Abnormal colonic fermentation in irritable bowel syndrome

Abstract

Background: The cause of irritable bowel syndrome (IBS) is unknown. It may follow gastroenteritis and be associated with an abnormal gut flora and with food intolerance. Our study was designed to assess whether these factors were associated with colonic malfermentation.

Methods: We carried out a crossover controlled trial of a standard diet and an exclusion diet matched for macronutrients in six female IBS patients and six female controls. During the final 72 h on each diet, faecal excretion of fat, nitrogen, starch, and non-starch polysaccharide NSP was measured, and total excretion of hydrogen and methane collected over 24 h in a purpose-built 1.4 m3 whole-body calorimeter. Breath hydrogen and methane excretion were then measured for 3 h after 20 g oral lactulose.

Findings: The maximum rate of gas excretion was significantly greater in patients than in controls (2.4 mL/min IQR 1.7-2.6 vs 0.6, 0.4-1.1). Although total gas production in patients was not greater than in controls (median 527 mL/24 h IQR 387-660 vs 412, 234-507), hydrogen production was higher (332, 318-478 vs 162, 126-217, p=0.009). In patients, the exclusion diet reduced symptoms and produced a fall in maximum gas excretion (0.5 mL/min IQR 0.3-0.7). After lactulose, breath hydrogen was greater on the standard than on the exclusion diet.

Interpretation: Colonic-gas production, particularly of hydrogen, is greater in patients with IBS than in controls, and both symptoms and gas production are reduced by an exclusion diet. This reduction may be associated with alterations in the activity of hydrogen-consuming bacteria. Fermentation may be an important factor in the pathogenesis of IBS.