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Why isn't the sorbitol H2-breath test being used more frequently to
diagnose and monitor celiac disease and GF dietary compliance?  The test
has been around for years.  Serological tests and biopsies have received
the predominance of attention and discussion in celiac disease research
papers, but yet the sorbitol H2-breath test has been shown to have greater
value in detecting early stage and "silent"-type celiac disease.
Additionally, the test has the ability to assess the extent of intestinal
recovery and to detect patients non-compliant with their GF diets.  It
seems that the test is mostly being used in Italy.  Doctors in the U.S. and
worldwide should become more aware of and be routinely using this test.
Below are abstracts describing and discussing the sorbitol H2-breath test:

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Minerva Pediatr. 1994 Dec;46(12):569-74.

[Hydrogen breath test in celiac disease: relationship to histological
changes in jejunal mucosa]

[Article in Italian]

Ansaldi-Balocco N, Malorgio E, Faussone D, Dell'Olio D, Morra I, Forni M,
Oderda G.

Istituto Discipline Pediatriche, Universita degli Studi, Torino.

Hydrogen concentration in expired breath depends on the fraction of
ingested carbohydrates unabsorbed by the small intestinal mucosa which
reach the large intestine and are fermented by the colonic flora. The aim
of this study is to assess whether in coeliac children breath hydrogen
excretion reflects the histological changes in the jejunal mucosa. Hydrogen
breath test was performed on 40 children (15 males 25 females) divided into
three groups. Group I (controls): 9 children with symptoms suggestive of
coeliac disease who, after the appropriate workup, were found to suffer
from other gastrointestinal disorders and had abnormal jejunal mucosa.
Group II: 14 children who had been diagnosed as coeliacs according to the
ESPGAN criteria, were kept on a gluten free diet for a minimum of 6 months
and had a normal jejunal mucosa. Group III: 17 coeliac children who ate
small quantities of gluten or were on a normal diet. At histology, 10 of
them showed a total and 7 a partial atrophy of the jejunal mucosa. Breath
hydrogen levels were measured both at baseline and after ingestion of a 2%
sorbitol solution in water, at 30 minute intervals for four hours. The peak
hydrogen level and the total surface area under the hydrogen excretion
curve were also assessed. Coeliac children on a gluten containing diet
excrete significantly more H2 than controls or coeliacs on a gluten free
diet. Patients with more severe histological lesions had higher peak H2
levels and greater total excretion areas. In coeliac children, sorbitol
breath H2 test represents a simple noninvasive technique to detect impaired
jejunal function and it should have an important role as a screening test
and in assessing dietary compliance.

PMID: 7731420 [PubMed - indexed for MEDLINE]

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Scand J Gastroenterol. 2001 Nov;36(11):1170-2.

Sorbitol H2-breath test versus anti-endomysium antibodies for the diagnosis
of subclinical/silent coeliac disease.

Tursi A, Brandimarte G, Giorgetti GM.

Division of Emergency, L. Bonomo Hospital, Andria (BA), Italy.
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BACKGROUND: Recent studies have shown that the prevalence of anti-
endomysial antibodies (EMAs) in clinical practice is lower than expected;
the aim of our study was therefore to compare the sorbitol H2-breath test
(BT) with EMAs in the diagnosis of subclinical/silent coeliac disease and
to compare with histologic lesions. METHODS: We studied 123 consecutive
patients with subclinical (96) and silent (27) coeliac disease. Expiratory
samples were collected before the patients drank the test solution (5 g of
sorbitol in 150 ml of tap water) and every 30 min for 4 h. An increase in
H2 concentration of at least 20 ppm over fasting baseline was considered
positive for sorbitol malabsorption. EMAs were screened by the indirect
immunofluorescence method. RESULTS: EMAs were positive in 77/96 (80.80%)
and sorbitol H2-BT in 94/96 (97.91%) patients with subclinical coeliac
disease, while EMAs were positive in 17/27 (62.96%) and sorbitol H2-BT in
26/27 (96.29%) patients with silent coeliac disease (P < 0.001 in both
forms of coeliac disease). The best cut-off values in ppm and minutes are
higher and shorter in the severe form than in the minor form of intestinal
damage, respectively (P < 0.001 in both forms). CONCLUSIONS: This study
indicates that almost all subclinical/silent coeliac patients show abnormal
sorbitol H2-BT and that there is a strict correlation between cut-off value
(in ppm and minutes) and histologic lesions. In particular, the maximal cut-
off value (in ppm and in minutes) correlates statistically with the more
severe the grade of intestinal damage. Finally, the prevalence of EMA in
subclinical/silent disease is lower than expected.

PMID: 11686216 [PubMed - indexed for MEDLINE]

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Scand J Gastroenterol. 2003 Jul;38(7):727-31.

Dig Liver Dis. 2002 Dec;34(12):846-50.

Sorbitol H2-breath test versus anti-endomysium antibodies to assess
histological recovery after gluten-free diet in coeliac disease.

Tursi A, Brandimarte G, Giorgetti GM.

Emergency Department "L. Bonomo" Hospital, Andria, BA, Italy.
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BACKGROUND: Gluten-free diet plays a key role in treatment of coeliac
disease, but it is difficult to evaluate its effect on improvement of
villous architecture using sensitive non-invasive tests. AIMS: To compare
sorbitol H2-Breath Test with antiendomysial antibodies in the follow-up of
coeliac disease to detect histological recovery METHODS: A total of 38
consecutive patients with coeliac disease were studied. All underwent
Sorbitol H2-Breath Test, antiendomysial and oesophagogastroduodenoscopy
with multiple bioptic samples before diet and then 6, 12 and 18 months
after gluten-free diet. Expiratory samples were collected before patients
drank the test solution (5 g sorbitol in 150 ml tap water) and thereafter
every 30 min for 4 hours. An increase in H2 concentration of > or = 20 ppm
above fasting baseline was considered positive for sorbitol malabsorption.
Antiendomysial antibodies were evaluated by the indirect immunofluorescent
method. RESULTS: Antiendomysial antibodies were positive in 32/38 patients
before gluten-free diet (84.21%), while they were positive in 20/34
(54.82%), 2/16 (12.5%) and 0/2 (0%) cases after 6, 12 and 18 months of
gluten-free diet, respectively, no correlation being found with improvement
of histological lesions (p = ns). As far as concerns sorbitol H2-Breath
Test, maximal cut-off value (in ppm) decreased progressively and parallel
to histological recovery during follow-up. Indeed, it decreased from a mean
63 ppm before diet to 35, 19 and 12 ppm, after 6, 12 and 18 months of
gluten-free diet, with a stetistical difference being found before and
after (p < 0.001). Likewise, the peak value (in minutes) appeared
progressively later during follow-up, parallel to histological recovery. In
fact, it appeared at a mean of 119 minutes before gluten-free diet, while
it appears at a mean of 164, 195 and 219 minutes after 6, 12 and 18 months
on gluten-free diet. A statistical difference before and after start of
gluten-free diet was found also in this case (p < 0.001). CONCLUSIONS:
Sorbitol H2-Breath Test is better than antiendomysial antibodies in
revealing histological recovery in the follow-up of coeliac patients after
the start of gluten-free diet due to its good correlation with histological
damage. Moreover, it also appears to be able to detect dietary mistakes of
the patients on gluten-free diet.

PMID: 12643292 [PubMed - indexed for MEDLINE]
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Continued in Part 2 of 2

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