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      Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus

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          Abstract

          Objectives:

          Breath tests (BTs) are important for the diagnosis of carbohydrate maldigestion syndromes and small intestinal bacterial overgrowth (SIBO). However, standardization is lacking regarding indications for testing, test methodology and interpretation of results. A consensus meeting of experts was convened to develop guidelines for clinicians and research.

          Methods:

          Pre-meeting survey questions encompassing five domains; indications, preparation, performance, interpretation of results, and knowledge gaps, were sent to 17 clinician-scientists, and 10 attended a live meeting. Using an evidence-based approach, 28 statements were finalized and voted on anonymously by a working group of specialists.

          Results:

          Consensus was reached on 26 statements encompassing all five domains. Consensus doses for lactulose, glucose, fructose and lactose BT were 10, 75, 25 and 25 g, respectively. Glucose and lactulose BTs remain the least invasive alternatives to diagnose SIBO. BT is useful in the diagnosis of carbohydrate maldigestion, methane-associated constipation, and evaluation of bloating/gas but not in the assessment of oro-cecal transit. A rise in hydrogen of ≥20 p.p.m. by 90 min during glucose or lactulose BT for SIBO was considered positive. Methane levels ≥10 p.p.m. was considered methane-positive. SIBO should be excluded prior to BT for carbohydrate malabsorption to avoid false positives. A rise in hydrogen of ≥20 p.p.m. from baseline during BT was considered positive for maldigestion.

          Conclusions:

          BT is a useful, inexpensive, simple and safe diagnostic test in the evaluation of common gastroenterology problems. These consensus statements should help to standardize the indications, preparation, performance and interpretation of BT in clinical practice and research.

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          Most cited references84

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          Effects of gut microbes on nutrient absorption and energy regulation.

          Malnutrition may manifest as either obesity or undernutrition. Accumulating evidence suggests that the gut microbiota plays an important role in the harvest, storage, and expenditure of energy obtained from the diet. The composition of the gut microbiota has been shown to differ between lean and obese humans and mice; however, the specific roles that individual gut microbes play in energy harvest remain uncertain. The gut microbiota may also influence the development of conditions characterized by chronic low-level inflammation, such as obesity, through systemic exposure to bacterial lipopolysaccharide derived from the gut microbiota. In this review, the role of the gut microbiota in energy harvest and fat storage is explored, as well as differences in the microbiota in obesity and undernutrition.
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            Methodology and indications of H2-breath testing in gastrointestinal diseases: the Rome Consensus Conference.

            Breath tests represent a valid and non-invasive diagnostic tool in many gastroenterological conditions. The rationale of hydrogen-breath tests is based on the concept that part of the gas produced by colonic bacterial fermentation diffuses into the blood and is excreted by breath, where it can be quantified easily. There are many differences in the methodology, and the tests are increasingly popular. The Rome Consensus Conference was convened to offer recommendations for clinical practice about the indications and methods of H2-breath testing in gastrointestinal diseases. Experts were selected on the basis of a proven knowledge/expertise in H2-breath testing and divided into Working Groups (methodology; sugar malabsorption; small intestine bacterial overgrowth; oro-coecal transit time and other gas-related syndromes). They performed a systematic review of the literature, and then formulated statements on the basis of the scientific evidence, which were debated and voted by a multidisciplinary Jury. Recommendations were then modified on the basis of the decisions of the Jury by the members of the Expert Group. The final statements, graded according to the level of evidence and strength of recommendation, are presented in this document; they identify the indications for the use of H2-breath testing in the clinical practice and methods to be used for performing the tests.
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              Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: the Toronto consensus.

              The medical management of ulcerative colitis (UC) has improved through the development of new therapies and novel approaches that optimize existing drugs. Previous Canadian consensus guidelines addressed the management of severe UC in the hospitalized patient. We now present consensus guidelines for the treatment of ambulatory patients with mild to severe active UC.
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                Author and article information

                Journal
                Am J Gastroenterol
                Am. J. Gastroenterol
                The American Journal of Gastroenterology
                Nature Publishing Group
                0002-9270
                1572-0241
                May 2017
                21 March 2017
                : 112
                : 5
                : 775-784
                Affiliations
                [1 ]GI Motility Program, Division of Gastroenterology, Department of Medicine, Cedars-Sinai , Los Angeles, California, USA
                [2 ]Division of Gastroenterology, Department of Medicine, University of Calgary , Calgary, Alberta, Canada
                [3 ]Beth Israel Deaconess Medical Center, Department of Medicine , Boston, Massachusetts, USA
                [4 ]New Mexico VA Health Care System, Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine , Albuquerque, New Mexico, USA
                [5 ]Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso , El Paso, Texas, USA
                [6 ]Division of Gastroenterology and Hepatology, Department of Medicine, Augusta University , Augusta, Georgia, USA
                [7 ]Laboratorio de Hígado, Páncreas y Motilidad (HIPAM)-Unit of Research in Experimental Medicine, Faculty of Medicine-Universidad Nacional Autónoma de México (UNAM), Department of Medicine , Mexico City, Mexico
                [8 ]GI Motility and Neurogastroenteroly Unit, Department of Gastroenterology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran , Mexico City, Mexico
                [9 ]Connecticut Gastroenterology Institute, Department of Medicine, Bristol Hospital , Bristol, Connecticut, USA
                Author notes
                [* ]Assistant Professor, Assistant Director, GI Motility Program, Cedars-Sinai Medical Center , 8730 Alden Drive, Suite 2E, Los Angeles, California 90048, USA. E-mail: ali.rezaie@ 123456cshs.org
                Article
                ajg201746
                10.1038/ajg.2017.46
                5418558
                28323273
                47ad948a-e8df-498c-85e8-66e5d2316d2d
                Copyright © 2017 American College of Gastroenterology

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License. The images or other third party material in this article are included in the article's Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/

                History
                : 01 August 2016
                : 02 January 2017
                Categories
                Functional GI Disorders

                Gastroenterology & Hepatology
                Gastroenterology & Hepatology

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