Using patterns of the Lactulose Hydrogen Breath Test to Make Decisions regarding antibiotic therapy in IBS with Small Intestinal Bacterial Overgrowth
Small Intestinal Bacterial Overgrowth (SIBO) is an
increasingly diagnosed pathophysiologic process that involves normal bacterial
flora of the colon being irregularly and excessively translocated to the small
intestine. In additions some will acquire SIBO by breakdown in mechanisms that normally clear bacteria from the small intestine such as the migrating motor complex. Once this bacteria has set up in the small intestine it can cause
bowel transit dysregulation (diarrhea, constipation, or both), bloating, excess
wind, and abdominal discomfort. Many top researchers feel it might be the
underlying component of Irritable Bowel Syndrome. It is diagnosed by clinical
symptoms combined with the Lactulose Hydrogen Breath Test (LHBT) which measures
the production of Methane and Hydrogen case being emitted from the small
intestine after an injection of a highly fermentable sugar called lactulose.
Testers will produce various levels of hydrogen and methane
throughout the 3 hour test and based on the levels a diagnosis is made. The
conventional treatment for SIBO is a round or more of specific antibiotics that
reduce these bacteria from the small intestine. Traditionally Rifaximin has
been the most used antibiotic. However Neomycin, Augmentin, Doxycycline,
Levofloxacin, Ciprofloxacin, and Metronidazole have all been used. In most
studies the efficacy of the aforementioned antibiotics in SIBO eradication is
anywhere from 65 to 100%.
Not all LHBT test look the same. There are various patterns
of gas production we see and even a positive LHBT test we see response to
treatment highly variable. Recently Kasir and colleagues performed a
retrospective chart review of 561 IBS patients with a positive LHBT to see
which LHBT patterns best responded to antibiotics. (Kasir, et al., 2015)
Kasir,et.al.2015 |
Group 1 is considered what’s called a “flat line” where we
do not see an elevation of hydrogen or methanogens greater then 20 ppm
throughout the test. Group 2 has a 20
ppm rise or more within the first part of
the test followed by a second peak greater then 1 ppm after 90 minutes in the
test. Group 2 is most typical. Group 3 is has a >50ppm rise after 90 minutes
into the test but less then 50ppm prior to that. And Group 4 are irregular
patterns that don’t fit either of the categories. So here is what happened:
Kasir,et.al.2015 |
Group 1: 94.7% reported improvement after antibiotics
Group 2: 81.4% reported improvement after antibiotics
Group 3: 46.3% reported improvement after antibiotics
Group 4: 79.9% reported improvement after antibiotics
What if you do not want to take antibiotics? Well certainly many herbal therapies exists
that are antimicrobial in nature and are highly active against gram positive,
gram negative bacteria, and even archaeal organisms. A qualified herbalist or
Naturopathic physician can certainly help design treatment protocols.
It is important to point out that "improvement in this study does not mean resolution of IBS.
The treatment for IBS with SIBO is not usually a one off scenario.
Addressing why it developed in the first place and preventing it from coming
back is something that involves dietary factors, nutritional interventions, and
microbiome balancing treatments. You can learn more by watching my video here.
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Adam Rinde, ND is a Naturopathic Physician in Kirkland, Washington at Sound Integrative Health . He has a general practice that focuses on Gastrointestinal disorders, Metabolism, and Stress-related disorders. He also is the founder of Blankets For Cancer a pediatric cancer focused charity.
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