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Clinical Question
What is the most effective management of flatulence?
Evidence-Based Answer
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). See Table 1 for a summary of the relative effectiveness of different methods for controlling flatus.1-10
Evidence Summary
Flatus 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, and methane, whereas odor is a result of sulfur gases in the flatus. Because flatus represents two different perceived problems, distinct treatments for either volume or odor may be required.
ANTIBIOTICS
One double-blind study comparing rifaximin, a nonabsorbed antibiotic, 400 mg orally twice daily and placebo showed that more patients reported relief of symptoms of abdominal bloating, distension, and flatulence with rifaximin (41 versus 23 percent; number needed to treat [NNT] = 5.4).1 This benefit diminished 10 days after the treatment course finished; however, it remained significant (29 versus 11 percent of patients reporting improvement; NNT = 5.8).
PROBIOTICS
Multiple probiotics have been shown in RCTs to have significant short- and long-term reduction in flatulence and bloating. Because each probiotic is a different mixture of bacteria, they have to be treated as 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 by 0.55...