Development and Validation of Test for “Leaky Gut” Small Intestinal and Colonic Permeability Using Sugars in Healthy Adults

Background: Oral monosaccharides and disaccharides are used to measure in vivo human gut permeability through urinary excretion. Aims: The aims were as follows: (1) to obtain normative data on small intestinal and colonic permeability; (2) to assess variance on standard 16 g fiber diet performed twice; (3) to determine whether dietary fiber influences gut permeability measurements; and (4) to present pilot data using 2 selected probes in patients with diarrhea-predominant irritable bowel syndrome (IBS-D). Methods: Sixty healthy female and male adults, age 18–70 years, participated in 3 randomized studies (2 studies on 16.25 g and 1 study on 32.5 g fiber) in otherwise standardized diets. At each test, the following sugars were ingested: ¹²C-mannitol, ¹³C-mannitol, rhamnose (monosaccharides), sucralose, and lactulose (disaccharides). Standardized meals were administered from 24 hours before and during 24 hours post-sugars with 3 urine collections: 0–2, 2–8, and 8–24 hours. Sugars were measured using high-performance liquid chromatography–tandem mass spectrometry. Eighteen patients with IBS-D underwent 24-hour excretion studies after oral ¹³C-mannitol and lactulose. Results: Baseline sugars (>3-fold above lower limits of quantitation) were identified in the 3 studies: ¹²C-mannitol in all participants; sucralose in 4–8, and rhamnose in 1–3. Median excretions/24 h (percentage of administered dose) for ¹³C-mannitol, rhamnose, lactulose, and sucralose were ∼30%, ∼15%, 0.32%, and 2.3%, respectively. ¹³C-mannitol and rhamnose reflected mainly small intestinal permeability. Intraindividual saccharide excretions were consistent, with minor differences with 16.25 g vs 32.5 g fiber diets. Median interindividual coefficient of variation was 76.5% (10–90 percentile: 34.6–111.0). There were no significant effects of sex, age, or body mass index on permeability measurements in health. ¹³C-mannitol measurements are feasible in IBS-D. Conclusions: Baseline ¹²C-mannitol excretion precludes its use; ¹³C-mannitol is the preferred probe for small intestinal permeability.