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Small Intestinal Bacterial Overgrowth And Breath Testing
Toni "Nicole" Garren. NP discusses signs and symptoms of SIBO and differential diagnosis. She highlights testing and ordering information for SIBO and she touches on treatment options and process for PCP treating or referral to DHI.
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Learn more about Toni "Nicole" Garren, NP
Toni "Nicole" Garren, NP
Toni "Nicole" Garren, NP is a Digestive Health specialist.Learn more about Toni "Nicole" Garren, NP
Transcription:
Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. And joining me today is Toni "Nicole" Garren. She's a nurse practitioner with the Carle Foundation Hospital, and she's here to tell us about SIBO and breath tests.
Nicole, thank you so much for joining us today. I'd like you to start by telling us what is SIBO or small intestinal bacterial overgrowth. How common is this?
Nicole Garren: Yes, of course. First of all, thanks for having me. So SIBO is actually an alteration or what we'd call an overgrowth of bacteria in the small bowel. We have bacteria naturally in our gut that helps us break down carbohydrates. But the by-product of that is production of hydrogen and methane, which the human cells are incapable of producing. And then, we then exhale those gases in our breath. This condition is common in a certain population of patients. The most common population of patients we see this in is patients who have any sort of altered gut motility. So in our irritable bowel patients, in patients with transit issues, so slow transit constipation. We also can see this in patients who have had some sort of surgical alteration to their gut, such as someone who's had like a gastrectomy or bypass surgery. And then it's also common in patients with metabolic syndrome, such as diabetes, immune disorders, such as HIV and then in liver disease patients such as those who may be cirrhotic or have fatty liver.
Melanie Cole (Host): Thank you, Nicole, for telling us about SIBO and what it is. Now, tell us signs and symptoms. Tell us a little bit about what would send someone to their doctor to be checked?
Nicole Garren: The most common symptoms that we see with SIBO are bloating, gassiness, postprandial abdominal distension or discomfort. And then, they can also cause diarrhea or, in some cases, constipation. Some patients feel a loss of appetite, abdominal pain and cramping, nausea. In severe cases, you may have weight loss or nutritional deficiencies and then also, maybe some fatigue or brain fog.
Melanie Cole (Host): Wow. Well, a lot of those signs and symptoms, Nicole, sound like so many other intestinal issues. Tell us about the testing and what we're talking about here today, the SIBO test for hydrogen or methane. What is this test and who orders it?
Nicole Garren: So this test is done in the office. It takes about two hours for the patient to complete. What we're looking for is a rise in hydrogen and methane. After the patient comes in in a fasting state, the day before the procedure, we have the patient eat a very bland diet. We usually recommend chicken and plain white rice. They have to have nothing but water 12 hours prior. And then, the day they come in, they can't even brush their teeth with toothpaste. They can use just water on their toothbrush, but there's very strict requirements before this test. So that the gut bacteria hasn't been stimulated in any way to give us a false reading.
So the day of the test, they come in and we get a baseline breath. We simply have them blow into a collecting device, like it's a little blue bag and they then take the breath from that bag and they put it into our machine that gives us the baseline levels and we measure the hydrogen and methane. So after they do the baseline breath, there is an administration of a substance called lactulose, which is a carbohydrate. And that substance then gets the bacteria in the gut fermenting and producing their gases. And then, every 20 minutes for the next 120 minutes, we collect that breath and we're looking for a rise in the hydrogen or methane. For the hydrogen, it's a rise of more than 20 above baseline. And for the methane, it's a rise of 10 at any point in the test. If we see those rises, then we do say that the patient is SIBO positive.
The test can be ordered by any provider. We have opened up this test to be ordered by primary care physicians, so that you do not need a GI consult. However, if it is ordered by the PCP, then we would read the test for them and then defer to them for treatment. If the PCP would be more comfortable with us managing the treatment, then they would have to place a consult for the patient to be seen in GI for treatment of SIBO.
Melanie Cole (Host): So what does a positive SIBO test mean?
Nicole Garren: So a positive SIBO test means that the patient has had an overgrowth of their normal gut bacteria into the small bowel. So we should see only a spike in hydrogen and methane when the patient has digested the product far enough into the gut where it reaches the colon. But when we see that early rise within that first 120 minutes, that means that that is being fermented in the small bowel, which indicates that the patient has an overgrowth of their normal gut bacteria up into the small bowel, which could then be causing a lot of their symptoms.
Melanie Cole (Host): Well, then speak about treatment options, Nicole, because you said primary care providers can treat this if the test is positive or they can refer for consult to your offices. What does treatment look like?
Nicole Garren: So treatment is typically with an antibiotic. There is a list of antibiotics that are recommended on, the UpToDate website. The preferred antibiotic treatment is an antibiotic called Xifaxan. However, it is costly. And we often find that insurance companies will not cover it as a first-line treatment. So we then typically have to go to some of our other antibiotics. Ones that we use commonly are metronidozole, doxycycline, ciprofloxacin, and Bactrim. After the patient has had a positive breath test and continues to have symptoms after we've used one of these other antibiotics, then sometimes we can get the Xifaxan covered by insurance showing that the patient had treatment failure. But typically, the patients will have resolution of symptoms even with these other antibiotics. However though, treatment for SIBO is not usually just a one and done regimen. They do sometimes require additional treatments in order to get full resolution of symptoms.
Melanie Cole (Host): Nicole, this is so interesting. And it's not something that a lot of people know about or have heard about really. When do you feel it's important to refer to the specialists at the Digestive Health Institute at the Carle Foundation Hospital?
Nicole Garren: I would say when the primary care provider feels that the patient's symptoms may be on the more severe side. And that would be when the patient is having additional symptoms beyond the bloating and gassiness that we typically see, that would be when they're starting to have nutritional deficiencies or weight loss or any other systemic effects such as the fatty liver, which sometimes can be caused by a prolonged overgrowth of bacteria in the small bowel causing inflammation.
Melanie Cole (Host): So, is there anything else you'd like to leave as key takeaways about the SIBO test result and really small intestinal bacterial overgrowth in general? Kind of summarize for us and what you would like other providers to take away from this interesting podcast.
Nicole Garren: I would like other providers to know that we do have an information pamphlet that they can order for their department to hand out to the patients. This can be ordered on Martin Graphics. This would be more for Carle providers who have access to Martin Graphics. But this could be a pamphlet they can have in their office that they can review with their patients when they suspect a patient has SIBO. It gives some good information on signs and symptoms, risk factors, and then the preparation for the breath test if the primary care provider has chosen to go ahead and order that to get that initiated for the patient.
Melanie Cole (Host): Thank you so much, Nicole, for telling us about treatment options and processes for primary care providers treating and referring for SIBO testing. Thank you so much. For more information on SIBO and breath tests or to get connected with one of our providers, you can visit carle.org or for a listing of Carle providers and to view Carle-sponsored educational activities, visit our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.
Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. And joining me today is Toni "Nicole" Garren. She's a nurse practitioner with the Carle Foundation Hospital, and she's here to tell us about SIBO and breath tests.
Nicole, thank you so much for joining us today. I'd like you to start by telling us what is SIBO or small intestinal bacterial overgrowth. How common is this?
Nicole Garren: Yes, of course. First of all, thanks for having me. So SIBO is actually an alteration or what we'd call an overgrowth of bacteria in the small bowel. We have bacteria naturally in our gut that helps us break down carbohydrates. But the by-product of that is production of hydrogen and methane, which the human cells are incapable of producing. And then, we then exhale those gases in our breath. This condition is common in a certain population of patients. The most common population of patients we see this in is patients who have any sort of altered gut motility. So in our irritable bowel patients, in patients with transit issues, so slow transit constipation. We also can see this in patients who have had some sort of surgical alteration to their gut, such as someone who's had like a gastrectomy or bypass surgery. And then it's also common in patients with metabolic syndrome, such as diabetes, immune disorders, such as HIV and then in liver disease patients such as those who may be cirrhotic or have fatty liver.
Melanie Cole (Host): Thank you, Nicole, for telling us about SIBO and what it is. Now, tell us signs and symptoms. Tell us a little bit about what would send someone to their doctor to be checked?
Nicole Garren: The most common symptoms that we see with SIBO are bloating, gassiness, postprandial abdominal distension or discomfort. And then, they can also cause diarrhea or, in some cases, constipation. Some patients feel a loss of appetite, abdominal pain and cramping, nausea. In severe cases, you may have weight loss or nutritional deficiencies and then also, maybe some fatigue or brain fog.
Melanie Cole (Host): Wow. Well, a lot of those signs and symptoms, Nicole, sound like so many other intestinal issues. Tell us about the testing and what we're talking about here today, the SIBO test for hydrogen or methane. What is this test and who orders it?
Nicole Garren: So this test is done in the office. It takes about two hours for the patient to complete. What we're looking for is a rise in hydrogen and methane. After the patient comes in in a fasting state, the day before the procedure, we have the patient eat a very bland diet. We usually recommend chicken and plain white rice. They have to have nothing but water 12 hours prior. And then, the day they come in, they can't even brush their teeth with toothpaste. They can use just water on their toothbrush, but there's very strict requirements before this test. So that the gut bacteria hasn't been stimulated in any way to give us a false reading.
So the day of the test, they come in and we get a baseline breath. We simply have them blow into a collecting device, like it's a little blue bag and they then take the breath from that bag and they put it into our machine that gives us the baseline levels and we measure the hydrogen and methane. So after they do the baseline breath, there is an administration of a substance called lactulose, which is a carbohydrate. And that substance then gets the bacteria in the gut fermenting and producing their gases. And then, every 20 minutes for the next 120 minutes, we collect that breath and we're looking for a rise in the hydrogen or methane. For the hydrogen, it's a rise of more than 20 above baseline. And for the methane, it's a rise of 10 at any point in the test. If we see those rises, then we do say that the patient is SIBO positive.
The test can be ordered by any provider. We have opened up this test to be ordered by primary care physicians, so that you do not need a GI consult. However, if it is ordered by the PCP, then we would read the test for them and then defer to them for treatment. If the PCP would be more comfortable with us managing the treatment, then they would have to place a consult for the patient to be seen in GI for treatment of SIBO.
Melanie Cole (Host): So what does a positive SIBO test mean?
Nicole Garren: So a positive SIBO test means that the patient has had an overgrowth of their normal gut bacteria into the small bowel. So we should see only a spike in hydrogen and methane when the patient has digested the product far enough into the gut where it reaches the colon. But when we see that early rise within that first 120 minutes, that means that that is being fermented in the small bowel, which indicates that the patient has an overgrowth of their normal gut bacteria up into the small bowel, which could then be causing a lot of their symptoms.
Melanie Cole (Host): Well, then speak about treatment options, Nicole, because you said primary care providers can treat this if the test is positive or they can refer for consult to your offices. What does treatment look like?
Nicole Garren: So treatment is typically with an antibiotic. There is a list of antibiotics that are recommended on, the UpToDate website. The preferred antibiotic treatment is an antibiotic called Xifaxan. However, it is costly. And we often find that insurance companies will not cover it as a first-line treatment. So we then typically have to go to some of our other antibiotics. Ones that we use commonly are metronidozole, doxycycline, ciprofloxacin, and Bactrim. After the patient has had a positive breath test and continues to have symptoms after we've used one of these other antibiotics, then sometimes we can get the Xifaxan covered by insurance showing that the patient had treatment failure. But typically, the patients will have resolution of symptoms even with these other antibiotics. However though, treatment for SIBO is not usually just a one and done regimen. They do sometimes require additional treatments in order to get full resolution of symptoms.
Melanie Cole (Host): Nicole, this is so interesting. And it's not something that a lot of people know about or have heard about really. When do you feel it's important to refer to the specialists at the Digestive Health Institute at the Carle Foundation Hospital?
Nicole Garren: I would say when the primary care provider feels that the patient's symptoms may be on the more severe side. And that would be when the patient is having additional symptoms beyond the bloating and gassiness that we typically see, that would be when they're starting to have nutritional deficiencies or weight loss or any other systemic effects such as the fatty liver, which sometimes can be caused by a prolonged overgrowth of bacteria in the small bowel causing inflammation.
Melanie Cole (Host): So, is there anything else you'd like to leave as key takeaways about the SIBO test result and really small intestinal bacterial overgrowth in general? Kind of summarize for us and what you would like other providers to take away from this interesting podcast.
Nicole Garren: I would like other providers to know that we do have an information pamphlet that they can order for their department to hand out to the patients. This can be ordered on Martin Graphics. This would be more for Carle providers who have access to Martin Graphics. But this could be a pamphlet they can have in their office that they can review with their patients when they suspect a patient has SIBO. It gives some good information on signs and symptoms, risk factors, and then the preparation for the breath test if the primary care provider has chosen to go ahead and order that to get that initiated for the patient.
Melanie Cole (Host): Thank you so much, Nicole, for telling us about treatment options and processes for primary care providers treating and referring for SIBO testing. Thank you so much. For more information on SIBO and breath tests or to get connected with one of our providers, you can visit carle.org or for a listing of Carle providers and to view Carle-sponsored educational activities, visit our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.