Patient information: Gas and bloating

GAS AND BLOATING OVERVIEW

Some people feel that they pass too much gas or burp too frequently, both of which can be a source of embarrassment and discomfort. The average adult produces about one to three pints of gas each day, which is passed through the anus 14 to 23 times per day. Burping occasionally before or after meals is also normal.

The amount of gas produced by the body depends upon your diet and other individual factors. However, most people who complain of excessive gas do not produce more gas than the average person. Instead, they are more aware of normal amounts of gas.

On the other hand, certain foods and medical conditions can cause you to make excessive amounts of gas.

This article reviews the sources of intestinal gas, conditions that increase sensitivity to gas, and measures to reduce gas production. A more detailed review of this topic is available by subscription. (See "Intestinal gas and bloating".)

SOURCES OF GAS

There are two primary sources of intestinal gas: gas that is ingested (mostly swallowed air) and gas that is produced by bacteria in the colon.

Air swallowing — Air swallowing is the major source of gas in the stomach. It is normal to swallow a small amount of air when eating and drinking and when swallowing saliva. You may swallow larger amounts of air when eating food rapidly, gulping liquids, chewing gum, or smoking.

Most swallowed air is eliminated by belching so that only a relatively small amount of air passes from the stomach into the small intestine (figure 1). Your posture may influence how much air passes to the small intestine.

• When sitting up, most swallowed air passes back up the esophagus and out of the mouth, which can cause you to belch.
• When lying down, swallowed air tends to pass into the small intestine, which can cause you to pass gas.

Belching may be voluntary or occur unintentionally. Involuntary belching is a normal process that typically occurs after eating to release air that enlarges or stretches the stomach. Belching is more common with certain foods that relax the ring-shaped muscle (sphincter) around the lower end of the esophagus where it joins the stomach. Such foods include peppermint, chocolate, and fats.

Bacterial production — The colon normally provides a home for billions of harmless bacteria, some of which support the health of the bowel. Certain carbohydrates are incompletely digested by enzymes in the stomach and intestines, allowing bacteria to digest them. The by-products of this process include odorless gases, such as carbon dioxide, hydrogen, and methane. Minor components of gas have an unpleasant odor, including trace amounts of sulfur.

Some carbohydrates, such as raffinose, are not well digested, and therefore cause increased amounts of gas. A number of vegetables contain raffinose, such as cabbage, Brussels sprouts, asparagus, broccoli, and some whole grains. As a result, these foods tend to cause more gas and flatulence.

Some people are not able to digest certain carbohydrates. A classic example is lactose, the major sugar contained in dairy products (table 1). Thus, consuming large amounts of lactose may lead to increased gas production, along with cramping and diarrhea (see 'Lactose intolerance' below.

Certain diseases can also cause excessive bloating and gas. For example, people with diabetes or scleroderma may, over time, have slowing in the activity of the small intestine. This can lead to bacterial overgrowth within the bowel, with poor digestion of carbohydrates and other nutrients.

GAS AND BLOATING SYMPTOMS

Some people feel they pass an excessive amount of gas or burp too frequently. Other people notice bloating and crampy abdominal pain. You may feel this pain in areas where gas can become trapped (figure 1), such as in bends in the colon, which occur naturally in the area under the liver (upper to mid-right part of the abdomen), and in the area under the spleen (upper to mid left part of the abdomen).

SENSITIVITY TO GAS

The link between gas, belching, and the actual amount of gas in the intestines is not always clear. The vast majority of people who are bothered by gas-related symptoms do not have an excessive amount of gas in the intestine, but rather they have an increased sensitivity to normal amounts of gas in the intestine. This can happen in a variety of circumstances.

Irritable bowel syndrome — Many people with irritable bowel syndrome (IBS) are sensitive to normal amounts of gas. Nerves that carry messages from the bowel may be overactive in people with IBS, so that normal amounts of gas or movement in the intestines feels painful or overactive. The primary symptoms of IBS are abdominal pain and changes in bowel habits (such as diarrhea and/or constipation). Many people also complain of bloating. (See "Patient information: Irritable bowel syndrome".)

Some people with severe IBS feel better when treated with medications that decrease the painful feelings coming from the intestine (such as low doses of imipramine or nortriptyline).

Functional dyspepsia — Dyspepsia is the term for recurrent or persistent pain or discomfort in the upper abdomen. Approximately 25 percent of people in the United States and other western countries experience dyspepsia. (See "Patient information: Abdominal pain (functional dyspepsia) in adults".)

Dyspepsia can arise from various underlying conditions, the most common of which is "functional" (or "nonulcer") dyspepsia. Functional dyspepsia causes abdominal pain without an identifiable cause, probably due to an increased sensitivity to gas in the upper intestines.

Irritation of the anus or esophagus — People who have irritation around their anus due to hemorrhoids or other problems may also experience more discomfort when they pass gas. (See "Patient information: Hemorrhoids".)

Similarly, people who have irritation of the esophagus (esophagitis) may find burping painful. (See "Patient information: Gastroesophageal reflux disease in adults".)

CAUSES OF INCREASED GAS

The vast majority of people who are bothered by gas do not produce excessive amounts of gas. However, there are several conditions that may lead to increased gas formation.

Swallowed air — Chronic, repeated belching can occur if you swallow large amounts of air (ie, aerophagia). Aerophagia is typically an unconscious process. Treatment focuses on decreasing air swallowing by eating slowly without gulping and avoiding carbonated beverages, chewing gum, and smoking.

Foods that cause gas — Several foods contain the carbohydrate raffinose, which is poorly digested and can increases gas production. Foods that contain raffinose include beans, cabbage, cauliflower, Brussels sprouts, broccoli, and asparagus. Avoiding these foods or eating them infrequently may reduce the amountn of gas you produce.

Starch and soluble fiber can also contribute increase gas. Potatoes, corn, noodles, and wheat produce gas while rice does not. Soluble fiber (found in oat bran, peas and other legumes, beans, and most fruit) also causes gas. Some laxatives contain soluble fiber and may cause gas, particularly during the first few weeks of use.

Lactose intolerance — Lactose intolerance occurs when your body has difficulty digesting lactose, the sugar found in most milk-based products (table 1). Symptoms of lactose intolerance include diarrhea, abdominal pain, and flatulence after consuming milk or milk-containing products.

Lactose intolerance is a common problem. In Europe and the United States, lactose intolerance affects 7 to 20 percent of people who are white, 80 to 95 percent of Native Americans, 65 to 75 percent of Africans and African Americans, and 50 percent of Hispanics. More than 90 percent of people in some regions of eastern Asia have lactose intolerance.

Lactose intolerance can be diagnosed with a lactose breath test. During this test, you drinks a beverage with lactose and then your breath is analyzed to measure the amount of hydrogen it contains. Treatment of lactose intolerance involves avoiding dairy products that contain lactose and/or use of supplements that contain the enzyme lactase (available in over-the-counter products such as Lactaid®).

If you do not drink milk, you should take a supplement that contains 1000 mg of calcium and 400 IU vitamin D every day since dairy products are a primary source of these important substances. This is especially true for children and women. (See "Patient information: Calcium and vitamin D for bone health".)

Intolerance to food sugars — Some people are intolerant of sugars contained in certainn foods. Two common examples are fructose (contained in dried fruit, honey, sucrose, onions, artichokes, and many foods and drinks that contain "high fructose corn syrup") and sorbitol (a sugar substitute contained in some sugar free candies and chewing gum).

Diseases associated with increased gas — A number of diseases can cause difficulty absorbing carbohydrates, which can lead to increased gas. This problem can occur in people with celiac disease (a disease caused by intolerance to a protein contained in wheat), short bowel syndrome, and in some rare disorders. (See "Patient information: Celiac disease in adults".)

GAS AND BLOATING DIAGNOSIS

Most people with gas and bloating do not need to have any testing. However, symptoms such as diarrhea, weight loss, abdominal pain, anemia, blood in the stool, lack of appetite, fever, or vomiting can be warning signs of a more serious problem; people with one or more of these symptoms usually require testing.

Tests may include:

• Examination of stool for blood, abnormally high levels of fat (steatorrhea), or a parasite (eg, Giardia). (See "Patient information: Giardia".)

• A lactose tolerance test, described above (see 'Lactose intolerance' above.
• X-ray examination of the small intestine.
• A test to examine the inside of the stomach and/or colon (upper endoscopy, sigmoidoscopy, or colonoscopy). (See "Patient information: Upper endoscopy" and "Patient information: Flexible sigmoidoscopy" and "Patient information: Colonoscopy".)

• A blood test for celiac disease. (See "Patient information: Celiac disease in adults".)

GAS AND BLOATING TREATMENT

Several measures can help to reduce bothersome gas.

Diet recommendations — Avoid foods that appear to aggravate your symptoms. These may include milk and dairy products, certain fruits or vegetables, whole grains, artificial sweeteners, and/or carbonated beverages. Keep a record of foods and beverages to help to pinpoint which foods are bothersome (graph 1).

If you are lactose intolerant, do not consume products that contain lactose (table 1) or use a lactose-digestive aid, such as lactose-reduced milk or over-the-counter lactase supplements (eg, LactAid® tablets or liquid). Take a calcium supplement if you avoid milk products. (See "Patient information: Calcium and vitamin D for bone health".)

Over-the-counter medications — Try an over-the-counter product that contains simethicone, such as certain antacids (eg, Maalox® Anti-Gas, Mylanta® Gas, Gas-X®, Phazyme®). Simethicone causes gas bubbles to break up and is widely used to relieve gas, although its benefit is questionable.

Try an over-the-counter product that contains activated charcoal (eg, Charcocaps®, CharcoAid®). The benefit of activated charcoal is unclear, although it is reasonable to try.

Try Beano™, an over-the-counter preparation that helps to breakdown certain complex carbohydrates. This treatment may be effective in reducing gas after eating beans or other vegetables that contain raffinose.

Try bismuth subsalicylate (eg, Pepto-Bismol®) to reduce the odor of unpleasant smelling gas due to sulfur.

Deodorizing products — Consider a device to deodorize gas, such as underwear made from carbon fiber (eg, Underease protective underwear {Under-Tec, Corp} and GasMedic® underair brief {Dairiair, LLC}). These appear to be effective but are expensive. Charcoal lined cushions or pads are also available, but may not be as effective.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Irritable bowel syndrome
Patient information: Abdominal pain (functional dyspepsia) in adults
Patient information: Hemorrhoids
Patient information: Gastroesophageal reflux disease in adults
Patient information: Calcium and vitamin D for bone health
Patient information: Celiac disease in adults
Patient information: Giardia
Patient information: Upper endoscopy
Patient information: Flexible sigmoidoscopy
Patient information: Colonoscopy

Professional Level Information:
Clinical manifestations and diagnosis of irritable bowel syndrome
Intestinal gas and bloating
Lactose intolerance
Treatment of irritable bowel syndrome

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (http://digestive.niddk.nih.gov/ddiseases/pubs/gas/index.htm, also available in Spanish)

• The American Gastroenterological Association

      (www.gastro.org/wmspage.cfm?parm1=689)

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