Chapter 14. Intestinal Gas

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Handbook of Nonprescription Drugs > Chapter 14. Intestinal Gas
Intestinal Gas: Introduction
Intestinal gas symptoms and conditions that predispose patients to intestinal gas are common, and they may cause
considerable discomfort and lifestyle impairment. The most frequent symptoms are eructation (belching of swallowed air),
bloating (excessive gas, particularly after eating), and flatulence (excessive passage of air from the stomach or intestines
through the anus). Differentiation of healthy individuals with temporary symptoms from those with a chronic gastrointestinal (GI)
condition such as irritable bowel syndrome (IBS), lactose intolerance, or celiac disease is important in recommending
appropriate nonprescription treatment.
The primary categories of nonprescription pharmacologic therapies for intestinal gas symptoms are antiflatulent medications
(simethicone and activated charcoal), digestive enzymes (lactase replacement and alpha-galactosidase products), and probiotic
products (Bifidobacterium, Lactobacillus, Saccharomyces, and Streptococcus species). Sales of antiflatulent and probiotic
products account for a significant portion of the nonprescription drug and dietary supplement markets.1
A significant portion of the U.S. population is affected by conditions that may cause intestinal gas symptoms. Intestinal gas can
be caused by lactose malabsorption (29% of the population), IBS (7%-10%), and other less common medical conditions, such
as celiac disease (1%-3% of the general population and 10% of first-degree relatives of the celiac disease population) and
pancreatic insufficiency (<1%).2-4 In the general population, abdominal distention and bloating are reported by approximately
10% and 20% of individuals in the United States, respectively.5 More than half of symptomatic respondents rated symptoms as
moderate-severe; most indicated that symptoms resulted in some limitation in their ability to conduct usual activities, with 10%
reporting that their activities were reduced by half or more.
Editors Note: This chapter is based on the 17th edition chapter of the same title, written by Patrick D. Meek.
Pathophysiology of Intestinal Gas
The pathophysiology of gas-related complaints in the GI tract (hereafter referred to as intestinal gas) is poorly understood;
however, minor disruptions of normal physiologic processes of the GI tract appear to play a role. Each time food, liquid, or saliva
is swallowed, a small amount of air passes into the stomach. Once in the stomach, the swallowed food and air are mixed with
gastric acid, pepsin, and other substances; churned into small fragments; and then emptied into the small intestine, where most
of the absorption of vitamins, minerals, and digestion products (e.g., food-derived monosaccharides, such as glucose) occurs.6
The rate at which the stomach empties varies but generally takes about 1-2 hours. Smooth muscle contractions in the small
intestine move the liquid food fragments and air downstream toward the large intestine, where the indigestible liquid waste is
mixed with the bacterial flora of the colon. In the colon, most of the remaining liquid is absorbed from the mixture of liquid waste,
bacteria, and intestinal gas as it is transported toward the rectum and temporarily stored as stool prior to a bowel movement.
During a bowel movement, stool is eliminated, and intestinal gas is expelled from the rectum as flatus.
Diet, underlying medical conditions, alterations in intestinal flora, and drugs may precipitate or aggravate symptoms attributed to
intestinal gas. Although the exact mechanisms are not fully known, the origin of gas retention and symptoms appears to be
affected by alterations in visceral sensitivity and intestinal transit that vary at different physiologic locations along the GI tract.6
Certain foods can increase intestinal gas production and lead to bothersome symptoms (Tables 14-1 and 14-2).7-9 Dietary
sugars (e.g., lactose in dairy products and prepared foods; fructose in fruits, vegetables, candies, and soft drinks; sucrose from
table sugar; and glucose from the breakdown of starches) may be incompletely absorbed in the healthy human small
intestine.7 These sugars are the principal substrates for hydrogen gas (H2) production in the colon. Similarly, other foods also
are malabsorbed, including fatty foods; foods rich in complex carbohydrates (e.g., wheat germ, brown rice, bran, and corn); and
indigestible oligosaccharides (e.g., raffinose, found in asparagus, broccoli, Brussels sprouts, and cabbage; and stachyose,
found in black-eyed peas, lima beans, and soy beans). These substances remain in the intestinal lumen, are passed into the
colon, and provide a substrate for bacterial fermentation and colonic production of H2 and carbon dioxide (CO2).6 Fermentation
in the colon is the primary process for generating intestinal gas and is influenced by the quantity of foods ingested.
Diets high in fiber also may lead to bloating and flatulence. Terminology, recommended intake, and potential benefits associated
with fiber are discussed in Chapter 23. Fiber is a valuable component of a balanced diet and may be beneficial in the treatment
of constipation (see Chapter 15). Soluble fiber absorbs water and stabilizes intestinal contractions; however, soluble fiber
supplementation does not appear to decrease IBS symptoms.10 Patients who experience gas-related symptoms (bloating and
flatulence) from natural fiber forms (e.g., psyllium) may prefer a soluble semisynthetic fiber supplement (e.g., calcium
polycarbophil). However, fiber may increase intestinal gas symptoms in patients with IBS, slow intestinal transit, and/or
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diverticulosis.11 Slowly increasing the intake of fiber or using a variety of fiber-containing foods may help reduce symptoms in
patients with these conditions.
TABLE 14-1 Gas-Producing Foods
Foods That Produce Minimal Amounts of Gas
Meats: fowl, fish
Vegetables: lettuce, peppers, avocado, tomato, asparagus, zucchini, okra, olives
Fruit: cantaloupe, grapes, berries
Carbohydrates: white rice, chips, popcorn, graham crackers
All nuts, eggs, gelatin, fruit juice
Foods That Cause Moderate Amounts of Gas
Potatoes
Eggplant
Citrus fruits, apples
Carbohydrates: pastries, bread
Foods That Cause Major Amounts of Gas
Vegetables: onions, celery, carrots, Brussels sprouts, cucumbers, cabbage, cauliflower, radishes
Beans
Fruit: raisins, bananas, apricots, prunes, dried fruit
Carbohydrates: bagels, wheat germ, pretzels
Peas
Green salads
Bran cereal, food high in bran
Brown rice
Leeks, parsnips
Dairy products: milk, ice cream, cheese (in patients who have trouble digesting lactose; check food labels of processed
foods for added lactose or milk-derived ingredients)
Fatty foods: pan-fried or deep-fried foods, fatty meats; rich cream sauces and gravies (although fatty foods are not
carbohydrates, these foods also can contribute to intestinal gas)
Foods with high sugar content or with high fructose corn syrup (e.g., soft drinks)
Products containing sorbitol and mannitol (e.g., sugar-free candies, sugar-free brownie and cake mixes, diet foods, chewing
gum)
Source: References 7 and 9.
The odor attributed to flatulence may be worsened by the ingestion of sulfate-containing foods, such as cruciferous vegetables
(e.g., broccoli and cabbage); breads and beers containing sulfate additives; and proteins with a high content of the sulfur-
containing amino acids methionine and cysteine (e.g., eggs, macadamia nuts, peanuts, pistachio nuts, and red meats).
Sulfur-based gases (e.g., hydrogen sulfide [H 2S]), methanethiol, and dimethyl sulfide are produced through the action of sulfate-
reducing bacteria on sulfate.12 Rating foods by their potential to cause intestinal gas symptoms is difficult, but clinical
experience suggests that certain foods are generally more problematic than others (Table 14-1).
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TABLE 14-2 Oligosaccharide-Containing Foods That Alpha-Galactosidase Might Affect
Vegetables Grains Beans
Beets Bagels Black-eyed peas
Broccoli Barley Bog beans
Brussels sprouts Breakfast cereal Broad beans
Cabbage Granola Chickpeas
Cauliflower Pasta Lima beans
Corn Rice bran Mung beans
Cucumbers Rye Peanuts and peanut butter
Leeks Sorghum, grain Pinto beans
Lettuce Wheat bran Red kidney beans
Onions Whole wheat flour Seed flour (sesame, sunflower)
Parsley Whole-grain breads Soy products (including lentils, soy milk, and tofu)
Peppers, sweet
Source: Reference 8.
Gas-related symptoms also may be associated with the amount of air that enters the upper GI tract upon swallowing. Smoking,
chewing gum, sucking on hard candies, drinking carbonated beverages, wearing poor-fitting dentures, hyperventilating, or being
overly anxious may cause individuals to swallow larger amounts of air than is normal.12 Poor eating habits (e.g., gulping food or
drinking beverages too rapidly) also may cause larger amounts of air to enter the stomach.
A number of medical conditions cause or predispose patients to the formation of intestinal gas. Some conditions (e.g.,
carbohydrate malabsorption and pancreatic insufficiency) lead to an increased amount of gas produced from bacterial
fermentation in the colon. The most common cause of carbohydrate malabsorption is lactase deficiency. Lactase is the enzyme
that normally breaks down lactose in the intestinal lumen so that it can be absorbed. Approximately 50 million people in the
United States are lactose maldigesters and experience symptoms of lactose intolerance when eating dairy products. The
condition is more common in black (90%) and Asian populations (75%) than in eastern Europeans (6%).
In patients with lactase deficiency, the lactase enzyme is not available in sufficient quantities to break down lactose in dairy
products before it reaches the colon. Patients who experience symptoms of lactose intolerance with even small amounts of
lactose may inquire about the lactose content of their medications. Reviewing the list of excipients in the package insert with the
patients and/or contacting the manufacturer can help to determine the lactose content of individual products. Lactose-free
formulations of these medications may be available from the manufacturer. If a lactose-free product is unavailable, a
compounded product may be considered.
In the colon, the malabsorbed lactose remains in the intestinal lumen, where it is available to colonic bacteria for fermentation to
H 2 and other substances. Individuals with lactase deficiency experience GI symptoms (e.g., gas pains, bloating, nausea, and
diarrhea) upon exposure to dairy and other products containing milk or milk-derived carbohydrates (e.g., caramel).13
Milk-derived protein (e.g., whey powder, caseinate, and other lactoproteins) does not cause lactose-associated GI symptoms
unless the product is contaminated with a milk-derived carbohydrate (i.e., lactose).
Bacterial fermentation in the small intestine resulting from bacterial overgrowth also may lead to excessive amounts of intestinal
gas. The effects of probiotics on bloating symptoms associated with small bowel bacterial overgrowth and lactose intolerance
are uncertain (see Chapter 23). Research suggests that probiotics improve bloating associated with lactose intolerance by
producing lactic acid, which in turn improves lactose digestion.13 Patients with lactose intolerance are at risk for the
development of low bone density and osteoporosis because of reduced dietary intake; they should be counseled to supplement
their diets to achieve the recommended daily intake of 1000-1200 mg of elemental calcium per day.
Other conditions such as IBS may predispose patients to intestinal gas symptoms. Gas pains and bloating are very common in
patients with IBS and may be caused by a number of interrelated factors, including heightened sensation of the GI tract to
intestinal stretch (or visceral hypersensitivity), altered intestinal motility, activated intestinal immunity, altered brain-gut
interaction, and autonomic dysfunction.14 Small bowel bacterial overgrowth has been proposed as a unifying theory linking each
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of these factors, which has stimulated exciting research that aims to further define the relationship between intestinal bacterial
overgrowth and the onset of IBS symptoms.14 Probiotics (e.g., lactobacilli, saccharomyces, and bifidobacteria) are part of the
normal healthy flora of the intestinal tract. They are thought to maintain intestinal health through a variety of mechanisms,
including by shifting the intestinal bacterial content in favor of nonpathologic organisms; by producing beneficial substances
(e.g., short-chain fatty acids); and by acting primarily as carbohydrate-fermenting bacteria, thereby reducing intestinal gas
production (see Chapter 23). Substances such as oligofructose (a prebiotic) are used as nutrients by the normal intestinal
bacterial flora and by probiotic organisms; however, the normal flora produces greater amounts of CO2 and H2, which may result
in increased symptoms of intestinal gas.5,15
Intestinal gas symptoms also may result from other less common medical conditions (e.g., celiac disease or diabetic
gastroparesis). Patients with celiac disease have an intolerance to gluten (a protein contained in wheat, rye, barley, and oats).
Once a diagnosis of celiac disease has been made, and once gluten intolerance has been confirmed with an accurate test,
patients should follow a gluten-free diet, preferably under the supervision of an experienced dietitian.2,15 Intestinal gas
symptoms may result from the inflammatory response that occurs in the GI tract after exposure to gluten. The most common
sources of gluten are baked goods containing the causative grains (wheat and oat cereals, noodles, and pastas); however,
many other food products (especially any processed foods containing thickeners) and some medications contain gluten.
Successful adherence to a gluten-free diet requires rigorous label reading and close scrutiny of the gluten content of foods and
nonprescription medications. A number of valuable resources exist for individuals seeking information about celiac disease.16,17
In addition, referral to a registered dietitian may be beneficial because all gluten must be removed from the diet to avoid
symptoms.
A variety of drugs may cause intestinal gas symptoms. These drugs can be categorized broadly by the mechanisms that cause
symptoms: drugs that affect intestinal flora (lactulose and antibiotics); drugs that affect metabolism of glucose and other dietary
substances (alpha-glucosidase inhibitors, including acarbose and miglitol; and the biguanides, including metformin); and GI
lipase inhibitors (orlistat). Drugs that affect GI motility (narcotics, anticholinergics, and calcium channel blockers); drugs that are
high in fiber (psyllium) or nonabsorbable polymers (cholestyramine); and drugs that contain or release gas (effervescent
solutions such as Alka-Seltzer) also may cause intestinal gas symptoms.
Clinical Presentation of Intestinal Gas
Patients with symptoms of intestinal gas complain most commonly of excessive belching, abdominal discomfort or cramping,
bloating, and flatulence. Complaints of gas pains and belching are more common than are complaints of flatulence. Other less
common symptoms associated with gaseousness include nausea; audible bowel sounds (called borborygmi); and dyspepsia
or indigestion.
Everyone experiences belching, especially after eating and drinking. Belching is the easiest way for air to leave the stomach
after it is swallowed. Some people have excessive belching, which may be annoying or embarrassing because of its frequency
and/or unexpected occurrence. The more frequently a person swallows, the greater the potential for air to enter the stomach.
Drinking carbonated beverages or eating food too quickly is an easy way to increase the amount of air that is swallowed
inadvertently, which may then cause excessive belching.
Gas pains often are described as a generalized, crampy discomfort associated with gaseousness. Passing gas or having a
bowel movement may relieve gas pains. In some patients, symptoms may be brought on by stress or anxiety. In others, the size
of a meal may be associated with the onset and severity of gas pains, with larger meals causing more bothersome symptoms.
Patients who complain of recurrent gas pains (occurring at least 3 days per month in the last 3 months) that are associated with
either diarrhea or constipation may have IBS. Because gas pains can mimic other conditions (e.g., biliary colic [and other
diseases of the gallbladder and biliary tract], diabetic gastroparesis, peptic ulcer disease, intestinal obstruction, neoplastic
disease, pancreatic insufficiency, or heart disease), a qualified health care provider (pharmacist, physician, nurse practitioner,
etc.) should be consulted prior to initiating self-management. Patients should be referred to a primary care provider if they are
experiencing new-onset, persistent, or frequent and/or severe symptoms. These symptoms may be related to an undiagnosed
condition and should not be self-managed. In addition, patients should be referred to a primary care provider for medical
evaluation if any of the criteria for exclusions for self-management are met (Figure 14-1).
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Self-care of intestinal gas symptoms. Key: GI = Gastrointestinal; OTC = over-the-counter.

Bloating may be characterized as a sensation of tension in the abdominal area after eating or as a subjective sensation that the
abdomen is larger than normal. Patients with bloating may observe that clothes fit more tightly or are difficult to fit into
comfortably. Eating certain foods (Tables 14-1 and 14-2) (especially foods high in fiber), eating too rapidly, or eating too much
may contribute to bloating. Similar to chronic gas pains, chronic bloating accompanied by a change in bowel function is
suggestive of IBS. Patients with diabetes who complain that their bloating symptoms are accompanied by a sensation of early
satiety or fullness after the ingestion of only a small amount of food may be experiencing diabetic gastroparesis and should be
referred to a primary care provider.
Most patients who complain of flatulence are referring to the unpleasant, uncontrollable, or frequent passage of intestinal gas
through the rectum. Passing gas is normal and occurs either consciously or unconsciously between 20 and 40 times a day, even
while sleeping. Certain foods (Tables 14-1 and 14-2) (especially those that contain fiber, fructose, lactose, or oligosaccharides)
are more likely to cause gas and therefore can contribute to flatulence. Sorbitol or mannitol from commonly used sweeteners in
low-calorie foods and liquid medications also can contribute to flatulence.
Treatment of Intestinal Gas
Treatment Goals
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The goals of therapy are to (1) reduce the frequency, intensity, and duration of intestinal gas symptoms and (2) reduce the
impact of intestinal gas symptoms on the patients lifestyle. Because a certain amount of intestinal gas production is normal and
necessary for normal GI function, the complete elimination of intestinal gas is not a realistic or attainable goal.
General Treatment Approach
Self-treatment of intestinal gas symptoms should begin with an assessment of the patients history of symptoms, diet, eating
habits, medication use, and relevant medical conditions. Most patients will be able to control their symptoms if they understand
how the symptoms occur, follow steps to reduce predisposing factors, and make informed decisions regarding the use of
nonprescription medications. Identification of the underlying cause of intestinal gas will guide treatment decisions (Figure 14-1).
Inquiry into the patients diet (including a review of the patients eating habits and rate of food ingestion) often can lead to
appropriate suggestions for reducing the problem. Symptoms that are related to eating habits or diet often will subside quickly,
once the source of the problem is identified and the necessary changes are made.
Patients who associate symptoms with foods containing lactose or oligosaccharides and who do not meet the criteria for
exclusions for self-treatment (Figure 14-1) may use digestive enzymes (e.g., lactase replacement or alpha-galactosidase
products). Although several nonprescription antiflatulent products are available (e.g., activated charcoal and simethicone), their
use is largely empiric, and evidence supporting their benefit is limited. Probiotics (see Chapter 23) maintain gastrointestinal
health by protecting against pathologic GI flora; they may be useful for some individuals with intestinal gas.18 No consensus
exists on whether probiotics or prebiotics are beneficial in patients with lactose intolerance or chronic abdominal bloating;
however, increasing evidence suggests that probiotics may be beneficial for treatment of intestinal gas symptoms in patients
with IBS because the probiotics have favorable effects on the bacterial content of the small intestine and colon.14,18,19 The
benefit of probiotic products may potentially be linked to specific bacterial strains. More research is needed to identify the true
value of individual probiotics.18,19
Exclusions for self-treatment (Figure 14-1) should be reviewed with the patient prior to recommending therapy. Referral of the
patient to a primary care provider for further evaluation should be considered for patients with exclusions for self-treatment and
for patients whose symptoms persist after initiating simple treatment options (e.g., dietary modification and nonprescription
medications).
Nonpharmacologic Therapy
General information for controlling intestinal gas symptoms is provided in Table 14-3.20 Patients may benefit from changes in
eating habits and changes in diet. Reducing the consumption of gas-producing foods (Tables 14-1 and 14-2) may be
appropriate, depending on the patients history. Some people are unable to tolerate gas-producing foods and need to completely
avoid these foods in their diet. Patients with lactose intolerance either should avoid milk and dairy products or should use
lactase replacement products. Low-lactose milk products (e.g., Lactaid Milk or Dairy Ease Milk), fortified soy milk, almond milk,
or rice milk products also may be used as milk substitutes. Low-lactose milk is a prehydrolyzed milk product (i.e., lactose is
already hydrolyzed) and contains the same nutrients as regular milk, but the product is not entirely lactose free. Soy milk,
almond milk, and rice milk products are palatable lactose-free milk alternatives that are low in fat and may be fortified to include
calcium and vitamin D. Similarly, patients who are unable to tolerate foods with high oligosaccharide content should attempt to
reduce or remove these foods from their diet.
Understanding the food values of people from different cultures, ethnicities, and socioeconomic backgrounds may lead to
improved identification of dietary patterns known to contribute to intestinal gas symptoms. This knowledge may allow health care
providers to identify and explain, in a culturally sensitive manner, why problematic gas-forming foods are not appropriate options
for all patients. Addressing dietary issues with family members may be a better approach for developing healthy eating habits
over time, especially for children experiencing intestinal gas symptoms.
Pharmacologic Therapy
Simethicone and activated charcoal may relieve symptoms after intestinal gas has formed. Alpha-galactosidase and lactase
enzymes are taken with foods to prevent gas from forming. Lactase replacement products may be beneficial for the treatment of
intestinal gas and diarrhea associated with lactose intolerance; they also are used as digestive aids, allowing individuals with
lactose intolerance to incorporate dairy foods into their diet without producing intolerable symptoms. Most lactose maldigesters
can tolerate some milk (up to 1 cup), so use of these products should be individualized according to the patients report of
symptoms.
TABLE 14-3 Useful Information to Help Patients Decrease Symptoms of Intestinal Gas
Eating Habits
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Eating Habits
Relax a bit before eating. Follow this simple breathing technique to enhance relaxation and release tension:
- Sit straight in a comfortable position with your arms and legs uncrossed.
- Breathe in comfortably, using your abdomen. Pause briefly before exhaling.
- Each time you exhale, count silently to yourself, One . . . two . . . three . . . four.
- Repeat this cycle for 5-10 minutes.
- Notice your breathing gradually slowing, your body relaxing, and your mind calming as you practice this breathing technique.
Avoid the temptation to rush through a meal. Eat and drink slowly in a calm environment.
Chew food thoroughly.
Avoid washing down solids with a beverage.
Avoid gulping and sipping liquids, drinking out of small-mouthed bottles or straws, or drinking from water fountains.
Eliminate pipe, cigar, and cigarette smoking.
Avoid chewing gum and sucking hard candy, especially those that contain artificial sweeteners (e.g., sorbitol or mannitol).
Check dentures for proper fit.
Attempt to be aware of and avoid deep sighing.
Do not attempt to induce belching or strain to pass gas.
Do not overload the stomach at any one meal.
Diet
Keep a dietary diary for a few days while tracking intestinal gas symptoms.
Avoid gas-producing foods (Table 14-1).
Avoid foods with air whipped into them (e.g., whipped cream, souffls, sponge cake, milk shakes).
Avoid carbonated beverages (e.g., sodas, beer).
Avoid caffeinated beverages (e.g., coffee, energy drinks).
Medication Use and Lifestyle Habits
Avoid long-term or frequent intermittent use of medications intended for relief of cold and allergy symptoms (e.g.,
anticholinergic antihistamines such as brompheniramine, carbinoxamine, chlorpheniramine, clemastine, and
diphenhydramine).
Avoid or minimize the use of drugs affecting GI motility (narcotics and calcium channel blockers).
Avoid or minimize the use of drugs affecting glucose metabolism (orlistat; alpha-glucosidase inhibitors, including acarbose
and miglitol; and the biguanides, including metformin).
Avoid or minimize the use of drugs that affect the intestinal flora (lactulose and antibiotics).
Avoid drugs high in fiber (psylium).
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Eating Habits
Avoid nonabsorbable polymers (cholestyramine).
Avoid drugs that contain or release gas (e.g., Alka-Seltzer).
Avoid tight-fitting garments, girdles, and belts.
Do not lie down or sit in a slumped position immediately after eating.
Develop a regular routine of exercise and rest.
Source: References 9 and 20.
Simethicone
Simethicone (a mixture of inert silicon polymers) is used as a defoaming agent to relieve gas. Simethicone acts in the stomach
and intestine to reduce the surface tension of gas bubbles that are embedded in the mucus of the GI tract. As surface tension
changes, the gas bubbles are broken or coalesced and then eliminated more easily by belching or passing gas through the
rectum.21
The Food and Drug Administration (FDA) considers simethicone safe and effective as an antiflatulent agent. In patients with
acute, nonspecific diarrhea, the combination of simethicone with loperamide produced quicker relief from gas-related discomfort
than either agent alone.22 However, simethicones ability to reduce intestinal gas symptoms for all patients with symptoms is
questionable.23 The use of simethicone may be encouraged on a trial basis because some patients report benefit. The usual
adult and pediatric dosages for simethicone are provided in Table 14-4.
Many antacid products contain a combination of simethicone and antacids; therefore, patients should follow the label
instructions for dosages of these products. However, use of both agents often is unnecessary, and the efficacy of such
combination products has not been well-studied. Furthermore, single-ingredient antiflatulent products (Table 14-5) usually
contain a higher concentration of simethicone than the combination products. Because simethicone is not absorbed from the GI
tract, it has no known systemic side effects; its safety has been well-documented. Simethicone is contraindicated in patients with
a known hypersensitivity to simethicone products or suspected intestinal perforation and obstruction.
Activated Charcoal
Activated charcoal also is promoted for relief of intestinal gas; however, it is neither approved nor shown to be effective for this
indication.24 The usual adult dosages for this agent are provided in Table 14-4. The proposed antiflatulent properties of activated
charcoal are related to the adsorbent effects of the substance and its potential to facilitate the elimination of intestinal gas from
the GI tract. Activated charcoal has been purported to be beneficial for the elimination of malodorous, sulfur-based gases.24
Activated charcoal also has poor palatability. External devices containing activated charcoal also are available to reduce the
odor of flatus in patients with ostomies (see Chapter 21).
Combination Products
Combination products containing simethicone and activated charcoal also are available; these products aim to provide relief
from intestinal gas symptoms by combining the gas-reducing activity of each of the individual components. Table 14-5 lists
examples of commercially available products, including products containing activated charcoal and simethicone.
Alpha-Galactosidase
Another FDA-approved product for use as an antiflatulent is the enzyme alpha-galactosidase. This enzyme, which is derived
from the Aspergillus niger mold and is classified as a food, hydrolyzes oligosaccharides into their component parts before they
can be metabolized by colonic bacteria. The usual adult and pediatric dosages for alpha-galactosidase are provided in Table
14-4.21
TABLE 14-4 Dosage Guideline for Intestinal Gas Products
Dosage
Children 2 to <
Agent Adults Children 12 Years Children < 2 Years
12 Years
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Dosage
Children 2 to <
Agent Adults Children 12 Years Children < 2 Years
12 Years
Simethicone 40-360 mg after meals and at bedtime, 40-360 mg 4 times 40 mg 4 times 20 mg 4 times daily,
as needed daily daily as needed
Activated 520 mg (2 capsules) orally after meals, Specific guidelines not

charcoal as needed; may repeat hourly available
Alpha- 300-450 units per serving of food Not recommended

galactosidase
Lactase enzyme 3000-9000 units at first bite of food or Specific guidelines not
drink containing lactose available
Probiotics Specific guidelines not available Specific guidelines not

available
Because high-fiber foods contain large amounts of oligosaccharides, alpha-galactosidase is recommended as a prophylactic
treatment of intestinal gas symptoms produced by high-fiber diets or foods that contain oligosaccharides (Table 14-2). Two
controlled trials of alpha-galactosidase demonstrated that the agent significantly reduced symptoms of intestinal gas in healthy
individuals fed oligosaccharide-containing foods.25,26
The safety of alpha-galactosidase remains to be determined. Although this enzyme has been used in food processing for years
and is regarded as safe by FDA, the amount contained in available pharmacologic products is probably much greater than that
in processed foods. Because the enzyme produces galactose, this product should not be used by patients with galactosemia
(an inherited metabolic disorder in which galactose accumulates in the blood because of the deficiency of an enzyme that
catalyzes galactoses conversion to glucose). Similarly, patients with diabetes should be cautioned about the use of the enzyme,
which may produce 2-6 grams of carbohydrates per 100 grams of food. 25 Because alpha-galactosidase is derived from mold,
allergic reactions are possible in patients allergic to molds.
Lactase Replacement Products
Lactase replacement products are used in patients with lactose intolerance (see Chapter 16). Lactase enzymes break down
lactose, a disaccharide, into the monosaccharides glucose and galactose, which are absorbed. Lactase replacement products
should be used in patients with lactose intolerance to aid in the digestion of dairy products. There are no adverse effects listed
for lactase replacement products. The usual adult dose for lactase enzymes is provided in Table 14-4.
Product Selection Guidelines
Special Populations
Several pediatric formulations of simethicone are indicated for the relief of intestinal gas. These products, which contain
simethicone 40 mg per 0.6 mL suspension, often are promoted and used to relieve gas associated with colic. However,
simethicone has not been found to be superior to placebo for intestinal gas and/or infantile colic.27 Although its efficacy is
questionable, simethicone is not absorbed from the GI tract, and it is considered safe for use in infants and children. There are
no reports linking simethicone to congenital defects.27 Simethicone is a Pregnancy Category C drug and is considered to be
safe for use by nursing mothers.
For alpha-galactosidase products, safety and efficacy have not been evaluated in infants and children. Therefore, this product
should not be used in pediatric patients until data are available to support such use. Manufacturers recommend that pregnant or
nursing patients first consult with a primary care provider before using alpha-galactosidase.
No special population considerations are listed for lactase replacement products. Patients should consult a primary care
provider if symptoms continue after using a lactase replacement product, or if symptoms are unusual and seem unrelated to
eating dairy products.
Patient Factors
Alpha-galactosidase and lactase replacement products are used to prevent the onset of symptoms in patients unable to tolerate
problematic foods. Patients with gas symptoms who need immediate relief and patients who cannot associate their symptoms
with certain foods should use simethicone. Activated charcoal may be an alternative to simethicone for patients with gas
symptoms, and also it may be beneficial for patients who experience malodorous gas production. Because alpha-galactosidase
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produces carbohydrates, patients with galactosemia or diabetes mellitus should avoid this product and use simethicone instead.
Patients with lactase maldigestion who experience symptoms of lactose intolerance should consider taking lactase replacement
products at the time of exposure to dairy products.
Patient Preferences
Most products for intestinal gas are available in a variety of strengths and dosage forms. A liquid formulation of simethicone is
available for infants. Simethicone also is available as chewable tablets, softgels, and an edible filmstrip. Liquid dosage forms
and alternative solid dosage forms are generally more expensive than standard solid oral dosage forms (e.g., tablets and
capsules) but may be more palatable. Activated charcoal is available in two solid oral dosage forms (tablets and capsules) and
in a combination product with simethicone.
TABLE 14-5 Selected Antiflatulent Products
Trade Name Primary Ingredients
Single-Entity Simethicone Products
Gas-X Regular Strength Simethicone 80 mg

Chewable Tablets
Gas-X Extra Strength Chewable Simethicone 125 mg

Tablets
Mylanta Gas Chewable Tablets Simethicone 125 mg
Phazyme Chewable Tablets Simethicone 125 mg
Gas-X Childrens Tongue Simethicone 40 mg per edible film strip

Twisters
Gas-X Thin Strips Simethicone 62.5 mg per edible film strip
Mylicon Infants Drops Simethicone 40 mg/0.6 mL
Activated Charcoal Products
Charcoal Tablets Activated charcoal 260 mg
CharcoCaps Capsules Activated charcoal 260 mg
Combination Charcoal Product
Charcoal Plus Tablets Activated charcoal 250 mg; simethicone 80 mg
Alpha-Galactosidase Replacement Products
Beano Chewable Tablets Alpha-galactosidase 150 units (1 tablet)
Beano Meltaway Tablets Alpha-galactosidase 300 units (1 tablet)
Lactaid Original Strength Lactase enzyme 3000 units

Caplets
Lactaid Chewable Tablets Lactase enzyme 4500 units
Lactase Fast Act Chewable Lactase enzyme 9000 units

Tablets
Lac-Dose Tablets Lactase enzyme 3000 units
Lactrase Capsules Lactase enzyme 250 mg (3750 lactase enzyme units)
Lacteeze Drops Lactase enzyme 5 drops (80 lactase enzyme units)
Probiotic Products
10 of 19 3/15/2015 1:20 AM
Trade Name Primary Ingredients
Single-Entity Simethicone Products
Activia Probiotic Yogurt Lactobacillus bulgaricus; Streptococcus thermophilus; Bifidobacterium animalis DN173010
(1 108 live bacteria per grama)
Align Digestive Care Probiotic Bifidobacterium infantis 35624 (4 mg = 1 109 live bacteria)
Supplement Capsules
Culturelle Probiotic Digestive Lactobacillus GG (1 1010 live bacteria per capsule)

Health Capsules
DanActive Probiotic Dairy Drink Lactobacillus bulgaricus; Streptococcus thermophilus; Lactobacillus casei DN-114 001
Danimals Yogurt Smoothie Lactobacillus bulgaricus; Streptococcus thermophilus; Lactobacillus rhamnosus GG (1

Drinks 108 live bacteria per grama)
FloraQ Lactobacillus acidophilus; Bifidobacterium; Lactobacillus paracasei; Streptococcus

thermophilus 230 mg (an aggregate of a minimum of 8 109 freeze-dried bacteria)
Florastor Saccharomyces boulardi freeze-dried capsules 250 mg
a Meets National Yogurt Association criteria for live and active culture yogurt.
Alpha-galactosidase is available as tablets, caplets, and meltaway tablets. There is no difference in onset of symptomatic relief
between these dosage forms, so the choice between dosage forms is left entirely to personal preference and convenience.
A variety of products also is available for patients with lactose intolerance. Lactase replacement products can be added to milk
or dairy products to reduce the amount of lactose in the product, or they can be ingested along with dairy products in an effort to
reduce the amount of lactose in the food. Additionally, patients may elect to use one of the available milk alternatives (e.g.,
low-lactose milk, fortified soy milk, almond milk, or rice milk).
Complementary Therapies
A variety of probiotic dietary supplements (see Chapter 23) is widely used for GI complaints, including intestinal gas and
bloating.18 The most common formulations for intestinal gas (Table 14-5) are capsules with one bacterium (e.g., Bifidobacterium
infantis) or multiple bacteria (e.g., Lactobacillus acidophilus, Lactobacillus paracasei, Bifidobacterium, and Streptococcus
thermophilus). Functional fermented food products with live active cultures of probiotic species (e.g., kombucha tea and kefir
products) also are available. In patients with IBS and those with lactose intolerance, increasing but limited evidence suggests
that specific probiotics provide temporary relief from GI symptoms.18,19 Probiotic bacteria leave the intestine soon after therapy
is discontinued. When using probiotic therapy, daily administration is required to maintain bacterial populations in the intestinal
flora. An adequate trial of 14 days is generally recommended for patients interested in using probiotic therapy. Research shows
that probiotics are effective in reducing the incidence of antibiotic-associated diarrhea. More studies are required to identify
which probiotic strains are most efficacious for patients receiving specific antibiotics.27
Carminatives (e.g., fennel, Japanese mint, peppermint, and spearmint) are other natural products commonly used for intestinal
gas.28 Despite insufficient evidence, these agents are widely used for the management of intestinal gas and IBS.28,29
Carminatives may reduce the tone of the lower esophageal sphincter and should be minimized or avoided by patients with
gastroesophageal reflux disease (see Chapter 13); however, the effect of carminatives on lower esophageal sphincter tone in
healthy individuals with intestinal gas symptoms may be less problematic.30 Fennel can cause photodermatitis, is
contraindicated during pregnancy, and enters breast milk in lactating women. If fennel is used, patients should be advised to
avoid excessive sunlight and to avoid use during pregnancy and lactation. In addition, coadministration of fennel with
ciprofloxacin may lead to reduced ciprofloxacin levels through a chelation mechanism, so doses should be spaced appropriately
in patients using both agents.31
Assessment of Intestinal Gas: A Case-Based Approach
When a patient complains of intestinal gas, it is important to try to discern the causes, duration, and frequency of the symptoms
(Table 14-6). Items that produce relief may provide clues as to the cause. A thorough review of dietary habits, medical problems,
and use of prescription and nonprescription medications may provide other clues.
TABLE 14-6 Differentiation of Intestinal Gas Discomfort and Irritable Bowel Syndrome
11 of 19 3/15/2015 1:20 AM
Criterion Intestinal Gas Discomfort Irritable Bowel Syndrome
Location Generalized discomfort in the upper, mid, or lower abdomen Generalized discomfort, bloating, and/or pain
in the lower abdomen or colon
Signs Eructation (upper abdomen): belching of air; bloating (mid No physical signs of disease; no fever,
abdomen): increased abdominal girth; flatulence (lower melena, hematochezia, or signs of other
abdomen, colon): excessive air or other gas in the stomach gastrointestinal conditions
and intestines
Symptoms Sensation of accumulated intestinal gas; may present as Vary widely but are commonly described as
minimal physical discomfort but with significant negative abdominal pain that is relieved after a bowel
psychosocial effects movement, is accompanied by either diarrhea
or constipation, and usually lasts at least 3
months
Onset May occur at any age Begins in early adulthood; rarely occurs after
the age of 60
Etiology Symptoms commonly believed to be caused by an Unknown

excessive amount of gas in the stomach (eructation) and May result from altered gastrointestinal
intestines (bloating, flatulence); other causes include lactase motility, heightened visceral sensitivity, and/or
deficiency, overgrowth of intestinal bacteria, and excessive overgrowth of intestinal bacteria
air swallowing (aerophagia)
Exacerbating Diet; underlying medical conditions; and certain drugs (e.g., Stress; overeating; problem foods (e.g.,
factors lactulose, antibiotics, alpha-glucosidase inhibitors, orlistat, alcohol, chocolate, caffeinated beverages,
narcotics, anticholinergics, calcium channel blockers, dairy products, and sugar-free products that
psyllium or cholestyramine, and effervescent solutions) contain sorbitol or mannitol); foods high in fat
Modifying Minimization of exacerbating factors Minimization of exacerbating factors; primary

factors care provider evaluation and treatment
Cases 14-1 and 14-2 are examples of the assessment of patients with intestinal gas.
Patient Counseling for Intestinal Gas
Patient counseling is important to ensure the appropriate selection and use of nonprescription medications for intestinal gas.
Patients should be encouraged to keep a diary of foods in an effort to identify those that are problematic. Avoidance of foods or
other substances that cause intestinal gas is the best advice to give patients. The health care provider should explain the proper
use of medications for intestinal gas and should warn the patient of possible adverse effects. The box Patient Education for
Intestinal Gas contains specific information to provide patients.
Case 14-1
Relevant Evaluation Criteria Scenario/Model Outcome
Information Gathering
1. Gather essential information about the patients

symptoms and medical history, including:
a. description of symptom(s) (i.e., nature, onset, The patient complains of occasional stomach pain, bloating, and
duration, severity, associated symptoms) flatulence. She states the symptoms started about 4-5 months ago and
have progressively been getting worse. Symptoms now include diarrhea,
nausea, and fatigue.
12 of 19 3/15/2015 1:20 AM
b. description of any factors that seem to The patient states that the symptoms seem to get worse when she
precipitate, exacerbate, and/or relieve the patients drinks her sugar-free vanilla lattes or eats fast food. There are times
symptom(s) when the pain is present in the lower abdomen, and the patient cannot
identify a cause. Having a bowel movement tends to relieve some of the
pain some of the time.
c. description of the patients efforts to relieve the She has tried several OTC products without much success. The
symptoms products include simethicone 125 mg 4 times a day and Tums 500 mg
3 times daily.
d. patients identity Ellie Dawn
e. age, sex, height, and weight 28 years old, female, 5 ft 6 in., 145 lb
f. patients occupation Social worker
g. patients dietary habits Skips breakfast unless she stops at a coffee stand for a latte and whole
wheat muffin. Eats sporadically during the day as her schedule allows.
Frequently eats at fast food restaurants or consumes prepackaged
meals.
h. patients sleep habits 7-8 hours nightly
i. concurrent medical conditions, prescription and Depression: citalopram 10 mg once daily; hypertension: lisinopril 20 mg
nonprescription medications, and dietary once daily
supplements
j. allergies None
k. history of other adverse reactions to None

medications
l. other (describe) _______ Over the past several months, the patient reports losing 10 pounds
without changing her diet or increasing exercise.
Assessment and Triage
2. Differentiate patients signs/symptoms and Abdominal symptoms are consistent with intolerance to multiple foods,
correctly identify the patients primary problem(s) which suggests the possibility of a lactose intolerance, oligosaccharide
(Table 14-6). intolerance, and glucose sensitivity (celiac disease). Fatigue and weight
loss also support a disorder with a nutritional deficiency component,
possibly IBS.
3. Identify exclusions for self-treatment (Figure Unintended weight loss; length of time symptoms have been present.
13 of 19 3/15/2015 1:20 AM
14-1).
4. Formulate a comprehensive list of therapeutic Options include:

alternatives for the primary problem to determine if (1) Refer to a primary care provider or gastroenterologist for a differential
triage to a health care provider is required, and diagnosis.
share this information with the patient or caregiver. (2) Recommend patient keep a food, stress, and symptom diary
(3) Take no action.
Plan
5. Select an optimal therapeutic alternative to Ellie should be referred to a primary care provider or gastroenterologist
address the patients problem, taking into account for a differential diagnosis.
patient preferences.
6. Describe the recommended therapeutic You should immediately follow up with your primary care provider or
approach to the patient or caregiver. gastroenterologist.
7. Explain to the patient or caregiver the rationale Current treatment available OTC will not adequately address the
for selecting the recommended therapeutic severity of the current symptoms you have. It is important that you follow
approach from the considered therapeutic up with your primary care provider to identify the cause of your
alternatives. complaints and associated weight loss.
Patient Education
8. When recommending self-care with Criterion does not apply in this case.
nonprescription medications and/or nondrug
therapy, convey accurate information to the patient
or caregiver.
Solicit follow-up questions from the patient or Is there anything that I can do right now to address my symptoms prior
caregiver. to getting in to see the doctor?
Answer the patients or caregivers questions. Immediately following up with your primary care provider is the best
course of action.
Evaluation of Patient Outcome
9. Assess patient outcome. Contact the patient in 1-2 days to ensure she sought medical care and
made an appointment.
Key: IBS = Irritable bowel syndrome; OTC = over-the-counter.
Case 14-2
14 of 19 3/15/2015 1:20 AM
1. Gather essential information about the

patients symptoms and medical history,
including:
a. description of symptom(s) (i.e., nature, Patient presents with complaints of bloating with an increased amount of burping
onset, duration, severity, associated and flatulence. The symptoms are mild in nature but uncomfortable and
symptoms) embarrassing.
b. description of any factors that seem to Symptoms seem to be worse after eating large meals, especially when ice
precipitate, exacerbate, and/or relieve the cream or milk is consumed. The bloating seems to decrease after episodes of
patients symptom(s) burping or flatulence.
c. description of the patients efforts to The patient has tried including 1 serving of Activia yogurt into his diet over the
relieve the symptoms past few weeks with no relief.
d. patients identity Francis Welker
e. age, sex, height, and weight 44 years old, male, 6 ft, 240 lb
f. patients occupation Publicist
g. patients dietary habits Never misses a meal and enjoys eating fried southern comfort food, ice cream,
and soda.
h. patients sleep habits 5-7 hours a night
i. concurrent medical conditions, Hypertension: losartan 50 mg, 1 tablet every morning GERD: omeprazole 20 mg,
prescription and nonprescription 1 capsule every morning with breakfast
medications, and dietary supplements
j. allergies Penicillin (rash)
k. history of adverse reactions to None

medications
Assessment and Triage
2. Differentiate patients signs/symptoms Patient is currently experiencing intestinal gas and bloating due to dietary
and correctly identify the patients primary intolerances.
problem(s).
3. Identify exclusions for self-treatment None

(Figure 14-1).
15 of 19 3/15/2015 1:20 AM
4. Formulate a comprehensive list of Options include:

therapeutic alternatives for the primary (1) Refer patient to an appropriate health care provider.
problem to determine if triage to a health (2) Recommend self-care with lactose intolerance product (e.g., Lactaid) in
care provider is required, and share this addition to simethicone and a reduction in meal size.
information with the patient or caregiver. (3) Recommend self-care until patient can see an appropriate provider.
(4) Take no action.
Plan
5. Select an optimal therapeutic alternative Francis should take a lactase enzyme whenever he eats more than 4 ounces of
to address the patients problem, taking dairy. Gas or bloating can be treated with simethicone. He should avoid large
into account patient preferences. meals and carbonated beverages.
6. Describe the recommended therapeutic You should take Lactaid Original Strength Capsules whenever you eat more
approach to the patient or caregiver. than 4 ounces of dairy. The Gas-X Extra Strength tablets can be taken with
meals or snacks. You should avoid large meals and carbonated beverages.
7. Explain to the patient or caregiver the The Lactaid will help with the digestion of dairy productsincluding yogurt, milk,
rationale for selecting the recommended and ice creamwhich should decrease the amount of gas produced. If you do
therapeutic approach from the considered experience an increase in belching, flatulence, or bloating, you can use Gas-X,
therapeutic alternatives. which helps expel gas bubbles formed within your stomach and intestine. By
reducing your meal size and avoiding carbonated beverages, you should notice
some relief from the bloating you have been experiencing.
Patient Education
8. When recommending self-care with

nonprescription medications and/or
nondrug therapy, convey accurate
information to the patient or caregiver.
a. appropriate dose and frequency of See Table 14-4.

administration
b. maximum number of days the therapy No maximum, as long as the symptoms are relieved and do not worsen.
should be employed
c. product administration procedures Take the product by mouth.
d. expected time to onset of relief Soon after administration.
e. degree of relief that can be reasonably If your bloating and gas are being caused by lactose intolerance, then the
expected Lactaid should give you mild to moderate relief.
f. most common side effects None
16 of 19 3/15/2015 1:20 AM
g. side effects that warrant medical None

intervention should they occur
h. patient options in the event that See Figure 14-1.

condition worsens or persists
i. product storage requirements Store in a cool, dry place out of childrens reach.
j. specific nondrug measures See Table 14-3.
Solicit follow-up questions from the patient Can I double the dose of any of the medications for quicker relief?
or caregiver.
Answer the patients or caregivers No, follow the manufacturers directions. Additional doses will not provide added
questions. benefit.
Evaluation of Patient Outcome
9. Assess patient outcome. Ask the patient to call and update you on his response to your recommended
treatment; alternatively, you could call him in a week to evaluate his response to
the treatment. If the latter, be sure you have the patients current telephone
number.
Key: GERD = Gastroesophageal reflux disease.
Patient Education for Intestinal Gas

The objectives of self-treatment are to (1) reduce the symptoms of intestinal gas and (2) reduce the chance of its recurrence.
For most patients, carefully following product instructions and the self-care measures listed below will help ensure optimal
therapeutic outcomes.
Nondrug Measures
If possible, avoid foods known to cause intestinal gas.

Avoid activities known to introduce gas into the digestive system, such as drinking carbonated beverages.
Nonprescription Medications
Lactase replacement products and alpha-galactosidase should be taken with foods to prevent intestinal gas from
forming.
Simethicone is used to treat intestinal gas after it has occurred.
Alpha-Galactosidase
Do not cook with this product. Add to food after it has cooled because food temperatures higher than 130F may
inactivate the enzyme.
If using drops, add drops to the first bite of problem foods.
If using tablets, swallow, chew, or crumble tablets with the first bite of problem foods.
An average meal may contain three servings of a problem food. If needed, use more tablets for larger meals, up to the
maximum recommended dose.
17 of 19 3/15/2015 1:20 AM
Take at first bite of dairy or lactose-containing food.

Dosing may vary according to the amount of lactase in the product and the level of lactose intolerance.
Do not take more than the recommended maximum daily dose.
Low-lactose milk or fortified soy milk products also may be used to supplement dietary intake of calcium.
Simethicone
For infants, to ease administration, mix the suspension with 1 ounce of cool water, infant formula, or other liquid.
Discontinue simethicone if adequate relief is not obtained within 24 hours.
When to Seek Medical Attention
Seek medical attention if symptoms do not improve or they worsen.
Evaluation of Patient Outcomes for Intestinal Gas
Many patients with intestinal gas have mild-moderate distress, and the discomfort is generally self-limiting within 24 hours.
Mild-moderate gas and bloating are managed primarily with diet modification, and some relief may occur with symptomatic drug
therapy. With effective treatment, the patient can expect reduced intensity and duration of gas-related symptoms such as
belching, abdominal pain, bloating, and flatulence. Patients who achieve symptomatic relief should be advised to continue the
self-care measures as needed. The provider should ask the patient to return or call after 1 week of self-treatment with dietary
measures, nonprescription antiflatulents, or digestive enzymes so outcomes can be assessed. Medical referral is necessary if
any of the following occurs before or during treatment:
Intestinal gas symptoms that persist for more than several days or occur more often than occasionally (e.g., several
times a month) and are associated with diarrhea or constipation.
Sudden change in the location of abdominal pain.
Significant increase in the severity or frequency of symptoms.
Sudden change in bowel function.
Presence of accompanying symptoms such as severe or persistent diarrhea/constipation; greasy or malodorous stools;
GI bleeding (e.g., hematemesis, melena, or hematochezia); fatigue; unintentional weight loss; or frequent nocturnal
symptoms.
Key Points for Intestinal Gas Complaints
Limit the self-treatment of intestinal gas symptoms to minor symptoms and to cases in which exclusions for
self-treatment (Figure 14-1) do not exist.
Counsel patients on dietary measures that may reduce the amount of intestinal gas. Certain foods (Tables 14-1 and
14-2) are more likely to cause gas and contribute to symptoms.
Patients who associate symptoms with lactose- or oligosaccharide-containing foods and who do not meet criteria for
exclusions for self-treatment may use digestive enzymes (lactase replacement or alpha-galactosidase products).
Probiotics may be helpful for patients with lactose intolerance who experience bloating or for patients with bloating
associated with irritable bowel syndrome.
Antiflatulents such as activated charcoal and simethicone also may be used, although there is contradictory evidence
supporting the ability of these agents to reduce the amount of intestinal gas formed.
Referral to a primary care provider for further evaluation should be considered for patients with exclusions for
self-treatment and for patients whose symptoms persist after initiating simple treatment options (e.g., dietary modification
and nonprescription medications).
References
1. Top 200 OTC/HBC brands of 2007. Drug Top. Accessed at http://drugtopics.modernmedicine.com/drugtopics, May 22, 2011.
2. World Gastroenterology Organization Global Guidelines on Celiac Disease. J Clin Gastroenterol. 2013:47(2):121-6. PubMed
3. Montalto M, Curigliano V, Santoro L, et al. Management and treatment of lactose malabsorption. World J Gastroenterol.
2006;12(2):187-91.
4. Brandt LJ, Chey WD, Foxx-Orenstein AE, et al. An evidence-based systematic review on the management of irritable bowel
syndrome. Am J Gastroenterol. 2009;104(suppl 1):S1-35.
5. Ringel Y, Williams RE, Kalilani L, et al. Prevalence, characteristics, and impact of bloating symptoms in patients with irritable
bowel syndrome. Clin Gastroenterol Hepatol. 2009;7(1):68-72. PubMed
6. Johnson LR. Gastrointestinal Physiology: Regulation. 7th ed. Philadelphia, PA: Mosby; 2007:107-26.
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7. Choi YK, Kraft N, Zimmerman B, et al. Fructose intolerance in IBS and utility of fructose-restricted diet. J Clin Gastroenterol.
2008;42(3):233-8.
8. Problem foods. Research Triangle Park, NC: GlaxoSmithKline; 2010. Accessed at http://www.beanogas.com/about-
beano/problem-foods, February 18, 2013.
9. Helpful hints for controlling gas (flatus). University of Michigan Health Systems Michigan Bowel Control Program. Accessed at
http://www.med.umich.edu/fbd/docs/Gas%20reduction%20diet.pdf, September 16, 2013.
10. Ford AC. In irritable bowel syndrome, antispasmodics and antidepressants improve abdominal pain and global assessment
and symptoms scores, but there is no evidence for the effectiveness of bulking agents. Evid Based Med 2012;17(4):114-5.
11. Korzenik JR. Case closed? Diverticulitis: epidemiology and fiber. J Clin Gastroenterol. 2006;40(suppl 3):S112-6.
12. Azpiroz F, Malagelada JR. The pathogenesis of bloating and visible distension in irritable bowel syndrome. Gastroenterol
Clin North Am. 2005;34(2):257-69.
13. Shaukat A, Levitt MD, Taylor BC, et al. Systematic review: effective management strategies for lactose intolerance. Ann
Intern Med. 2010; 152(12):797-803.
14. Lin HC. Small intestinal bacterial overgrowth: a framework for understanding irritable bowel syndrome. JAMA.
2004;292(7):852-8. PubMed
15. Bizzaro N, Tozzoli R, Villalta D, et al. Cutting-edge issues in celiac disease and in gluten intolerance. Clin Rev Allergy
Immunol. 2012;42(3):279-87.
16. Gluten free drugs. Accessed at http://www.glutenfreedrugs.com, September 16, 2013.
17. Celiac Sprue Association (CSA/USA). Accessed at http://www.csaceliacs.info, September 16, 2013.
18. Whelan K. Probiotics and prebiotics in the management of irritable bowel syndrome: a review of recent clinical trials and
systematic reviews. Curr Opin Clin Nutr Metab Care. 2011;14(6):581-7.
19. Whelan K, Quigley MM. Probiotics in the management of irritable bowel syndrome and inflammatory bowel disease. Curr
Opin Gastroenterol. 2013;29(2):184-9.
20. Mayer EA. The neurobiology of stress and emotions. Participate [quarterly publication of the International Foundation of
Functional Gastrointestinal Disorders]. 2010;10(4):2-5.
21. McEvoy GK, ed. AHFS Drug Information. Bethesda, MD: American Society of Health-System Pharmacists; 2013:2944.
22. Hanauer SB, DuPont HL, Cooper KM, et al. Randomized, double-blind, placebo-controlled clinical trial of loperamide plus
simethicone versus loperamide alone and simethicone alone in the treatment of acute diarrhea with gas-related abdominal
discomfort. Curr Med Res Opin. 2007; 23(5):1033-43.
23. Hall B, Chesters J, Robinson A. Infantile colic: A systematic review of medical and conventional therapies. J Paediatr Child
Health. 2012;48 (2):128-37.
24. Suarez FL, Furne J, Springfield J, et al. Failure of activated charcoal to reduce the release of gases produced by the colonic
flora. Am J Gastroenterol. 1999;94(1):208-12.
25. Ganiats TG, Norcross WA, Halverson AL, et al. Does Beano prevent gas? A double-blind crossover study of oral alpha-
galactosidase to treat dietary oligosaccharide intolerance. J Fam Pract. 1994;39(5):441-5.
26. Di Stefano M, Miceli E, Gotti S, et al. The effect of oral alpha-galactosidase on intestinal gas production and gas-related
symptoms. Dig Dis Sci. 2007; 52(1):78-83.
27. Hempel S, Newberry SJ, Maher AR, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a
systematic review and meta-analysis. JAMA. 2012;307(18):1959-69.
28. Merat S, Khalili S, Mostajabi P, et al. The effect of enteric-coated, delayed-release peppermint oil on irritable bowel
syndrome. Dig Dis Sci. 2010;55:1385-90.
29. Alam MS, Roy PK, Miah AR, et al. Efficacy of peppermint oil in diarrhea-predominant IBSa double-blind randomized
placebo-controlled study. Mymensingh Med J. 2013;22(1):27-30.
30. Bulat R, Fachnie E, Chauhan U, et al. Lack of effect of spearmint on lower oesophageal sphincter function and acid reflux in
healthy volunteers. Aliment Pharmacol Ther. 1999;13(6):805-12. PubMed
31. Brinker FJ. Herb Contraindications & Drug Interactions: Plus Herbal Adjuncts With Medicines. 4th ed. Sandy, OR: Eclectic
Medical Publications; 2010: 227-50.
2015 American Pharmacists Association. All Rights Reserved.
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Handbook of Nonprescription Drugs > Chapter 14. Intestinal Gas

Intestinal Gas: Introduction

Pathophysiology of Intestinal Gas

Foods That Produce Minimal Amounts of Gas

Meats: fowl, fish

Vegetables: lettuce, peppers, avocado, tomato, asparagus, zucchini, okra, olives

Fruit: cantaloupe, grapes, berries

Carbohydrates: white rice, chips, popcorn, graham crackers

All nuts, eggs, gelatin, fruit juice

Foods That Cause Moderate Amounts of Gas

Citrus fruits, apples

Carbohydrates: pastries, bread

Foods That Cause Major Amounts of Gas

Fruit: raisins, bananas, apricots, prunes, dried fruit

Carbohydrates: bagels, wheat germ, pretzels

Bran cereal, food high in bran

Source: References 7 and 9.

TABLE 14-2 Oligosaccharide-Containing Foods That Alpha-Galactosidase Might Affect

Vegetables Grains Beans

Beets Bagels Black-eyed peas

Broccoli Barley Bog beans

Brussels sprouts Breakfast cereal Broad beans

Cabbage Granola Chickpeas

Cauliflower Pasta Lima beans

Corn Rice bran Mung beans

Cucumbers Rye Peanuts and peanut butter

Leeks Sorghum, grain Pinto beans

Lettuce Wheat bran Red kidney beans

Onions Whole wheat flour Seed flour (sesame, sunflower)

Clinical Presentation of Intestinal Gas

Self-care of intestinal gas symptoms. Key: GI = Gastrointestinal; OTC = over-the-counter.

Treatment of Intestinal Gas

General Treatment Approach

- Breathe in comfortably, using your abdomen. Pause briefly before exhaling.

- Repeat this cycle for 5-10 minutes.

Chew food thoroughly.

Avoid washing down solids with a beverage.

Eliminate pipe, cigar, and cigarette smoking.

Check dentures for proper fit.

Attempt to be aware of and avoid deep sighing.

Do not attempt to induce belching or strain to pass gas.

Do not overload the stomach at any one meal.

Avoid gas-producing foods (Table 14-1).

Avoid carbonated beverages (e.g., sodas, beer).

Avoid caffeinated beverages (e.g., coffee, energy drinks).

Medication Use and Lifestyle Habits

Avoid drugs high in fiber (psylium).

Avoid nonabsorbable polymers (cholestyramine).

Avoid drugs that contain or release gas (e.g., Alka-Seltzer).

Avoid tight-fitting garments, girdles, and belts.

Do not lie down or sit in a slumped position immediately after eating.

Develop a regular routine of exercise and rest.

Source: References 9 and 20.

Activated 520 mg (2 capsules) orally after meals, Specific guidelines not

Alpha- 300-450 units per serving of food Not recommended

Probiotics Specific guidelines not available Specific guidelines not

Lactase Replacement Products

Product Selection Guidelines

Trade Name Primary Ingredients

Single-Entity Simethicone Products

Gas-X Regular Strength Simethicone 80 mg

Gas-X Extra Strength Chewable Simethicone 125 mg