Mouth to Pouch Transit After Restorative Proctocolectomy: Hydrogen Breath Analysis Correlates With Scintigraphy Charles A. Ternent, M.D., Alan G. Thorson, M.D., Garnet J. Blatchford, M.D., Mark A. Christensen, M.D., Jon S. Thompson, M.D., Stephen J. Lanspa, M.D., and Thomas E. Adrian, Ph.D., F.R.C. Path. Sections of Colon and Rectal Surgery, Biomedical Sciences, and Gastroenterology, Creighton University School of Medicine; and Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska OBJECTIVES: Fast intestinal transit may be responsible for slow adaptation and unacceptable steady-state function after restorative proctocolectomy. Investigation of GI transit time may be valuable in such a setting. We hypothesized that postprandial hydrogen breath tests may yield transit data that correlate with technetium-labeled meal scintigrams. METHODS: This study compared intestinal transit after a lactulose and bean meal via the breath hydrogen and scin- tigraphy methods in 21 ileoanal pouch subjects. The meal consisted of baked beans (425 g), 30 ml (20 g) lactulose syrup, 1 mCi 99m technetium sulfur colloid in finely chopped liver and 170 ml tap water. The meal contained 120 Kcal (70% carbohydrate, 18% protein and 12% fat). RESULTS: Of 21 pouch subjects, 11 (53%) had breath tests and scintigraphy transit studies that differed by 5–21 min. Three of 21 (14%) scintigraphy mouth to pouch transit times were faster than breath test transits by 43–107 min. Seven of 21 (33%) subjects did not have breath test peaks 10 ppm. Mouth to pouch transit for breath hydrogen (104  16 min) and scintigraphy (98  7 min) tests had significant corre- lation (r = 0.96, p  0.0001) among subjects with alveolar hydrogen peaks and accurate scintigrams (n = 11). Scinti- grams were five times more expensive than breath tests. CONCLUSIONS: A peaking hydrogen breath test provides an alternative to scintigraphy for estimating intestinal transit after ileoanal pouch. (Am J Gastroenterol 2001;96: 1460 –1463. © 2001 by Am. Coll. of Gastroenterology) INTRODUCTION Restorative proctocolectomy with ileal pouch–anal anasto- mosis is the preferred treatment of choice for most subjects with ulcerative colitis and familial adenomatous polyposis. Published studies indicate good overall results and good quality of life without a stoma (1, 2). Functional outcome after pouch construction may be related to alterations in gastric emptying and small bowel transit, as well as pouch and sphincter function. This study tests the hypothesis that postprandial breath hydrogen measurements may correlate with meal scintigraphy in determining mouth to pouch tran- sit after ileoanal pouch construction. The clinical relevance of a reliable mouth to pouch transit time study may stem from identifying subjects with rapid transit who would benefit from pharmacologically pro- longed intestinal transit. Measures of mouth to pouch transit include the small bowel series, ingestion of radiopaque markers, meal scintigrams, and breath tests, among others (3, 4). The ideal transit study should be inexpensive, non- invasive, and acceptable to the patient. Exposure to ionizing radiation should be minimized and accurate analysis of intestinal transit attained. Santavirta (4) has shown that the lactulose hydrogen breath test produces significant alveolar hydrogen peaks in two-thirds of ileoanal pouch subjects. An alveolar hydrogen peak after ileoanal pouch is associated with overgrowth of anaerobic organisms in the pouch that ferment carbohy- drates and produce volatile fatty acids, methane, and hydro- gen (5). A study using chicken soup, lactulose, and a barium meal shows rapid intestinal transit after ileoanal pouch and questions the reliability of this technique (6). Lactulose decreases intestinal transit time, whereas beans prolong transit of the meal and provide additional carbohydrate for bacterial hydrogen production in the distal bowel (7). There- fore, combining lactulose with a bean meal can provide a test rich in nonabsorbable carbohydrates and long enough transit to study intestinal transit after restorative proctoco- lectomy (8). MATERIALS AND METHODS Subjects The study group was comprised of 21 subjects (10 women and 11 men, mean age 40 yr (range 18–64 yr) who had undergone restorative proctocolectomy with ileoanal pouch–anal anastomosis. Mean time after protecting ileos- tomy closure was 50 months (range 3– 84 months). All subjects had concomitant hydrogen breath and scintigraphy THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 96, No. 5, 2001 © 2001 by Am. Coll. of Gastroenterology ISSN 0002-9270/01/$20.00 Published by Elsevier Science Inc. PII S0002-9270(01)02362-0