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Hydrogen breath tests are widely used to explore pathophysiology of functional gastrointestinal (GI) disorders. Small intestinal bacterial overgrowth (SIBO) and carbohydrate malabsorption are disorders detected by these tests that have been proposed to be of great importance for symptoms of GI diseases. Glucose hydrogen breath test is more acceptable for diagnosis of SIBO whereas lactose and fructose hydrogen breath tests are used for detection of lactose and fructose maldigestion respectively. Lactulose hydrogen breath test is also used widely to measure the orocecal transit time for GI motility. These methods are noninvasive and inexpensive.
Many patients with functional gut disorders are unaware of the relationship between diet and GI symptoms they present. In particular, patients with chronic symptoms may regard their condition as normal and may not be aware that their symptoms can be effectively managed following a proper diagnosis. Patients with symptoms of abdominal pain, bloating, flatulence and altered bowel movements (diarrhea and constipation), or with a medical diagnosis of irritable bowel syndrome or celiac disease, may have undiagnosed carbohydrate malabsorption or SIBO. Hydrogen breath tests are specific and sensitive diagnostic tests that can be used to either confirm or eliminate the possibility of carbohydrate malabsorption or SIBO in such patients. Breath tests, though valuable tools, are underutilized in evaluating dyspepsia and functional bloating and diarrhea as well as suspected malabsorption. However, because of their simplicity, reproducibility and safety of procedure they are now being substituted to more uncomfortable and expensive techniques that were traditionally used in gastroenterology.
Keywords: Hydrogen breath tests, Carbohydrate malabsorption, Small intestinal bacterial overgrowth, Orocecal transit time
The breath analysis for various diseases goes back to the time of Hippocrates, father of medicine. He asked his students to detect the diseases by the smell of breath of patients, like the smell of rotten apples indicated diabetic ketoacidosis and urine like smell indicated renal failure. Further with more achievements in science and technology, Lavoisier (father of chemistry) discovered CO2 gas in breath. Alcohol breath test, first initiated in the early 1950s, has presented a number of issues relative to scientific inquiry. Harger et al.  presented a device for sampling breath to determine blood alcohol concentration. Borkenstein and Smith  applied the use of breath alcohol concentration testing to forensic purposes. The scientification of medicine and gastroenterology began during the latter part of the nineteenth century when the discovery of bacterial causes of disease revealed the potential of research in the discovery of new knowledge. It was Linus Pauling’s milestone discovery of 250 unique substances present in exhaled breath that offered promising insight into breath testing .
In 1970s the concept of lactose intolerance (LI) was evaluated using Hydrogen breath test. Newcomer and his associates in 1975 studied lactose malabsorption by analyzing breath H2 and CO2 labelled lactose and blood sugar . They showed the supremacy of H2 breath measurement for detection of lactose malabsorption. Moreover in 1978, Bond and Levitt  used breath H2 to conclude that some disaccharides remain unbroken and unabsorbed in small intestine due to incomplete digestion. They concluded this due to the fact that there was change in H2 concentration in expired air after ingested sugar reached colon undigested and intact. The most well-known application of breath test back then was to study of lactose malabsorption or intolerance. During those times, H2 breath test replaced blood test in which lack of blood glucose response to lactose indigestion lead to conclusion that lactose was not digested.
Bacteria in the bowel generally produce hydrogen gas on fermentation of carbohydrates. In bowel, bacteria can only do this when dietary carbohydrates are not absorbed in small intestine and stay as undigested material as it travels along the digestive tract into large intestine. Though some of the hydrogen gas produced by the bacteria is expelled as flatus or in making other molecules such as sulphides, acetate and short chain fatty acids but most of the gas is absorbed across the lining of the large intestine into blood stream. The gas is then transported to lungs via the blood stream and from blood it is exchanged into the airways of lungs and breathed out. The only source of hydrogen gas in the breath can be from bacterial fermentation in the bowel. The same applies to the gas called methane which is exhaled by some people and not all. The bacteria in their large bowel make methane from the hydrogen. The amount of hydrogen and methane gases breathed out from the lungs can be easily measured by taking a breath sample, and measuring by a breath-testing machine.
Hydrogen breath testing is used in the diagnosis of three conditions.
All three of these conditions may cause abdominal pain, bloating, distention, flatulence and diarrhea.
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