Compostela, Spain; (M.-J.d.C.); (R.P.); (M.L.C.)
- IDIS-Health Research Institute of Santiago de Compostela, 15704 Santiago de Compostela, Spain
- CIBERER, Instituto Salud Carlos III, 28029 Madrid, Spain
| | - Carmela de Lamas
- Facultad de Medicina, Departamento de Pediatría, Universidad de Santiago de Compostela, 15704 Santiago de Compostela, Spain;
| | - Rosaura Picáns
- Department of Pediatrics, University Clinical Hospital of Santiago de Compostela, 15704 Santiago de Compostela, Spain; (M.-J.d.C.); (R.P.); (M.L.C.)
| | - María L. Couce
- Department of Pediatrics, University Clinical Hospital of Santiago de Compostela, 15704 Santiago de Compostela, Spain; (M.-J.d.C.); (R.P.); (M.L.C.)
- IDIS-Health Research Institute of Santiago de Compostela, 15704 Santiago de Compostela, Spain
- Facultad de Medicina, Departamento de Pediatría, Universidad de Santiago de Compostela, 15704 Santiago de Compostela, Spain;
- CIBERER, Instituto Salud Carlos III, 28029 Madrid, Spain
| |
Collapse
|
|
6
|
Szilagyi A, Ishayek N. Lactose Intolerance, Dairy Avoidance, and Treatment Options. Nutrients 2018; 10:nu10121994. [PMID: 30558337 PMCID: PMC6316316 DOI: 10.3390/nu10121994] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/11/2018] [Accepted: 12/12/2018] [Indexed: 12/12/2022] Open
Abstract
Lactose intolerance refers to symptoms related to the consumption of lactose-containing dairy foods, which are the most common source for this disaccharide. While four causes are described, the most common is the genetically-determined adult onset lactose maldigestion due to loss of intestinal lactase governed by control of the gene by a 14,000 kb promoter region on chromosome 2. Gastrointestinal symptoms from lactose have expanded to include systemic effects and have also been confounded by other food intolerances or functional gastrointestinal disorders. Partly because lactose maldigestion is often interpreted as lactose intolerance (symptoms), focus of therapy for these symptoms starts with lactose restriction. However, withholding of dairy foods completely is not appropriate due to a more favorable impact on health. Industrial efforts to substitute with plant-based products is not completely successful at this time. This narrative article reviews the complexities of the perception of lactose intolerance, its epidemiology, and pathogenesis. Treatments are discussed, including the inappropriateness of dairy avoidance. In conjunction, effects of dairy products on 19 common diseases are reviewed. Different methods of treatment, lactose-reduced products, plant-based dairy substitutes, adaptation, prebiotics, exogenous lactase, probiotics, and some other dietary interventions are further discussed.
Collapse
Affiliation(s)
- Andrew Szilagyi
- Department of Medicine, Division of Gastroenterology, Jewish General Hospital, McGill University School of Medicine, 3755 Cote St Catherine Rd, Room E110, Montreal, QC H3T 1E2, Canada.
| | - Norma Ishayek
- Department of Medicine, Division of Gastroenterology, Jewish General Hospital, McGill University School of Medicine, 3755 Cote St Catherine Rd, Room E110, Montreal, QC H3T 1E2, Canada.
| |
Collapse
|
|
7
|
Xiong L, Wang Y, Gong X, Chen M. Prevalence of lactose intolerance in patients with diarrhea-predominant irritable bowel syndrome: data from a tertiary center in southern China. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2017; 36:38. [PMID: 29157302 PMCID: PMC5697418 DOI: 10.1186/s41043-017-0113-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 10/20/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Symptoms associated with lactose intolerance (LI) and diarrhea-predominant irritable bowel syndrome (IBS-D) are almost the same. These disease entities are difficult to differentiate clinically. In practice, differential diagnosis depends on self-reported patient milk intolerance. However, there is limited data on the prevalence of LI in China. The aim of this study was to investigate the prevalence of LI in IBS-D patients and asymptomatic healthy controls. METHODS Lactose malabsorption (LM) was diagnosed by a lactose hydrogen breath test (HBT) and was defined by peak breath H2 excretion over the baseline level of ≥ 20 ppm. LI-related symptoms were monitored for 8 h following lactose administration. LI was defined in LM patients with positive symptoms during the observation time. Patients with IBS-D were additionally asked if they were intolerant to milk. RESULTS A total of 109 eligible IBS-D patients (Rome III criteria) and 50 healthy controls were enrolled in this study. Except for hydrogen non-producers, the prevalence of LM did not differ between IBS-D patients and the control group (85%, 82/96 vs 72%, 34/47; P = 0.061). There was, however, a higher LI prevalence in IBS patients than in healthy subjects (45%, 43/96 vs 17%, 8/47; P = 0.002). Sensitivity, specificity, and positive and negative predictive values of self-reported milk intolerance for detecting LI were 58, 58, 53, and 63%, respectively. CONCLUSIONS Prevalence of LI is significantly higher in IBS-D patients than in healthy subjects. Self-reported milk intolerance is a poor diagnostic predictor of LI.
Collapse
Affiliation(s)
- Lishou Xiong
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China
| | - Yilin Wang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China
- Department of Gastroenterology, The First People's Hospital of Foshan, Foshan, 528000, People's Republic of China
| | - Xiaorong Gong
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China.
| |
Collapse
|
|
8
|
Houben E, De Preter V, Billen J, Van Ranst M, Verbeke K. Additional Value of CH₄ Measurement in a Combined (13)C/H₂ Lactose Malabsorption Breath Test: A Retrospective Analysis. Nutrients 2015; 7:7469-85. [PMID: 26371034 PMCID: PMC4586543 DOI: 10.3390/nu7095348] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/31/2015] [Accepted: 09/01/2015] [Indexed: 12/18/2022] Open
Abstract
The lactose hydrogen breath test is a commonly used, non-invasive method for the detection of lactose malabsorption and is based on an abnormal increase in breath hydrogen (H2) excretion after an oral dose of lactose. We use a combined 13C/H2 lactose breath test that measures breath 13CO2 as a measure of lactose digestion in addition to H2 and that has a better sensitivity and specificity than the standard test. The present retrospective study evaluated the results of 1051 13C/H2 lactose breath tests to assess the impact on the diagnostic accuracy of measuring breath CH4 in addition to H2 and 13CO2. Based on the 13C/H2 breath test, 314 patients were diagnosed with lactase deficiency, 138 with lactose malabsorption or small bowel bacterial overgrowth (SIBO), and 599 with normal lactose digestion. Additional measurement of CH4 further improved the accuracy of the test as 16% subjects with normal lactose digestion and no H2-excretion were found to excrete CH4. These subjects should have been classified as subjects with lactose malabsorption or SIBO. In conclusion, measuring CH4-concentrations has an added value to the 13C/H2 breath test to identify methanogenic subjects with lactose malabsorption or SIBO.
Collapse
Affiliation(s)
- Els Houben
- Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven 3000, Belgium.
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven 3000, Belgium.
| | - Vicky De Preter
- Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven 3000, Belgium.
- Group Health and Social Work, University College Leuven-Limburg (UCLL), Leuven 3000, Belgium.
| | - Jaak Billen
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven 3000, Belgium.
| | - Marc Van Ranst
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven 3000, Belgium.
- Laboratory of Clinical and Epidemiological Virology, KU Leuven, Leuven 3000, Belgium.
| | - Kristin Verbeke
- Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven 3000, Belgium.
- Leuven Food Science and Nutrition Research Centre (LFoRCe), Leuven 3000, Belgium.
| |
Collapse
|
|
9
|
Marie I, Leroi AM, Gourcerol G, Levesque H, Ménard JF, Ducrotte P. Fructose Malabsorption in Systemic Sclerosis. Medicine (Baltimore) 2015; 94:e1601. [PMID: 26426642 PMCID: PMC4616824 DOI: 10.1097/md.0000000000001601] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/24/2015] [Accepted: 08/25/2015] [Indexed: 12/11/2022] Open
Abstract
The deleterious effect of fructose, which is increasingly incorporated in many beverages, dairy products, and processed foods, has been described; fructose malabsorption has thus been reported in up to 2.4% of healthy subjects, leading to digestive clinical symptoms (eg, pain, distension, diarrhea). Because digestive involvement is frequent in patients with systemic sclerosis (SSc), we hypothesized that fructose malabsorption could be responsible for intestinal manifestations in these patients. The aims of this prospective study were to: determine the prevalence of fructose malabsorption, in SSc; predict which SSc patients are at risk of developing fructose malabsorption; and assess the outcome of digestive symptoms in SSc patients after initiation of standardized low-fructose diet. Eighty consecutive patients with SSc underwent fructose breath test. All SSc patients also completed a questionnaire on digestive symptoms, and a global symptom score (GSS) was calculated. The prevalence of fructose malabsorption was as high as 40% in SSc patients. We also observed a marked correlation between the presence of fructose malabsorption and: higher values of GSS score of digestive symptoms (P = 0.000004); and absence of delayed gastric emptying (P = 0.007). Furthermore, in SSc patients with fructose malabsorption, the median value of GSS score of digestive symptoms was lower after initiation of standardized low-fructose diet (4 before vs. 1 after; P = 0.0009). Our study underscores that fructose malabsorption often occurs in SSc patients. Our findings are thus relevant for clinical practice, highlighting that fructose breath test is a helpful, noninvasive method by: demonstrating fructose intolerance in patients with SSc; and identifying the group of SSc patients with fructose intolerance who may benefit from low-fructose diet. Interestingly, because the present series also shows that low-fructose diet resulted in a marked decrease of gastrointestinal clinical manifestations in SSc patients with fructose malabsorption, our findings underscore that fructose malabsorption may play a significant role in the onset of gastrointestinal symptoms in these patients. Finally, we suggest that fructose malabsorption may be due to reduced fructose absorption by enterocytes, impaired enteric microbiome, and decreased intestinal permeability.
Collapse
Affiliation(s)
- Isabelle Marie
- From the Department of Internal Medicine, CHU Rouen, and INSERM U 905 (IM, HL); Department of Digestive Physiology, CHU Rouen, and INSERM UMR 1073, University of Rouen IFRMP, Institute for Biochemical Research (A-ML, GG); Department of Biostatistics, CHU Rouen (J-FM); and Department of Gastroenterology, CHU Rouen, and INSERM UMR 1073, University of Rouen IFRMP, Institute for Biochemical Research, Rouen, France (PD)
| | | | | | | | | | | |
Collapse
|
|
10
|
Wang Y, Xiong L, Gong X, Li W, Zhang X, Chen M. Small intestinal bacterial overgrowth as an uncommon cause of false positive lactose hydrogen breath test among patients with diarrhea-predominant irritable bowel syndrome in Asia. J Gastroenterol Hepatol 2015; 30:995-1000. [PMID: 25470082 DOI: 10.1111/jgh.12862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM It has been reported that small intestinal bacterial overgrowth (SIBO) may lead to false positive diagnoses of lactose malabsorption (LM) in irritable bowel syndrome patients. The aim of this study was to determine the influence of SIBO on lactose hydrogen breath test (HBT) results in these patients. METHODS Diarrhea-predominant irritable bowel syndrome patients with abnormal lactose HBTs ingested a test meal containing (99m) Tc and lactose. The location of the test meal and the breath levels of hydrogen were recorded simultaneously by scintigraphic scanning and lactose HBT, respectively. The increase in hydrogen concentration was not considered to be caused by SIBO if ≥ 10% of (99m) Tc accumulated in the cecal region at the time or before of abnormal lactose HBT. RESULTS LM was present in 84% (31/37) of irritable bowel syndrome patients. Twenty of these patients agreed to measurement of oro-cecal transit time. Only three patients (15%) with abnormal lactose HBT might have had SIBO. The median oro-cecal transit time between LM and lactose intolerance patients were 75 min and 45 min, respectively (Z=2.545, P=0.011). CONCLUSIONS Most of irritable bowel syndrome patients with an abnormal lactose HBT had LM. SIBO had little impact on the interpretation of lactose HBTs. The patients with lactose intolerance had faster small intestinal transit than LM patients.
Collapse
Affiliation(s)
- Yilin Wang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | | | | | | | | | | |
Collapse
|
|
11
|
Abstract
Breath tests are non-invasive tests and can detect H2 and CH4 gases which are produced by bacterial fermentation of unabsorbed intestinal carbohydrate and are excreted in the breath. These tests are used in the diagnosis of carbohydrate malabsorption, small intestinal bacterial overgrowth, and for measuring the orocecal transit time. Malabsorption of carbohydrates is a key trigger of irritable bowel syndrome (IBS)-type symptoms such as diarrhea and/or constipation, bloating, excess flatulence, headaches and lack of energy. Abdominal bloating is a common nonspecific symptom which can negatively impact quality of life. It may reflect dietary imbalance, such as excess fiber intake, or may be a manifestation of IBS. However, bloating may also represent small intestinal bacterial overgrowth. Patients with persistent symptoms of abdominal bloating and distension despite dietary interventions should be referred for H2 breath testing to determine the presence or absence of bacterial overgrowth. If bacterial overgrowth is identified, patients are typically treated with antibiotics. Evaluation of IBS generally includes testing of other disorders that cause similar symptoms. Carbohydrate malabsorption (lactose, fructose, sorbitol) can cause abdominal fullness, bloating, nausea, abdominal pain, flatulence, and diarrhea, which are similar to the symptoms of IBS. However, it is unclear if these digestive disorders contribute to or cause the symptoms of IBS. Research studies show that a proper diagnosis and effective dietary intervention significantly reduces the severity and frequency of gastrointestinal symptoms in IBS. Thus, diagnosis of malabsorption of these carbohydrates in IBS using a breath test is very important to guide the clinician in the proper treatment of IBS patients.
Collapse
|
|
12
|
Melchior C, Gourcerol G, Déchelotte P, Leroi AM, Ducrotté P. Symptomatic fructose malabsorption in irritable bowel syndrome: A prospective study. United European Gastroenterol J 2014; 2:131-7. [PMID: 24918018 DOI: 10.1177/2050640614521124] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 12/30/2013] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Fructose can trigger or worsen symptoms in irritable bowel syndrome (IBS) patients. The aim of this study was to determine the prevalence of symptomatic fructose malabsorption in IBS patients and to test whether the patient's characteristics can help to detect a fructose malabsorption. MATERIALS AND METHODS Ninety Rome III IBS patients (predominant diarrhoea (IBS-D): 31%, predominant constipation (IBS-C): 18%, mixed type (IBS-M): 51%) were included prospectively. After exclusion of a small intestinal bacterial overgrowth by a glucose breath test, fructose malabsorption was assessed by a five-hour breath test, with symptom monitoring, after a 25 g load of fructose. An increase of more than 20 ppm of hydrogen (H2) or methane (CH4) levels in the exhaled air led to the diagnosis of malabsorption. RESULTS Fructose test was abnormal in 20/90 patients among whom only 35% were intolerant, with a simultaneous rise of H2/CH4 levels and the onset of abdominal discomfort or diarrhoea. IBS characteristics were not predictive even if young (p = 0.031) and male IBS patients (p = 0.029) were at higher risk of malabsorption. At variance, 18 additional patients experienced intestinal symptoms during the test despite normal fructose absorption. DISCUSSION After a 25 g fructose load, symptomatic fructose malabsorption and intolerance without malabsorption were detected in 22% and 28% of IBS patients respectively.
Collapse
Affiliation(s)
- Chloé Melchior
- Gastroenterology Department, Rouen University Hospital, Rouen, France ; INSERM UMR-1073, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- INSERM UMR-1073, Rouen University Hospital, Rouen, France ; Physiology Department, Rouen University Hospital, Rouen, France
| | - Pierre Déchelotte
- INSERM UMR-1073, Rouen University Hospital, Rouen, France ; Nutrition Unit, Rouen University Hospital, Rouen, France
| | - Anne-Marie Leroi
- INSERM UMR-1073, Rouen University Hospital, Rouen, France ; Physiology Department, Rouen University Hospital, Rouen, France
| | - Philippe Ducrotté
- Gastroenterology Department, Rouen University Hospital, Rouen, France ; INSERM UMR-1073, Rouen University Hospital, Rouen, France
| |
Collapse
|
|
13
|
Schiller LR, Pardi DS, Spiller R, Semrad CE, Surawicz CM, Giannella RA, Krejs GJ, Farthing MJG, Sellin JH. Gastro 2013 APDW/WCOG Shanghai working party report: chronic diarrhea: definition, classification, diagnosis. J Gastroenterol Hepatol 2014; 29:6-25. [PMID: 24117999 DOI: 10.1111/jgh.12392] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2013] [Indexed: 02/06/2023]
Abstract
Diarrhea is best defined as passage of loose stools often with more frequent bowel movements. For clinical purposes, the Bristol Stool Form Scale works well to distinguish stool form and to identify loose stools. Laboratory testing of stool consistency has lagged behind. Acute diarrhea is likely to be due to infection and to be self-limited. As diarrhea becomes chronic, it is less likely to be due to infection; duration of 1 month seems to work well as a cut-off for chronic diarrhea, but detailed scientific knowledge is missing about the utility of this definition. In addition to duration of diarrhea, classifications by presenting scenario, by pathophysiology, and by stool characteristics (e.g. watery, fatty, or inflammatory) may help the canny clinician refine the differential diagnosis of chronic diarrhea. In this regard, a careful history remains the essential part of the evaluation of a patient with diarrhea. Imaging the intestine with endoscopy and radiographic techniques is useful, and biopsy of the small intestine and colon for histological assessment provides key diagnostic information. Endomicroscopy and molecular pathology are only now being explored for the diagnosis of chronic diarrhea. Interest in the microbiome of the gut is increasing; aside from a handful of well-described infections because of pathogens, little is known about alterations in the microbiome in chronic diarrhea. Serological tests have well-defined roles in the diagnosis of celiac disease but have less clearly defined application in autoimmune enteropathies and inflammatory bowel disease. Measurement of peptide hormones is of value in the diagnosis and management of endocrine tumors causing diarrhea, but these are so rare that these tests are of little value in screening because there will be many more false-positives than true-positive results. Chemical analysis of stools is of use in classifying chronic diarrhea and may limit the differential diagnosis that must be considered, but interpretation of the results is still evolving. Breath tests for assessment of carbohydrate malabsorption, small bowel bacterial overgrowth, and intestinal transit are fraught with technical limitations that decrease sensitivity and specificity. Likewise, tests of bile acid malabsorption have had limited utility beyond empirical trials of bile acid sequestrants.
Collapse
|
|
14
|
Moran S, Mina A, Duque X, Anaya S, San-Martin U, Yañez P, Rodriguez-Leal G. Prevalence of lactose malabsorption in Mexican children: importance of measuring methane in expired air. Arch Med Res 2013; 44:291-5. [PMID: 23643920 DOI: 10.1016/j.arcmed.2013.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 04/08/2013] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND AIMS To compare the prevalence of lactose malabsorption (LM) in children by analyzing hydrogen content in expired air vs. the inclusion of methane excretion. METHODS A total of 138 children (4-17 years old) attending different boarding schools in Mexico were included in this study. To measure H₂ and CH₄ in expired air, breath samples were collected before administering whole milk (240 mL for 4- to 6-year-old children and 360 mL for 7- to 17-year-old children) and at 60, 120, 180, and 240 min afterward. A coprological examination was also carried out. RESULTS Methane production prevalence was 47.8% (29.7% of the children produced methane and hydrogen, whereas 18.1% produced methane only). When measuring only exhaled hydrogen in expired air (H₂ ≥20 ppm), prevalence of LM was 31%; however, when methane concentration was considered (H₂ + (CH₄ x 2)) ≥18 ppm, prevalence increased significantly to 44%. Among children with LM, 51.6% presented intestinal parasites. CONCLUSIONS Methane should be measured in exhaled air to improve diagnosis of LM in populations with a high prevalence of methane production.
Collapse
Affiliation(s)
- Segundo Moran
- Laboratory of Gastro-Hepatology Research and Department of Nutrition, Hospital de Pediatría, Centro Médico Nacional, Instituto Mexicano del Seguro Social, México City, Mexico.
| | | | | | | | | | | | | |
Collapse
|