Bloating or gas accumulation of gas in the pouch affects many ostomates. The following are some considerations to control or avoid the uncomfortable pouch ballooning.
Bloating and Distention Pathophysiology
“Exactly what is responsible for sensations of bloating and distention remains controversial. Patients have no doubt that excessive intestinal gas is the cause of the problem. This belief is based on several lines of evidence. Most convincing is the observation that passage of gas per rectum or movement of gas in the gut is seemingly associated with transient relief of the bloating sensation. In addition, protuberance of the abdomen, requiring loosening of belts or tight garments, frequently is associated with the sensation of bloating. Gas is presumed to be the source of the increased volume of abdominal contents responsible for the enhanced abdominal girth. A large body of evidence suggests, however, that excessive intestinal gas may have little to do with bloating and distention.”1
“In general, the term bloating refers to the subjective sensation of increased abdominal pressure without an increase in abdominal size, whereas distension describes the same subjective sensation but with a corresponding objective increase in abdominal girth. Approximately 50% of patients with a sensation of bloating also describe abdominal distension. Bloating is more commonly seen in patients with IBS (Symptoms of Irritable Bowel Syndrome), whereas distension is more readily seen in patients with constipation and pelvic floor dysfunction, in whom plethysmographic studies confirm an increase in abdominal girth of as much as 12 cm.
Bloating is a difficult endpoint because it is largely a subjective symptom. Patients’ descriptions of bloating vary significantly, but it is often vaguely described as a sensation of fullness, heaviness, tightness, or discomfort. Bloating ranges from mild to severe but is difficult to quantify and almost impossible to standardize. Although bloating commonly occurs in conjunction with functional gastrointestinal disorders, such as IBS, up to 50% of patients who present with bloating do not fulfill the Rome diagnostic criteria for IBS. The Rome III diagnostic criteria for functional gastrointestinal disorders fail to include bloating as a primary criterion for IBS or functional dyspepsia because of its nondiscriminatory nature. It is a supportive symptom for a diagnosis of IBS. Functional bloating (described as a recurrent feeling of bloating or visible distension with insufficient evidence for a diagnosis of IBS, functional dyspepsia, or a functional gastrointestinal disorder) in isolation is relatively uncommon. As a result, few studies have included bloating as a primary endpoint, despite its clinical relevance. Fortunately, bloating is often included as a secondary endpoint or as part of a composite endpoint in studies targeted at IBS symptoms, and some data are therefore available for review.
Unfortunately, the overall pathogenic mechanisms behind such symptoms remain incompletely understood, although recent research indicates that they are likely to be multifactorial. As a result, treatment paradigms are often unsatisfactory because their empiric nature fails to adequately address the underlying pathophysiology. The effective management of bloating and distension requires therapies targeted at clearing the pathophysiologic mechanisms.”2
How Do I Handle Ballooning?
Ballooning refers to the accumulation of gas from the stoma in an ostomy pouch.
“The gastrointestinal tract contains, on average, less than 200 mL of gas, whereas daily gas expulsion averages 600–700 mL. On average, healthy men pass flatus 14 times per day, especially after meals. Flatus rates up to 25 per day are normal. The major gases in flatus are nitrogen, oxygen, carbon dioxide, hydrogen, and methane. Gases produced by colonic bacterial fermentation of ingested nutrients and endogenous glycoproteins (hydrogen, methane, and carbon dioxide) represent 74% of flatus. Flatus odor correlates with hydrogen sulfide concentrations. Other sulfur-containing gases in flatus include methanetriol and dimethyl sulfide. Men produce more aromatic flatus than women.
Insight into normal patterns of intestinal gas transit has been provided by experiments in which physiologic gas mixtures containing nitrogen, oxygen, and carbon dioxide are perfused into the jejunum. In healthy volunteers, gas perfusion produces steady-state flow with little distention and few symptoms. Gas collected from the rectum in such studies is expelled in pulsatile fashion, indicating that flow is regulated by intrinsic motor patterns in the distal gut. Gas transit is accelerated by liquid or solid meals, providing an experimental correlate to the observation that gas passage and gaseous symptoms increase postprandially”3
Try Not to Swallow Excessive Air When Eating
Some people swallow more air than others when eating. However, we must strive to minimize the amount of air we swallow with r food, and during other activities like smoking, sipping drinks and chewing gum to avoid gas accumulation. Furthermore, doing these and talking at the same time allows, even more air inside. If this happens often, adjust your habits to lower the volume of air bubbles ingested.
Balance Consumption of Gas Producing Food and Drinks
“The effect of diet on rectal gas has been mentioned, but diet can also affect such symptoms as bloating and abdominal discomfort. As in the case of excessive flatus, the amount of unabsorbed carbohydrate that reaches the colon appears to be the culprit. A number of studies have shown that carbohydrates in a normal diet may not be totally absorbed and may thus cause increased gas production by colonic flora as well as such symptoms as gas, bloating, abdominal cramps and diarrhea. These carbohydrates include lactose, sorbitol, mannitol, fructose, carbohydrates in all-purpose wheat flour and, perhaps the most infamous, the oligosaccharides in many beans.”3>sup
Some types of vegetables like cabbages, lettuce, sprouts, cauliflower, broccoli, spinach, beans, corn, and cucumbers tend to produce gas.
“Certain foods, such as legumes, starch, sorbitol, fructose, fiber, and lactose, are poorly digested or absorbed and therefore are prone to fermentation and cause excessive gas in the colon. Thus, malabsorption of food is thought to be a cause of abdominal bloating. Altering the intestinal microflora in patients with bacterial overgrowth can improve intestinal bloating and distention. […]
Antibiotics that are effective in altering the intestinal microflora include neomycin, ciprofloxacin, doxycycline, and metronidazole. In addition, the probiotic Lactobacillus Plantarum also can alter colonic flora and can decrease flatulence and abdominal pain. Other treatments for bloating include prokinetic agents such as metoclopramide and anti-gas agents such as simethicone and activated charcoal, although they appear to be relatively ineffective.”4
Ileostomates have a higher tendency to present symptoms of bloating and ballooning. “These side effects occur more often in patients with ileostomies because of the area and amount of bowel usually resected resulting in greater nutrient and fluid losses. However, many of these symptoms resolve-improve in four to six weeks after surgery. Loose stools, bloating, and ostomy odor may be an ongoing problem for some patients. Some other possible complications, particularly in ileostomy patients, would be ostomy blockages because of the smaller stoma (opening) size. Diet modification may help to alleviate some of these problems, however, there is no one recommendation for everyone; each patient needs to base their diet on their own individual symptoms.”5
In addition, avoid carbonated drinks as they are gaseous; they are at the top of the ‘guilty list’ among ostomates. They are difficult to avoid because they are common, as well as beers, sodas, and mineral water.
In any case, consult your nurse, caregiver or doctor to get some dietary advice on how to balance food and drink.
Apply Various Techniques to Control Gas Build-Up in Your Pouch
Once gas begins accumulating in the pouch, handling will depend upon the type of ostomy bag and ostomy procedure involved (ileostomy, colostomy or urostomy).
Some bags have charcoal filters that neutralize the chemical compounds from human waste odor. “There are new and improved accessory products such as ring or seals for managing abdominal contours that are uneven or peristomal skin that is not intact. Some pouches have effective gas filters that allow flatus to escape slowly from the pouch through a charcoal filter. This filter absorbs odor and does not allow leakage of fluid effluent through the filter.”6
Specialists rarely recommend filtered pouches for ileostomies since stool tends to be liquid, and small amounts can leak through the filter, causing obstructions and embarrassing situations. Patients with colostomies tend to have less issues with filters since their stool is usually thicker.
To mitigate ballooning, separate the pouch system from the flange and allow the gas to escape. Then, place the bag back around the flange. Do not make any holes on the pouch, you want to preserve its enclosure and effectiveness.
Some products and accessories on the market are available to control gas build-up.
Incorporate Supplements in Your Diet
For instance, people with lactose intolerance sometimes require supplements to control gas buildup and other upsetting symptoms. Some are suitable to control the digestion of milk derivatives.
Controlling pouch ballooning might be different for each person, so gaining experience you will discover what works for you. Consult your nurse or caregiver for more information on how to handle and prevent ballooning.
(1) Suarez, F. L., & Levitt, M. D. (2000). An understanding of excessive intestinal gas. Current gastroenterology reports, 2(5), 413-419. Available online at https://link.springer.com/article/10.1007/s11894-000-0042-8
(2) Foley, A., Burgell, R., Barrett, J. S., & Gibson, P. R. (2014). Management strategies for abdominal bloating and distension. Gastroenterology & hepatology, 10(9), 561. Available online at https://pdfs.semanticscholar.org/6541/5f47958f1df84eb4681ecb6118e2ddec9567.pdf
(3) Hasler, W. L. (2006). Gas and bloating. Gastroenterology & hepatology, 2(9), 654. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5350578/
(4) Fardy, J., & Sullivan, S. (1988). Gastrointestinal gas. CMAJ: Canadian Medical Association Journal, 139(12), 1137. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1268474/pdf/cmaj00181-0019.pdf
(5) Fink, R. N., & Lembo, A. J. (2001). Intestinal gas. Current treatment options in gastroenterology, 4(4), 333-337. Available online at https://link.springer.com/article/10.1007/s11938-001-0059-6
(6) Herbold, N. H., & Edelstein, S. (2007). Rapid Reference for Nurses: Nutrition. Jones & Bartlett Learning. Available online at https://books.google.co.ve/books?id=ctygCdKwAQQC&pg=PA253&dq=ostomy+and+bloating&hl=es-419&sa=X&ved=0ahUKEwihivaJ4bziAhVIA6wKHWwEArsQ6AEIMjAB#v=onepage&q=ostomy%20and%20bloating&f=false
(7) Perry, A. G., Potter, P. A., & Ostendorf, W. (2015). Nursing Interventions & Clinical Skills-E-Book. Elsevier Health Sciences. Available online at https://books.google.co.ve/books?id=dGQMBAAAQBAJ&pg=PA868&dq=ostomy+pouching+system+charcoal+filters&hl=es-419&sa=X&ved=0ahUKEwjtoffM7bziAhWpnuAKHa8UBo0Q6AEINDAB#v=onepage&q=ostomy%20pouching%20system%20charcoal%20filters&f=false