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FLATULENCE

Editors note: This remarkable literary masterpiece is reproduced from a pamphlet found in the Das Island Clinic, Abu Dhabi, UAE 2005

Flatulence is the state of having excessive stomach or intestinal gas. This can result in uncomfortable feelings of bloating, as well as increased belching or passing of gas from the rectum.

Flatulence itself, although not life threatening, can definitely cause social embarrassment. This embarrassment is often the reason why people seek medical help for excessive gas.

History has numerous anecdotal accounts of flatulence, including Hippocratic himself professing, "Passing gas is necessary to well-being." The Roman Emperor Claudius equally decreed that "all Roman citizens shall be allowed to pass gas whenever necessary." Unfortunately for flatulent Romans, however, Emperor Constantine later reversed this decision in a 315 BC edict. In the mid-1800s flatulence took center stage with the French entertainer Joseph Pugol ("Le Petomane"). Pugol was able to pass gas at will and at varying pitch, thereby playing tunes for sold-out shows at the Moulin Rouge. Such was his success that lesser competitors began to appear, including the Spaniard "El-Rey" and the female Angele Thiebeau (later revealed as a fake using hidden air bellows). More recently, flatulence was immortalized by Mel Brooks in Blazing Saddles with his bean-eating cowboys.

Nonetheless, if you are concerned about excess gas, it is not a laughing matter. lt is a medical concern that you will want to talk about with your doctor.

  • The primary components of gas (known as flatus, pronounced FLAY-tuss) are 5 odorless gases: nitrogen, hydrogen, carbon dioxide, methane, and oxygen.
  • The characteristic odor is attributed to trace gases such as skatole, indole, and sulfur-containing compounds.
  • The flammable character of flatus is caused by hydrogen and methane.
  • The proportions of these gases depend largely on the bacteria that live in the human colon that digest, or ferment, food that has not been absorbed by the gastrointestinal (GI) tract before reaching the colon.
  • An estimated 30-150 grams of this undigested food reach the colon in the form of carbohydrate every day. But this amount can vary with diet and how well your GI tract is functioning.
    • The presence of methane is only noted in about 40% of the population, caused by the existence of specific methane-producing bacteria in these colons.
    • The unpleasant odor often associated with flatus is generally attributed to trace sulfur-containing compounds, produced only by particular bacteria not found in everyone.

CAUSES
The sensation of being flatulent can be caused by an actual increase in intestinal gas but has also been recorded in people with normal amounts of intestinal gas.

  • These people are thought to have increased sensitivity to intestinal bloating or an increased awareness of gas passing.
  • So the first step in dealing with flatulence is to determine if you actually are overly flatulent.
  • This can be assisted if you keep a diary, noting when each passage occurs, as well as relation to time and the content of your meals.

Limited studies are available on the passage of gas, likely because of social stigma and the difficulty measuring gas passage, but the studies that exist have found the following:

  • An average of 150 ml of gas is in the human GI tract at any one time, mainly in the stomach and colon.
  • The normal amount of flatus generated has been estimated to be between 400-2400 ml.
  • Flatus occurs in a daily average of 10 events of up to 125 ml each, but varying widely with each person (upper limit of normal considered to be 20-25 events).

Flatus passage in excess of these values could be considered abnormal and is largely due to one of 2 factors, increased intake of gas or increased production of gas within the GI tract.

You can have an increase in the intake of gas into the GI tract by swallowing air (aerophagia).

  • This can occur with improper swallowing while eating or even unconscious swallowing of air out of habit.
  • Activities that increase aerophagia include rapid drinking, chewing gum, use of tobacco products, sucking on hard candy, drinking carbonated beverages, and hyperventilation in anxious people.
  • Analysis of flatus can help determine if the gas originated from aerophagia (predominantly nitrogen) or Gi production (mainly carbon monoxide, hydrogen, and methane).

The most common cause of flatulence is the excess production of gas by bacteria in the colon.

  • Any condition that increases the delivery of food to these bacteria will increase flatulence.
  • Certain foods contain carbohydrates that aren't absorbed well by the human G1 tract.
  • Foods that can create gas:
    Broccoli, Cabbage, Brussels sprouts, Beans, Cauliflower, Onions, Prunes, Dark beer, Red wine, Sorbitol (a sweetener in sugar-free gum, candy, and other diet products) & Fructose (found in fruits and honey, and soft drinks).
  • Another major source of flatulence is lactase deficiency, which results in a decreased ability to digest lactose, a sugar found in milk and other dairy products. This flatulence is often associated with diarrhea and cramping but can appear as only gas.

Certain conditions can result in other foods being poorly absorbed in the GI tract, allowing for increased bacterial activity.

  • These malabsorption syndromes can be the result of the following:
    • Decreased production of enzymes by the pancreas.
    • Dysfunction of the gallbladder.
    • Dysfunction of the lining of the intestines.

If transit through the colon is slowed down for any reason, bacteria have increased opportunity to ferment remaining material.

  • Therefore, if you are constipated or have decreased bowel function for any reason, flatulence can follow.
  • Alterations in bowel habits can be a result of the following:
    • Poor dietary fiber.
    • Parasites
    • Inflammatory bowel disease.
    • Intestinal obstruction (including cancer).
    • Diverticulosis or diverticulitis.
    • Poor thyroid function.
    • Narcotic and other drug use.

SIGNS AND SYMPTOMS

  • Symptoms are of course increased passage of gas.
  • Embarrassment can be caused by the increased passage of flatus or the often offensive odor it causes.
  • Unfortunately, it is not always easy to determine the cause of flatulence, and medical remedies often have only limited success.

HOME CARE
Because this problem is most often related to diet, and sometimes to those habits that cause aerophagia, you can begin by trying to remove offending agents from your diet.

  • This may take some careful observation to notice what foods cause increased gas.
  • If lactose intolerance is suspected, all dairy should be removed from the diet for 10-14 days to assess the effect on flatulence (using a diary).
  • Any of the gas-producing foods can also be removed in the same manner until a resolution of symptoms is found. Sorbitol and fructose are common offenders.
  • If this method does not work, a more restrictive approach is to start with a very limited number of safe foods, and add one new food every 48 hours in order to determine what food or food group causes difficulty.

If the offending agent is found, then that food can be avoided.

If you do not desire to avoid the food, some over-the-counter supplements could help.

  • Lactase supplements, some of which are added to milk, can help lactose intolerance.
  • Beano is an enzyme supplement that may be useful with bean ingestion (but has mixed reviews for other foods).
  • Simethicone and charcoal can be taken before meals, although the effectiveness of these treatments is debatable.
  • If odor is a concern, there is also some reported success with charcoal filter undergarments.
  • Avoid overeating because this contributes to flatulence as well as obesity.

WHEN TO CALL THE DOCTOR
Cramp discomfort.
Change in bowel habits.

  • Diarrhea
  • Constipation.
  • Blood in the stool.

Fever
Nausea
Vomiting
Abdominal pain and distention

PHYSICIAN DIAGNOSIS
The diagnosis of the cause of simple gas is often found by trying food elimination at home.

  • If you see a doctor, the primary tests will likely include measuring the amount of hydrogen in your breath following eating suspected foods.
    • Because bacteria are largely responsible for the production of hydrogen, an increase in exhaled hydrogen as measured by the breath test will suggest a food intolerance, with the bacteria fermenting the undigested food to produce excess gas.
    • After you eat a problem food, breath testing should show an increase in hydrogen in as little as 2 hours.
    • Another possible test is analysis of flatus for gas content. This should help differentiate gas produced by swallowing air from gas produced in the GI tract.

If these tests produce no answers, more broad testing can be accomplished to help exclude diabetes, malignancy, malabsorption, cirrhosis of the liver, poor thyroid function, and infection.

If people complain of abdominal pain or appear distended, x-rays can help show intentional obstruction or perforation.

X-rays can also be taken after drinking x-ray dye to show the GI tract, which can be followed up with an internal view of the colon through colonscopy, if problems are noted.

PHYSICIAN TREATMENT
The goal of treatment is to reduce gas and odor.

  • Medical intervention includes treatment with antibiotics if bacterial overgrown of the Gi tract is suspected or evidence of parasitic infection is seen.
  • Some promising studies have investigated feeding non offensive strains of bacteria to push out the bacteria that are offensive, although no established treatments are available at this time.
  • Regulation of bowel function is essential. Constipation should be treated with increased dietary fiber or certain laxatives.
  • Some medicines such as metoclopramide (Clopra) have also been shown to decrease gas complaints by increasing gut activity.
  • In cases where aerophagia results from an anxious state, psychotherapy can be helpful in changing habit patterns and relieving gaseous trouble.

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  • Posted 03Nov05