Using the trio-smart SIBO Breath Test by Gemelli Biotech in Your Clinic

Small intestinal bacterial overgrowth (SIBO) is increasingly recognized as a contributing factor to a spectrum of gastrointestinal disorders. It affects up to 22% of the general population and 85% of patients with irritable bowel syndrome (IBS). Accurate diagnosis remains a clinical challenge due to overlapping symptoms with other gastrointestinal conditions. 

The advent of the trio-smart SIBO breath test by Gemelli Biotech, capable of measuring hydrogen (H2), methane (CH4), and hydrogen sulfide (H2S), offers a more comprehensive diagnostic approach. This article explores the utility of the trio-smart breath test in clinical practice, providing healthcare professionals with evidence-based insights to enhance patient care.

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What Is Small Intestinal Bacterial Overgrowth (SIBO)?

SIBO is defined as the presence of gastrointestinal (GI) symptoms caused by an excessive concentration of bacteria in the small intestine, typically exceeding 10³ colony-forming units per milliliter (CFU/mL). SIBO is categorized based on the predominant gas produced by the overgrown bacteria:

SIBO Subtypes

1. Hydrogen SIBO (H2-SIBO): Predominant production of hydrogen gas

2. Intestinal Methanogen Overgrowth (IMO): Predominant production of methane gas by bacteria-like microorganisms called archaea

3. Hydrogen Sulfide SIBO (H2S-SIBO): Predominant production of hydrogen sulfide gas

 Causes and Risk Factors

 Several factors predispose individuals to SIBO, including:

• Anatomical Abnormalities: such as strictures, diverticula, or blind loops
• Motility Disorders: conditions like diabetic neuropathy, scleroderma, or post-infectious dysmotility
• Immunodeficiency: including HIV/AIDS or immunosuppressive therapies
• Chronic Conditions: such as inflammatory bowel disease (IBD), celiac disease, or hypothyroidism
• Lifestyle Factors: long-term use of proton pump inhibitors (PPIs) may reduce intestinal acidity and alter gut flora

SIBO Symptoms 

SIBO presents with a variety of gastrointestinal and systemic symptoms, including:

• Gastrointestinal: bloating, abdominal pain, diarrhea, constipation, flatulence, and malabsorption leading to weight loss
• Systemic: fatigue, nutrient deficiencies (e.g., vitamin B12, iron), changes in mood, headaches, skin rashes, and joint pain (8) 

SIBO Diagnosis

Diagnosis of SIBO traditionally relies on the following:

• Clinical Evaluation: assessing symptoms and risk factors, though this is non-specific
• Small Intestinal Aspirate and Culture: often considered the gold standard but is invasive, expensive, and time-consuming
• Breath Tests: measuring hydrogen and methane levels after ingestion of a fermentable substrate (e.g., lactulose or glucose)

What Is the trio-smart SIBO Breath Test?

The trio-smart SIBO breath test by Gemelli Biotech is an advanced diagnostic tool and the only SIBO breath test that measures all three gases – H2, CH4, and H2S – related to SIBO. This comprehensive approach allows for the detection of a broader range of bacterial overgrowth patterns, including those that produce hydrogen sulfide, which are not identified by traditional dual-gas tests.

SIBO breath tests are designed based on the principle that human cells do not produce hydrogen or methane gases. Therefore, detecting these gases in breath samples indicates their production by gut microbes through the fermentation of carbohydrates. (25) 

During the test, patients ingest a carbohydrate substrate (lactulose or glucose), which travels to the small intestine. It is fermented by bacteria, resulting in the production of hydrogen, methane, or hydrogen sulfide gases. These gases are then absorbed into the bloodstream and exhaled through the lungs, allowing for their measurement in breath samples. (25) 

Clinical Indications for the trio-smart SIBO Breath Test

Many patients can benefit from the trio-smart SIBO breath test, particularly in the workup of unexplained GI symptoms, such as bloating, abdominal discomfort, heartburn, nausea, gas, diarrhea, and constipation.

SIBO testing can also be considered in the diagnostic workup of other health conditions that have overlapping symptoms or where SIBO is suspected to play a role, including: 

• IBS
• Rosacea
• Restless legs syndrome (RLS)
• Interstitial cystitis (IC)
• Autoimmune arthritides, such as rheumatoid arthritis and lupus

You may consider ordering the trio-smart breath test over other SIBO breath testing options in cases where initial hydrogen and methane breath testing are inconclusive or when symptoms suggest hydrogen sulfide excess (e.g., chronic diarrhea).

Implementing the trio-smart SIBO Breath Test in Your Clinical Practice

The trio-smart test involves the following steps:

• A doctor orders the trio-smart breath test for a patient. The test kit includes glucose. If the doctor prefers to order a lactulose breath test, they must send a prescription to the patient's pharmacy. 
• The patient needs to prepare for the breath test by discontinuing antibiotics, promotility drugs, and laxatives 7-14 days before sample collection. 
• The patient eats a restricted diet the day before sample collection. During this time, the diet is limited to only meat, tofu, eggs, potatoes, white rice, water, black coffee, and unsweetened tea. 
• The patient fasts 8-12 hours before sample collection.
• On the day of sample collection, the patient will follow the test kit instructions to complete a series of breath sample collections. This process involves collecting a baseline breath sample, drinking a sugar substrate drink (either lactulose or glucose), and then collecting eight more breath samples in 15-minute intervals. 
• The patient mails the completed test kit to the lab.
• The estimated turnaround time for the results is seven days after receiving the patient's samples. 

Lactulose vs. Glucose SIBO Breath Tests

There is no universal standard SIBO breath test, and both the glucose and lactulose SIBO breath tests offer their own benefits (25). 

Glucose Breath Tests

• Glucose does not require a prescription.
• Glucose is rapidly absorbed in the proximal small intestine. Because of this, glucose breath tests can diagnose SIBO and IMO in the early portions of the small intestine. They are associated with lower false positives caused by colonic bacteria; however, they can underdiagnose SIBO and IMO in the distal portions of the intestines. 

Lactulose Breath Tests

• Lactulose requires a prescription.
• Lactulose is not absorbed in the small intestine and travels to the colon. This allows for detecting SIBO and IMO in the distal portions of the intestines but can also lead to higher false-positive rates.

Interpreting trio-smart SIBO Breath Test Results

Per the North American Consensus, a SIBO breath test is considered positive if at least one of the following criteria is met (25)

• H2-SIBO: hydrogen levels rise at least 20 parts per million (ppm) from baseline within the first 90 minutes of the test
• IMO: methane level is at least 10 ppm at any time point during the test

Although the North American Consensus has not released official diagnostic criteria for H2S-SIBO, trio-smart guidelines state that hydrogen sulfide levels of 3 ppm or higher at any time during the test qualify as a positive test result (1).

Integrating trio-smart SIBO Breath Test Results Into Clinical Practice

The trio-smart test identifies the SIBO subtype and quantifies the severity based on gas concentrations. This allows clinicians to determine the appropriate treatment duration, monitor treatment responses through follow-up breath tests, and implement strategies to prevent recurrence, such as integrating prokinetics, dietary interventions, and lifestyle modifications.

Comprehensive gas profiling also assists doctors in maximizing the therapeutic efficacy of treatment plans, dependent upon the specific subtype of SIBO present. For instance: 

• Patients diagnosed with H2-SIBO typically respond well to mono-therapy with an antibiotic called rifaximin (21). 
• Those with IMO will require a combination of two antibiotics (rifaximin with either metronidazole or neomycin) (21).  
• Patients with H2S-SIBO often respond best to rifaximin with bismuth subsalicylate alongside a low-sulfur diet (18).

For more information on treating SIBO, check out these Rupa Health Magazine articles:

• A Functional Medicine SIBO Protocol: Testing and Treatment
• A Functional Medicine Intestinal Methanogen Overgrowth Protocol (IMO): Testing, Nutrition, and Supplements
• Elemental Diet for SIBO: Expert Tips and Patient Experiences   

Resources for Further Information

• Ready to order the trio-smart SIBO Breath Test by Gemelli Biotech through Rupa Health? Click here!
• View a breath test sample report
• Watch Rupa Health's free class called Diagnosing SIBO, IMO, and Excess Hydrogen Sulfide Using the Gemelli trio-smart Breath Test
• Visit the trio-smart website for more information and additional resources

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Key Takeaways

• The trio-smart SIBO breath test is the only test on the market that measures all three gases (hydrogen, methane, and hydrogen sulfide) associated with SIBO. Compared to traditional dual-gas tests, this provides a complete diagnostic assessment of SIBO.
• Healthcare professionals should consider ordering the trio-smart test for patients with persistent gastrointestinal symptoms such as bloating, abdominal pain, diarrhea, or constipation that have not responded to standard treatments.
• Given its advantages in diagnostic accuracy and treatment personalization, healthcare providers should consider integrating the trio-smart SIBO breath test into their clinical practice to achieve more precise diagnoses and optimize therapeutic interventions for patients with SIBO.