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Background Hydrogen and methane breath tests (HMBT) are widely used clinical investigations but lack standardization. To address this, the North American Consensus (NAC) group published evidence-based recommendations for HMBT. Aims To evaluate results obtained using NAC recommendations for HMBT, compared to retrospective data that utilized guidelines previously recommended. Methods HMBT data from 725 patients referred for small intestinal bacterial overgrowth (SIBO) and/or carbohydrate malabsorption (CM) testing were analyzed. Data were compared regarding dose of substrate for SIBO testing (16 vs. 10 g lactulose, and 50 vs. 75 g glucose) and the effect of post-ingestion sampling period for malabsorption testing. The effect of different recommended cut-off values for SIBO were examined. Results Substrate dose did not affect methane production. 10 g lactulose significantly reduced positive SIBO results compared to 16 g lactulose (42 vs. 53%, p = 0.04). 75 g glucose significantly increased positive results compared to 50 g glucose (36 vs. 22%, p = 0.04). Provoked symptoms were significantly more prevalent in patients testing positive by both North American Consensus and Ledochowski cut-off values. 34.5% of patients tested positive for CM at 180-min compared to 28% at 120-min (not significant, p = 0.19). Conclusions and Inferences 10 g lactulose substrate produces fewer positive SIBO results than 16 g lactulose, while 75 g glucose dose produces more positive SIBO results than 50 g. Performing CM breath tests for 180 min increases number of positive results when compared to 120 min. SIBO cut-off timings require further investigation, but our findings broadly support the NAC recommendations for SIBO and CM testing.

Table 1 Diagnostic colonoscopy histopathological and endoscopic characteristics in missed CRC cohort Anatomical site in colorectum (% total) Sigmoid 3 (25%) Splenic flexure 1 (8.33%) Transverse 3 (25%) Hepatic flexure 2 (16.67%) Ascending 2 (16.67%) Caecum 1 (8.33%) Dysplasia (% total) Low grade 11 (91.67%) High grade 1 (8.33%

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endotherapy (median 2.5 treatments; range 2-12); mean SS was 1.0 at latest follow-up.Per-procedure, mean reduction in SS was 0.8 points (p<0.01) with overall positive response rate of 67%. By symptom, vomiting was most responsive to endotherapy (86% pre v 32% post). By treatment type, Botox alone (n!66) had the highest overall response (78%) compared to EBD (38%, p!0.02) or combination therapy (66%, p!0.3). Response to Botox was greater in patients under 40 (83% v 61%, p!0.04) and females (81% v 33%, p!0.002). By indication, diabetic GP(n!17) were most likely to respond (76%).Sub-group analysis showed procedures for gastroparesis (diabetic/idiopathic, n!75) responded significantly more to Botox (mean SS reduction 1, p<0.01) than EBD (mean SS reduction 0.2, p>0.1) or combination therapy (mean SS reduction 0.44, p!0.12). Procedures for gastric transposition (n!42) showed significant SS reduction post combination therapy (2.1 v 1.2, p!0.01) but not post EBD (1.9 v 1.6, p>0.1) or Botox (1.7 v 1.1, p!0.08). Conclusions Endotherapy is a safe and effective treatment for refractory gastroparesis. We found Botox monotherapy significantly improved symptoms in diabetic or idiopathic gastroparesis, especially younger females; conversely, combination therapy was preferable for delayed gastric emptying post gastric transposition. Careful patient selection may augment therapeutic response.