Breath testing for small intestinal bacterial overgrowth (SIBO) is commonly used in patients with symptoms most frequently associated with Irritable Bowel Syndrome (IBS). However, it is well known that a large proportion of patients with symptoms of Gastro-oesophageal Reflux Disease (GORD) also have overlapping symptoms of IBS.

Gastro-Oesophageal Reflux Disease is not solely restricted to cases of Irritable Bowel Syndrome. It is far more wide-reaching, as it is calculated as affecting 10-20% of the entire population of the western world. Undiagnosed and diagnosed sufferers of Coeliac Disease often encounter GORD which is exacerbated by the toxin, gluten, trying to escape the body, through the oesophagus or in rectal waste.

It is classed too as a chronic condition in that it causes considerable discomfort and is often a permanent life-long condition.

Other factors contribute to GORD too:

    • Hiatus hernia.
    • Obesity
    • Increased gastric acidity, as in the Zollinger-Ellison syndrome, where a gastrin-secreting tumour (mainly found in the pancreas) increases the likelihood of mucosal ulceration.
    • Hypercalcaemia, where high blood calcium measurements can increase gastritis and acidity.
    • Scleroderma and systemic sclerosis, two skin conditions, which can affect internal organs including the oesophagus.
    • The use of Corticosteroid medicines.

A 24-hour pH-Impedance tracing using pH sensors in the oesophagus (bottom red trace), pharynx (top pink trace) and impedance traces along the length of the oesophagus which detect liquid and gas reflux and monitor swallowing.

In many cases, it is difficult for the patient to fully dissociate these symptoms which is very important as the therapeutic options open to them will target different aspects of their symptomatology.

Typical Gastro-Oesophageal Reflux Disease Symptoms

Typical GORD symptoms include heartburn, reflux and regurgitation. These are the symptoms which tend to respond best to antacid medication and correlate best with reflux events during 24-hour ambulatory pH testing. Atypical symptoms such as throat discomfort, hoarseness, cough and throat clearing can be associated with laryngo-pharyngeal reflux (where refluxed contents from the stomach come all the way up into the back of the throat) and these can best be assessed objectively using combined multi-channel ambulatory pH and Impedance techniques.

As well as these typical and atypical symptoms, others can include bad breath, a feeling of being sick or being actually sick. There can also be pain when swallowing and difficulty in swallowing.  Sore throats and hoarseness may be experienced, as well as a persistent cough, which often worsens at night. Tooth decay and gum disease are other symptoms of GORD.

But many patients also have symptoms such as nausea, bloating, abdominal cramping, excessive belching and erratic bowel habits which may not be directly related to reflux but certainly exacerbate reflux symptoms. In many cases these ‘digestive’ symptoms are at least as troublesome as the patient’s reflux symptoms and it is important to delineate the cause of both aspects prior to considering treatments such as anti-reflux surgery. GORD can be chronic, progressive and long-term.

Many people mistake the symptoms of GORD for heartburn, a common manifestation of acid reflux. Longer term problems can emerge though, if GORD is left untreated or undiagnosed. These include oesophagus ulcers, laryngospasm, oesophagitis, chronic lung disease and longer term may increase the risks of developing oesophageal cancer. Antacid medicines will ease the discomfort caused by GORD but not cure it, whereas Anti Reflux Surgery will.

Anti-reflux surgery in a safe and effective treatment for GORD if the patients are selected to a stringent pre-operative criteria. Anti-reflux surgery augments the lower oesophageal sphincter either with an implanted device such as the LINX magnetic implant or more traditionally with a fundoplication or ‘wrap’ where the top of the stomach is wrapped around the bottom of the oesophagus. This procedure has been performed successfully for over 60 years, since 1955. Performed by keyhole surgery, small incisions means risks are minimised and recovery times are reduced. This can make it much more difficult to belch and patients can suffer from post operative bloating and distension.

If patients already have these symptoms before surgery, then the likelihood is that they will worsen after surgery.

It is worth noting that anti-reflux surgery does not come with a guarantee of eradicating all symptoms of GORD. Often patients may need to continue with some ant-acid drugs after surgery, but many patients worldwide in feedback and forums report total satisfaction. Some patients report minor complications after surgery, namely: some swallowing difficulty, bloating and, rarely, infection of the wound.

Hydrogen Breath Testing UK

Therefore, at the Functional Gut Clinic, we frequently work with our surgical colleagues to not only perform High Resolution Oesophageal Manometry with Impedance to assess swallowing function and 24-hour pH and Impedance studies to quantify reflux status , but we also often perform a lactulose hydrogen and methane breath testing to see if SIBO or caecal mal-fermentation may also be contributing to their symptoms.

A hydrogen breath test, is a simple examination which is non-invasive and usually performed after a short period of fasting to detect hydrogen and methane. Some patients produce both gases. It’s a safe and common test often used to check for lactose intolerance in children.

In this way we can clearly define which aspects of a patient’s symptoms correlate with which physiological phenomenon. Anti-reflux surgery cures reflux, it is not a magic wand which will erase all aspects of a patient’s gastro-intestinal symptoms and if this is clearly understood by both parties before surgery, this helps to manage everyone’s expectations and improve outcomes.

If you’d like to know about hydrogen breath test costs or hydrogen breath test preparation, please contact us, and below is a guide to the breath hydrogen test.

What do I need to do before a Hydrogen Breath Test?

The hydrogen breath test prep itself is relatively straightforward:

    • Our specialist will check that you have not had anything to eat or drink apart from water after midnight.
    • A breath sample will be collected with you exhaling into a foil bag.
    • A glass of water mixed with either glucose (for the glucose hydrogen breath test), lactose, lactulose, or fructose will be given to drink. You should drink this whole amount over a minute or two.
    • Repeat Breath samples will be collected approximately every 15 minutes.
    • During the Breath Test, you should take notice of your symptoms and inform the healthcare professional if you have your typical symptoms for which the test is being performed.
    • During it, you should not eat, chew gum, smoke, sleep, or exercise.
    • When the hydrogen breath test procedure is over, generally after 2-4 hours, you may leave. You may return to your usual diet and activity after the test.
    • The hydrogen breath test results will be sent to your doctor within 24 hours.

If SIBO and caecal mal-fermentation can be treated with antibiotics and dietary interventions such as a low fibre / FODMAP diet either prior to or following surgery then this reduces the need for return visits to the surgeon if the surgery has been successful in dealing with the patients reflux symptoms.

Small Intestinal Bacterial Overgrowth is a chronic infection of the small intestine. It can be treated with a diet avoiding foods containing lgrains, starchy vegetables, lactose, some beans and any sweeteners other than honey and saccharine. A diet high in monosaccharides starves the bacteria. Non-starchy vegetables (typically the flowering part of a vegetable, like lettuce, broccoli and cauliflower), meat, fish, poultry, eggs, some beans, lactose-free dairy, ripe fruit, nuts/seeds are all recommended to fight the effects of SIBO.

An introduction diet, excluding beans and nuts, is often a good starting point to counter early the impact of bacteria in the small intestine.

The LINX device itself is a small expandable ring of magnetic beads. It is fitted via keyhole surgery or laparoscopy and has been successfully installed in 2500 people worldwide. Patients are placed under general anaesthetic for the procedure where the LINX device is quickly fitted. The LINK device works by mimicking the workings of a Reflux Barrier. It safely allows swallowing of food and liquids but prevents acid entering the oesophagus in reflux.

Below is an example of a reflux patient who had severe night time reflux when tested with 24-hour pH and Impedance but we also saw that he had excessive gas and belching. This was noted in the report as a risk factor for post-operative symptoms but the severity of the reflux meant that anti-reflux surgery was needed and a LINX device was fitted.

Combined 24-hour pH and Impedance study showing oesophageal pH (red trace second from bottom) gastric pH (orange trace at bottom) and impedance tracings along the length of the oesophageal body. The big dip in the oesophageal pH occurred during the night and lasted several hours. The frequent ‘spikes’ seen in the impedance tracings represent gas and belching with many symptomatic belching episodes indicated. This was highlighted as a risk prior to surgery.

Following surgery, the patient’s reflux symptoms had improved dramatically but as expected the belching, bloating and gas symptoms had not abated. We therefore repeated 24-hour ph and Impedance to assess this objectively. What we observed (see below) was that the LINX device had completely abolished any acid reflux but the gas and belching had remained. We therefore progressed to do a Lactulose Hydrogen and Methane breath test to see if SIBO was contributing to his persisting symptoms.

We performed the breath test using 16g of lactulose mixed with 200ml of water with breath samples taken at baseline and at 15-minute intervals for two-hours after the drink was consumed. We carefully mapped symptoms at baseline and throughout the study. We observed a significant early peak in hydrogen levels at 45-minutes which indicated SIBO was present and this was associated with an increase in symptoms of bloating, nausea and belching. In addition, the patient had high baseline methane reading which is indicative of colonic dysbiosis. These findings helped to explain the patients residual symptoms and the patient underwent treatment for SIBO with Rifaxamin along with dietary advice (low FODMAP) and the eventual addition of a potent probiotic to treat the dysbiosis.

Hydrogen and Methane breath test showing an early rise in hydrogen levels indicative of SIBO and associated with an increase in the patients usual symptoms supporting the clinical translation of these physiological findings. Additionally the patient had high baseline methane levels which is indicative of colonic dysbiosis and in the co-presence of hydrogen producing bacteria can result in an erratic bowel habit.

This case highlighted to us that in patients with overlapping upper and lower GI symptoms, pre-operative assessment can give important information as to which symptoms will respond best to surgery and which should be managed separately either prior to or following a surgical intervention.

In some cases, actually treating the SIBO is enough to alleviate symptoms to a point where surgical intervention is not warranted.

As stated before, managing expectations and targeting therapy on the basis of objective physiological evidence is hugely important and what we do on a daily basis at The Functional Gut Clinic with our clinical partners.

We are experts in Anti Reflux surgery, carried out from our base at 19 Harley Street in the heart of London’s medical district and at the famous Cromwell Hospital, led by Nicholas Boyle, consultant surgeon who is one of the leading reflux surgeons in the UK.

Hydrogen and Methane Breath Testing & Oesophageal manometry

For more information on breath testing please visit: Hydrogen and Methane Breath Testing and for information on Oesophageal manometry, please visit: Oesophageal manometry & 24 hr pH/Imp