2022/2/2


Colonic Gas and Fecal Incontinence

 

Yoshiharu Uno, MD, PhD

 

Corresponding author: Yoshiharu Uno

 
Office Uno Column; 419-2, Yota, Ono-Cho, Kakogawa, Hyogo, Japan

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Word count: 500/500

Author Conflict of Interest

Guarantor of the article: Uno Y

Specific author contributions: Uno Y contributed to the writing of the manuscript, creation of theory, reference collection.

Potential competing interests: Uno Y is granted a trademark of low FODMAP diet from the Japan Patent Office, and has published a book on the low FODMAP diet.

Supported by: No dedicated source of funding

Financial support: None.

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Menees et al. described the effect of a low FODMAP diet (LFD) and psyllium on fecal incontinence (FI) (1). In accordance with the Rome III criteria, the FI cases in this study excluded neurogenic bowel (NB) with central or peripheral nerve abnormalities or injury. However, LFD may be effective in FI due to various causes, including NB. Their study confirmed that the frequency of liquid FI was reduced by LFD.

 

Reducing the amount of FODMAPs reduces the amount of water in the intestinal tract, which is the main reason why LFD can improve FI. However, a serious problem with FODMAPs is that they ferment in the digestive tract and produce large amounts of gas. For this reason, for LFD to improve frequent bowel movements, the effect of LFD on inhibiting gas production needs to be taken into account.

 

Previously, I had reported on percutaneous endoscopic cecostomy (PEC) by the introducer method (2). Initially, PEC was performed for drainage purposes, but later, PEC was performed as a route for antegrade continence enema (ACE) to control constipation and FI caused by NB in pediatric and adult patients with spinal cord injury and spina bifida. From my experience with these patients, I understood that even if ACE is performed at the same flow rate with lukewarm water, if there is a great amount of gas in the colon, excretion will be incomplete, resulting in inadequate prevention of FI. As for the velocity of transit through the intestine, hydrodynamically, more viscous fluids decrease the velocity (3). This is the reason why the frequency of soft FI decreased with psyllium administration in the study by Menees et al. Gases have very little potential energy, so gases in the colon are harder to move than liquids. In addition, the width of the lumen also regulates the velocity (3). The colon has many sphincters (3,4), which contract to form a gas-filled bulge. During this process, as per Bernoulli’s principle, the velocity of the liquid within the bulge decreases, leading to pooling of the liquid within the bulge (3,4). The fluid in the bulge moves slowly with the gas, and when it reaches the rectum, it is excreted with the gas by the recto-anal reflex. The intermittent and frequent occurrence of such fluid-filled flatus incontinence is the most troublesome phenomenon for FI by NB. It is very likely that the LFD will prevent this simultaneous incontinence of liquid and gas by reducing gas production. In fact, in the case of ACE in NB patients, I have also experienced a faster rate of complete excretion of intestinal contents with LFD and a decrease in the frequency of FI. Menees et al. reported an increase in bloating with psyllium and a decrease with LFD. These results may indicate colonic gas suppression by LFD. In conclusion, LFD is expected to not only reduce fluid volume but also inhibit inspiratory incontinence and reduce the patient burden of FI due to various causes including NB. Research on LFD for flatus incontinence is needed.


 

REFFERNCES

1.     Menees SB, Jackson K, Baker J, et al. A Randomized Pilot Study to Compare the Effectiveness of a low FODMAP diet vs psyllium in patients with fecal incontinence and loose stools. Clin Transl Gastroenterol 2022 Jan 19. doi: 10.14309/ctg.0000000000000454.

 

2.  Uno Y. Introducer method of percutaneous endoscopic cecostomy and antegrade continence enema by use of the Chait Trapdoor cecostomy catheter in patients with adult neurogenic bowel. Gastrointest Endosc 2006;63(4):666-673. doi: 10.1016/j.gie.2005.12.035.

 

3.  Uno Y, Nakamura M. Japanese low FODMAP diet manual. Cambridge, UK: Cambridge Scholars Publishing, 2019. ISBN: 1-5275-2671-2

 

4.  Uno Y. Colonic transit time and pressure based on Bernoulli's principle. Clin Exp Gastroenterol. 2018;11 (5):153-163. doi: 10.2147/CEG.S153676

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