FLATULENCE AND BORBORYGMI

FLATULENCE AND BORBORYGMI: Excerpt from Differential Diagnosis in Primary Care

Flatulence is increased output of gas by mouth or rectum. Borborygmi are audible sounds of hyperperistalsis of gas. Both are caused by similar physiologic mechanisms. The increase of gas in the intestinal tract depends on three physiologic mechanisms:

1. Increased intake of air. This is probably one of the most frequent causes of flatulence and borborygmi. Aerophagia in neurosis is a well-known psychogenic cause. However, compulsive eating, compulsive drinking, excessive smoking, or excessive talking may produce the same effect. All of us take in a certain amount of air when we swallow food or liquids. When we overeat, however, or when we drink too much, the amount of gas taken in may exceed our ability to absorb it. Salesmen and public speakers have an additional problem because talking increases salivation and swallowing, and frequently air is swallowed between sentences. Some people have a particular beverage they are fond of, such as cola, coffee, or alcohol. Excessive drinking of these beverages entails the swallowing of excess air. In addition, some of these beverages release gas after ingestion (carbonated beverages especially), which causes flatulence. Reflux esophagitis is a frequent cause.
2. Increased production of gas in the intestinal tract. In acute bacterial gastroenteritis (e.g., Salmonella and Shigella), gas-producing organisms multiply and produce excess gas. The diarrhea or vomiting associated with these disorders usually makes the diagnosis easy. A more obscure cause of increased production of gas is chronic mild intestinal obstruction leading to excessive bacterial overgrowth. Adhesions, intestinal polyps, regional ileitis, and the various causes of paralytic ileus (e.g., anticholinergic drugs, tranquilizers, uremia, and chronic anoxia) cause increased gas production by this mechanism. Gas production is also increased when bacteria are allowed to accumulate in large numbers in chronic intestinal disorders. The blind loop syndrome, diverticulitis, and Meckel diverticulum fall into this category. Some types of irritation in the intestinal tract cause a mild paralytic ileus and allow bacteria to multiply and ferment: Esophagitis and hiatal hernia, chronic gastritis, ulcers, regional ileitis, and ulcerative and mucus colitis may cause mild paralytic ileus on this basis. When the amount of digestive juices is insufficient to digest food, more food is available for bacterial fermentation. Thus, in chronic atrophic gastritis, the reduced level of hydrochloric acid (HCl) leaves undigested food for bacterial action. In cholecystitis and partial bile duct obstruction or liver disease, there are insufficient bile acids for digestion and more food is left for bacterial fermentation. In chronic pancreatitis, the reduction in pancreatic enzymes causes the same problem. Lactase deficiency leaves food for fermentation.
3. Decreased absorption of gas. Malabsorption syndromes cause this condition. In acute gastroenteritis, the swollen inflamed intestines cannot absorb the gas. Intestinal motility may be so rapid that there is not enough time for absorption. In celiac disease, the atrophied villi cannot pick up food and gas, and these are passed through the intestines. Intestinal parasites may preempt food from absorption and produce excessive gas in their own digestive processes.

Approach to the Diagnosis

If excessive food, beverages, or air swallowing from nervous tension or talking can be excluded, reflux esophagitis and diverticulitis must be considered. Upper gastrointestinal (GI) series, esophagram, small-bowel series, and sigmoidoscopy with a barium enema should be done. A gallbladder series is also ordered. If these findings are questionable, a more definitive diagnosis may be made with endoscopy. Stools for ova, parasites, blood, and cultures should be done. When the outcome is still uncertain, evaluation of the adequacy of the intestinal digestive secretions is worthwhile. Gastric analysis with Histalog and duodenal analysis for bicarbonate, bile, and pancreatic enzymes is done. A lactose tolerance test should be done. If the digestive secretions are adequate, a small-bowel biopsy may be necessary to exclude a malabsorption syndrome. Xylose absorption is a good screening test for this.

Other Useful Tests

1. Amylase and lipase levels (chronic pancreatitis)
2. Stool for trypsin (chronic pancreatitis)
3. Quantitative stool fat (malabsorption syndrome)
4. Liver function test (chronic hepatic disease)
5. Urine 5-hydroxyindole acetic acid (5-HIAA) (carcinoid syndrome)
6. Esophagoscopy (reflux esophagitis)
7. Gastroscopy (gastric ulcer, neoplasm)
8. Colonoscopy (diverticulitis, colitis)
9. Analysis of flatus (aerophagia, carbohydrate intolerance)
10. Hydrogen breath test (carbohydrate intolerance, bacterial overgrowth)
11. Schilling test (pernicious anemia)

Pictures

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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