A 37-year-old female frequently complains of excess gas in the gut. A detailed history reveals that her complaints refer to abdominal bloating and fullness. When specifically questioned, she admits straining at stools and sensation of difficult gas evacuation, without excessive flatulence or belching.
Anorectal manometry evidences functional outlet obstruction due to impaired anal relaxation during attempted evacuation. After normalization of the defecatory maneuver by biofeedback training her symptoms relieve significantly.
Treatment depends on the pathophysiological mechanisms involved. The level of evidence is low.
Aerophagia usually resolves, or at least improves, with a clear pathophysiological explanation of the symptoms. If present, dyspeptic symptoms may also be treated. Some patients present psychological problems that may require specific therapy.
Patients complaining of excessive and/or odoriferous gas evacuation may benefit from a low-flatulogenic diet that includes: meat, fowl, fish, and eggs; gluten-free bread, rice bread, and rice; some vegetables, such as lettuce and tomatoes; and some fruits, such as cherries and grapes. On the contrary, high-flatulogenic foodstuffs should be avoided including beans, Brussels’ sprouts, onions, celery, carrots, raisins, bananas, wheat germ, and fermentable fiber. After a 1-week gas-free diet these patients usually experience significant symptom relief. By an orderly reintroduction of other foodstuffs, they should be able to identify the offending meal components. If strict diet fails, malabsorption may be investigated and treated accordingly.
In patients with gas retention due to impaired anal evacuation, anal dyscoordination can be resolved with biofeedback treatment , which also resolves fecal retention, and thereby the time for fermentation and gas production are also reduced.
Bloating and abdominal symptoms may improve with the treatment of the underlying functional gut disorder. Since patients with bloating and distension seemingly suffer from a common variant of irritable bowel syndrome, the basic approach to treatment should be similar to that prescribed for irritable bowel syndrome. However, these patients may have mixed syndromes resulting from several altered mechanisms. A hypersensitive gut may be associated with impaired anal evacuation, particularly in constipation- predominant irritable bowel syndrome patients, and symptoms will worsen if gas production is increased.
In these patients a combined treatment strategy should be considered. Recent experimental studies suggest that mild exercise, a traditional recommendation, facilitates intestinal gas clearance. Avoiding high flatulogenic foodstuffs and fiber overload usually helps, but strict exclusion diets cannot be recommended. The effect of spasmolytics, prokinetics, antibiotics, and gas-reducing substances has not been clearly established.
Prognosis is good, as in most functional gut disorders.
Patients complaining of intestinal gas may refer to different types of conditions.
Identify the specific clinical complaint: repetitive eructation, excessive/odoriferous flatus, impaired anal evacuation, or abdominal bloating/discomfort.
Understand the mechanism of symptoms: aerophagia, bacterial fermentation of food residues, functional outlet obstruction, or intestinal sensory/reflex dysfunction.
Plan the treatment strategy depending on the pathophysiology.