61 What is now needed are studies addressing the pathogenesis of SIBO that is found in a proportion of patients with IBS, clinical parameters that predict its occurrence and efficacy of treatment of SIBO in relieving symptoms or curing IBS. We believe that the Western criteria of the peak in breath hydrogen value of 20 ppm above basal within 90 min of ingestion of Maraviroc nmr lactulose during lactulose HBT for diagnosis

of SIBO in Asia is inappropriate; available data from the region show that mouth-to-cecum transit time is often shorter than 90-min. Glucose hydrogen breath test with estimation of methane may be used instead. Post-infective malabsorption syndrome should be excluded by appropriate investigations before a diagnosis of PI-IBS is made, because symptom-based criteria may be fallacious in such situations. Particular attention should be given to diagnose malabsorption syndrome and SIBO in patients with diarrhea-predominant IBS in Asia. Studies from non-Asian countries showed that Giardia lamblia infection could lead to development

of functional bowel disease, including IBS.62 In a study from Norway, structured interview and questionnaires given 12–30 months after the onset of Giardia infection revealed that 66 of 82 (81%) patients had symptoms of IBS according to Rome II criteria.62 Diarrhea-predominant IBS was the commonest subtype (47%).62 A few other studies from non-Asian countries showed similar findings.63–65 In a study from Thailand, HIF inhibitor however, the frequency of detection of parasites among 59 patients with IBS diagnosed by Rome II criteria was comparable with the frequency among the control group.66 However, this study had a case-control design with a small sample size, which might have resulted in type II statistical error. In general, persistent infection with

Giardia is expected to cause chronic diarrhea, irregular bowel movement and abdominal discomfort, which may be diagnosed as IBS by a symptom-based criterion. However, there are scanty data from Asian countries where this infection is expected to be more common. For example, a study on 78 members from 15 families from rural India revealed that all except two (97%) MG-132 in vitro shed parasites in the stool as detected by microscopy on alternate days for one month, and 42 (54%) showed Giardia.67 Hence, more studies evaluating the role of Giardia lamblia in Asia are needed. Association of Giardia infection and IBS would be of importance even in non-Asian countries due to the high frequency of giardiasis (5.3 of 100 000) in travelers returning from endemic areas.68 Highest frequencies have been noted among travelers returning from the Indian Subcontinent (628 of 100 000), East Africa (358 of 100 000), and West Africa (169 of 100 000).