W. Steven Pray, PhD, DPhBernhardt Professor, Nonprescription Products and DevicesCollege of Pharmacy, SouthwesternOklahoma State UniversityWeatherford, Oklahoma 


US Pharm. 2009;34(12):16-22.

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Patients often consider pharmacists as experts to who they have the right to confide awkward medical difficulties in the hope the the pharmacist will administer some assistance. One such trouble is ab bloating, regularly thought to be because of excess intestinal gas. However, patients may additionally experience ab discomfort castle attribute to gas, yet can be caused by number of serious clinical conditions.

Prevalence of Bloating and Gas

The prevalence of minister gas and also bloating is unknown, as reliable massive studies execute not exist. However, bloating and flatulence (defined as extreme air or various other gas in the stomach and/or intestines) space two of the most usual complaints because that which patients seek medical care.1

Manifestations the Bloating and also Gas

Bloating and gas can reason several complaints or coexist with them. Patients complain of extreme belching (eructation).2Belching is a normal response during or after a meal, specifically one the was eaten so rapidly that the patient additionally swallowed air. However, part patients swallow air purposely to facilitate belching, a exercise that can construct into an unconscious habit. Thus, if civilization burp excessively, they may be chronic air swallowers. Patients may deny the they sloop down air as a nervous habit, forcing medical professionals to give them a winter to watch the illustration themselves.

Flatulence is a common and logical an effect of minister gas. Average patients through no pathology or underlying medical problem produce 1 come 4 pints of intestinal gas per day and flatulate 14 to 23 time daily.2,3

Abdominal distention is rise in abdominal girth the is commonly ascribed to excessive intestinal gas.2,4This perception is regularly incorrect, as many such patients have normal amounts of gas. Rather, investigators think that these patients have a heightened awareness of intestinal gas. Thus, also normal volumes of gas cause troublesome symptoms.

Abdominal pain is one more complaint regularly thought come be because of gas.2,3It may arise native either side of the colon, mimicking such conditions as love disease, gallstones, and also appendicitis.

Possible reasons of Bloating and also Gas

Various resources of overabundance gas have been identified, consisting of air swallowing, diet, lactose intolerance, and irritable bowel syndrome (IBS).

Aerophagia:Aerophagia, or air swallowing, has actually long been believed to it is in responsible because that bloating and also gas, as formerly described.5,6But there had been little evidence to assistance the hypothesis, as logical as it sounds. However, in 2009, investigators evidenced the theory by assessing swallowing frequency in general and also air swallowing frequency in certain in patients through suspected aerophagia.5They determined a group of patients with usual complaints the bloating, ab distention, flatulence, and/or excessive belching. Abdominal x-rays shown the visibility of excessive abdominal muscle gas, the presumed source of the complaints. The researchers brought out 24-hour pH-impedance monitoring on subjects, finding out that swallowing frequency because that the 24-hour duration was regular (741 +/- 71 episodes), but the variety of air swallows and also gastric belches was excessive (521 +/- 63 and 126 +/-37, respectively). Thus, the advice presented in this month’sPatient Informationsection regarding air swallowing might be advantageous for these patients.

Diet:Diet is a significant cause of bloating and also gas. Among the most typical dietary issues is eating foodstuffs that can not be spend in the cradle (GI) tract due to a absence of the necessary enzymes.1,2

If specific food residual water (mostly carbohydrates) reach the huge intestine, regular bacterial citizens utilize them together food sources, producing carbon dioxide, hydrogen, and also sometimes methane together by-products.1,2Exactly which foods reason gas different from person to person. Some patients’ bowel microorganisms destroy hydrogen, lessening their intestinal gas burden.2Nevertheless, some foodstuffs are universally determined as gas producers.

Carbohydrate-containing foods items are among the most typical culprits in leading to intestinal gas, whereas fat foods and proteins are hardly ever responsible.1,2,7Raffinose is one such complex sugar, being found in the indigestible particle coatings the beans, cabbage, brussels sprouts, broccoli, asparagus, various other vegetables, and also whole grains.2Fructose is one more offender, found in onions, artichokes, pears, and wheat; that is also used as an artificial sweetener. Sorbitol is additionally an synthetic sweetener, however it is a naturally developing component the apples, pears, peaches, and also prunes. Sorbitol is a reason of “Halloween diarrhea,” a phenomenon experienced by many kids who consume large amounts of candy on Halloween night. Many patients additionally report the psyllium ingested come ensure regularity reasons gas (e.g., Metamucil, Konsyl). This patients may advantage by convert to methylcellulose, an FDA-approved fiber supplement the is not fermented by colonic bacteria (e.g., Citrucel).

Lactose Intolerance:Lactose intolerance (LI) is another form of carbohydrate malabsorption, discussed separately because of its various etiologies.1Lactase found in the brush border cell of the tiny intestine is vital for breaking lactose down right into its component sugars for absorption. Lactase deficiency is the underlying defect behind LI.

There are two significant types of LI. Castle share the exact same consequences, in the undigested lactose get the minister tract, wherein the colonic microbiota digest it, creating gas, diarrhea, bloating, borborygmus, and also a host of other complaints, start as early on as 30 minutes after ingestion.8,9The more common form of LI is the major form, skilled by many of the world’s peoples, consisting of those of African, aboriginal American, and Asian heritage. In main LI, lactase activity drops sharply after weaning from breast milk, till it is basically absent. Drinking milk or ingesting dairy products reasons the symptoms to begin.

Some people likewise suffer from an additional LI. They normally develop lactase together adults, however an environmental insult or operation procedure compromises their capacity to execute so. Feasible causes of an additional LI include chemotherapy, diarrheal diseases, tiny intestine resection, or celiac disease.1Pharmacists can direct patients with suspected LI to lactase-containing supplements (e.g., Lactaid) or lactose-free dairy products.

Irritable Bowel Syndrome:IBS causes abdominal muscle pain, cramping, bloating, constipation, and also diarrhea.10-12About 20% of Americans suffer from IBS, perhaps as result of colonic hypersensitivity to certain foods or in an answer to stressful situations.11Pharmacists have to refer patients with suspected IBS come a physician for a complete evaluation, but they can also advise patients to keep a food diary to aid identify dietary causes of IBS. Remove of certain foods and drinks (e.g., chocolate, alcohol, caffeine, cola, tea, peppers, onions) might be all the is required to carry out relief.

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Nonprescription Products

Pharmacists can recommend two varieties of nonprescription assets other 보다 lactose-intolerance products. One group of commodities contains simethicone, a nontoxic and hypoallergenic ingredient the is FDA approved as safe and also effective in breaking down bubbles or froth in the GI tract, although the full amount the gas stays the same.1Simethicone’s usefulness may be because of several factors. Some patients might experience ab discomfort together normal quantities of intestinal gas relocate through them. Reducing froth may allow the gas to pass through an ext readily. Further, patients utilizing simethicone may have the ability to eliminate gas in several larger episodes, reducing the late of too much gas. Products with simethicone encompass Mylanta Gas, Phazyme, and also Gas-X. The dosage is generally 1 or 2 systems as necessary after meals and at bedtime.

Alpha-galactosidase is another means to stop bloating and also gas.1,13This is one enzyme derived fromAspergillus niger, and also it has actually the capability to breakdown the oligosaccharide linkages that human beings cannot digest. The patience is climate able come absorb the single-component street residues. In research trying out the enzyme’s efficacy, topics ingested two meals of meatless chili written of several varieties of beans, cabbage, cauliflower, and also onions.14They were provided either a placebo or the commercially easily accessible alpha-galactosidase product, recognized asBeano. Beano decreased the number of flatulence occasions at all times except for 2 hrs postingestion. The impact was many pronounced 5 hours after the meal.14

To usage Beano solution, the patient places about 5 autumn on the first bite of troublesome food, such as beans, cabbage, cauliflower, broccoli, grains, cereals, nuts, seeds, and also whole-grain breads.13That amount normally covers a half-cup offer of food. If the meal is composed of two or three servings that the food, the patient should place 10 to 15 fall on the meal. However, if the patient still experiences flatulence, the amount can be readjusted upward until an efficient dose is reached. The patient may likewise swallow or chew a Beano tablet computer with the first bite that food or crumble it onto the very first bite. One tablet usually digests a half-cup serving; more tablets deserve to be offered for larger portions. Patient cannot cook with Beano since of heat-induced enzyme degradation. Patients v galactosemia should consult a physician prior to use because enzymatic destruction of oligosaccharides produce galactose. Beano is labeled only for patients age 12 years and above. If it shows up to be safe throughout pregnancy and breastfeeding, there space no research studies to confirm that observation. In ~ one time, the manufacturer recommended that patients allergic to molds not usage Beano, however the existing view is that the caution is not sustained by clinical literature.13

Addition Diets

Pharmacists can likewise advise patients to experience an enhancement diet.15With this method, the patient eliminates all foods and drinks that room thought to create symptoms. If symptoms improve, the patient proceeds the diet for number of days until getting to a perceived normal level, a state well-known asnormoflatulence.15Then one brand-new food or drink is added, and the patient documents the outcomes in a diary, paying specific attention come the intensity of the symptoms. Patients must discontinue any type of troublesome food because that the duration of the enhancement diet and include another suspected food or drink after ~ 48 hours. After several weeks of complying with this an easy procedure, the patient begins to build a profile of difficult foods. At some point all suspected foods items will it is in identified, and the patient will have actually a much much better idea of exactly how to pick foods and drinks, even when visiting a restaurant.

PATIENT INFORMATION

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Swallowing Air

When friend swallow air, it have to either it is in burped up or expelled together gas. Several difficulties can reason one to swallow air. Dentures that execute not fit well cause you to swallow more saliva, i m sorry is blended with waiting bubbles. If this is a feasible cause, you must see the dental professional who fitted her dentures to have them adjusted. If you have actually postnasal discharge, you tend to swallow an ext than normal, allowing an ext air to go into your stomach. Cautious use that a nasal decongestant (e.g., Sudafed, Afrin) might help. Cigarette smoking cigarettes, cigars, or pipes and also using chewing tobacco can increase salivation and contribute to extreme bloating, as have the right to talking also much.

Some civilization belch excessively, either as a nervous habit or probably as a source of humor. To achieve intentional belching, the person often an initial swallows air, complied with by the belching. However, he or she hardly ever releases every one of the swallowed air, and also it i do not care flatulence.

Dietary Issues

Eating as well rapidly causes you come swallow extra air. You must slow your eating and chew the food thoroughly before swallowing it. Chewing gum and also sucking on tough candy additionally increase the quantity of swallowed air, so these practices must be reduced.

An easy method to aid minimize bloating and gas is to focus on carbonated beverages (e.g., Coke, Pepsi). Manufacturers intentionally include carbonation to all of these sodas to offer the assets their “fizz.” as soon as the bottle or deserve to is agitated before being opened, everyone knows what the result will be—a great deal that bubbly drink ~ above the floor. Together a person drinks the beverage, the carbonation bubbles go into the stomach. If they are not belched out, they end up being excess flatulence. Many people could minimize gas difficulties dramatically by just eliminating all carbonated beverages. If a person refuses to take it this basic step, maybe he or she can be convinced to enable the drink to sit the end on the counter at room temperature for numerous hours, which allows them to go flat and thus reduce the amount of swallowed gas.

The very same advice deserve to be provided to beer drinkers. Beer includes gas, as indicated by the frothy head that creates when it is poured. Girlfriend should completely eliminate it from her diet to view if your symptoms improve.

A significant dietary cause of gas is beans, and other foods with indigestible components, such as cabbage, cauliflower, and broccoli. Her intestinal bacteria usage these contents as foods, producing gas together a by-product.

Lactose intolerance also contributes to gas and bloating. It is ideal to prevent dairy commodities or to take supplements the contain lactase, such together Lactaid.

Consult her Pharmacist

There are number of OTC products you have the right to take to help relieve symptoms. Her pharmacist have the right to assist friend by advising ~ above the use of simethicone (e.g., Gas-X, Mylanta Gas, Phazyme), which eases remove of gas. Beano, a product the reduces the amount of gas, is a liquid solution that deserve to be used directly come food or taken as a tablet prior to eating

Remember, if you have actually questions, Consult your Pharmacist.

REFERENCES

1. Pray WS.Nonprescription Product Therapeutics.2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006.2. Gas in the digestive tract. NIDDK.http://digestive.niddk.nih.gov/ddiseases/pubs/gas/. Accessed October 29, 2009.3. Gas—flatulence. MedlinePlus.www.nlm.nih.gov/medlineplus/ency/article/003124.htm. Accessed October 29. 2009.4. Agrawal A, Whorwell PJ. Testimonial article: ab bloating and distension in sensible gastrointestinal disorders—epidemiology and explorations of possible mechanisms.Aliment Pharmacol Ther. 2008;27:2-10.5. Hemmink GJ, Weusten BL, Bredenoord AJ, et al. Aerophagia: excessive air swallowing prove by esophageal impedance monitoring.Clin Gastroenterol Hepatol. 2009;7:1127-1129.6. Azpiroz F. Minister gas dynamics: mechanisms and clinical relevance.Gut. 2005;54:893-895.7. Hernot DC, Boileau TW, Bauer LL, et al. In vitro fermentation profiles, gas manufacturing rates, and also microbiota modulation as influenced by details fructans, galactooligosaccharides, and also polydextrose.J Agric Food Chem. 2009;57:1354-1361.8. Saulnier DM, Kolida S, Gibson GR. Microbiology the the human being intestinal tract and approaches for its dietary modulation.Curr Pharm Des. 2009;15:1403-1414.9. Ozdemir O, Mete E, Catal F, et al. Food intolerances and also eosinophilic esophagitis in childhood.Dig Dis Sci. 2009;54:8-14.10. Gasbarrini A, Lauritano EC, Garcovich M, et al. New insights right into the pathophysiology that IBS: intestinal microflora, gas production and also gut motility.Eur Rev Med Pharmacol Sci. 2008;12(suppl 1):111-117.11. Irritable bowel syndrome. NIDDK.http://digestive.niddk.nih.gov/ddiseases/pubs/ibs/. Accessed October 29, 2009.12. Rana SV, Sharma S, Sinha SK, et al. Incidence of predominant methanogenic flora in irritable bowel syndrome patients and also apparently healthy controls from phibìc India.Dig Dis Sci. 2009;54:132-135.13. Beano FAQs. GlaxoSmithKline.www.beanogas.com/FAQ.aspx. Accessed October 29, 2009.14. Ganiats TG, Norcross WA, Halverson AL, et al. Go Beano protect against gas? A double-blind crossover research of dental alpha-galactosidase to treat diet oligosaccharide intolerance.J Fam Pract. 1994;39:441-445.15. Clearfield HR. Clinical minister gas syndromes.Prim Care. 1996;23:621-628.16. Adolf Hitler had poor table manners and also suffered flatulence.

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Telegraph. February 17, 2009.www.telegraph.co.uk/news/newstopics/howaboutthat/4678840/Adolf-Hitler-had-poor-table-manners-and-suffered-flatulence.html. Accessed October 29, 2009.