Impact of Oral-Cecal Transit Time on the Interpretation of Lactulose Breath Tests After RYGB: a Personalized Approach to the Diagnosis of SIBO

Obes Surg. 2019 Mar;29(3):771-775. doi: 10.1007/s11695-018-3575-3.


Background: Traditionally, small intestinal bacterial overgrowth (SIBO) is diagnosed when there is an early peak in breath hydrogen or methane. Given unclear intestinal transit time in Roux-en-Y gastric bypass (RYGB) patients, it is unknown if the traditional approach at diagnosing SIBO is adequate in this patient population.

Aim: To assess oral-cecal transit time (OCTT) and its impact on the interpretation of breath tests in the diagnosis of SIBO in patients with RYGB.

Methods: This study was a retrospective review of prospectively collected data on RYGB patients who underwent testing for SIBO using lactulose breath test (LBT) with or without small bowel follow-through (SBFT) to assess OCTT. Outcomes of SIBO test based on LBT alone versus LBT with OCTT were compared using a chi-squared test.

Results: Sixty-two of the 151 RYGB patients who underwent LBT underwent an additional SBFT to assess OCTT. Median OCTT was 60 min. Of these, 59.7% had OCTT shorter than 90 min. Based on LBT alone, 36/62 patients (58.1%) were classified as positive SIBO. When LBT results were combined with OCTT, 26/36 patients (72.2%) had hydrogen or methane rise within OCTT, suggesting 27.8% false positive rate. Patients with true positive SIBO based on LBT and OCTT had a higher response rate to antibiotics compared to those with false positive SIBO (78.3% vs. 33.3%, p = 0.03).

Conclusion: A personalized approach of combining LBT with SBFT to assess OCTT may improve the accuracy of SIBO testing and enhance clinical outcomes in patients with RYGB.

Keywords: Abdominal pain; Bacterial overgrowth; Bariatric; Bloating; Breath test; RYGB; SIBO.

MeSH terms

  • Breath Tests / methods*
  • Dysbiosis* / diagnosis
  • Dysbiosis* / metabolism
  • Gastric Bypass / adverse effects*
  • Gastrointestinal Transit / physiology*
  • Humans
  • Intestinal Diseases* / diagnosis
  • Intestinal Diseases* / etiology
  • Intestinal Diseases* / metabolism
  • Lactulose / analysis*
  • Lactulose / metabolism
  • Retrospective Studies


  • Lactulose