Gas

Summary

Gas in the digestive tract varies from belching and bloating to flatulence and abdominal pain. It can be annoying and uncomfortable. It can also be downright embarrassing. In this article I will describe some of the causes of gas. Also, though gas is rarely a sign of serious disease, it is occasionally an accompanying symptom, and I will discuss a number of the diseases it sometimes accompanies. Finally, I will describe some of the ways to alleviate common gas problems.

Gas, an Introduction

"Doctor, I pass more gas that anyone else and it smells so bad."

If I had a nickel for every time a patient said this to me, it would pay for at least a couple of dinners at my favorite restaurant. Everyone thinks they pass the most gas. The average person passes gas 14-24 times per day producing one to three pints during this period of time. It is interesting to note that the studies documenting this fact were all conducted in healthy young men, so there may be some difference in women.

Upper gas, what we call belching or burping, generally consists of swallowed air, which is largely nitrogen. This gas reflects the air around us, so burping rarely smells bad. However, flatulence, or passing gas from the rectum, is determined by the food you eat and the activity of the bacteria in your colon. When undigested food reaches the large intestine, it is broken down by the bacteria that are normally found there into hydrogen, carbon dioxide and, in one-third of individuals, methane. It is not clearly understood why some people produce methane and others do not, and it may have something to do with the balance of different bacteria in the colon.

Causes of Gas

Dairy Products and Lactose Intolerance
"My friend told me that dairy products cause gas, so I cut these out of my diet but I still get very bloated."

Dairy products contain the sugar lactose, and in some people lactose can produce gas. Lactose is found not only in milk, but in cheese and ice cream as well. It is very important to read labels and look not only for lactose, but for 'casein' and 'whey.' These ingredients also contain milk sugars, and can be found in cereals, salad dressings and processed foods.

Lactose intolerance is a deficiency of the enzyme 'lactase' in the small intestine, the enzyme required to digest lactose. This decrease occurs as a result of ‘growing up’, or growing older. Those of African, Native American, Asian or Ashkenazi Jewish descent, may have even greater propensity for lactose intolerance. Unfortunately lactose is not the only sugar that causes gas. The other sugars or carbohydrates that cause gas are raffinose, sorbitol and fructose.

Raffinose
Raffinose is the culprit in beans that causes so much gas. It is also found in the cruciferous vegetables like broccoli, cabbage and brussel sprouts, as well as other vegetables and whole grains. These foods are good for you, and I do not suggest you cut them from your diet. Rather, instead of eating big portions at one sitting, eat smaller portions several times per week.

Fructose
Another cause of increased gas is fructose. Fructose occurs naturally in pears, wheat, onions and artichokes. Many juices, soft drinks and iced teas contain high fructose corn syrup as a sweetener, and oftentimes people consume more of these drinks than they realize, which can result in increased gas.

Sorbitol
Sorbitol is used as an artificial sweetener and is commonly found in gum, candies and dietetic foods. Like fructose, it can cause an increase in gas if ingested to excess. Now and then I see a patient who has been bingeing on these foods causing a large amount of gas. Sorbitol also occurs naturally in many fruits, such as peaches, apples, prunes and pears.

Starches
Starches, such as potatoes, noodles and corn, also produce gas as they break down in the digestive tract. Rice is the only starch that does not produce gas.

Soluble Fiber
Most of us know that a healthy diet is high in fiber, and fiber is recommended to protect against colon cancer. Soluble fiber, found in beans, oat bran, peas and most fruits, is particularly likely to cause gas when digested in the large intestine. Insoluble fiber, found in most vegetables, produces less gas. You don't need to cut fiber out of your diet. Rather, to lessen the likelihood of gas, you may eat smaller amounts spread out over the day.

Smoking, Gum and Soda
Smoking, chewing gum, and drinking carbonated beverages all require that we swallow a significant amount of air. These habits result in increased gas.

Gas to Be Concerned About

"Sometimes I have so much gas that it is painful. Does this mean that something more serious is going on?”

Gas in the digestive tract creates not only an increase in flatulence, but an increase in burping, bloating and even abdominal pain. The vast majority of gas in the digestive tract is not serious. The gas symptoms you experience depend on how much gas your body produces, how much fatty acid your body absorbs, and your own sensitivity to gas in the large intestine. Sometimes, however, gas can be symptomatic of more serious problems. Let's look at belching, bloating and abdominal pain and see when these symptoms may be cause for concern.

Belching Related Problems
Occasional burping after eating or drinking soda is normal. However, when you start to have chronic belching, you may be experiencing a symptom of heartburn (reflux), gastritis or stomach ulcers. Usually these disorders are accompanied by nausea, heartburn or stomach pain.

There are two rare belching syndromes to be aware of:

Gas bloat syndrome – This can occur after surgery to correct gastric reflux. The surgery results in a one-way valve that allows food and air to enter the stomach, but does not allow the stomach to release gas through belching. This gas then moves into the small and large intestines causing bloating and flatulence.

Meganblase syndrome – This syndrome is a result of chronic belching which leads to the formation of large gas bubbles in the stomach. It occurs particularly after a heavy meal. The fullness in the stomach and subsequent shortness of breath can be very painful and feel similar to a heart attack.

If chronic belching is a problem, or if there are signs of upper abdominal pain, an examination of the esophagus, stomach and upper small intestine may be in order. This can be accomplished with either an upper GI series (an x-ray) or an upper endoscopy (where a flexible tube with a small camera inside is inserted into the mouth and down into the stomach).

Bloating Related Problems
Those who experience abdominal bloating may simply be sensitive to gas in the digestive tract. Bloating can, however, be symptomatic of a number of more grave problems.

Intestinal Motility Disorder
Visible distention of the abdomen may be the result of an intestinal motility disorder, such as splenic-flexure syndrome. This is a chronic disorder in which gas is trapped in bends in the colon. It may accompany irritable bowel syndrome, an essentially benign disorder. Symptoms include bloating, abdominal discomfort and muscle spasms.

Malabsorption, Colon Cancer, Crohn's Disease, Adhesions
Occasionally, bloating may be a symptom of a more serious disorder such as malabsorption (e.g. sprue), colon cancer, Crohn's disease or adhesions (bands of scar tissue). Adhesions usually result from abdominal surgery but can also be the result of trauma, or endometriosis. Usually these disorders have other accompanying symptoms.

Ulcer Disease
Bloating is also often a prominent symptom of Helicobacter pylori, the bacteria associated with ulcer disease.

Confusing Gas Pain With Other Symptoms

Appendicitis, Gallstones, Heart Attacks
Additionally, severe gas pain on the right side of the abdomen can be confused with appendicitis or gallstones. If prolonged or severe pain is experienced on the right side, it may be more serious than gas pain, and should be evaluated. Occasionally, left-sided gas pain can be confused with chest pain related to heart disease.

For people experiencing gas pain in addition to other symptoms, such as anemia resulting from chronic blood loss, diarrhea or weight loss, an examination of the large intestine may be indicated. Individuals with family histories of colon cancer who are experiencing strong gas pain may also be due for an examination of the large intestine. Such an examination may consist of a barium enema or a colonoscopy (a procedure where a long flexible tube with a fiberoptic camera is inserted into the colon through the rectum to look at the inside lining of the large intestine.

What Can I Do about Gas?

Diagnosing and Treating Lactose Intolerance
"I've heard there's a test to evaluate lactose intolerance. Should I do it?"

Although lactose intolerance is one of the most common causes of intestinal gas, it is certainly not the only one. To begin a diagnosis, a doctor will need a list of your symptoms and a good dietary history. It may be very helpful if you can keep a log of all that you eat and drink over the course of a week or two. You may even want to keep track of the number of times you pass gas. This exercise may help you and your doctor discern which dietary items are contributing to the gas.

Lactase deficiency can be diagnosed with a breath or blood test. However, most doctors don't have easy access to the necessary equipment in their office. Offering a two week lactose-free diet to patients is another effective way to see whether lactose is creating excess gas in their systems. If you have less gas when you are not eating lactose products, you are likely to have lactase deficiency.

I don't suggest that people who are lactose intolerant cut dairy out of their diets altogether. Dairy foods are rich in calcium, and calcium is necessary for building strong bones and preventing osteoporosis.

There are a number of products on the market designed to aid in lactose digestion. These products are available in both supermarkets and drugstores. Lactase is available in pill and liquid form (Lactaid, Lactrase or Dairyease) and is either added to dairy products or taken with these foods. In addition, Lactaid produces a lactose-reduced milk as well as other lactose-reduced dairy products.

Watch the Way You Eat
"Doctors tell you to eat more fruits and vegetables and then they tell you that all these things cause more gas. How do I deal with this?"

Fiber
As I have suggested above, you don't want to cut fiber (contained in fruits, vegetables and grains) out of your diet entirely because fiber is good for you. You can, however, try eating smaller amounts at one sitting, and spreading out these servings over the course of the week.

High Fat Foods
Cutting back on high fat foods allows the stomach to empty faster, and allows gas to move into the small intestine, limiting bloating and discomfort. Remember, each body is different. It is up to each individual to determine which foods create the most gas and alter the diet accordingly.

Over the Counter Products for Gas

BEANO
Over-the-counter products are available at the local drugstore to decrease gas and bloating. If you are eating a meal rich in beans or cruciferous vegetables, you may want to try BEANO. BEANO is an enzyme, alpha-galactosidase, and it helps in digesting these foods. Approximately 10 drops/serving is the suggested dose.

Simethicone
For upper-gas or belching, you can try simethicone. Simethicone is available either alone (Phazyme or Mylicon) or as a component of many antacids (Mylanta, Gas-Ex, Maalox). It works by joining gas bubbles so they are more easily burped away.

Lower Intestinal Gas Products
Until recently, not much has been available for lower intestinal gas. Activated charcoal (Charcotabs) has been recommended by some doctors. However, it can result in black stools and constipation. In recent months, various pro-biotic products, e.g. Culturelle, have come on the market. These products work by populating the intestine with "healthy" bacteria that may be more efficient in digesting food. These agents, virtually without side-effect, hold great promise for the future and have been very effective in the treatment of bloating in my irritable bowel syndrome patients.

Conclusion

I hope the above discussion proves helpful, and encourages better digestion. Remember, gas pain is very common. Certain modifications in eating, and the use of over the counter products can help to alleviate most gas pain. I also urge people to remember that if they are concerned about their gas symptoms, they should not hesitate to discuss these symptoms with a doctor.

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