"Cleanliness is the Key to Prayer as Prayer is the Key to Paradise”.  Ramadan is a month of spiritual consciousness and high sense of social responsibility. Hajj, pilgrimage to Makkah, is a duty which every Muslim must perform once in his lifetime. Prayer extended for hours is the focus in both these religious duties. To pray for extended period, one needs to maintain cleanliness (Wudhu/Ablution). Allah (SWT) gave clear guidelines on Wudhu:  “O ye who believe! When ye rise up for prayer, wash your faces, and your hands up to the elbows, and lightly rub your heads and (wash) your feet up to the ankles. And if ye are unclean, purify yourselves. ..... (Al-Quran, Surah Al-Maeda 5:6).” Prophet Mohammad (SAW) said, “A person is considered in prayer as long as he is waiting for the prayer in the mosque and as long as he does not do Hadath (Arabic word meaning event)." A non-Arab man asked, "O Abii Huraira! What is Hadath?" I replied, "It is the passing of wind. (Reference: Sahih Bukhari, Book 4: Volume 1, Book 4, Number 176: Narrated Abu Huraira).” Passage of gas/wind per anus (flatus) nullifies Wudhu.  I counsel a number of my patients who are worried and even frustrated as they cannot maintain Wudhu either during a prayer especially on Friday or during Ramadan prayer or during Hajj prayers. It also limits attendance to religious functions, which may extend for longer duration during Ramadan and Hajj.

Gas is a normal constituent of intestines in every person. An estimated 200 ml of gas is present in every healthy person’s intestines. All of us pass gas per anus (flatus) between 10 to 20 times per day and the amount passed per anus per day ranges from 500 to 1500 ml (average 700 ml).  Five gases namely nitrogen (N2), oxygen (O2), carbon dioxide (CO2), hydrogen (H2) & methane (CH4) are the main constituents in normal persons. The odour is due to sulfur containing gases namely hydrogen sulphide etc. It forms by bacterial fermentation of sulphate, cysteine and mucin (namely hydrogen sulfide), fermentation of methane (namely methanethiol) and fermentation of garlic (namely allyl methyl sulphide).  The usual foods which supply sulfur containing substrates include cruciferous vegetables (sulphate), mutton, egg and other sources of proteins (sulphur containing amino acids) etc. 

Flatulence and excess gas formation and expulsion is multifactorial and needs to be explored by questionnaire to those who suffer from it. Broadly some people may swallow excess gas which reaches the stomach and then to intestines. Such persons have a nervous personality and the gas becomes worse whenever such persons have some form of tension or problem in their day to day life. Another commonest cause of gas in abdomen is related to foods. Flatulence-producing foods are typically high in certain polysaccharides. These foods include beans, lentils,  onions, potatoes, cashews, wheat, and yeast in breads. Cauliflower, broccoli, cabbage, Brussels sprouts and other cruciferous vegetables that belong to the genus Brassica are commonly reputed to not only increase flatulence, but to increase the pungency of the flatus. Rice is the only starch absorbed almost completely by the small intestine. Because rice starch never reaches the large intestine, gas-producing bacteria don't break this starch down and rice can never be the source of gas. But other starches, including potatoes, corn, noodles and wheat, are gas producers. Dietary fiber, found in beans and wheat bran, also tends to produce gas.   Milk and milk products (except yoghurt) can be a source of excess gas in those who have Lactase (an enzyme in brush border of small intestines) deficiency.  In fact in Kashmir about one fourth of population is lactase deficient and milk intolerant. In such persons one glass of milk sends these persons to toilet on a number of times with watery acidic stools and lot of passage of gas. Another common cause of excess gas production in intestines is due to abnormal bacterial population (small bowel bacterial overgrowth). Such people have normal digestive enzymes and normal capacity to digest all food items but have imbalance in gas producing and gas consuming bacteria. In such persons the normally malabsorbed food items are changed in to hydrogen and carbon dioxide and organic acids in colon.

Most of the subjects with flatulence can easily identify the cause of their symptoms and address these. However, in difficult circumstances some tests may need to be performed. One such test is called “Hydrogen Breath Test (HBT).” HBT is a highly sophisticated, accurate and non-invasive test to measure intestinal gas produced by the intestines and to find its cause. H2 gas produced in the intestines is absorbed in to blood and on reaching lungs all is cleared and passed in to the breath. HBT determines the H2 in the exhaled breath. Breath H2 is measured in fasting state and thereafter serial estimation are done for 3 hours after challenge with a substrate (carbohydrate). Subjects with carbohydrate malabsorption reveal a rise in breath H2 around 2 to 3 hours after carbohydrate challenge. Subjects with “small bowel bacterial overgrowth” show an early (within half to one hour) rise of breath H2 after carbohydrate challenge.  
Managing excessive intestinal gas depends on the cause, should be individualized and may be problematic.

 Milk: Those who have milk intolerance should restrict milk intake, in tea or otherwise, to their tolerance. Some people find that yogurt, in which the lactose has been broken down partially by bacteria, produces less gas than milk. In special circumstances (severe milk intolerance), Lactase can be supplemented with milk or milk products to reduce gas formation.

 Diet: The list of gas-producing foods is rather long, and it may be difficult to eliminate them all without severely restricting the diet. Those with flatulence must identify the food items in their diet which cause symptoms and modify their diet accordingly by trial and error.   Intestinal gas can be reduced by fermenting the beans, and making them less gas-inducing. Some legumes especially, red beans stand up to prolonged cooking (a common practice in Kashmir), which can help break down the oligosaccharides into simple sugars. Certain spices have been reported to counteract the production of intestinal gas, most notably cumin, coriander, and caraway.  Often it may be helpful to ingest small quantities of acidic liquids with meals, such as lemon juice or vinegar, to stimulate the production of gastric hydrochloric acid. In turn, acid ingestion may increase normal gastric enzyme and acid production, facilitating normal digestion and perhaps limiting intestinal gas production.

Ingestion of bromelain- or papain-containing supplements (such as raw pineapple or papaya, respectively) may be helpful  Simethicone, Charcoal and digestive enzymes: Simethicone has an effect on gas in the stomach, limits swallowed gas and reduces flatulence. Activated charcoal has been shown to reduce the formation of gas in the colon, though the way in which it does so is unknown. Many patients take supplemental pancreatic enzymes with meals which help their digestion and also limit flatulence. An interesting form of treatment for excessive gas is alpha-D-galactosidase, an enzyme that is produced by a mould. This enzyme is consumed as either a liquid or tablet with meals. This enzyme is able to break down some of the difficult-to-digest polysaccharides in vegetables so that they may be absorbed. This prevents them from reaching the colonic bacteria and causing unnecessary production of gas. Alpha-D-galactosidase has been shown to be effective in decreasing the incidence of intestinal gas.

 Probiotics: Probiotics are reputed to reduce flatulence when used to restore balance to the normal intestinal flora. Live (bioactive) yogurt contains, among other lactic bacteria, Lactobacillus acidophilus which may be useful in reducing flatulence. L. acidophilus may make the intestinal environment more acidic, supporting a natural balance of the fermentative processes. L. acidophilus is available in supplements (some believe non-dairy is best).

  Antibiotics: Bacterial overgrowth of the small bowel is usually treated with antibiotics. However, this treatment is frequently only temporarily effective or not effective at all. When antibiotics provide only a temporary benefit, it may be necessary to treat patients intermittently or even continuously with antibiotics. The antibiotic rifaximin, often used to treat diarrhea caused by the microorganism E. coli, may reduce both the production of intestinal gas and the frequency of flatus events. Odour from flatulence, caused by the intestinal bacteria called microflora in the bowel, can be treated by taking bismuth subgallate. Bismuth subgallate is commonly used by individuals who have had ostomy surgery, bariatric surgery, fecal incontinence and irritable bowel syndrome.

(Prof. Muhammad Sultan Khuroo,  MD, DM, FRCP (Edin), FACP, MACP (Emeritus) is   Director, Digestive Diseases Centre, Dr. Khuroo’s Medical Clinic,  Srinagar, Kashmir. Feedback at Khuroo@yahoo.com)

Lastupdate on : Wed, 1 Sep 2010 21:30:00 Mecca time
Lastupdate on : Wed, 1 Sep 2010 18:30:00 GMT
Lastupdate on : Thu, 2 Sep 2010 00:00:00 IST