Flatulence is a common problem in the community presenting as abdominal bloating or discomfort, excessive farting or burping. Diet and lifestyle-related issues predominate in apparently healthy persons. However, flatulence of sudden onset or as a persistent symptom in a sick individual demands further evaluation to rule out the significant gastrointestinal disorder. In this article, Dr. YK Amdekar discusses the clinical approach and management.

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Introduction

Flatulence refers to the accumulation of gas in the gastrointestinal tract. Normally, gas is formed in the large intestine as a result of bacterial (helpful bacteria exist in the intestine) action on digested food (bacterial fermentation) that produces gases like methane, nitrogen and carbon dioxide which exit out. Gas also may be swallowed while eating or drinking rapidly, eating gas-producing food items, soft aerated drinks and chewing gums. Flatulence may also result from indigestion caused by food intolerance, food allergy or gastrointestinal diseases. Whenever excessive gas is produced or normally produced gas does not exit, it results in retention of gas in the alimentary canal. It leads to bloating of the abdomen as well as frequent farting and burping. It produces discomfort and embarrassment.

Gas-producing food items

It is mainly the carbohydrates in food that produce gas as a result of their digestion while proteins and fats contribute to a little gas. Amongst sugars, lactose (dairy products) and fructose (some fruits like mangoes, grapes, oranges, sweet lime, figs) cause excessive gas though other sugars also may do so especially if ingested in excess. Complex sugars such as starch are difficult to break down and so produce excessive gas as happens in the consumption of potatoes, corn, noodles and wheat. Rice produces very little gas. Beans, cabbage, broccoli, sprouts, green leafy vegetables produce excessive gas. However it is important that many of such gas-producing food items are also beneficial in many other ways and hence food intake should be balanced with proteins, fats, carbohydrates, vegetables, fruits and dairy products based on what suits an individual’s digesting system the most.

Common causes of flatulence

1. It is often a result of wrong eating habits including imbalanced food consumption and constipation that upset digestive processes causing flatulence. This does not represent any disease process.
2. Gastrointestinal diseases also lead to flatulence and at times may be the only symptom of developing the disease.
3. Food intolerance is an individual person’s inability to handle food effectively and while it is not a disease but an isolated defect that demands avoiding food items to which a person is intolerant.
4. Food allergy results from an abnormal response to ingested food that worsens over repeated exposure to an offending agent unlike in the case of food intolerance in which there are no worsening symptoms.
   1. Gluten induced allergy– Celiac disease is due to an allergic reaction to wheat, barley, oats and is a classic example of food allergy that is quite common.
   2. GERD – gastroesophageal reflux disease – may present with burping in addition to retrosternal discomfort (heartburn), vomiting and aspiration into airways leading to cough.
   3. Lactose intolerance is due to a lack of lactase – an enzyme that is necessary to break down lactose – that presents with flatulence, abdominal bloating and pain often with watery stools. This is seen often as secondary to acute intestinal infection in children, is transient and self-limiting. It is also more prevalent in old age, especially in those individuals who are not used to consuming dairy products.
5. Inflammatory bowel disease may present with flatulence in addition to abdominal pain, abnormal stools often with blood and deteriorating health. In such cases, other systems may also be involved such as joints, eyes, kidneys etc.
6. Irritable bowel syndrome presents in a similar way but with normal health status and is mainly due to stress rather than any intestinal pathology.
7. Chronic intestinal infections including parasitic disease such as amoebiasis and giardiasis also present with flatulence. In fact, chronic intestinal disorders of any cause including GI malignancy may result in flatulence.

Clinical approach

1. The first step is to note whether symptoms pertain to the frequent passage of gas (farting or burping) or just abdominal bloating with discomfort without passing gas.
2. Acute onset bloating of short duration with severe abdominal pain is the hallmark of surgical abdomen such as acute intestinal obstruction and presents with vomiting.
3. Those who present with excessive farting also have bloating and abdominal discomfort. If such a person is otherwise healthy and not sick, it may be due to irritable bowel syndrome.
4. If such a person is sick, one needs to evaluate more sinister causes that include inflammatory bowel disease (IBD), chronic intestinal infections including TB, parasitic diseases and even malignancy. Physical examination often fails to diagnose such conditions and would need further relevant investigations.
5. If burping is a main presenting symptom, one may consider upper GI disorders such as GERD in a sick individual with other accompanying symptoms or simply an imbalanced diet in an otherwise healthy person.

Investigations

An individual presenting with a chronic problem does not justify any investigations as the problem lies often in eating habits. Similarly, no tests are necessary in case of strong clinical suspicion of irritable bowel syndrome.

1. Stool microscopy may reveal evidence of chronic parasitic infection. Occult blood in microscopic stool examination or faecal calprotectin may indicate the presence of intestinal inflammation. Reducing substance in the stool (lactose) is seen in every loose stool and does not suggest per se lactose intolerance and hence not routinely asked for.
2. CBC may show neutrophilic leukocytosis with thrombocytosis in IBD along with low serum albumen. ESR may be useful in monitoring the course of the disease rather than the diagnosis of a specific condition.
3. Serum IgA anti-tTG level is a screening test for celiac disease.
4. Imaging may be necessary for selective conditions such as GERD, IBD, intestinal TB, malignancy but with limited use.
5. Colonoscopy and intestinal biopsy help in diagnosing IBD, celiac disease though again not specific.

OGDscopy- upper GI study with biopsy is necessary to diagnose GERD along with 24 hours oesophagal pH monitoring. However, tests for celiac disease or GERD must be further supplemented with therapeutic trial as all such tests have limitations and at best are highly suggestive but not confirmative by themselves.

Management

It depends on the cause. Lifestyle and diet modification is the key to many benign conditions. Home remedies include eating low carbohydrate-containing fruits such as berries (blue, black, straw), apricots, grapefruit, peach, watermelon and low carb vegetables such as carrots, tomatoes, green beans. Rice and fermented items like Idli produce less gas. Knee-chest position, hot water, ginger helps to relieve gas.

In pathological disorders, diet modification to avoid offending agent is the standard management in allergic disorders as is in celiac disease in which wheat, barley and oats should be avoided. Diet change is also necessary for other intestinal disorders such as IBD besides immune-suppressive drugs such as prednisolone, salazopyrine and other chemotherapeutic agents as palliative measures.

Prokinetic drugs, H2 blockers and proton pump inhibitors may help in the case of GERD. Chronic intestinal infections are treated with specific antibiotics. Surgical treatment may rarely be necessary for GERD as fundal plication or rarely in IBD – especially ulcerative colitis with fistula formation as seen in adults.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.