trio-smart Malabsorption Breath Test - Fructose

The Trio-Smart malabsorption breath test by Gemelli Biotech offers a comprehensive diagnostic approach for individuals experiencing gastrointestinal symptoms such as bloating, gas, abdominal pain, constipation, and diarrhea. By measuring hydrogen, methane, and hydrogen sulfide levels in the breath, this test can detect three variations of bacterial overgrowth: small intestinal bacterial overgrowth (SIBO), intestinal methanogenic overgrowth (IMO), and excess hydrogen sulfide. [8.,9.]

Through at-home sample collection and analysis at a CLIA-certified lab, patients and healthcare providers gain insight into the underlying causes of gastrointestinal symptoms, facilitating the development of tailored treatment plans. [8.]

Breath tests are effective in detecting conditions like small intestinal bacterial overgrowth (SIBO) and carbohydrate malabsorption, which are strongly linked to GI symptoms.  These tests offer a noninvasive and cost-effective approach to diagnosing GI disorders, providing valuable insights for effective management.

Many individuals with functional gut disorders may not realize the impact of their diet on their GI symptoms. Particularly, those experiencing chronic symptoms like abdominal pain, bloating, flatulence, and altered bowel movements may overlook the possibility of carbohydrate malabsorption or SIBO. Breath tests offer specific and sensitive diagnostic capabilities, allowing healthcare providers to confirm or rule out these conditions in such patients.

Elevated levels of hydrogen, methane, and hydrogen sulfide can indicate disruptions in the microbiome, leading to various gastrointestinal symptoms. Depending on the substrate used, a carbohydrate malabsorption may also be discovered.  

The Trio-Smart test provides data to guide treatment decisions, offering patients a personalized approach to addressing their symptoms and improving their overall well-being.

What is the Science Behind the trio-smart Malabsorption Breath Test - Fructose By Gemelli Biotech?

Breath testing serves as a valuable tool in identifying various gut microbiome-related conditions by analyzing fermented gasses in exhaled breath samples. The three primary gasses measured in breath testing are hydrogen, methane, and hydrogen sulfide, which can provide insights into disorders affecting gut health. These gasses are produced by bacteria in the gastrointestinal tract during the fermentation of sugars,  [7.]

High levels of hydrogen, methane, or hydrogen sulfide in breath testing can have distinct clinical implications. Elevated hydrogen levels are commonly associated with small intestinal bacterial overgrowth (SIBO), where excess bacteria in the small intestine produce hydrogen gas during the fermentation of carbohydrates. This can lead to symptoms such as bloating, abdominal discomfort, and diarrhea. 

High methane levels are indicative of intestinal methanogenic overgrowth (IMO), which is often linked to constipation. Methane is produced by archaea in the gut that consume hydrogen, slowing gut transit time and potentially contributing to constipation.

In contrast, elevated hydrogen sulfide levels in breath testing are associated with excess hydrogen sulfide production in the gut microbiome. This condition, previously undetectable by traditional breath tests, is linked to symptoms such as diarrhea and abdominal pain. Excess hydrogen sulfide is believed to be produced by sulfate-reducing bacteria and can lead to gut inflammation and dysbiosis.

Each gas—hydrogen, methane, and hydrogen sulfide—provides valuable clinical information about the underlying gut microbiome composition and function, helping healthcare providers tailor treatment strategies for patients with gastrointestinal symptoms. Therefore, understanding the clinical relevance of high levels of these gasses in breath testing is crucial for accurate diagnosis and management of gut-related disorders.

Additionally, the substrate chosen may also provide clinical insight.  While glucose hydrogen breath tests are preferred for diagnosing SIBO, lactose and fructose hydrogen breath tests are utilized to identify lactose and fructose malabsorption, respectively.

What is the Clinical Relevance of the trio-smart Malabsorption Breath Test - Fructose By Gemelli Biotech?

A positive finding on a Trio-Smart breath test using a fructose substrate indicates potential malabsorption of fructose in the small intestine, which can lead to gastrointestinal symptoms such as bloating, abdominal pain, diarrhea, and flatulence. Fructose malabsorption occurs when the small intestine is unable to properly absorb fructose due to deficiencies in fructose transporters or enzyme activity. As a result, unabsorbed fructose reaches the colon where it is fermented by gut bacteria, leading to the production of gasses such as hydrogen and methane, which can be detected in breath testing.

The clinical significance of a positive finding on a Trio-Smart breath test with a fructose substrate lies in its ability to identify individuals with fructose malabsorption, allowing for targeted dietary interventions and symptom management. By confirming fructose malabsorption as the underlying cause of gastrointestinal symptoms, healthcare providers can advise patients to limit their intake of fructose-containing foods and beverages, such as fruits, honey, and high-fructose corn syrup. Additionally, supplementation with digestive enzymes that aid in fructose digestion may be recommended to improve symptoms and overall quality of life.

When Should Clinicians Order the Following Substrates: Fructose, Lactose, or Sucrose?

Fructose, lactose, and sucrose are commonly used substrates in breath testing for bacterial overgrowth.  The choice of substrate depends on the suspected underlying cause of the patient's symptoms and their dietary habits. [7.]

Fructose is often used to assess for fructose malabsorption, which can contribute to symptoms of bloating, gas, and diarrhea. Patients suspected of having fructose intolerance may undergo breath testing with fructose to evaluate their ability to absorb this sugar. 

Lactose, found in dairy products, is commonly used to assess for lactose intolerance. Breath testing with lactose can help diagnose lactase deficiency, which leads to the inability to digest lactose and can result in symptoms such as bloating, abdominal pain, and diarrhea after consuming dairy products.

Sucrose, although less commonly used compared to fructose and lactose, can also be used as a substrate in breath testing for SIBO. Sucrose is a disaccharide composed of glucose and fructose, and its malabsorption may contribute to gastrointestinal symptoms in certain individuals. [4.]

Lactulose is an additional substrate used for breath testing.  Lactulose hydrogen breath tests are commonly used to assess GI motility by measuring orocecal transit time. [7.]

Breath testing with sucrose can help identify patients with sucrase-isomaltase deficiency or other conditions affecting the digestion and absorption of sucrose. Overall, the selection of substrate for SIBO breath testing should be based on the patient's clinical presentation, dietary history, and suspected underlying disorders, with the goal of accurately diagnosing and managing their gastrointestinal symptoms.

Who Can Benefit from the trio-smart Malabsorption Breath Test- Fructose?

Individuals with Unexplained Gastrointestinal Symptoms: Those experiencing chronic symptoms such as bloating, gas, abdominal pain, and altered bowel habits (diarrhea or constipation) could benefit from the trio-smart malabsorption breath test for fructose. Studies have shown that fructose malabsorption is common in individuals with functional gastrointestinal disorders (FGIDs) and can contribute to these symptoms.  [2.]

Patients with Suspected Irritable Bowel Syndrome (IBS): IBS is a common condition characterized by abdominal discomfort or pain and altered bowel habits. Research suggests a significant association between fructose malabsorption and IBS symptoms. [kim, <<<<<<  Therefore, individuals with suspected IBS who have not responded to conventional treatments may benefit from testing for fructose malabsorption.

Individuals with Suspected Fructose Intolerance: Fructose intolerance is a condition where the body has difficulty digesting and absorbing fructose, leading to gastrointestinal discomfort. The trio-smart malabsorption breath test for fructose can help diagnose fructose intolerance and guide dietary management.  [3.]

Patients with Unexplained Abdominal Discomfort: Those experiencing unexplained abdominal discomfort or pain, especially after consuming foods high in fructose, may benefit from fructose breath testing. Research suggests that identifying and addressing fructose malabsorption can alleviate symptoms and improve quality of life [1., 3.]

Individuals Seeking Dietary Management: For individuals looking to optimize their diet and improve gastrointestinal symptoms, identifying fructose malabsorption through breath testing can guide dietary modifications. This personalized approach can help individuals avoid foods high in fructose and alleviate symptoms associated with malabsorption.  [3., 5.]

Collection and Shipping

Key Details

• Save the box your kit comes in. You will need this to ship your sample back to the lab.
• You must avoid certain medications before sample collection.  Discuss this with your ordering healthcare provider.
• You must avoid certain foods the day before sample collection.
• You must fast for 8-12 hours before sample collection.
• Samples must be shipped within 24 hours of collection.

Preparation & Timing

If you are taking antibiotics, consult with your healthcare provider regarding the timing of sample collection.  Some antibiotics should be avoided before sample collection.

Avoid the following medications for at least 7 days before sample collection:

• Promotility drugs
• Laxatives

You must follow a restricted diet the day before sample collection. YOU CAN ONLY EAT AND DRINK THE FOLLOWING ITEMS: 

Food:

• Poultry
• Fish
• Beef
• Pork
• Tofu
• Eggs
• White potatoes
• White rice

Seasonings:

• Salt
• Pepper
• Oil

Drinks

• Water
• Black coffee (NO ADDITIVES like sugar or milk)
• Plain tea (NO ADDITIVES like sugar or milk)

You must fast for 8-12 hours before sample collection. DO NOT eat or drink anything during this fasting period and sample collection time, except for your glucose or lactulose solution. You may drink a few sips of water if necessary.

Collection Instructions

1. Ensure you follow the restricted diet and fasting guidelines.
2. Mix the full contents of the substrate packet into an 8 oz glass of room-temperature water. 
3. DO NOT DRINK THE SUBSTRATE YET. 
4. This collection is strictly timed. You MUST follow the collection time exactly. 

Complete a sticker label with the following information:

• Sample number
• Sample collection time
• Date of collection
• Your full name
• Your date of birth

1. Place the sticker label on one of the deflated collection bags.
2. Attach the mouthpiece to the end of the valve until it fits snugly.
3. The small hole on the mouthpiece should be facing up.
4. Turn the cap on the valve counterclockwise until it is fully in the "Open" position.
5. Take a deep breath.
6. Exhale continuously into the mouthpiece.
7. After 2 seconds, cover the small hole on the mouthpiece with your finger while still exhaling. 
8. DO NOT inhale.
9. DO NOT exhale more than one breath.
10. Close the cap by turning it clockwise until it is fully in the "Closed" position.
11. Remove the mouthpiece from your mouth
12. Remove the mouthpiece from the valve
13. Wait 30 minutes before collecting your next sample.

Repeat steps 4-14 for the second sample collection.

Immediately after collecting your second sample, drink the sugar substrate solution within 5 minutes. Drink the entire substrate dose provided in your collection kit. Wait 30 minutes before collecting your next sample. Repeat steps 4-14 for each sample collection. Wait 30 minutes between each sample collection. 

Once you have finished all eight collections, place all filled collection bags into the provided biohazard bag. Seal the bag tightly.

Complete the test requisition form. Click here for instructions on completing your Requisition Form. Place the biohazard bag and your completed test requisition form into the shipping box.

Requisition & Payment

• Your kit has been prepaid. You DO NOT need to pay anything extra.
• You must complete your requisition form and send it back with your samples.   Click here for more information on completing your Requisition Form.
• Since you pre-paid for your tests, you do not need to fill in any payment information on this form.

Shipping

Samples must be shipped within 24 hours of collection. Ship your samples via UPS. To prepare your samples for shipping:

1. Place all filled sample collection bags into the provided biohazard bag.
2. Seal the biohazard bag tightly.
3. Place the biohazard bag into the trio-smart box.
4. Place the completed requisition form into the trio-smart box.
5. Place the prepaid return label over the original shipping label.
6. Seal the trio-smart box with packing tape.
7. Make a note of the tracking number on the return label so you can track your samples back to the lab.

Results

Results should be released to your provider 7 business days after samples are received at the lab. Rupa Health cannot guarantee processing time.

Additional Resources for Clinicians

Article: SIBO Testing 101: A Complete Guide to The Top 3 SIBO Tests 

Article: How to Use the trio-smart Test from Gemelli Biotech in Clinic

References

[1.] Gibson PR, Newnham E, Barrett JS, Shepherd SJ, Muir JG. Review article: fructose malabsorption and the bigger picture. Aliment Pharmacol Ther. 2007 Feb 15;25(4):349-63. doi: 10.1111/j.1365-2036.2006.03186.x. Epub 2007 Jan 8. PMID: 17217453.

[2.] Kim Y, Choi CH. Role of Fructose Malabsorption in Patients With Irritable Bowel Syndrome. J Neurogastroenterol Motil. 2018 Apr 30;24(2):161-163. doi: 10.5056/jnm18057. PMID: 29605972; PMCID: PMC5885715.

[3.] Ledochowski M, Widner B, Bair H, Probst T, Fuchs D. Fructose- and sorbitol-reduced diet improves mood and gastrointestinal disturbances in fructose malabsorbers. Scand J Gastroenterol. 2000 Oct;35(10):1048-52. doi: 10.1080/003655200451162. PMID: 11099057.

[4.] Losurdo G, Leandro G, Ierardi E, Perri F, Barone M, Principi M, Leo AD. Breath Tests for the Non-invasive Diagnosis of Small Intestinal Bacterial Overgrowth: A Systematic Review With Meta-analysis. J Neurogastroenterol Motil. 2020 Jan 30;26(1):16-28. doi: 10.5056/jnm19113. PMID: 31743632; PMCID: PMC6955189.

[5.] Ong DK, Mitchell SB, Barrett JS, Shepherd SJ, Irving PM, Biesiekierski JR, Smith S, Gibson PR, Muir JG. Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome. J Gastroenterol Hepatol. 2010 Aug;25(8):1366-73. doi: 10.1111/j.1440-1746.2010.06370.x. PMID: 20659225.

[6.] Pimentel, Mark MD, FRCP(C), FACG1; Saad, Richard J. MD, FACG2; Long, Millie D. MD, MPH, FACG (GRADE Methodologist)3; Rao, Satish S. C. MD, PhD, FRCP, FACG4. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. The American Journal of Gastroenterology 115(2):p 165-178, February 2020. | DOI: 10.14309/ajg.0000000000000501  

[7.] Rana SV, Malik A. Hydrogen breath tests in gastrointestinal diseases. Indian J Clin Biochem. 2014 Oct;29(4):398-405. doi: 10.1007/s12291-014-0426-4. Epub 2014 Mar 21. PMID: 25298621; PMCID: PMC4175689.

[8.] Rezaie A, Buresi M, Lembo A, Lin H, McCallum R, Rao S, Schmulson M, Valdovinos M, Zakko S, Pimentel M. Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus. Am J Gastroenterol. 2017 May;112(5):775-784. doi: 10.1038/ajg.2017.46. Epub 2017 Mar 21. PMID: 28323273; PMCID: PMC5418558.

[9.] Tahli Singer-Englar, Rezaie A, Gupta K, et al. 182 - Competitive Hydrogen Gas Utilization by Methane- and Hydrogen Sulfide-Producing Microorganisms and Associated Symptoms: Results of a Novel 4-Gas Breath Test Machine. Gastroenterology. 2018;154(6):S-47. doi:https://doi.org/10.1016/s0016-5085(18)30625-5