PROF MOHAMMAD SULTAN KHUROO
I am often greeted in practice and social functions by many with their hands on their tummy and confronted with one or more of such questions and asked for their remedy which includes: “Doctor, I have too much gas in my abdomen”; “1 suffer from a belching problem”; “I pass excess gas and it limits me to attend social functions”; “I have a problem in keeping Wadoo hindering prayers”; “I pass foul smelling gas and it makes me feel embarrassed at home”; “I suffer from abdominal bloating and discomfort”; “My partner complains of bad breath from my mouth”; and “Doctor, I suffer from Irritable Bowel Syndrome (IBS)”.
Gas is a psychological embarrassment.
Gas is one of the commonest human problems. Gas problem is more a social nuisance and psychological embarrassment than a health hazard.
Gas in many has caused broken marriages; many have never attended a social function and in many gases cause a major psychological breakdown. Many wish to enjoy a good feast meal and have never tasted it.
Why is abdominal gas such an intractable problem in the community and why cannot we get rid of the gas in those who suffer from it? To answer this, we need a detailed discussion on the formation of intestinal gas and the way it causes suffering in those who have it.
Gas is a normal constituent of the bowel in every person.
Gas is a normal constituent of the intestines in every person. An estimated 200 ml of gas is present in every healthy person’s intestine.
All of us pass gas per anus (flatus) between 10 to 20 times per day and the amount passed per anus per day ranges from 500 to 1500 ml (average 700 ml).
Five gases namely nitrogen (N2), oxygen (O2), carbon dioxide (CO2), hydrogen (H2) & methane (CH4) are the main constituents in normal persons and are in varied proportions.
What are the sources of intestinal gas?
Broadly there are 5 sources of intestinal gas, which include: (i). air swallowing, (ii). CO2 in the upper intestines from the interaction of bicarbonate and acid, (iii). H2 by intestinal bacteria during fermentation of carbohydrates or protein, (iv) formation of CH4 by a common bacteria in the colon namely Methanobrevibacter smithii, CH4 is formed by combining 4 molecules of H2 and one molecule of CO2 (4H2+CO2 → CH4+2HO2), (v). formation of odoriferous (foulsmelling) gases by bacterial fermentation of sulfate, cysteine, and mucin (namely hydrogen sulfide); methane (namely methanethiol); and garlic (namely allyl methyl sulfide). H2 & CH4 always diffuse from the intestines into the blood and these gases reach the lungs and then are excreted out through breath. In contrast, N2 diffuses from the blood into the intestines. Thus, the major source of N2 in the flatus may be the diffusion of the gas from blood to the intestinal lumen. Secondly, the rate of propulsion and passage of gases out of the intestines is a crucial determinant of the amount of gas staying in the abdomen.
What are the problems causes by excessive gas?
Broadly gas causes five problems namely (1). Belching, (2). Bad Breath (Halitosis), (3). Abdominal Bloating (Flatulence), (iv). Passage of noisy voluminous gases per anus (Flatus), and (v). Passage of odoriferous gases per anus.
What is the cause of belching?
A single belch (in Kashmiri vernacular called “dakkur”) is a common phenomenon after a meal or drink. In many, this satisfies the person who has had a full meal. However, those who repeatedly eructate, or belch find themselves in big trouble. Belching often causes noise and it causes social embarrassment in the family or at social functions. Others are convinced that belching is a sign of internal disease namely ailment of the stomach, liver, or intestines. Belching is an expulsion of gas which you swallow (aerophagia). People who eructate/belch too much, have a habit of swallowing too much gas which reaches the throat and upper food pipe. This gas which is eructated does not reach the stomach. It is not caused by excess gas production inside the bowel. Nearly always belching is not a symptom of an internal disease but a functional disorder in which the person swallows excess gas and simultaneously belches it out. These people with noisy belching need an explanation and genesis of their symptoms and should be counseled for reducing aerophagia (swallowing gas). Maneuvers that reduce aerophagia include chewing food (rather than gulping it), eating and drinking slowly, avoiding chewing gums, and clenching a pencil between teeth whenever possible (which inhibits swallowing). With all this advice given, belching can be intractable problem in some and need specialized counseling and treatment.
Bad Breath (Halitosis).
Bad breath can be normal in the early morning (morning mouth) and is due to changes in our mouth while we are sleeping. It is more common in those who breathe through the mouth (mouth breathers). After a morning mouthwash and brush this odour in the breath disappears and causes no problems. However, bad breath which persists most of the day is a major social embarrassment for those who suffer from it. It can be a big problem for those colleagues who work with such people. Persons who emit bad breath do not smell the bad odour as odourdetecting cells in the nose of such persons eventually get used to the smell. I have seen many marriages broken due to bad breath. Many people become psychologically depressed because they suffer from bad breath or have a partner or colleague with bad breath. Some people are afraid to be engaged or married for fear of bad breath.
What are the causes of bad breath?
The commonest cause of bad breath is poor oral hygiene because millions of bacteria are formed in the back of the tongue or within the gums. These bacteria cause the fermentation of residual food in the mouth and produce bad breath. This is a difficult problem to treat and needs intensive mouth hygiene and toilet including a visit to a dentist You also can combat bad breath by drinking plenty of water every day; an occasional swish of the mouth with water; sugar-free gum, sugarless breath mints, raw carrots, and celery. Other causes of bad breath include constant nasal discharge, sinus infections, and recurrent chest infections especially because of bronchiectasis and in people who eat too much garlic, onions, and coffee or chew tobacco or smoke. Diabetes (fruity breath), gastroesophageal reflux disease, gastroparesis, gastric stasis, liver disease, and kidney disease (urine smell) can also cause bad breath and it is worthwhile seeing a physician to explore these conditions if one is suffering from bad breath.
Bloating is a common complaint in the community.
Bloating has several causes which include excess fat in the abdomen (fatty liver), excess water (ascites), or enlargement of any organs in the abdomen (like spleen enlargement or tumor, etc). However, the commonest cause of bloating is related to either excess gas in the abdomen (flatulence) or irritable bowel syndrome. In the later condition, the bowel is unusually sensitive to distention and even normal gas contents can lead to distension and bloating. Bloating either caused by excess gas or IBS can be a major problem for many people.
What causes excess intestinal gas and what remedies can be offered?
Excess gas is multifactorial. So, persons with flatulence must find the exact cause of excess gas production. This is effectively done by a questionnaire on those people who suffer and by a test called the “Hydrogen Breath Test”. The causes of excess gas can be classified as follows:
Excess gas swallowing. Such persons have nervous personalities, and the gas becomes worse whenever such persons have some form of tension or problem in their day-to-day life.
Selective intestinal enzyme lactase deficiency. Lactase deficiency causes maldigestion of lactose. Lactose is present in large quantities in milk and such persons are milk intolerant. In fact, in Kashmir, about one-fourth of the population is lactase deficient and milk intolerant. One glass of milk sends these persons to the toilet with watery acidic stools and a lot of passage of gas. Treatment is to limit or avoid milk. Some people find yogurt, in which the lactose has been broken down partially by bacteria, produces less gas than milk. In difficult cases, enzymes that are like intestinal lactase can be added to the milk to break down the lactose before its ingestion so that it can be absorbed normally.
Generalized intestinal enzymes (disaccharidases) deficiencies. The items in foods (carbohydrates) which can be maldigested include Lactose in milk; Fructose is present in onions, artichokes, pears, wheat, soft drinks, and processed foods; Sorbitol is present in apples, pears, peaches, prunes, and some sugar-free foods, candies, and chewing gum and Raffinose is found in beans, cabbage, brussels sprouts, broccoli, asparagus, and whole grains. Reducing the intake of these vegetables and fruits, as well as foods made from whole grains, should reduce gas and flatulence. However, the list of gas-producing foods is rather long, and it may be difficult to eliminate them all without severely restricting the diet. An interesting form of treatment for excessive gas is alphaD-galactosidase, an enzyme that is produced by a mold. Two other types of treatment have been promoted for the treatment of gas simethicone and activated charcoal.
Abnormal bacterial flora. Such people have an imbalance in gas-producing and gas-consuming bacteria. In such persons, the normally ingested food items are changed into hydrogen and carbon dioxide, and organic acids in the colon. Several food items (barring rice) namely wheat, potatoes, corn, noodles, and dietary fiber tend to produce gas in such people. Bacterial overgrowth of the small bowel is usually treated with antibiotics. If antibiotics are not effective, probiotics (e.g., lactobacillus) can be tried although their use in bacterial overgrowth has not been well studied. This condition may be difficult to treat. Organic disorders of the gut. When maldigestion is due to pancreatic insufficiency, then supplemental pancreatic enzymes can be ingested with meals to replace the missing enzymes. If maldigestion and/or malabsorption is caused by a disease of the intestinal lining, the specific disease must be identified, most commonly through a small bowel biopsy. Then, treatment can be targeted for that condition. For example, if celiac disease is found on the biopsy, a glutenfree diet can be started.
Passage of Voluminous gas (Flatus).
Passage of noisy voluminous gas (flatus) per anus: Passage of voluminous gas per anus (flatus) is a common problem and a source of major social embarrassment. Many people are frustrated as they cannot maintain “Wadoo” either during a prayer especially on Friday or during Ramadhan prayer or Haj prayers. It also limits attendance to social functions and makes the person uncomfortable when he passes noisy flatus either in a family or at work. The cause of this problem is excess gas production due to one of the causes defined as bloating and flatulence and management are on similar lines.
Passage of Odoriferous Flatus per Anus.
In this condition, the flatus is foul-smelling and sometimes awful. Passage of odoriferous flatus can be the most distressing symptom for those who pass it or for those who face it. What causes odoriferous flatus? The odor is due to sulfur-containing gases namely hydrogen sulfide etc. It forms by bacterial fermentation of sulfate, cysteine, and mucin (namely hydrogen sulfide), fermentation of methane (namely methanethiol), and fermentation of garlic (namely allyl methyl sulfide). The usual foods which supply sulfur-containing substrates include cruciferous vegetables (sulfate), mutton, egg, and other sources of proteins (sulfurcontaining amino acids) or beer (sulfate), etc. Such people may also have a deranged population of bacteria that produce more odor forming gases. Dietary manipulations, reduction of intestinal bacteria, probiotics, and other means to reduce intestinal gas are recommended to treat this entity.
(Khuroo is MD, DM, FRCP (Edin), FACP, Master American College of Physicians (MACP, Emeritus) Former Dean & Director SKIMS and Ex-officio Secretary to Govt, Former Professor & Head of Gastroenterology and Chairman of Dept. Medicine, SKIMS, Former Consultant & Head Gastroenterology and Liver Transplantation, KFSH&RC, Riyadh, Director, Digestive Diseases Centre, Dr. Khuroo’s Medical Clinic, Srinagar
