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

Rezaie, Ali, MD, MSc, FRCP(C)1; Buresi, Michelle, MD2; Lembo, Anthony, MD3; Lin, Henry, MD4; McCallum, Richard, MD5; Rao, Satish, MD6; Schmulson, Max, MD7; Valdovinos, Miguel, MD8; Zakko, Salam, MD9; Pimentel, Mark, MD, FRCP(C)1 on behalf of The North American Consensus group on hydrogen and methane-based breath testing

American Journal of Gastroenterology: May 2017 - Volume 112 - Issue 5 - p 775–784
doi: 10.1038/ajg.2017.46

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.

1GI Motility Program, Division of Gastroenterology, Department of Medicine, Cedars-Sinai, Los Angeles, California, USA

2Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada

3Beth Israel Deaconess Medical Center, Department of Medicine, Boston, Massachusetts, USA

4New Mexico VA Health Care System, Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA

5Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA

6Division of Gastroenterology and Hepatology, Department of Medicine, Augusta University, Augusta, Georgia, USA

7Laboratorio 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

8GI Motility and Neurogastroenteroly Unit, Department of Gastroenterology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico

9Connecticut Gastroenterology Institute, Department of Medicine, Bristol Hospital, Bristol, Connecticut, USA

Correspondence: Ali Rezaie, MD, MSc, FRCP(C), Assistant Professor, Assistant Director, GI Motility Program, Cedars-Sinai Medical Center, 8730 Alden Drive, Suite 2E, Los Angeles, California 90048, USA. E-mail:

Received 01 August 2016; accepted 02 January 2017

Guarantor of the article: Ali Rezaie, MD, FRCPC.

Specific author contributions: Conceived and planned the consensus group and designed the pre-meeting survey questions: A.R. and M.P.; responded to the pre-meeting survey questions, and all authors participated in the consensus group meeting: M.B., A.L., H.L., R.M., S.R., M.S., M.V., and S.Z.; voted on the consensus statements: M.B., A.L., H.L., R.M., S.R., M.S., M.V., M.P. and S.Z.; drafted the manuscript: A.R. and M.P.; and reviewed and edited the manuscript: M.B., A.L, H.L., R.M., S.R., M.S., M.V., and S.Z.; all the authors approved the final draft submitted.

Financial support: The consensus group meeting was supported in part by Commonwealth Laboratories (Commonwealth Laboratories, Boston, MA). Commonwealth Laboratories had no role in the election of committee members, determination of the topics of presentations/discussion, drafting or approving these consensus statements.

Potential competing interests: Ali Rezaie reports support from the following sources for teaching, research, and consultation, outside the submitted work: Commonwealth Laboratories, Actavis, and Salix Pharmaceuticals. Henry Lin reports related intellectual property rights. Michelle Buresi, Richard McCallum, Salam Zakko and Miguel Valdovinos report no conflicts of interest. Anthony Lembo reports receiving fees for serving on advisory boards from Allergen, Furiex Pharmaceuticals, Prometheus Laboratories, Salix Pharmaceuticals, Valeant Pharmaceuticals, Forest Laboratories, Alkermes, AstraZeneca, and Ironwood Pharmaceuticals. Satish Rao reports support from the following sources for teaching, research, and consultation, outside the submitted work: Forest Laboratories, Hollister, Ironwood Pharmaceuticals, Sucampo Pharmaceuticals, In Control Medical, Vibrant, American Medical Systems, Sun Sweet Corporation, Synergy Pharmaceuticals, Salix Pharmaceuticals, and Ventrus Laboratories. Max Schmulson has received grant supports from Alfa Wasserman and Nestle. He has served on the Advisory Board of Alfa Wasserman, is currently a consultant for Commonwealth Laboratories Inc and Commonwealth Diagnostics International Inc and in the past has been a consultant for Almirall, Janssen, Nestle, Novartis, Procter and Gamble, Senosiain and Takeda Mexico. Has been a speaker for Alfa Wasserman, Commonwealth Diagnostics International Inc, Janssen, Mayoly-Spindler and Takeda Mexico. Mark Pimentel is a consultant for Valeant Pharmaceuticals, Commonwealth Laboratories, Synthetic Biologics, Micropharma, and Naia Pharmaceuticals, and is on the advisory boards for Valeant Pharmaceuticals and Commonwealth Laboratories. Cedars-Sinai has a licensing agreement with Valeant Pharmaceuticals International Inc., Commonwealth Laboratories, and Synthetic Biologics.

SUPPLEMENTARY MATERIAL is linked to the online version of the paper at

© The American College of Gastroenterology 2017. All Rights Reserved.
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