Hydrogen Breath Test Interpretation Report

Report Title: [Hydrogen Breath Test Interpretation Report / Hydrogen–Methane Breath Test Interpretation Report]

Patient Name: [Full name or "Not provided"]

DOB: [MM/DD/YYYY or "Not provided"]

MRN: [Medical record number or "Not provided"]

Ordering Clinician: [Name, credentials or "Not provided"]

Order Date: [MM/DD/YYYY or "Not provided"]

Test Date: [MM/DD/YYYY or "Not provided"]

Test Start Time: [Time or "Not provided"]

Report Date: [MM/DD/YYYY or "Not provided"]

Accession/Order ID: [ID or "Not provided"]

Performing Laboratory: [Laboratory name and full address or "Not provided"]

Interpreting Clinician: [Name, credentials or "Not provided"]

Clinical Indication

Primary indication: [suspected SIBO / suspected IMO / suspected carbohydrate malabsorption (specify: lactose, fructose, other) / post-treatment reassessment]

Presenting symptoms: [Key symptoms prompting test]

Relevant risk modifiers: [Prior GI surgery, motility disorder, other predisposing factors, or "None known"]

(If clinical indication was not provided with the order, state: "Clinical indication not provided; interpretation based on gas criteria only.")

Pre-Test Preparation

• Antibiotics avoided ≥4 weeks: [Yes / No / Unknown]. (If recent use, last dose date: [Date])
• Recent bowel preparation or colonoscopy within 2 weeks: [No / Yes (date) / Unknown]
• Relevant medications held per protocol:
  • Prokinetics: [Yes / No / Unknown]
  • Laxatives: [Yes / No / Unknown]
  • Antidiarrheals: [Yes / No / Unknown]
  • Opioids: [Yes / No / Unknown]
  • Other: [Specify or "None"]
• Preparatory diet followed day prior: [Yes / No / Unknown]
• Fasting duration: [Hours or "Not provided"]
• Smoking avoided day of test: [Yes / No / Unknown]
• Oral hygiene protocol used: [Yes / No / Unknown]
• Comments on preparation deviations: [Describe any factors affecting validity, or "None"]

Test Protocol

• Substrate: [glucose / lactulose / lactose / fructose / other]
• Dose administered: [grams] at [time]
• Sampling schedule: [e.g., every 15–20 minutes from T=0 to T=180 minutes]
• Deviations/missed samples: [None / specify timepoints and reasons]
• Breath collection method: [end-expiratory (alveolar) / other]
• Analyzer: [Device/model or "Not provided"]
• Gases measured: [H₂ only / H₂ and CH₄ / H₂, CH₄, and CO₂]
• Units: ppm
• CO₂-based correction applied: [Yes / No / Unknown]

Results

Values shown are: [raw / CO₂-corrected]

(Omit CH₄ columns if methane not measured. Flag values meeting diagnostic criteria with bold or asterisk.)

Timepoint (min)	H₂ (ppm)	CH₄ (ppm)	ΔH₂ from baseline	ΔCH₄ from baseline	Notes/Symptoms	Flag
0	[Baseline H₂]	[Baseline CH₄]	0	0	[Quality check, baseline symptoms]
[Timepoint]	[H₂]	[CH₄]	[ΔH₂]	[ΔCH₄]	[Notes]	[* if criterion met]
[Additional timepoints as collected]

Summary: Baseline H₂: [ppm]; baseline CH₄: [ppm or N/A]. Peak H₂: [ppm] at T=[minutes]; peak CH₄: [ppm or N/A] at T=[minutes]. Maximum ΔH₂: [ppm] at T=[minutes]; maximum ΔCH₄: [ppm or N/A] at T=[minutes]. Trend: [e.g., steady rise, early peak, flatline, late rise].

Symptoms During Test

Assessment method: [validated questionnaire / standardized checklist / informal query / not assessed]

• [Timepoint]: [bloating / abdominal pain / cramping / nausea / diarrhea-urgency / borborygmi / other] – Severity: [none / mild / moderate / severe]
• [Additional symptom entries by timepoint]

(If symptoms were not assessed, state: "Symptoms were not assessed during the test." Note: "Intolerance" requires both gas criteria for malabsorption AND documented symptoms. If symptoms not recorded, limit conclusions to "malabsorption" only.)

Interpretation

Test Validity

Protocol completion: [completed as planned / deviations (specify)]

Baseline gases: [normal / elevated (specify values)]

Sample quality: [acceptable / concerns (specify)]

Preparation deviations: [none / specify impact on interpretation]

Overall validity: [valid / limited validity (explain) / invalid]

Criteria Applied

• SIBO (hydrogen-predominant): [rise ≥20 ppm above baseline by ≤90 minutes / lab-specific threshold and time window]
• Methane positivity (IMO): [CH₄ ≥10 ppm at any timepoint / lab-specific threshold]
• Carbohydrate malabsorption: [H₂ rise ≥20 ppm above baseline / lab-specific threshold]
• Combined gas criteria (if used): [H₂+CH₄ thresholds per laboratory protocol]

Findings

SIBO Assessment: [Positive / Negative / Indeterminate]. Supporting data: [Timepoint(s) and H₂ values meeting criterion, or rationale for negative/indeterminate].

Methane/IMO Assessment: Baseline CH₄: [ppm]. Status: [Positive / Negative / Indeterminate / Not measured]. Supporting data: [Timepoint(s) and CH₄ values, or rationale]. (Note: Methane is produced by intestinal methanogens, not bacteria.)

Carbohydrate Malabsorption/Intolerance: (Include if carbohydrate substrate used.) Classification: [malabsorption with symptoms (intolerance) / malabsorption only / symptoms only (no gas criteria met) / neither]. Gas criteria: [met / not met]. Symptom correlation: [present / absent / not assessed].

Limitations

• [Preparation deviations affecting interpretation]
• [Medications affecting transit or gas production]
• [Elevated baseline gases]
• [Flatline/non-producer pattern]
• [Missing or invalid samples]
• [Rapid transit concerns (particularly with lactulose)]
• [Other limitations]

(Omit items that do not apply.)

Impression

[One to two sentence summary of overall interpretation, incorporating key findings and confidence level given validity and limitations.]

Recommendations

• (If SIBO positive) Consider evaluation for predisposing factors and guideline-concordant therapy.
• (If methane/IMO positive) Consider constipation-directed management and methane-targeted therapy.
• (If carbohydrate malabsorption/intolerance) Consider dietary modification and/or dietitian referral.
• (If indeterminate or limited validity) Consider repeat testing under optimized preparation or alternate diagnostic strategy.

(Include only recommendations relevant to findings. Avoid specifying drug regimens unless laboratory policy explicitly permits.)

Authentication

Interpreting Clinician: [Name, credentials]

Specialty/Role: [e.g., Gastroenterology, Clinical Pathology, Laboratory Medicine]

Electronic Signature: [Signed electronically by Name, credentials]

Date/Time of Interpretation: [MM/DD/YYYY, HH:MM]

Corrected Report

(Include this section only if issuing a corrected report.)

• Label: Corrected Report
• Changes made: [Describe what was changed; preserve original values in audit trail]
• Reason for correction: [Reason]
• Correction date/time: [MM/DD/YYYY, HH:MM]