 Hi, this is Dr. Ruscio and what is the best test for small intestinal bacterial overgrowth or SIBO? And small intestinal bacterial overgrowth is exactly what the name implies is a excess of bacteria in the small intestine. This has been correlated with IBS to varying degrees, but there's definitely a trend showing a correlation between IBS ear mobile syndrome and SIBO, small intestinal bacterial overgrowth. And the symptoms of IBS, gas, loading, abdominal pain, all through bowel function. And there may also be a correlation with things like reflux and just general indigestion. Now continuing further, why is SIBO and potentially its connecting point IBS relevant? We know via the guts to other area of the body connections, gut brain, gut joint, skin that IBS may correlate with fatigue and depression as one example. And we know that some therapies for SIBO may also help with various skin eruptions and potentially even joint pain. Some other evidence is correlating to a greater or lesser degree small intestinal bacterial overgrowth with metabolic imbalances like being overweight, having higher blood sugar and cholesterol. So not a surprising contention to put forth that imbalances in the gut in this case SIBO may correlate with a myriad of various symptoms and conditions. This is why it can be very helpful to have a diagnostic test to tell you yes or no, I have small intestinal bacterial overgrowth. Now this is not the only ailment in the digestive tract, but if one is going to pursue testing then it begs the question what is the best test for SIBO small intestinal bacterial overgrowth and thankfully a meta-analysis which is a summary of all of the available high quality data has been published to give us a definitive answer as to what is the trend line in the data regarding what is the best test for SIBO. And here is the meta-analysis I'll put the abstract up here on the screen entitled breath test for small intestinal bacterial overgrowth diagnosis a systematic review with meta-analysis. Now moving to their results section this is really where we get to the meat of the matter what is the best test and let me just preface by saying that the two most practical and clinically available tests are two different types of breath tests. These are breath tests where before the breath test someone either drinks a glucose solution or a lactulose solution. So breath tests probably the best test but then it begs the question what type of breath test should you do and this is where there is debate regarding is lactulose better or is glucose better and the results of this meta-analysis the pinnacle of scientific evidence points to the answer and here I will quote their results. GBT or glucose breath test showed a sensitivity excuse me of 58% and a specificity of 83% juxtapose that with the LBT the lactulose breath test which has a lower sensitivity at 42 and a lower specificity at 70. Now regarding sensitivity and specificity which you just die you know detail or define with these mean sensitivity tells you if you correctly were diagnosed with a condition and specificity tells you if you were correctly found not to have that condition. Now this is relevant in my opinion this is very relevant because one of the things I've grown increasingly concerned about in some of the natural health communities is the degree to which patients are being incorrectly diagnosed with SIBO and subjected to unnecessary fear dietary restrictions and treatments of various sorts. Things in the field are getting better as we are enhancing our understanding but I think it's fair to say unfortunately that there are a number of patients out there who have been told they have SIBO when they likely do not and this is likely because the laculose breath test while it can be helpful and in the hands of a astute clinician can be used correctly actually does suffer from higher false positives and that is why when we look at the meta analysis data here we see that the glucose breath test actually has better scores for sensitivity and specificity meaning it correctly diagnoses those who have the condition and it correctly tells you that you do not have the condition in those who do not have the condition. The lower scores that you're seeing for the laculose test informs that it is not as accurate of a test. People who do not have the condition are more often told they do have it and people who do have are more often told that they do not have it. So this is pretty damning evidence for the laculose breath test it can be used and there's one caveat here I'll come to in just a moment but let me read the conclusion of the researchers first. Breath tests do not show excellent performance in comparison to the gold standard. However keeping into account that SIBO is being I'm sorry that SIBO is a benign disease that in most cases requires a simple antibiotic therapy they can be considered as a surrogate test to replace the invasive one. So essentially what they're saying there is the SIBO breath test is not perfect. However given the fact that the gold standard test involves a endoscopy and sampling of fluid from the small intestine which is quite invasive and really can't be done in routine clinical practice the breath test albeit imperfect is probably the most justifiable test. Continuing in this context the glucose breath test has a better sensitivity and specificity than the laculose breath test and therefore should be preferred. So this is the conclusion that the meta-analysis has reached and now my my caveat here and this is more so my opinion but I think this is what the research will eventually come to bear out one of the challenges with the laculose breath test is in the time interpretation of the test. So I'll put up here on the screen what a typical SIBO breath test looks like we have readings at zero and then usually every 15 or 20 minute intervals from there usually 20 minutes most labs will use 20 minute interval and so we have zero 20 40 60 80 and so on. Now it's important when looking at the laculose breath test to identify at what point you should identify that you're no longer seeing the small intestine and I'll put up here the the preferred window is really 80 to 90 minutes if you want to be extra liberal you could in my opinion go up to 100 minutes but when we get to the 80 90 minute point that's when we're starting to come up on the transition in many cases to the large intestine why this matters is because if you see the gas levels go up in the large intestines that is actually normal now unfortunately the SIBO lab analyzers haven't really caught up with this interpretation just yet so it's incumbent upon a clinician to make this interpretation whereas the lab machines will oftentimes use 120 minutes as the cutoff so people who are having elevation at 100 minutes at 120 minutes and if you're if a provider is really kind of liberal with their diagnosis perhaps even at 140 minutes if elevations there are seen sometimes erroneously a patient is told that they have SIBO so if you're more judicious with a time window you're looking at with a laculose breath test in theory you can mitigate this false positive and again why this is important let's say you have some symptoms you've seen a provider you've done the laculose test and now you've been told you have SIBO well if the only time you're seeing a significant elevation over significantly over 10 for methane or significantly over 20 for hydrogen so that might mean that your methane needs to be I would say higher than 20 and your hydrogen needs to be higher than 40 these significant elevations toward that 80 to 90 minute that would make you positive but if you don't see that until a bit later on in the test after a 100 minutes then that would be a false positive and not something for you to be concerned about now albeit this is getting a little bit nuanced but why this is important is again because there will be a number of patients who will show this positivity towards the end of the test and many of these patients actually do not have SIBO now to play devil's advocate here I can't say definitively that every one of those cases will not benefit from therapy and that's kind of a different question but back to the issue at hand with a SIBO breath test if you're using laculose it's important to not be overly liberal in throwing around a diagnosis especially if the only elevation of gases is seen towards the end of the test the nice thing about the glucose test is it seems to protect against that false positive so again pardon the the level of detail here but I feel this is very important for patients to understand because unfortunately this this update hasn't seemed to permeate the SIBO community and while I would assume any provider has the best intentions with a vectoring diagnosis it does seem that patients are being told to have SIBO when they don't and why this is a problem is because it subjects people don't necessarily fear worry and potentially dietary restrictions and treatments now all this being said the overall utility of SIBO breath testing I think is moderate it can be helpful it can help the steer decisions but it's not the end all be all and there are probably loosely said as many things that can go awry in the gut that we can test for that we can't test for and just as a as a point here to reinforce this we know that SIBO exists we also know that small intestinal fungal overgrowth exists and this is something we've talked about in the podcast before with Dr. Steech Rao who's at university I believe of Augusta and we know that CFO small intestinal fungal overgrowth does exist however routine testing is not available for that so right there we see well we can test for about half of the imbalances we know exist in the small intestines which is why I don't think it's in the best interest of a patient or in the best interest of a provider to overly harp on testing we can use testing as part of the informative process to determine what may be going on underneath the hood with a given individual but we can also use many a therapy without needing any type of lab results probiotics as one example can be quite effective and helpful for small intestinal bacterial growth we've discussed now five clinical trials in one minute analysis showing that probiotics can be an effective treatment for SIBO you don't need a breath test to use a probiotic for SIBO or for your IBS symptoms and the same likely applies for CFO knowing that probiotics also have antifungal effects the picture I'm trying to paint here is that testing can be helpful it is imperfect of the SIBO breath tests the better is the glucose test although with a well-trained clinician a lactulose test could be responsibly used all that being said I wouldn't go through large lengths to perform testing if you haven't yet tried to improve your diet tried to use probiotics potentially carefully used herbal antimicrobial therapy consider elemental dieting all the things that I've laid out in healthy good healthy you can really lead to quite a bit of improvement which has been evidenced by the number of individuals we've spoken with who have seen numerous doctors and not recovered their gut health and then gone through the simple protocol laid out in the book healthy good healthy you and see the results they're looking for that's an attestament to the fact that copious testing isn't necessary in most cases but rather having a well-constructed clinical stepwise process that's very evidence based and scientifically informed can actually work better unfortunately in many cases than seeing a clinician now there's certainly a time and a place for a clinician and I do not want to dissuade anyone ever from checking in with their family doctor their gastroenterologist and going through the appropriate evaluations however that said if you've had the appropriate evaluation and you're still floundering then healthy good healthy you really does seem to offer some nice benefits it's really a derivative of what I do in the clinic combined with a pretty strong evidence informed review so in any case coming back to the issue hand for SIBO testing the two best tests that are readily available are both breath tests a glucose test and I'll not do those tests and thankfully we now have gold level gold standard level evidence that the meta analysis has found and that points to the glucose test as being the best so this is Dr. Ruscio and I hope this information helps you get healthy get back to your life and if you do perform the SIBO breath test be able to choose the one that is probably in your best interest