L.I. Butorova, A.N. Kolomoets, E.S. Tarasova, T.N. Popova, A.V. Kalinin

State Institute for Advanced Training of Physicians of the Ministry of Defense of the Russian Federation

Main Military Clinical Hospital named after N.N. Burdenko

Complaints of bloating, increased frequency and volume of gases emitted are among the most common among patients with diseases of the gastrointestinal tract. The stench and untimely emission of gases sometimes cause patients more trouble than even abdominal pain. Occasionally, excessive accumulation of gases occurs in healthy people. There is practically no person who is not familiar with the feeling of emotional discomfort at the moment when a loud rumbling in the stomach or specific sounds accompanying the release of gases become accessible to the ears of others.

The problem of excessive gas formation in the gastrointestinal tract intestinal tract has worried people since ancient times. It is not for nothing that the god of Flatulence, Crepitus, was one of the gods of the ancient Roman pantheon. Hippocrates and Galen recommended using hollow reeds “to cleanse the body from the winds.”

Modern gastroenterology has knowledge of how and in which parts of the gastrointestinal tract the main gases are formed and the gas composition of the cavities is regulated, why all more people suffer from flatulence (bloating as a result of the accumulation of gases in the digestive tract due to their increased formation or insufficient excretion from the body), flatulence (increased formation and discharge of gases through the anus), borborygmas (transfusion in the abdomen), what should be the tactics for the prevention and treatment of this suffering. However, the true physiological significance of intestinal gases, which gives a person a unique odor and plays a significant role in the manifestation of certain behavioral reactions, has not yet been established.

Physiology of gas formation

Gases are present in the intestines as a result of:

1) swallowing air (aerophagia);

2) their formation in the intestinal lumen;

3) diffusion from the blood.

It is believed that normally 65-70% of intestinal gas is of exogenous origin, 30-35% is endogenous.

Aerophagia occurs normally in small quantities during eating and drinking. With every act of swallowing, air enters the stomach; its quantity varies among different people, but on average it is 2-3 ml. Eating quickly with insufficient chewing of food, swallowing large pieces leads to an increase in the volume of the gastric gas bubble. Patients who have the habit of smoking and talking while eating swallow more air. Frequent swallowing movements are characteristic of patients with chronic pathology of the nasopharynx, with hypersalivation. Some people swallow air unconsciously and unrelated to food intake, especially when feeling anxious. The gas “stomach bladder” is represented mainly by nitrogen and oxygen, i.e. those gases that are present in sufficient concentrations in the atmosphere. Some of this air leaves the stomach during belching, but most of it enters the intestines. Approximately 20 to 60% of the gas in the intestines comes from swallowed air.

In the lumen of the intestine itself the following are formed: carbon dioxide (CO2), hydrogen (H2), methane (CH4), hydrogen sulfide (H2S), ammonia (NH3). Gas formation in the intestinal lumen occurs in various ways.

Thus, in the upper parts of the small intestine formation occurs significant quantities CO2 as a result of the reaction between bicarbonate ions HCO3-, secreted by the pancreas, intestines and liver, and H+ ions released with gastric juice, as well as split off from fatty acids in food formed during the digestion of fats. Theoretically, after each meal, up to four liters of carbon dioxide can be released in the duodenum, most of it is quickly reabsorbed in the small intestine.

CO2 in the gas that accumulates in the large intestine is formed, to a greater extent, as a result of the enzymatic action of intestinal bacteria on organic substances that are not absorbed in the small intestine. These substances include mainly plant fibers - cellulose, hemicellulose, pectins, lignins. The acidic products of bacterial fermentation of these substances in the colon can also react with bicarbonates, forming CO2.

As a result of microbial metabolism of unabsorbed carbohydrates and amino acids, significant volumes of H2 are formed in the lumen of the colon. It should be noted that all the hydrogen in exhaled air is the result of the activity of intestinal bacteria. Therefore, the hydrogen breath test can be used not only to study the rate of evacuation of food from the small intestine, but also to diagnose excessive growth of microflora. A lot of hydrogen is released when eating certain fruits and vegetables (for example, beans, peas) that contain poorly digestible carbohydrates, as well as malabsorption syndromes.

Methane is formed in the colon obligately by anaerobic bacteria during the processing of endogenous substances; food intake only slightly affects the rate of its formation. Approximately a third of the adult population produces fairly large amounts of CH4, so the density fecal matter is less than 1.0 and they float on the surface of the water. In persons with colonic diverticulosis, the methane content in the gases released is increased.

High concentrations of H2 and CO2 may be associated with rapid and/or frequent excretion of gases from the intestines, such as a “sounding breakthrough”. Hydrogen and methane released from the intestines are flammable, and gas explosions have been reported during jejunal or colonic surgery and even during proctosigmoscopic examinations during diathermy.

Ammonia is formed in the colon due to microbial degradation of urea or amino acids. Under the influence of intestinal microorganisms, as a result of hydrolytic processes, up to 30% of urea formed in the liver is converted into ammonia.

Hydrogen sulfide is formed predominantly during the microbial transformation of sulfur-containing amino acids by anaerobic bacteria.

The unpleasant odor of gases released from the intestine is associated with the presence of trace amounts of aromatic compounds such as indole, skatole, mercaptan, which are formed in the colon as a result of the action of intestinal microflora on organic compounds that are not digested in the small intestine.

Another source of gases in the intestinal lumen is their diffusion from the plasma. The direction of diffusion is determined by the relative partial pressures of gas in the plasma and in the intestinal lumen.

Normally, the gastrointestinal tract contains on average about 200 ml of gas. When digesting lunch, about 15 liters of gas is formed, which is mostly resorbed through the intestinal wall. In healthy people, about 600 ml of gases are released through the rectum every day (from 200 to 2000 ml) and they are released in the form of approximately 15 portions of 40 ml each, although there is significant individual variation.

Under physiological conditions, carbon dioxide is well absorbed, less oxygen is absorbed, partly absorbed by acidophilic intestinal bacteria. Methane and hydrogen are partially absorbed and released by the lungs. Nitrogen and hydrogen sulfide are not absorbed and are excreted through the rectum.

When the relationship between the formation of gases in the intestines, their absorption and removal is violated, conditions arise for excessive accumulation of gases in the gastrointestinal tract in the form of gas foam. The fact is that in the lumen of the intestine there are various organic substances that have foaming properties: proteins, fats, bile acids, mucopolysaccharides, soaps. The free energy of these substances and the surface tension forces at the liquid-gas interface contribute to the formation of structures with a minimal surface (which ensures equilibrium and stability of the structure). This condition is met by the spherical shape of drops in a liquid-in-gas system (water drops in a gas intestinal mixture or gas bubbles in a liquid medium).

The more disrupted the processes of normal digestion and absorption of food ingredients are, the more intestinal gases are formed, but also the conditions for the formation of stable gas foam are facilitated. This mucous foam covers the surface of the intestinal mucosa with a thin layer, which in turn complicates parietal digestion, reduces the activity of enzymes, disrupts the absorption of nutrients, and the resorption of gases, thereby closing the pathological circle.

The main causes of excess gas formation

Almost any disease of the gastrointestinal tract can lead to increased formation of gases and/or disruption of their passage through the intestines. Such conditions can appear at different ages due to a variety of reasons. Thus, flatulence can occur in a child already in the first days of life as a result of imperfections in the enzyme digestive system. In practically healthy elderly people, “senile flatulence” is associated with age-related lengthening of the intestine, a decrease in the number of functioning glands that secrete digestive enzymes, and atrophy of the muscular layer of the intestinal wall. Depending on the leading cause of gas formation disorders, there are the following types flatulence.

1. Alimentary flatulence occurs due to the consumption of foods, the digestion process of which is accompanied by an increased release of gases in the intestine. The cause of nutritional flatulence can also be carbonated drinks, products that cause fermentation processes (lamb meat, black bread, raisins, kvass, beer).

2. Digestive flatulence is a consequence of a violation of the digestive processes: enzymatic deficiency, absorption disorders, disruption of the enterohepatic circulation of bile acids. As a result of the processes of maldigestion and malabsorption, a mass of under-digested products appears, which are exposed to microflora with the formation of various, including gaseous, products.

3. Dysbiotic flatulence develops due to a disturbance in the composition of the microflora in the intestines. Excess microflora in the small intestine leads to the breakdown of products in the upper sections of the latter with the release large quantity gases At the same time, in the lower sections digestive system The processes of decay and fermentation are significantly activated, also with the release of increased amounts of gases and aromatic compounds.

4. Mechanical flatulence is a consequence of mechanical disorders of the evacuation function of the gastrointestinal tract, leading to passage disorders - adhesions, stenoses, tumors. In these cases, it is often local in nature.

5. Dynamic flatulence occurs as a result of impaired intestinal motor function. In this case, there may not be a clearly increased amount of gas or altered gas composition, but its transit through the intestines is slowed down. This option is possible with intestinal paresis in the postoperative period, intoxication, peritonitis, after vagotomy, as well as with irritable bowel syndrome, accompanied by impaired motility and coordination of the activities of various parts of the intestine. Nervous disorders and emotional overload can lead to flatulence due to spasm of the smooth muscles of the intestine and slowing down peristalsis. Flatulence that occurs with certain variants of anomalies in the structure and position of the large intestine can also be classified as dynamic.

6. Circulatory flatulence is associated with a violation of the formation and resorption of gases in general and local circulatory disorders (for example, with stagnation in the intestinal veins).

7. High-altitude flatulence develops with decreasing atmospheric pressure, since when raised to a height, gases expand and their pressure increases.

Thus, the etiological and pathogenetic factors of excessive gas formation in the intestines are very diverse, usually several mechanisms operate simultaneously.

Clinical picture and diagnosis

Four ailments arise from the accumulation of winds: “colic, spasms, dropsy, and also dizziness.”

Salerno Code of Health (IV century)

Clinical manifestations of excessive accumulation of gases in the gastrointestinal tract are: pain, bloating and rumbling in the abdomen, belching, increased volume and fetidity of emitted gases, constipation or diarrhea. Flatulence is often accompanied by various dyspeptic disorders: a feeling of discomfort and/or pain in the epigastric region, early satiety, a feeling of overfilling, nausea. In some cases, especially among young people, a kind of psychoneurosis develops.

The severity of symptoms does not always correlate with the volume of “excess gases”. In most healthy people, antegrade injection of gas into the intestine at a rate of one liter per hour is accompanied by only minimal symptoms, while patients with functional bowel diseases (functional flatulence syndrome, irritable bowel syndrome) often cannot tolerate much smaller amounts of gas in the intestine. Apparently, clinical symptoms are caused not only by biochemical disorganization of the processes of gas formation and gas elimination, but are also associated with increased sensitivity of the intestine and functional disorders of its contractile activity. Clinical observations allow us to consider functional flatulence as a result of emotional disorders in the system of interpersonal disorders. As a rule, these patients are passive in their personal characteristics, not prone to confrontation, do not have sufficient persistence in achieving goals and have certain difficulties in containing anger. Often these patients develop an avoidant type of behavior, and conflicts arise in everyday life and at work.

On the other hand, in the presence of chronic diseases of the gastrointestinal tract, even minimal excesses of gas formation can be accompanied by significant clinical manifestations.

With excessive accumulation of gases in the intestines, quite painful sensations from other organs and systems (digestive asthenia) can be observed: a burning sensation in the heart, palpitations, interruptions in heart rhythm, sleep disturbances, mood disorders, general weakness. Sometimes patients are bothered by shortness of breath, in some cases it is quite severe (dyspeptic asthma).

There are two main variants of the manifestation of flatulence.

1. In some cases, patients are bothered by feelings of overfilling, distension, a significant increase in the abdomen due to bloating of the intestines, while the passage of gases does not occur due to spastic dyskinesia of the colon. The severity of symptoms in the absence of a mechanical obstacle depends on visceral hypersensitivity and is determined by the degree of motor impairment. Relief usually occurs after defecation and release of gas. Bloating and pain usually increase in the afternoon, i.e., during the period of greatest activity of digestive processes.

Varieties of this option include local flatulence, when gas accumulates in one or another part of the intestine. The combination of local flatulence with a certain type of pain can lead to the development of symptom complexes with a characteristic clinical picture: splenic flexure syndrome, hepatic angle syndrome and cecal syndrome.

Splenic flexure syndrome is more common than others. There are certain anatomical prerequisites for its occurrence. The left bend of the colon (splenic flexure) is located high under the diaphragm, it is fixed by peritoneal folds and forms an acute angle, which can play the role of a kind of trap accumulating gas and chyme. The development of the syndrome is facilitated by poor posture and wearing tight clothing. Gas retention in the splenic flexure can cause diffuse bloating. As a result, there is a feeling of overfilling and pressure in the left upper quadrant, radiating to left side chest. In the minds of patients, such symptoms are often associated with heart disease, in particular angina. Physical examination data (limited bloating, high tympanitis along the edge of the left lateral side of the upper abdomen), indications of pain relief after bowel movements and the passage of gases help in making the correct diagnosis. During an X-ray examination, during pain, it is possible to note the accumulation of gases in the area of ​​the left flexure of the colon.

Hepatic angle syndrome occurs as a result of the accumulation of gas in the hepatic flexure of the colon, resulting in the intestine being pinched between the liver and the diaphragm. In its clinical picture, this syndrome imitates the pathology of the biliary tract. Patients complain of a feeling of fullness or pressure in the right hypochondrium. The pain spreads to the epigastric region, to the middle half of the chest, and sometimes to the right hypochondrium, shoulder, and back.

Cecal syndrome occurs quite often in patients with increased mobility of the cecum, manifested by a feeling of fullness and pain in the right iliac region. A known role in the pathogenesis of cecal syndrome is played by insufficiency of the ileocecal sphincter - gaping of the ileocecal sphincter due to its distension by gases. In such cases, palpation of the ileum causes pain if it is done towards the cecum; palpation in the opposite direction is painless. Sometimes massage in the area of ​​the projection of the cecum promotes the evacuation of gas and causes relief, so some patients themselves massage the abdomen. Retrograde filling of the terminal ileum during irrigoscopy helps to recognize ileocecal sphincter insufficiency.

2. The second option is characterized by constant violent release of gases from the intestines. The emission of gases can occur slowly, silently, or as a “sounding breakthrough”. The smell may vary. With this option, the abdominal pain syndrome is usually mildly expressed; complaints of rumbling and transfusion in the abdomen predominate, heard not only by the patient himself, but also by others. The latter phenomenon is based on the simultaneous movement of liquid and gases through a relatively narrowed space. Only in rare cases does this usually unpleasant symptom turn into an advantage, as was the case with a certain Frenchman who performed on the stage of the Moulin Rouge, playing melodies with emitted gases.

General flatulence occurs when gases accumulate in the small intestine, lateral flatulence occurs when gases accumulate in the large intestine. When percussing the abdomen, an increase in tympanic sound is noted. Auscultation can detect high-pitched whistling noises that occur at an early stage of intestinal obstruction, or a splashing noise caused by an increased amount of liquid and gas in the dilated intestinal lumen. Bowel sounds may be increased (in front of an obstruction), weakened, or absent depending on the etiology of bloating. On palpation, a palpable cecum may indicate the localization of a pathological process in it; a collapsed cecum may indicate small bowel ileus.

A plain abdominal radiograph is a screening method. Signs of excessive gas formation are: increased pneumatization of the stomach and colon, mainly the distal parts in the flexure area, high standing of the diaphragm, especially the left dome. The volume of gases in the body can be measured using plethysmography, a method based on blowing argon into the intestines.

Since the symptom of excessive gas formation is nonspecific and can be combined with both functional and organic diseases of the gastrointestinal tract, a detailed study of the anamnesis and identification of dietary patterns are essential to justify a program of further medical examination. In a young patient who is otherwise healthy and not losing weight, the prolonged presence of such symptoms is usually not associated with serious organic disease. Elderly patients - especially if these symptoms have appeared recently and are progressive - need a more thorough examination and, above all, to exclude oncological pathology and diseases of the hepato-pancreaticobiliary system.

Basic principles of treating gas syndrome

Flatulence is difficult to treat, since in most cases the complaints are due to either visceral hypersensitivity to normal amounts of gas (irritable bowel syndrome, functional flatulence) or are associated with the presence of a chronic disease of the gastrointestinal tract.

It is necessary to begin treatment of a patient with flatulence with the organization of a balanced diet. Therapeutic nutrition is based on the underlying disease. It is recommended to avoid foods containing non-absorbable carbohydrates and refractory fats. If you are lactose intolerant, products containing milk should be excluded from your diet.

In addition to treating the underlying disease, in some cases it is necessary to prescribe special medications that reduce flatulence. These include adsorbents (activated carbon, smecta), carminatives (fennel fruits and oil, caraway fruits, chamomile flowers), defoamers (organosilicon compounds dimethicone and simethicone).

A drug that reduces foaming in the intestinal lumen by 84-87% is Espumisan® (simethicone), which is a high-molecular silicon-based polymer - dimethylsiloxane with the addition of silicon dioxide. Simethicone (activated dimethicone), according to its mechanism of action, belongs to the so-called defoamers - surfactants that reduce the surface tension of gas bubbles in chyme and mucus in the intestinal lumen, leading to their rupture. In this case, a process of coalescence occurs - the fusion of gas bubbles and the destruction of foam, as a result of which free gas is able to be absorbed through the intestinal mucosa or evacuated along with the intestinal contents. Espumisan® does not absorb food components or medications. The drug is inert, is not absorbed from the gastrointestinal tract, is not fermented by microorganisms, is excreted unchanged and does not interfere with the biochemical processes of digestion and absorption. At the same time, due to the defoaming effect and reducing the gas content in the intestines, simethicone indirectly affects the normalization of digestive functions. The drug is suitable for long-term use. We have data on the absence side effects when taking espumisan for five years.

Due to its properties, espumisan can be used to treat any pathology associated with excessive gas formation; flatulence caused by disturbances in the processes of cavity and membrane digestion, absorption or reduced peristalsis; postoperative abdominal bloating, as well as for preparation for X-ray contrast and ultrasound examinations, gastroduodenoscopy.

Contraindications are mechanical intestinal obstruction and hypersensitivity to the components of the drug. There are no restrictions on use for children, the elderly, pregnant or lactating women.

The drug is available in capsules and emulsion form. One capsule, or 5 ml of emulsion, contains 40 mg of simethicone. For excessive gas formation, adults and older children are prescribed 1-2 capsules or 1-2 teaspoons 3-5 times a day (children early age 1 teaspoon 3-5 times a day). To prepare for radiography and ultrasound examinations: the day before the examination, 2 capsules or 2 teaspoons 3 times a day, on the day of the examination in the morning, 2 capsules or 2 teaspoons of emulsion.