Do you have Gas Problem? – I

If yes, you will have to take the required measures to get rid of what is more of a social nuisance and a psychological embarrassment than a health hazard, writes Prof....

If yes, you will have to take the required measures to get rid of what is more of a social nuisance and a psychological embarrassment than a health hazard, writes Prof. Muhammad Sultan Khuroo.
 I have too much gas in my abdomen. 1 suffer from belching problem. I pass excess gas and it limits me to attend social functions. I have problem in keeping "wadoo" hindering prayers. I pass foul smelling gas and it makes me feel embarrassed at home. I suffer from abdominal bloating and discomfort. My partner complains of bad breath/smell from my mouth. I   suffer from "Irritable Bowel Syndrome (IBS)".
 Anyone of these is the commonest human problems. Gas problem is more a social nuisance and psychological embarrassment than a health hazard. Gas in many has caused broken marriages; many have never attended a social function and in many gas causes a major psychological breakdown. Many wish to enjoy a good feast meal and have never tasted it. Why is gas such an intractable problem in the community and why cannot we get rid of the gas in those who suffer from it? To answer this we need a detailed discussion on formation of intestinal gas and the way it causes suffering in those who have it.
 First I must make a point and that is 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) and methane (CH4) are the main constituents in normal persons. The proportion of gases in normal persons is highly variable: N2, 11-92%, O2, 0-11%, CO2, 3-54%, H2, 0-86% and CH4, 0-56%. What is the source of gas seen in normal persons? Broadly there are 5 sources of intestinal gas, including
 (i) Air swallowing.
 (ii)  Formation of CO2 in upper intestines from interaction of bicarbonate and acid.
 (iii)  Formation of H2 by intestinal bacteria during fermentation of carbohydrate or protein.
 (iv)  Formation of methane by a bacteria in colon, namely Methanobrevibacter smithi; methane is formed by combining 4 CH4+2HO2).?molecules of H2 and one molecule of CO2 (4H2+CO2 
 (v)  Formation of odoriferous (foul smelling) gases by bacterial fermentation of sulfate, cysteine and mucin (namely hydrogen sulfide), fermentation of methane (namely methanethiol) and fermentation of garlic (namely allyl methyl sulfide).
 Two aspects of gas in intestines need comments namely (i) diffusion of gas between intestines and the blood; and (ii) propulsion and passage of gas through the intestinal tract and out from anus (flatus). H2 and CH4 always diffuse from intestines in to blood and these gases reach lungs and then are excreted out through breath. In contrast N2 diffuses from blood in to intestines. Because of this major source of N2 in flatus may be diffusion of the gas from blood to intestinal lumen. Secondly rate of propulsion and passage of gases out of intestines is a crucial determinant of amount of gas staying in the abdomen.
  are the problems gas causes in different situations. Broadly gas causes five problems namely (1) eructation/belching, (2) bad breath, (3) abdominal bloating (flatulence), (4) passage of noisy voluminous gases per anus, and (5) passage of odoriferous gases per anus.

 A single belch (in Kashmiri vernacular called "dakkur") is a common phenomenon after a meal or drink. In many this satisfies the person who has had a full meal. However, those who repeatedly eructate or belch find themselves in a big trouble. Belching often causes big noise and it causes social embracement in family or at social functions. Others are convinced that belching is a sign of internal disease namely ailment of stomach, liver or intestines.
What causes belching? In fact belching is expulsion of gas which you swallow (aerophagia). People who eructate/belch too much, has habit of swallowing too much gas which reaches the throat and upper food pipe. This gas which is eructated does not reach the stomach. It is not caused by excess gas production in side the bowel. Nearly always belching is not a symptom of internal disease but a functional disorder in which the person swallows excess gas and simultaneously belches it out. These people with noisy belching need explanation and genesis of their symptoms and should be counseled for reducing aerophagia. Maneuvers that reduce aerophagia include chewing food (rather gulping it), eating and drinking slowly, avoiding chewing gums and clenching a pencil between teeth whenever possible (which inhibits swallowing). With all this advice given, belching can be intractable problem in some and needs specialized counseling and treatment.

Bad breath:
 Bad breath means an unpleasant odor in breath. This in medical terminology is called "halitosis". One type of bad breath is normal and this occurs in many of us in early morning (morning mouth) and is due to changes in our mouth while we are at sleep. It is more common in those who breathe through mouth (mouth breathers). After a morning mouth wash and brush this odor in breath disappears and causes no problems. However, bad breath which persists most of the day is a major social embracement for those who suffer from it. In fact it can be a big problem for those colleagues who work with such persons. I have seen many marriages broken due bad breath. Many people become psychologically depressed because they suffer from bad breath or have partner with bad breath. Some people are afraid to be engaged or married for fear of bad breath.
 What causes bad breath? Commonest cause of bad breath is poor oral hygiene and because of this millions of bacteria are formed in back of tongue or within gums. These bacteria cause fermentation of residual food in mouth and produce bad breath. This is a difficult problem to treat and needs intensive mouth hygiene and toilet (Brushing your teeth, tongue and gums after meals, flossing daily and rinsing with a mouthwash approved by the American Dental Association). You also can combat bad breath by drinking plenty of water every day to help your body make saliva. An occasional swish of the mouth with water can loosen bits of food. Other products can help you keep breath fresh and prevent plaque from forming. They include: sugar-free gum, sugarless breath mints, raw carrots and celery. A dental opinion is helpful in order to have dental hygiene. In fact dental hygiene is useful to have even in those who do not have bad breath to prevent it. Apart from this bad breath is often seen in persons with constant nasal discharge and sinus infections. People with recurrent chest infections also can suffer from bad breath. Smoking makes this problem worse and should be avoided.  Bad breath is also seen in persons who eat too much of garlic, onions, coffee or chew tobacco or smoke.  Diabetes (fruity breath), gastroesophageal reflux disease, gastroparesis, gastric stasis, liver disease, and kidney disease (urine smell) can also cause bad breath and it is worthwhile seeing a physician to explore these conditions if one is suffering from bad breath.
Bloating or Flatulence: 
 Bloating or flatulence is the most frequently encountered abdominal complaints. Bloating means abdominal distension either after a meal or on a constant basis. Bloating has a number of causes which include excess fat in abdomen (fatty liver), excess water (ascites) or enlargement of any organs in the abdomen (like spleen enlargement or tumor etc). However the commonest cause of bloating is related to either excess gas in the abdomen (flatulence) or irritable bowel syndrome. In later condition bowel is unusually sensitive to distension and even normal gas contents can lead to distension and bloating. Bloating either caused by excess gas or due to IBS can be a major problem in many persons.
 What causes excess gas in such persons? Gas in many persons 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.

(Prof. Muhammad Sultan Khuroo is Master of American College of Physicians (MACP) and Director, Digestive Diseases Centre. He can be mailed at The second and the concluding part will be published on our regular Health Page the Monday next)

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