Probiotics and rifaximin (Xifaxan) have been shown to reduce total number of flatus episodes and associated discomfort. (Strength of Recommendation [SOR]: B, based on small randomized controlled trials [RCTs]). Oral alpha-galactosidase (Beano) has been shown to reduce volume of flatus associated with fermentable carbohydrates and high-fiber diets. (SOR: B, based on small RCTs). Oral bismuth subsalicylate (Pepto-Bismol) and odor-reducing external devices containing activated charcoal have shown benefit in reducing flatus-associated odor. (SOR: C, based on disease-oriented evidence). Evidence for oral activated charcoal and simethicone has been inconsistent and does not support their use. (SOR: B, based on multiple small RCTs)

Bailey, Justin

Carter, Nakia Joyce

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June 15, 2009 Table of ContentsJUSTIN BAILEY, MD, David Grant Medical Center, Travis Air Force Base, CaliforniaNAKIA J. CARTER, MSIS, East Tennessee State University, Quillen College of Medicine, Johnson City, TennesseeClinical Commentary by JON O. NEHER, MD, Valley Medical Center, Renton, WashingtonClinical QuestionWhat is the most effective management of flatulence?Evidence-Based AnswerProbiotics and rifaximin (Xifaxan) have been shown to reduce total number of flatus episodes andassociated discomfort. (Strength of Recommendation [SOR]: B, based on small randomized controlledtrials [RCTs]). Oral alpha-galactosidase (Beano) has been shown to reduce volume of flatus associatedwith fermentable carbohydrates and high-fiber diets. (SOR: B, based on small RCTs). Oral bismuthsubsalicylate (Pepto-Bismol) and odor-reducing external devices containing activated charcoal haveshown benefit in reducing flatus-associated odor. (SOR: C, based on disease-oriented evidence).Evidence for oral activated charcoal and simethicone has been inconsistent and does not support their use.(SOR: B, based on multiple small RCTs). See Table 1 for a summary of the relative effectiveness ofdifferent methods for controlling flatus.1-10Table 1. Relative Effectiveness of Different Methods for ControllingFlatusTreatment Symptoms treatedOutcomevariableAntibioticsRifaximin (Xifaxan)1 Volume +++ProbioticsVSL#32 Volume +Prescript-Assist3 Volume +++Other Bifidobacterium and Lactobacillus speciesmixtures4,5Volume +++Activated charcoalOral6 Odor 01 of 4 9/3/2009 1:16 PMDevices7Briefs Odor +++Pads in underwear Odor ++Seat cushions Odor +OtherBismuth subsalicylate (Pepto-Bismol)8 Odor +++Alpha-galactosidase (Beano)9 Volume + (300 GaIU)++ (1,200GaIU)Simethicone/loperamide (Imodium Advanced)10 Volume associated withdiarrhea00 = not effective; + = minimally effective, or effective only in certain situations; ++ = moderatelyeffective; +++ = very effective.Information from references 1 through 10.Evidence SummaryFlatus represents two distinct problems: (1) volume of flatus resulting in bloating and discomfort; and (2)odor possibly disturbing persons around the patient. Volume is caused by hydrogen, nitrogen, andmethane, whereas odor is a result of sulfur gases in the flatus. Because flatus represents two differentperceived problems, distinct treatments for either volume or odor may be required.ANTIBIOTICSOne double-blind study comparing rifaximin, a nonabsorbed antibiotic, 400 mg orally twice daily andplacebo showed that more patients reported relief of symptoms of abdominal bloating, distension, andflatulence with rifaximin (41 versus 23 percent; number needed to treat [NNT] = 5.4).1 This benefitdiminished 10 days after the treatment course finished; however, it remained significant (29 versus 11percent of patients reporting improvement; NNT = 5.8).PROBIOTICSMultiple probiotics have been shown in RCTs to have significant short- and long-term reduction inflatulence and bloating. Because each probiotic is a different mixture of bacteria, they have to be treatedas different medications. VSL#3 probiotic (a Bifidobacterium and Lactobacillus species mixture)demonstrated a 50 percent reduction in flatulence in more patients at four weeks compared with placebo(52 versus 33 percent; NNT = 6.4).2 A proprietary agent, Prescript-Assist (30 soil-based organisms),showed a reduction in flatulence symptom scores at four weeks compared with placebo (reduction by0.55 standard score units on a 0 to 1.2 unit scale; P < .001). Follow-up of the treatment group at 60 weeksshowed persistent reduction of symptoms.3 Other formulations of Bifidobacterium and Lactobacillusspecies alone and in mixtures have had differing results, but most studies showed modest reduction inflatus-associated discomfort.4,5ACTIVATED CHARCOALEarly studies (many uncontrolled) of oral activated charcoal looked promising; however, more recenttrials have failed to demonstrate benefit.6 Odor-reducing external devices containing activated charcoalare effective at binding sulfur gases, thus reducing odor. Activated charcoal briefs were most effective,and absorbed almost 100 percent of sulfur gases. Charcoal pads worn in underwear absorbed 55 to 77percent of sulfur gases. Charcoal seat cushions absorbed about 20 percent of sulfur gases, whereasregular seat cushions absorbed one half that amount. Cushions were more effective when sat on, thuslimiting situations in which the device could be used.7 A major limitation with clinical application of2 of 4 9/3/2009 1:16 PMabsorbed sulfur gases is that the minimum level to reduce social discomfort has never been established.BISMUTH SUBSALICYLATEBismuth subsalicylate (524 mg orally four times daily) has been shown to bind more than 95 percent ofsulfide gases in the gut. Concern for salicylate toxicity inhibits its use as a chronic treatment; however,episodic use is safe and could be used strategically to prevent social unease.8ALPHA-GALACTOSIDASEAlpha-galactosidase is effective for reducing symptoms of bloating and flatus associated withconsumption of fermentable carbohydrates (e.g., those found in beans, bran, or fruit). In an RCT, all eightpatients taking 300 or 1,200 galactosidase International Units showed significant improvement in symptomscore compared with those receiving placebo.9SIMETHICONESimethicone has been recommended for treatment of flatulence and bloating; however, no benefit has beenshown for common flatulence. A combination of simethicone and loperamide (Imodium Advanced) iseffective in relieving abdominal bloating and gas associated with acute diarrhea (more than eithertreatment alone); however, it has not been studied in nondiarrhea-associated flatus.10Recommendations from OthersNo consensus guidelines about effective management of flatulence were found. Recommendations inUpToDate include use of alpha-galactosidase for flatus associated with beans, avoidance of flatus-causing foods, and a trial of antibiotics. Oral bismuth subsalicylate and external odor-absorbing devicesmade of carbon fiber were recommended to help reduce odor. Use of simethicone or oral activatedcharcoal was not recommended.11Clinical CommentaryWhat is the cost of flatulence control? Pepto-Bismol is widely available and is the least expensivemedication in this review (about $6 for 16 fl oz).12 Beano can be found in most grocery stores andpharmacies. It costs approximately $17 for 100 tablets.12 Activated charcoal underwear liners (the varietythat can be washed and reused for several weeks) are approximately $20 through a manufacturer's Website. The probiotics discussed in this review range from $40 (for 60 capsules of Prescript-Assist) and $48(for 60 capsules of VSL#3) to $80 (for 30 packets of VSL#3 powder), depending on the Web site. At$161 for 30 200-mg tablets, rifaximin is the most expensive option.12 The International Classification ofDiseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for flatulence is 787.3.Copyright Family Physicians Inquiries Network. Used with permission.Address correspondence by e-mail to Justin Bailey, MD, at justinbailey2@hotmail.com. Reprints are not available from the authors.The opinions and assertions contained herein are the private views of the authors and are not to be construed asofficial or as reflecting the views of the U.S. Air Force Medical Department or the U.S. Air Force at large.Author disclosure: Nothing to disclose.REFERENCES1. Sharara AI, Aoun E, Abdul-Baki H, Mounzer R, Sidani S, Elhajj I. A randomized double-blind placebo-controlled trial of rifaximin in patients with abdominal bloating and flatulence. Am J Gastroenterol.2006;101(2):326-333.2. Kim HJ, Vazquez Roque MI, Camilleri M, et al. A randomized controlled trial of a probiotic combinationVSL#3 and placebo in irritable bowel syndrome with bloating. Neurogastroenterol Motil.2005;17(5):687-696.3. Bittner AC, Croffut RM, Stranahan MC, Yokelson TN. Prescript-assist probiotic-prebiotic treatment for3 of 4 9/3/2009 1:16 PMirritable bowel syndrome: an open-label, partially controlled, 1-year extension of a previously publishedcontrolled clinical trial. Clin Ther. 2007;29(6):1153-1160.4. Di Stefano M, Miceli E, Armellini E, Missanelli A, Corazza GR. Probiotics and functional abdominalbloating. J Clin Gastroenterol. 2004;38(6 suppl):S102-S1033.5. Kajander K, Hatakka K, Poussa T, Färkkilä M, Korpela R. A probiotic mixture alleviates symptoms inirritable bowel syndrome patients: a controlled 6-month intervention. Aliment Pharmacol Ther.2005;22(5):387-394.6. Suarez FL, Furne J, Springfield J, Levitt MD. Failure of activated charcoal to reduce the release ofgases produced by the colonic flora. Am J Gastroenterol. 1999;94(1):208-212.7. Ohge H, Furne JK, Springfield J, Ringwala S, Levitt MD. Effectiveness of devices purported to reduceflatus odor. Am J Gastroenterol. 2005;100(2):397-400.8. Suarez FL, Furne JK, Springfield J, Levitt MD. Bismuth subsalicylate markedly decreases hydrogensulfide release in the human colon. Gastroenterology. 1998;114(5):923-929.9. Di Stefano M, Miceli E, Gotti S, et al. The effect of oral alpha-galactosidase on intestinal gas productionand gas-related symptoms. Dig Dis Sci. 2007;52(1):78-83.10. Hanauer SB, DuPont HL, Cooper KM, Laudadio C. Randomized, double-blind, placebo-controlledclinical trial of loperamide plus simethicone versus loperamide alone and simethicone alone in thetreatment of acute diarrhea with gas-related abdominal discomfort. Curr Med Res Opin.2007;23(5):1033-1043.11. Abraczinskas D, Goldfinger S. Intestinal gas and bloating. In: Rose BD, ed. UpToDate. Wellesley,Mass.: UpToDate, Inc.; 2007.12. Drugstore.com. http://www.drugstore.com. Accessed March 26, 2009.Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family PhysiciansInquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine.Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength ofrecommendations and the level of evidence for individual studies are rated using criteria developed by theEvidence-Based Medicine Working Group (http://www.cebm.net/levels_of_evidence.asp).The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submittingquestions or writing answers for this series, go to http://www.fpin.org or e-mail: questions@fpin.org.4 of 4 9/3/2009 1:16 PM

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