Seeing Patients with Functional Gastrointestinal Symptoms



The Most Important Diagnostic Test You Aren’t Using

Seeing patients with functional gastrointestinal symptoms? An underutilized diagnostic test covered by Medicare and virtually every insurance plan can make a big difference in patient outcomes…and practice income

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The Gold Standard

If there’s one test that is highly important yet completely underutilized by primary care physicians, it’s the hydrogen breath test. After all, primary care physicians see plenty of GI problems such as bloating, gas, distention, diarrhea, loose stools, urgency and abdominal pain. Research shows these IBS-like symptoms are not necessarily “functional” and are often not IBS. When patients present with such problems, hydrogen breath testing provides clear evidence of malabsorption or overgrowth issues pertinent to the patient’s symptomology.

Hydrogen breath testing provides insight into the underlying physiologic processes taking place inside the patient’s gut. Because it has the potential to prevent an array of negative clinical consequences, it is an important and necessary diagnostic technology.

Hydrogen breath testing has been a diagnostic standard of care for over twenty years. The American Gastroenterology Association, the National Institutes of Diabetes, Digestive and Kidney Diseases, the American Academy of Family Practice, and the American Academy of Pediatrics unanimously recommend it for diagnosing lactose intolerance.

It’s the validated diagnostic methodology in hundreds of research studies on lactose, fructose and other sugar malabsorption as well as small intestinal bacterial overgrowth, which recent studies show are often misdiagnosed as IBS, are significantly more widespread than most physicians suspect, and are directly related to the functional GI complaints physicians encounter every day. In addition, it’s covered by virtually every insurance carrier, including Medicare and Medicaid.

Hydrogen breath testing is the gold standard. It’s time-tested. It’s validated. It’s highly accurate. It has a sound physiologic basis. It’s non-invasive. It’s painless. It’s objective. It’s easy to use. Insurance covers it. It’s profitable. So why aren’t more doctor’s using it?

Why Doctors Aren’t Using HBT

There are so many reasons to use hydrogen breath testing. Yet despite the benefits, very few primary care physicians use it. Why? For most physicians, there are several reasons:

1. They don’t realize what a dramatic difference it could make in quickly and easily solving the challenging functional GI problems they frequently see.

2. They aren’t aware how prevalent fructose malabsorption and small intestinal bacterial overgrowth are; nor are they aware of the negative consequences of misdiagnosis of SIBO.

3. They don’t know that hydrogen breath testing is much more accurate, with far fewer false positives and false negatives than the simple elimination diet they often use for diagnosing lactose intolerance (false positives >30% and false negatives>20% with simple elimination).

4. They don’t realize how easy it is to implement and use in their practice and that their patients would want to do it if they knew it was offered.

5. Many don’t realize what a great investment hydrogen breath testing is.

Common Causes of Functional GI Symptoms

The literature clearly shows that irritable bowel syndrome, lactose intolerance, fructose malabsorption, and small intestinal bacterial overgrowth are frequently encountered at the primary care level, are often co-morbid, and share a similar clinical presentation. Therefore, it is not possible to diagnose based on symptoms alone.

Although lactose intolerance is often suspected, seldom, if ever is fructose malabsorption or SIBO, even though they frequently occur and are often misdiagnosed as IBS:

• Controlled studies on small intestinal bacterial overgrowth show frequency in IBS cases between 31-84%

• A 2008 Mayo Clinic study showed that 38% of study participants diagnosed with IBS had fructose malabsorption causing their symptoms

• Diagnosis and treatment of fructose malabsorption can improve depression and mood disorders, as well as GI symptoms

• A 2006 ADA study showed that outcomes in fructose malabsorption are dependent on more than just restriction of fruit

The evidence suggests that failure to account for these various causes is a chief reason patients with functional GI symptoms often continue to experience symptoms.

Utilizing hydrogen breath testing in such situations is both prudent and necessary.

A Sound Physiologic Basis

The physiologic basis for hydrogen breath testing is straightforward: Symptoms are caused by fermentation of unabsorbed sugars by the colonic bacterial microflora leading to the production of short chain fatty acids, hydrogen, carbon dioxide, and in some cases, methane.

Nutritional Consequences of SIBO

Excessive bacteria in the small bowel can interfere with the metabolism and absorption of carbohydrates, protein, lipids, and vitamins. Bacteria may compete with the host for protein and lead to the production of ammonia which may be directly toxic and alter gut permeability (or leaky gut). Ultimately, a leaky gut can lead to the development of protein-loss and food sensitivities. B12 deficiency can also occur.

SIBO is more prevalent in those taking H2RA’s, PPI’s, celiac disease, cirrhosis, Crohn’s disease, diabetes, fibromyalgia, hypothyroidism, hypochlorhydria, interstitial cystitis, renal failure, rheumatoid arthritis, small bowel dysmotility, pancreatitis, and in the elderly.

Diagnostic Shortcomings of Elimination Diets

Although simple elimination of dairy is the easiest and most common method used by physicians to make a diagnosis of lactose intolerance, studies have shown that this approach has significant diagnostic flaws:

1. High incidence of false positives. One third of patients following a simple elimination of dairy diagnosed as lactose intolerant were in fact not.

2. The incidence of false negatives is high (> 20%).

3. Simple elimination cannot distinguish between lactose intolerance, milk allergy, or milk sensitivity, 3 distinctly different pathways with different treatment implications.

Lactose intolerance is a spectrum disorder which ranges from mild to severe. Mildly lactose intolerant patients can safely consume moderate amounts of dairy without developing symptoms. Severely lactose intolerant individuals can become symptomatic from a small amount of lactose. Because lactose and dairy are commonly in processed foods and baked goods, simply avoiding milk and milk products often leaves substantial amounts of lactose in the diet because those with severe lactose intolerance often fail to avoid all sources of lactose and erroneously conclude they are not lactose intolerant, when in fact they are.

All three of the diagnostic shortcomings of simple elimination are overcome with hydrogen breath testing. The hydrogen breath test is widely considered to be the most cost-effective, non-invasive, and reliable test to measure lactose maldigestion.

Acceptance by Patients

Chronic symptoms such as bloating, flatulence, diarrhea, loose stools, abdominal pain, and urgency represent a significant physical, emotional, and financial burden for patients and the healthcare system. Approximately 12% of primary care visits involve IBS. At least 20% of gastroenterology clinic referrals involve IBS. The incidence of IBS-like but non-diagnosed IBS GI complaints is even higher at both the primary and specialty care levels.

Breath hydrogen testing provides the patient an ideal method to diagnose the cause(s) of their digestive symptoms. Breath hydrogen testing is simple, non-invasive, and has been covered by virtually every type of insurance for over 20 years. Within a few days patients can have the answers they seek with targeted treatments that address the underlying cause of their symptoms.

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