Case Report | Published:

Evaluation of an extremely flatulent patient: Case report and proposed diagnostic and therapeutic approach

American Journal of Gastroenterology volume 93, pages 22762281 (1998) | Download Citation

This paper was supported in part by general medical research funds from the Department of Veterans Affairs and a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (RO1-DK-13093).

Subjects

Abstract

We recently encountered a patient with severe flatulence who previously had been subjected to innumerable diagnostic tests and ineffective therapies based on the belief that his rectal gas was produced in the colon. Analysis of three flatus samples demonstrated that nitrogen (N2) was the predominant flatus gas whereas the three gases produced in the gut (CO2, H2 [hydrogen], and CH4 [methane]) comprised <16% of rectal gas. This result plus a series of other diagnostic tests clearly indicated that the patient's flatus was derived almost entirely from swallowed air. Based on this case, the present report summarizes available data on excessive flatulence and suggests a rational approach to the patient complaining of this problem. Particular emphasis is placed upon a sequential strategy consisting of: 1) a count of flatus passages to determine if the subject truly is abnormal (normal: <20 passages/day); 2) an analysis of flatus to determine if the flatus originates from swallowed air (predominantly nitrogen) or intraluminal production (predominantly CO2, H2, and CH4); and 3) treatment based upon the origin of the rectal gas.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

References

  1. 1.

    , , , et al. Insights into human colonic physiology obtained from study of flatus composition. Am J Physiol 1997;272: G1028–G1033.

  2. 2.

    , , , et al. Fecal hydrogen sulfide production in ulcerative colitis. Am J Gastroenterol 1998;93: 83–87.

  3. 3.

    , , , et al. Detection of malabsorption of low doses of carbohydrate: Accuracy of various breath H2 criteria. Gastroenterology 1993;105: 1404–1410.

  4. 4.

    , , , et al. Studies of a flatulent patient. N Engl J Med 1976;295: 260–262.

  5. 5.

    , , . Investigation of normal flatus production in healthy volunteers. Gut 1991;32: 665–669.

  6. 6.

    , , . A comparison of symptoms in people with self-reported severe lactose intolerance after drinking milk or lactose-hydrolyzed milk. N Engl J Med 1995;333: 1–4.

  7. 7.

    , , . Absence of gaseous symptoms during ingestion of commercial fiber preparations. Aliment Pharmacol Therapeut 1997;11: 1067–1072.

  8. 8.

    , , . The relationship of passage of gas and abdominal bloating to colonic gas production. Ann Intern Med 1996;124: 422–424.

  9. 9.

    , , . Gases produced by human intestinal microflora. Nature 1966;212: 1238–1239.

  10. 10.

    , , , et al. Esophageal bolus transit imaged by ultrafast computerized tomography. Gastroenterology 1996;110: 1422–1428.

  11. 11.

    , . Intestinal Gas. In: Sleisenger MH, Fordtran JS, eds. Gastrointestinal and liver diseases 6th ed.. Saunders: Philadelphia, 1998: 153–160.

  12. 12.

    , . Factors affecting production and consumption by human fecal flora: The critical role of hydrogen tension and methanogenesis. J Clin Investig 1992;89: 1304–1311.

  13. 13.

    , , , et al. Alterations of the colonic flora and their effect on the hydrogen breath test. Gut 1978;19: 602–605.

  14. 14.

    , , . Colonic adaptation to the daily lactose feeding in lactose maldigesters reduces lactose intolerance. Am J Clin Nutr 1996;64: 1232–1236.

  15. 15.

    , , , et al. Alternative pathways for hydrogen disposal during fermentation in the human colon. Gut 1990;31: 679–683.

Download references

Author information

Affiliations

  1. The Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA

    • Michael D Levitt
    • , Julie Furne
    • , M R Aeolus
    •  & Fabrizis L Suarez

Authors

  1. Search for Michael D Levitt in:

  2. Search for Julie Furne in:

  3. Search for M R Aeolus in:

  4. Search for Fabrizis L Suarez in:

Corresponding author

Correspondence to Michael D Levitt.

Appendices

APPENDIX: Methodology of collection and analysis of flatus samples

Collection of sample

The sample is collected via a rectal tube. To minimize dead space the tube should be of narrow caliber (i.e., 6 mm I.D.) and about 50 cm in length. A two-way stopcock is attached to the external end of the tube. The lubricated tube is inserted approximately 7 cm into the rectum and fixed in this position with adhesive tape. An approximately 600-ml gas-impermeable bag (Quintron, Milwaukee, WI) is attached via a three-way stopcock to the stopcock on the tube. The stopcocks are turned to allow gas to pass from the rectum to the bag. Because the rectal tube contains about 14 ml of deadspace, the first several hundred ml of flatus (2–3 flatus passages) should be discarded by closing the two-way stopcock affixed to the tube and, via the free arm of the three-way stopcock, the bag is opened to the atmosphere. The bag is completely emptied via compression, the three-way stopcock is closed to the atmosphere, and the two-way stopcock is opened to the bag. Following collection of 300 to 500 ml of flatus for analysis, the bag is sealed by appropriate manipulation of the three-way stopcock.

Analysis of sample for quantitatively important gases (1, 2, 7)

All gases are analyzed by gas chromatography. Care must be taken to avoid contamination with atmosphere during dilution and analysis of the sample. Using a 50-ml oiled glass syringe previously rinsed with argon, a sample is removed and analyzed for O2 and N2 using a thermal conductivity detector. If the O2 concentration exceeds 5%, atmospheric contamination during the collection process is likely. H2 is determined using a reduction detector and methane via a flame ionization detector. CO2 is determined with an infrared detector.

The materials required for flatus collection and/or the performance of the gas-analysis are available from the laboratory of the communicating author of this manuscript.

About this article

Publication history

Received

Accepted

Published

DOI

https://doi.org/10.1111/j.1572-0241.1998.00635.x