# Consult Your Pharmacist -Excessive Gas: What Can Be Done?



## eric (Jul 8, 1999)

W. Stephen Pray, PhD, RPh, Southwestern Oklahoma StateUniversity, Weatherford, Okla.[U.S. Pharmacist 23(6), 1998. ï¿½ 1998 Jobson PublishingCorp.]IntroductionPharmacists can help patients determine whether theirflatulence is within normal limits and make referrals ifsymptoms indicate a more serious problem.Perhaps the most frequent gastrointestinal complaint, intestinalgas is one of the more embarrassing symptoms for whichpatients seek assistance.[1] While passing gas is normal,patients often have several concerns. Some are fearful of passing gas with others present. Othersexperience discomfort due to excessive gas or passage of gas.Still others fear that gas denotes some dangerous underlyingdisease, such as cancer.[2] The pharmacist can tactfully provideinformation to allay the patients' fears and to help them reducethe quantity of gas they produce.What Is Flatulence?How does the patient concerned about flatulence gauge whetherhis or her intestinal gas is excessive? In one study of healthysubjects aged 21-59, diaries revealed that gas was excreted anaverage of 10 times daily (although other authorities quote afigure of 14 per day).[3,4] The volume of gas passed per episoderanges from 33-125 mL. More than 10 passages of gas dailycould be considered excessive. Males and females do notdiffer in this respect, so this figure is valid regardless ofgender. Approximately 20% of patients aged 65-93 experienceabdominal distention,[2] often due to gaseous buildup. Somepatients complain of excessive gaseousness when the volumethey produce is within normal limits. In these cases, the patientmay be more acutely sensitive to passage of gas through the GItract. Unless swallowed air is expelled by belching, it will beeliminated as intestinal gas.Etiology of Excessive GasIntestinal gas originates from several sources.Dietary FactorsA major source of gas is ingestion of complex carbohydrates(e.g., raffinose, stachyose, verbascose) that cannot be brokendown into component sugars for absorption.[5] Theseundigestible carbohydrates then serve as substrates forbacterial fermentation, yielding gas as a by-product. Thepatient teaching aid information page describes specific foodsthat tend to cause gas, since diet can be manipulated by thepatient. However, a few additional dietary points deserveconsideration. Sugar-free foods often contain sorbitol orfructose, which are both poorly absorbed in the small intestine.This poor absorption leads to gas.[2] Sorbitol is one of thehexitol sugar alcohols, frequently implicated in the conditionknown as "chewing gum diarrhea" or "dietetic food diarrhea."[6]Thus, the patient who chews sugar-free gum to control cariesand the diabetic patient who utilizes dietetic foods to controlweight are at high risk of flatulence and diarrhea. Reducingintake of sugar-free foods may help prevent gaseousness.Air SwallowingAtmospheric air consists mainly of oxygen and nitrogen in a20:80 ratio. Some patients swallow excessive atmospheric airfor a variety of reasons. Unless this air is expelled by belching,it will be eliminated as intestinal gas. The person who eatslying down not only swallows more air but cannot belch it backout. This is because the position of the esophagus, which entersthe stomach at the back and top, does not allow air to exit in thereclining patient.[5]Sodium Bicarbonate Sodium bicarbonate is not a good choice as an antacid forseveral reasons (e.g., systemic alkalization, the milk-alkalisyndrome, short duration of action). It also produces gas whileneutralizing stomach acids. As little as a half teaspoon ofsodium bicarbonate liberates as much as 475 mL of carbondioxide.[2] Therefore, pharmacists should advise against sodiumbicarbonate use as an antacid.Lactase Deficiency When a patient lacks intestinal lactase, undigested lactosepasses into the colon, where bacterial fermentation occurs.Several troubling symptoms result, one of which is excessflatulence.[7] Lactase deficiency might be suspected whenflatulence is accompanied by diarrhea, stomach rumbling,abdominal pain, and abdominal bloating, all occurring withinseveral hours after lactose ingestion. Three approaches may betried to reduce the symptoms of lactose intolerance. In one,patients reduce the amount of lactose ingested until symptomsno longer occur. This may mean a drastic reduction in theamount of milk and dairy products patients ingest. In the secondapproach, patients ingest exogenous lactase (e.g., Lactaid,Dairy Ease) in the form of tablets or capsules at the same timethat lactose is taken in, allowing breakdown of lactose tooccur. Finally, patients may add lactase drops to milk and wait24 hours before drinking it. During this time, lactosebreakdown will occur. If these simple measures fail to resolvethe problem, the patient should visit a physician.Irritable Bowel Syndrome Some patients who complain of excessive gas actually have anormal amount of gas but experience a bloated feeling. Bloatingwithout excessive gas is often indicative of irritable bowelsyndrome, a motility disorder associated with abdominal pain,constipation or diarrhea. In this case, the patient should see aphysician.[8]Gallbladder Involvement A well-known gallbladder complaint is known as flatulentdyspepsia.[9,10] The patient with flatulent dyspepsia belchesrepeatedly; eats a normal-sized meal but feels stuffed; may notbe able to finish a normal meal; complains of abdominaldistention so severe that clothes must be loosened; andexperiences upper abdominal burning, nausea, vomiting orgastroesophageal reflux. If flatulent dyspepsia is suspected, thepatient should be referred -- a cholecystectomy may benecessary.The Composition of Intestinal GasThe primary components of intestinal gas are carbon dioxide,methane, nitrogen, oxygen and hydrogen.[2] Nitrogen and oxygencome from swallowed air, and hydrogen and carbon dioxideare by-products of bacterial fermentation. Methane is producedby certain methanogenic bacteria.[11] These gases are odorless.It is the trace gases (in concentrations as low as one part permillion) that produce the odor of intestinal gas. These tracegases include sulfur-containing compounds such asmethanethiol, dimethylsulfide, and hydrogen sulfide.[12]Hydrogen sulfide is produced by sulfate-reducing bacteria.The Flatus DiaryPatients may not be able to relate episodes of excess flatulenceto any particular dietary factor at first. Alternatively, the patientmay harbor unfounded suspicions about certain foods. Muchuncertainty can be eased if patients keep a flatus diary. In itthey should record foods eaten, drinks ingested and times ofeach flatulence episode. In this way, the diary helps identifywhich foods are causing excess gas.continued...


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## eric (Jul 8, 1999)

The Role of SimethiconeSimethicone is a defrothicant used in manufacturing toeliminate bubbling in processes that involve liquid movements.It is also used in certain medical procedures such asendoscopy, during which air is inadvertently infused into thegastrointestinal tract. When this air mixes with biliarysecretions, a froth that obscures the endoscopist's vision isgenerated.[2] For many years, this problem has been preventedby placing simethicone on the surface of the endoscope prior toinsertion.Simethicone is also useful in reducing frothing in the lumen ofthe gastrointestinal tract. This effect does not reduce the actualamount of gas in the intestinal lumen. In fact, in some studies,simethicone does not exhibit any beneficial effect on symptomsof intestinal gas.[13] However, the product was rated as safe andeffective by the FDA as a treatment for excess gas. There areseveral possible reasons why it may help some patients.Passage of gas through the bowel lumen may be facilitated byuse of simethicone. Simethicone may also allow patients toexcrete a greater volume of gas at one time, thereby reducingthe number of flatus events. Thus, less residual gas is present tocause uncomfortable cramping.The Role of Alpha-GalactosidaseAlpha-galactosidase is an enzyme derived from Aspergillusniger. This enzyme breaks down oligosaccharide linkages,which humans cannot digest.[14] It allows patients to absorbsingle component sugar residues. In one study, volunteers weregiven two meals of meatless chili composed of several types ofbeans, cabbage, cauliflower and onions.[14] They were alsogiven either a placebo or the commercially availablealpha-galactosidase product known as Beano. Beano reducedthe number of flatulence events at all times except for 2 hourspost-ingestion. The effect was most pronounced at 5 hours afterthe meal.To use Beano solution, patients place approximately 5 drops onthe first bite of food. However, if the patient still experiencesflatulence, the amount can be adjusted upward until an effectivedose is reached. The patient may also swallow or chew 2-3Beano tablets with the first bite of food or crumble them ontothe first bite. That number of tablets usually controls gasassociated with the ingestion of 0.5-1 cup of food. More tabletscan be used for larger servings.Patients cannot cook with Beano because the heat inducesenzyme degradation. Patients who are allergic to molds shouldnot use the product. Patients with galactosemia should consult aphysician before using Beano because enzymatic degradation ofoligosaccharides produces galactose.The Addition DietThe patient whose flatulence responds poorly to other measuresmay be placed on an addition diet.[2] The patient eliminates allfoods except those known not to produce symptoms. Thesefoods are ingested for several days to ensure that symptoms areabsent (a state known as "normoflatulence"). Then, one newfood is added each 48 hours. With the help of the flatus diary,each new food is rated as to its propensity to cause gas. Once atroublesome food is identified, it is eliminated from the diet forthe duration of the addition diet. The diet is continued until allsuspected foods have been tried. The patient then has a list offoods to avoid or moderate intake.Bowel ObsessionsOccasionally patients develop an unhealthy fear of flatulenceand its social consequences. In one case, a 35-year-old manhad never actually been flatulent around people but becamepreoccupied with fear that such an episode might occur.[15] Forthe next 35 years, he gave up a highly successful businesscareer and engaged in extreme social withdrawal. Hispsychiatrist classified his bowel obsession as a social phobia.Administration of nortriptyline produced marked improvementin the patient. In a second case, a 28-year-old male becamepreoccupied with purity of foods and flatulence, starting hisown diet regimen. The patient once broke his hand hitting awall in response to his fear of losing control over flatulence.[16]His symptoms improved remarkably when he was givenfluoxetine. The drug caused a remission of symptoms thatallowed the patient to work full-time.------------------ http://www.ibshealth.com/


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## JeanG (Oct 20, 1999)

Excellent articles, Eric. Thanks for posting them.







JeanG[This message has been edited by JeanG (edited 08-24-2000).]


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## Ashwoman (Jun 18, 2000)

How fascinating! Thanks for the information.


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## kitty2 (Nov 27, 1999)

Thanks for the great info Eric!


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## kitty2 (Nov 27, 1999)

I noticed in one of the articles Eric posted that a patient with excess flatulence was given fluoxetine. Anyone know what type of drug that is?


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