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Anal Gas Evacuation and Colonic Microbiota in Patients with Flatulence: Effect of Diet

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Anal Gas Evacuation and Colonic Microbiota in Patients with Flatulence: Effect of Diet Gut microbiota ORIGINAL ARTICLE Gut: first published as 10.1136/gutjnl-2012-303013 on 13 June 2013. Downloaded from Anal gas evacuation and colonic microbiota in patients with flatulence: effect of diet Chaysavanh Manichanh,1 Anat Eck,1 Encarna Varela,1 Joaquim Roca,2 José C Clemente,3 Antonio González,3 Dan Knights,3 Rob Knight,3 Sandra Estrella,1 Carlos Hernandez,1 Denis Guyonnet,4 Anna Accarino,1 Javier Santos,1 Juan-R Malagelada,1 Francisco Guarner,1 Fernando Azpiroz1 ▸ Additional material is ABSTRACT published online only. To view Objective To characterise the influence of diet on Significance of this study please visit the journal online (http://dx.doi.org/10.1136/ abdominal symptoms, anal gas evacuation, intestinal gas gutjnl-2012-303013). distribution and colonic microbiota in patients fl 1 complaining of atulence. What is already known on this subject? Digestive System Research fl Unit, Departament de Design Patients complaining of atulence (n=30) and ▸ Some patients specifically complain of Medicina, University Hospital healthy subjects (n=20) were instructed to follow their excessive evacuation of gas per anus. Vall d’Hebron, Centro de usual diet for 3 days (basal phase) and to consume a ▸ Intestinal gas content depends by-and-large on Investigación Biomédica en Red high-flatulogenic diet for another 3 days (challenge gas production by bacterial fermentation of de Enfermedades Hepáticas y Digestivas (Ciberehd), phase). unabsorbed substrates. Universitat Autònoma de Results During basal phase, patients recorded more ▸ Diet influences anal gas evacuation and gut Barcelona, Barcelona, Spain abdominal symptoms than healthy subjects in daily microbial composition. 2Molecular Biology Institute of questionnaires (5.8±0.3 vs 0.4±0.2 mean discomfort/ Barcelona, Consejo Superior de pain score, respectively; p=<0.0001) and more gas What are the new findings? Investigaciones Cientificas, evacuations by an event marker (21.9±2.8 vs 7.4±1.0 ▸ A proportion of patients complaining of Barcelona, Spain fl 3Department of Chemistry and daytime evacuations, respectively; p=0.0001), without atulence have increased number of gas Biochemistry, University of differences in the volume of gas evacuated after a evacuations, but the net volume of gas Colorado at Boulder, and standard meal (262±22 and 265±25 mL, respectively). evacuated is within the normal range. Howard Hughes Medical fl ▸ Flatulence is associated with abdominal Institute, Boulder, Colorado, On atulogenic diet, both groups recorded more abdominal symptoms (7.9±0.3 and 2.8±0.4 discomfort/ symptoms. http://gut.bmj.com/ USA ▸ ’ 4Digestive Health Department, pain, respectively), number of gas evacuations (44.4±5.3 Patients microbiota present dysbiotic traits and Danone Research, Palaiseau, and 21.7±2.9 daytime evacuations, respectively) and characteristically respond with instability in France had more gas production (656±52 and 673±78 mL, microbial composition when consuming a respectively; p<0.05 vs basal diet for all). When flatulogenic diet. Correspondence to ▸ Professor Fernando Azpiroz, challenged with flatulogenic diet, patients’ microbiota A number of gut bacterial taxa correlate with Digestive System Research developed instability in composition, exhibiting variations anal gas evacuations and volume of gas Unit, Hospital General Vall evacuated. on September 24, 2021 by guest. Protected copyright. ’ in the main phyla and reduction of microbial diversity, d Hebron, Barcelona 08035, whereas healthy subjects’ microbiota were stable. Taxa Spain; How might it impact on clinical practice in [email protected] from Bacteroides fragilis or Bilophila wadsworthia the foreseeable future? correlated with number of gas evacuations or volume of ▸ fl fl Received 1 June 2012 Diet in uences atulence, abdominal gas evacuated, respectively. symptoms, digestive comfort and stability of Revised 7 May 2013 Conclusions Patients complaining of flatulence have a Accepted 14 May 2013 the gut microbial ecosystem in patients Published Online First poor tolerance of intestinal gas, which is associated with complaining of flatulence. 13 June 2013 instability of the microbial ecosystem. ▸ Microbial biomarkers may predict symptoms associated with flatulence. INTRODUCTION Some patients complain of excessive evacuation of residues, and the composition and metabolic activ- gas per anus, which may become socially disabling. ity of colonic microbiota. However, the physiology and pathophysiology of We hypothesised that patients complaining of flatulence remain poorly understood.12 excessive passage of gas per anus: (a) really have Open Access Gas evacuated per anus originates by-and-large higher number of gas evacuations on their usual Scan to access more free content in the colon, where unabsorbed meal residues are diet than healthy subjects; (b) have more intestinal – fermented by colonic bacteria.3 5 However, even gas production and evacuate more volume of gas; on the same diet, the amount of gas production (c) gas evacuation depends on diet, but the differ- exhibits very large interindividual differences. ences in number of evacuations and volume of gas To cite: Manichanh C, Hence, the volume of gas produced and evacuated evacuated between patients and healthy subject are Eck A, Varela E, et al. Gut per anus is determined by two main factors: the not due to differences in diet, that is, are also – 2014;63:401 408. diet, particularly the amount of fermentable present on a standardised diet; and (d) these Manichanh C, et al. Gut 2014;63:401–408. doi:10.1136/gutjnl-2012-303013 401 Gut microbiota differences are associated with differences in the colonic micro- were instructed to carry the event marker during daytime and to biota. Hence, our aims were to determine: (a) the effect of diet register every evacuation of gas per anus. Previous studies meas- Gut: first published as 10.1136/gutjnl-2012-303013 on 13 June 2013. Downloaded from on the number of gas evacuations and the volume of gas evacu- uring the number of gas evacuations simultaneously by an event ated; (b) whether the number of evacuations and the gas volume marker and continuous recording of anal gas evacuation showed – evacuated are increased in patients complaining of flatulence; a very good correlation.8 11 and (c) the relationships among diet, abdominal sensations, gas evacuation and colonic microbiota. To this aim, we designed a Clinical data comprehensive study comparing patients complaining of exces- Participants were instructed to fill out a questionnaire at the end sive passage of gas per anus and healthy subjects. We took of the 3 days during each study phase that evaluated the follow- advantage of high-throughput sequencing technology and ing parameters: (a) number of bowel movements and stool form recently developed bioinformatic tools to comprehensively using the Bristol scale;12 (b) subjective sensations of flatulence analyse the whole spectrum of gut microbial communities. (defined as anal gas evacuation), abdominal bloating (pressure/ fullness), abdominal distension (girth increment), borborygmi MATERIAL AND METHODS and abdominal discomfort/pain, by corresponding 0–10 ana- Participants logue scales; and (c) digestive well-being using a 10-point scale A total of 30 patients complaining of excessive passage of gas graded from +5 (satisfaction) to −5 (dissatisfaction). On the last per anus (age range 25–65 years) and 20 healthy subjects day of each study phase, body weight and girth were measured. without gastrointestinal symptoms (age range 21–63 years) par- ticipated in the study. Antibiotic consumption during the previ- Volume of intestinal gas produced after a test meal ous 2 months was an exclusion criterion. Patients who consulted Gas collection tests were conducted after overnight fast the for excessive passage of gas per anus were instructed to pro- fourth day of each study phase. A standard meal (either normal spectively fill out a clinical questionnaire (see details in clinical or flatulogenic) was administered and the volume of gas evacu- data section below) for 3 days (entry period), and only those ated was measured for 6 h, as previously described;13 14 in scoring anal gas evacuation ≥5 on a 10-point scale were offered brief, gas was collected using a rectal balloon catheter (20 F to participate in the study. All patients reported associated symp- Foley catheter, Bard, Barcelona, Spain) connected via a line toms and fulfilled Rome III criteria for postprandial distress syn- without leaks to a barostat, and the volume was continuously drome (n=15), irritable bowel syndrome (n=11; five recorded. The normal meal was administered at the end of the diarrhoea-predominant, two constipation-predominant and four basal phase and consisted of a glass of milk (coffee optional) alternating) or functional abdominal pain (n=4).67In healthy and buttered toasts with marmalade (330 Kcal, 1.2 g fibre); the subjects, the same evaluation was performed during the entry flatulogenic meal was administered at the end of the challenge period to confirm the absence of gastrointestinal symptoms. phase and consisted of cooked beans with sausage, whole wheat Subjects gave written informed consent to participate in the bread and canned peach (874 Kcal, 26.5 g fibre). study. The protocol for the study was previously approved by the Institutional Review Board of University Hospital Vall Volume of abdominal gas http://gut.bmj.com/ d’Hebron. Abdominal CT scans were obtained after the 6 h gas collection test with a helical multislice CT scanner (M×8000, Philips Study design
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