In this episode of The Dr. Hedberg Show, I interview Gary Stapleton of Aerodiagnostics Laboratory answering the question, "What is the best SIBO test?" We covered a lot of ground about the ins and outs of SIBO breath testing including the best methodology, glucose vs. lactulose, how to properly perform the test, proper test interpretation, hydrogen sulfide, when to retest and much more.
Gary is the founder of Aerodiagnostics Laboratory which I personally use in my practice and highly recommend to everyone who wants the most accurate SIBO test on the market today. Combine that with the best customer service and support and it's a no-brainer to use them for your SIBO testing.
Below is a transcript of the entire interview with important links at the end:
Dr. Hedberg: Okay. Well, welcome, everyone. This is Dr. Hedberg and welcome to "The Dr. Hedberg Show." I'm excited today to be talking to Gary Stapleton. And Gary is the founder of Aerodiagnostics Laboratory. And this is the laboratory that I use for small intestinal bacterial overgrowth testing. Their lab offers non-invasive hydrogen and methane breath testing. It's the lab I've been using to test for SIBO because the quality is really unparalleled in the SIBO world and I've been very, very pleased with the quality of the results I've been getting and the customer service. So we're going to be talking about some really interesting items today about SIBO and SIBO testing. So, Gary, welcome to the program.
Gary: Oh, thank you, Dr. Hedberg. I really appreciate joining today and I look forward to discussing SIBO and breath testing, hydrogen and methane breath testing with the audience.
Dr. Hedberg: Excellent. Yeah, it's good to have an expert like you here because this is really a hot topic. I mean, the prevalence of SIBO is continuing to grow and we're seeing it more and more. And then, of course, our IBS population really struggles with SIBO, for the most part. So why don't you start by just talking to us about hydrogen and methane breath testing and how it works in the diagnosis of SIBO?
Gary: Yes, so thank you. And please feel free to interject if there's something that I've said or am in the process of saying that might be beneficial as well. So hydrogen and methane gas, for those listening that aren't aware, are not produced by the body. Hydrogen and methane gases are produced by bacteria that is fermenting. So the way that the test works and why it's so incredibly important to prepare correctly, to use the right devices correctly and to administer and ensure that your devices are operating correctly, to ensure that we're measuring hydrogen and methane gas appropriately, it all begins with the preparation. And then, if you prepare correctly, which means you're moving food from the GI tract, there...even if there's bacteria, there's no gas being produced because the bacteria, if it's there, needs to be fed to ferment and to produce this gas.
So if you have bacteria in your small intestine and you're not supposed to have bacteria in your small intestine, I believe it should be less than 103 colony-forming units in the small intestine. If there's bacteria there and you've prepped, which means you've removed all food, your baseline breath sample should be relatively low to no gas because, again, the bacteria's there, it's not being fed.
Now, after that baseline sample, you ingest either glucose or lactulose as a substrate that has been validated to ensure appropriate measurement of gas levels inhalation of small intestinal bacterial overgrowth. When you ingest either that glucose or lactulose, that is a food source. And that food source will now feed bacteria, if it is there. That bacteria will ferment or rot and the gas that's produced, either hydrogen or methane, will diffuse through the blood and exit via the lung air.
I'll deflect for just a moment and say everyone is aware that there's a third gas. It's called hydrogen sulfite gas. And in our experience, and I know that some of the SIBO thought leaders and some of the very good clinicians that are treating SIBO today may suggest that there's a higher prevalence of hydrogen sulfide, there's not a lot of data on that and we'll talk about that. But I will tell you we've run nearly 20,000 breath tests and by the definition of utilizing a lactulose breath test and having a flat line, we're only seeing hydrogen sulfide suspicion 1 to 2%. So it doesn't really occur that often, from our perspective.
So back to how does the test work. So if you've now prepped correctly and then you've taken a breath sample and then you ingest either the lactulose or glucose, now that lactulose and/or glucose is traveling through the small intestine. And when it meets up with bacteria, it will ferment and leak gas into the blood that exits via the lung air. We capture that and then it's tested in the lab. If it happens between zero minutes...and again, this is another of points that we will probably get into later, but the way that the test...the gold standard interpretation has been if you have a rise of gases between 0 minutes and 120 minutes, that would be a positive indication that there is bacterial overgrowth.
There are some newer data and some newer perspectives that look only at 90 minutes. And, from a laboratory perspective, it's accurate data. We want to provide you, the clinician, with accurate data. If you'd like to interpret these looking only at 0 minutes to 90, you can do that. You can look at 0 to 120 and challenge the more distance, which is what we recommend, considering then we can do that. And, again, we'll talk about that a little later.
If your choice is lactulose, then that lactulose will pass into the large intestine. And because there is bacteria, and should be, typically, you have elevated levels of hydrogen and/or methane gas when it gets into the colon. With glucose, it is absorbed and you still get some gas levels. But not necessarily elevated through the last three test tubes. Okay? So this is how the hydrogen and methane breath test actually works.
What I like about this test, with the total accuracy by the studies that were involved with it, over 90%, but what I like about it is that it's binary. If you have hydrogen and/or methane gas within that first 120 minutes or 90 minutes, that is evidence that there are bacteria producing gas. It's the only way if the patient prepared correctly. The only way you would get that gas. As I mentioned earlier, the body doesn't produce the gas. So that's the way we do that. So I'll pause there, Dr. Hedberg, and see if that answers the question.
Dr. Hedberg: Yes, yes. That's a great overview. And one of the ways I explain it to patients is just like you're putting gasoline into a car and the engine burns the gasoline and then the gas comes out. And the bacteria are basically the engine burning that fuel that you put in. And it could be either glucose or lactulose, like you said. So can you talk just a little bit about your specific methodology? Because not all labs are equal in this. And I learned that early on. So how do you ensure the data you're seeing is accurate?
Gary: Well, thank you for that question. I will tell you this is why I founded the laboratory a few years back. I think it's three and a half years ago. My wife, who is a physician, has owned and operated her own diagnostic laboratory in the pathology world. I've either owned or operated or have run large diagnostic laboratories during my career. My wife was suffering from SIBO and, of course, like many of your patients, was asked to take a breath test.
So we live in Boston and the first test was asked to go to a very well known hospital in Boston. We'll refrain from saying the exact one, but I assure you, it's a very good one. And the first process was that she had to call to organize when they would go there and have the breath collected. So there was a lot of back and forth. It was very inconvenient. And, finally, it was settled that it was going to be on a Wednesday, in Boston at 1:00 in the afternoon.
Well, as everyone knows, you have to prep for this, which includes 24 hours of a limited diet. Well, 12 hours of a limited diet and 12 hours of a fast. Clearly, you don't want to be fasting all morning. Typically, you fast overnight. So it's inconvenient for the patient there. Then, when we got there, it was to go down in the basement. And now you're in the basement for three hours with upwards of 20 other people having breath collected. No internet, no phone. For people, this is very inconvenient for obvious reasons.
And then, when the test was over, the collections were actually done, you would have . . . first of all, the prep information was not consistent with how the test was actually validated. So that led to some inaccuracies. But then, the clinician or the technicians that were collecting the breath, you could tell that they were trained by someone else, not by the equipment manufacturers or anyone directly. Almost like whispered down the lane. So things have changed and they didn't really know how to work with the devices and different things. So we were suspect from the very beginning. Needless to say, it was an inconvenient process and it wasn't that good.
So the next one was we received a kit at home because we weren't going to try again. And it was obvious that the kit was a homemade kit. The most important thing, and this goes to the question, how do you ensure accurate results, the most important thing is that you have very direct and personal involvement with that patient to help them with the prep questions. The prep is very specific.
Now, any clinician can change this, but the test has been validated on the preparation, meaning that the first 12 hours, you eat from a limited list of foods. They are very straight, very direct: chicken, fish, eggs, white rice, white bread, white potatoes. Now,
