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W2315810040 abstract "FigureINTRODUCTION This guideline on a World Digestive Health Day theme is the first to take 4 key gastrointestinal (GI) symptoms as its starting-point: heartburn, abdominal pain/discomfort, bloating, and constipation. It is also unique in featuring 4 levels of care in a cascade approach: self-care and “over-the-counter (OTC)” aids; the pharmacist’s view; the perspective of the primary care doctor—wherein symptoms play a primary role in patient presentation; and the specialist. This paper focuses on the first 3 levels; algorithms for the specialist can be found in the full version of this guideline on the World Gastroenterology Organisation (WGO) Web site. The aim is to provide another unique and globally useful guideline that helps in the management of common, troubling but not disabling GI complaints. A team of GI and primary care experts, as well as the International Pharmaceutical Federation, were involved in the creation of the guideline. GI symptoms—with the possible exception of heartburn—usually occur as chronic or recurrent complaints attributed to the pharynx, esophagus, stomach, biliary tract, intestines, or anorectum. Whereas some data are available on the epidemiology of individual symptoms, there are more on the symptom clusters or aggregations known as functional GI disorders (FGIDs)—disorders as yet not explained by structural or biochemical abnormalities. These disorders affect a large segment of the population, and comprise a large proportion of primary care and gastroenterology practice. A categorization of these symptoms into discrete FGIDs has been developed in a multinational consensus in accordance with predefined symptom criteria.1 Relatively few data are available on the epidemiology of individual symptoms (with the exception of constipation), although there are considerable data on FGID syndromes. The latter are frequently used as a surrogate for the former throughout this guideline—eg, gastroesophageal reflux disease (GERD) for heartburn, irritable bowel syndrome (IBS) for abdominal pain/bloating. In addressing any disorder in the community, it is important to distinguish between diagnosed and undiagnosed GI problems; there is a huge reservoir of people who have problems and who have not been given a specific diagnosis by their clinician.2 In dyspepsia, there is evidence that only 50% of sufferers actually consult their doctor.3 The reasons for consultation may be determinants of management. Local or regional disease epidemiology is relevant to the management of these GI problems: the prevalence of parasitic diseases such as worms, Giardia, and viruses, as well as the incidence of malignant diseases, need to be considered. For example, in Mexico, giardiasis; in South-East Asia, hepatitis viruses; and in the southern regions of the Andes, gastric and gallbladder cancer, need to be considered in the differential diagnosis. There are also cultural and religious aspects that modify the patient’s response to symptoms: the Japanese population is recognized for being pain-tolerant; in other cultures, showing resistance to pain or other complaints may be regarded as a sort of sacrifice that can be beneficial for the soul and future life. Coping with environmental or psychological stressors such as war, migration, starvation, sexual abuse, or bullying may be very important in the causation of diseases and symptoms. Finally, in some cultures, spicy foods are a real issue. EPIDEMIOLOGY OF FUNCTIONAL GI SYMPTOMS Between-country variations in the occurrence rates for abdominal symptoms must be interpreted with caution; they may also reflect differences in culture, language, or expression, as well as study methods.4 Cultural differences are likely to cause differences in5: Perception of symptoms—differences in ideas and concerns. Presentation to medical care (including access to care) Use of medication. Preferred types and patterns of treatment. Expectations for treatment outcome. Relative availability of OTC and prescription drugs. Region-specific information on the epidemiology of functional GI symptoms can be found in the full version of this guideline online on the WGO Web site. WGO Cascades The WGO has developed diagnostic and treatment cascades for the WGO guidelines to provide resource-sensitive recommendations rather than focusing on a gold standard. However, for this guideline, a different approach has been chosen, on the basis of the point of care: from self-care to pharmacist, general practitioner/family physician, and finally, GI specialist. For the GI specialist, no extensive instructions are provided here, as sufficient sources are available on the Internet and in the published literature; references are provided throughout this guideline (see also the full version of this guideline on the WGO Web site). Patients who are taking medications should consult a pharmacist to see whether the self-medication options mentioned in this document have any labeled contraindications or known interactions with other drugs they may be taking. In some countries, OTC medicines are only available through community pharmacies. In most countries in the world, pharmacists can only recommend OTC medicines (as they do not have prescribing rights) to help patients, whereas in some other countries there is an intermediate class of medicines: pharmacy-only medicines. It is therefore often challenging to distinguish between management decisions that are based on a pharmacist’s recommendation and those that are truly a choice of self-care. To resolve this issue, both the process (self-care vs. pharmacist-driven) and the solution have been considered here (OTC medicines in both cases). Still, it should be taken into account that pharmacists systematically review medications for 2 purposes: To determine whether the GI symptoms could be a side effect of a medication To determine whether medicines used to treat GI symptoms have any known drug interactions with medicines the patient is already taking Increasing evidence suggests that dietary,6 lifestyle, cognitive, emotional/behavioral, and broader psychosocial factors may all play a role in the etiology, maintenance, and clinical effectiveness of treatments for FGIDs.7 DIAGNOSIS In interpreting the common symptoms considered in this guideline, a diagnosis of an FGID can be made if the patient’s symptoms are consistent with published diagnostic criteria for a given FGID8 in the absence of a history suggestive of any structural (organic) diagnosis that might provide an alternative explanation for the symptoms (see below). Age and sex (with no significant interaction) are the most clinically relevant variables. Diagnostic responsibility is usually limited to medical doctors, and generally excludes self-care and pharmacist’s interventions. A list of functional GI symptoms and a complaints profile can be found in the full version of this guideline online on the WGO Web site. Diagnostic Tests for Functional GI Symptoms Physical examination Basic diagnostic laboratory tests: Complete blood cell count. Erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP). Biochemistry panel. Fecal occult blood (patient aged above 50 y). Pregnancy test. Liver function tests. Calprotectin or other fecal test to detect inflammatory bowel disease (IBD) in patients thought to have IBS, but in whom IBD is a possibility; now routine in many primary care settings (in the United Kingdom). Celiac serology; considered routine in areas with a high prevalence of celiac disease. Stool testing for ova and parasites. Endoscopy Visible abnormalities. Biopsy, histology. pH study—24-hour (48 to 72-hr with the Bravo esophageal pH capsule) esophageal pH or impedance-pH monitoring: measurement of esophageal acid exposure and assessment of the temporal association between heartburn symptoms and acidic reflux episodes. Manometry Esophageal motility study, high-resolution manometry. Anorectal manometry. Imaging GI barium series—air contrast swallow, meal and follow-through, enteroclysis. Double-contrast barium enema. Abdominal ultrasonography. Abdominal computed tomography, magnetic resonance imaging of the abdomen. Miscellaneous Breath tests: lactose, glucose, fructose.9 Dietary exclusion, followed by challenge with specific dietary components, may be considered a diagnostic test. Therapeutic trial of acid suppression [the “proton-pump inhibitor (PPI) test”] in patients with heartburn or other symptoms that might be related to acid reflux. Food allergy or intolerance, lactose intolerance, eosinophilic infiltrates. HEARTBURN It should be noted that not all common GI symptoms are functional. This concept is particularly relevant for the symptom of heartburn. Most patients presenting with heartburn have GERD, with or without visible lesions in the esophageal mucosa. According to the Rome III consensus, even endoscopically normal patients with heartburn are diagnosed as having reflux disease as long as there is evidence that their symptoms are caused by the reflux of gastric contents. This constitutes the diagnosis of nonerosive reflux disease. These patients do not have an FGID. Only when heartburn occurs in the absence of mucosal lesions, abnormal esophageal acid exposure, and a positive symptom-reflux association during reflux monitoring, and when it does not respond to acid-suppressive treatment, is it regarded as functional, and only then can a diagnosis of “functional heartburn” be made.10 Definition and Description Heartburn is a retrosternal burning or warm sensation that may move upward toward the neck, throat, and face. A synonym for it is “pyrosis.” Heartburn may also coexist with other symptoms referable to the upper GI tract. It may be accompanied by regurgitation of sour/acid-tasting fluid or gastric contents into the mouth—acid or food regurgitation. The symptoms are typically intermittent and may be experienced: In early postprandial periods, During exercise, While in a recumbent position, At night. In practice, there may be no clear differentiation between what are regarded as GERD symptoms and “dyspepsia”—indeed, the results of the Diamond study11 call into question the value of heartburn and reflux as indicative symptoms of GERD. Diagnostic/Symptoms Remarks It is important to determine whether or not acid may be associated with heartburn. This is most simply done by defining the response to antacids and acid suppression (or alginate preparations). Twenty-four-hour (48 to 72 h with the Bravo esophageal pH capsule) esophageal pH or impedance-pH monitoring can be carried out to assess the presence of esophageal acid exposure and a temporal association between heartburn and reflux episodes, using a measure such as the symptom-association probability. Patients with symptoms of GERD who do not respond to a PPI and have a negative endoscopy, with no evidence of acid reflux as a cause of their symptoms, should be diagnosed as having functional heartburn.12 The Rome III diagnostic criteria for functional heartburn are: Burning retrosternal discomfort or pain, Evidence that gastroesophageal reflux is not the cause of the symptom, Absence of histologically confirmed esophageal disorders, Criteria fulfilled for the previous 3 months, with symptom onset at least 6 months before diagnosis. Epigastric pain or discomfort that does not rise to the retrosternal region should not be called heartburn. Helicobacter pylori infection does not play a direct causative role in heartburn and GERD; there is no indication for testing for H. pylori infection. Together with heartburn, atypical symptoms of GERD may occur, including chest pain, which may mimic ischemic cardiac pain, or cough and other respiratory symptoms (as a result of either aspiration of refluxate into the lungs or a reflex triggered by the refluxate in the distal esophagus, or a combination of both mechanisms) that may mimic asthma or other respiratory or laryngeal disorders. In PPI-refractory patients, a combined pH and impedance study may be useful for reaching a diagnosis. It can also focus research on potential alternative causes of symptoms, such as esophageal hypersensitivity, and treatments that can address them. Differential Diagnosis GERD—esophagitis, Barrett's esophagus, nonerosive reflux disease. Achalasia. Diffuse esophageal spasm. Eosinophilic esophagitis. Other chest pathology. Alarm Features Dysphagia—difficulty in swallowing. Odynophagia—painful swallowing. Recurrent bronchial symptoms, aspiration pneumonia. Dysphonia, recurrent cough. GI bleeding. Evidence of iron-deficiency anemia. Progressive unintentional weight loss. Lymphadenopathy. Epigastric mass. New-onset heartburn at age above 50 to 55 years. Family history of esophageal adenocarcinoma.13 Heartburn—Management Cascade (Fig. 1) Occasional/intermittent heartburn usually has no long-lasting effects. Pain and discomfort caused by heartburn, if frequent, can severely limit daily activities, work productivity, sleep, and quality of life. Proper management and monitoring can control symptoms and avoid complications (such as peptic strictures) in most cases. “Older” simple remedies may be useful: Occasional reflux can be treated effectively with antacids. Patients should avoid foods that trigger symptoms—typically chocolate, coffee, fatty food. The use of chewing gum increases saliva production and partially neutralizes acid. For nocturnal heartburn, elevating the head of the bed on books or bricks may help. H2-receptor antagonists (H2RAs) are a widely used and effective OTC treatment. Although PPIs are very safe, some studies suggest that there may be long-term safety concerns with them.14 Most people with occasional heartburn do not need lifetime PPIs, and so these long-term safety issues are not of any concern. Those who need long-term full-dose treatment should be followed up. PPIs at lower dosages are now available OTC in many countries. PPI overuse—people who need sustained gastric acid suppression should have an appropriate indication for long-term PPI use; the long-term need for PPIs should be reassessed regularly. The response to acid suppression (or neutralization) in patients with functional heartburn is, by definition, minimal or absent and patients are at risk of being referred for surgical treatment for GERD. Hence, all patients with symptoms of GERD who are referred for surgery should have 24-hour pH monitoring to rule out functional heartburn if an objective diagnosis of GERD has not been provided by other means.12 FIGURE 1: Self-care algorithm for heartburn. Note: some of the over-the-counter options are not available in all countries.15Heartburn Self-help Exclusions for self-treatment15: Heartburn symptoms: For >3 months, severe, or nocturnal heartburn. Continuing after 2 weeks of treatment with a nonprescription H2RA or PPI. Occurring when taking a prescription H2RA or PPI. New-onset heartburn at age above 50 to 55 years. Dysphagia or odynophagia. Signs of GI bleeding: vomiting blood or black material or black tarry stools, anemia, iron deficiency. Symptoms or signs of laryngitis: hoarseness, wheezing, coughing, or choking. Unexplained weight loss. Continuous nausea, vomiting, diarrhea. Symptoms suggestive of cardiac-type chest pain: radiating to shoulder, arm, neck, jaw, and shortness of breath, sweating. Pregnant women or nursing mothers. Children below 12 years of age for antacids/H2RA, below 18 years for PPI. Management: Triggers—identify the most common trigger substances and behaviors; avoid these triggers to reduce the risk of acid reflux symptoms. Lifestyle measures: Losing weight, if overweight; the single most important lifestyle measure. Avoiding nicotine, coffee, alcohol, carbonated drinks, chocolate, mint, fried or fatty foods, citrus fruits or juices, tomato products, garlic or onions, spicy foods. Eating smaller, more frequent meals. Elevating the head of the bed head 20 to 25 cm on bricks or blocks. Avoiding food or liquids for 3 hours before lying down. Options for self-medication—availability varies between countries: Antacids—recommended for short-term or intermittent relief Simple antacids neutralize gastric acid—that is, sodium, calcium, magnesium, and aluminium salts. Alginate-containing agents, containing alginic acid with small doses of antacids: minimal buffering effects. Reduction of gastric acid secretion H2RA—effects last up to 10 hours. PPI—effects last up to 24 hours. Stomach emptying—prokinetic agents decrease gastroesophageal reflux, but few drugs are available for clinical use, and efficacy in clinical trials has been modest. Metoclopramide should be avoided. Follow-up action: The goals of self-treatment are to become symptom-free and restore an optimal quality of life, by using the most cost-effective therapy. If satisfactory and complete relief is not achieved, patients are recommended to visit a health care professional for diagnostic evaluation. Pharmacist A check should be made for any medications that may be contributing to heartburn: Bisphosphonates, aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs), iron, potassium, quinidine, tetracycline. Zidovudine, anticholinergic agents, α-adrenergic antagonists, barbiturates. β2-adrenergic agonists, calcium channel blockers, benzodiazepines, dopamine. Estrogens, narcotic analgesics, nitrates, progesterone, prostaglandins, theophylline. Tricyclic antidepressants (TCAs), chemotherapy. If any of these drugs are being taken, suggest referral to a general practitioner/family physician. Management: The patients should avoid NSAIDs, potassium supplements, bisphosphonates, and other trigger medications. In addition to lifestyle and dietary measures, aluminium salts, magnesium salts, calcium salts, a combination of aluminium and magnesium salts, alginates, or antacids/H2RAs or PPI (in OTC dose) should be considered. Alarm signals and follow-up action: If a patient is above 60 or aged 50 to 60 and has risk factors for cancer (eg, tobacco, alcohol, obesity), referral to a physician. If there is no improvement after 2 weeks, referral to general practitioner/family physician. Primary Care Doctor Diagnosis: Patient history, health status, medications, age. Allergies, family history of food allergies or eosinophilic esophagitis, hereditary angioedema; to be differentiated from food intolerances. Symptoms, duration, frequency, situation, remedies. Alarm signals. Management: Evaluate the response to PPI treatment; ensure that PPI is being taken in the recommended manner in relation to meals. There is no evidence that increasing the PPI dose in response to an inadequate response to a standard dosage is useful. However, taking a PPI twice daily 30 minutes before food may increase the response in some patients. “Blind” escalations of PPI dose are a major contributor to costs. The patient should avoid any food or drink after the end of the last meal of the day—no “nightcap.” If treatment is satisfactory, the dose should be reduced to the lowest effective level. If treatment fails, endoscopy should be considered. Biopsies should be taken if there are visible abnormalities, if dysphagia is an additional presenting symptom, or if H. pylori infection or eosinophilic esophagitis is a diagnostic consideration. Follow-up action: An annual review should be offered to patients who require long-term management of symptoms. Routine endoscopy is not necessary for patients without alarm signs; urgent referral for endoscopy is needed for patients above 55 years of age with unexplained, persistent, recent-onset dyspepsia. Early endoscopy could be considered in areas with a high incidence of gastric cancer. Specialist Full details of the specialist management of heartburn are beyond the scope of this guideline, and the reader is referred to the relevant guidelines on the management of GERD.16,17 ABDOMINAL PAIN/DISCOMFORT Definition and Description A chronic, localized or diffuse unpleasant feeling or pain in the abdominal cavity. Dyspepsia (or indigestion) is a chronic or recurrent pain in the upper abdomen, with a sensation of fullness and early satiety when eating. It may be accompanied by bloating, belching, nausea, or heartburn. It is frequently associated with GERD and may be the first symptom of peptic ulcer disease and occasionally of gastric cancer. Diagnostic/Symptoms Remarks Abdominal pain accompanied by disordered defecation is usually labeled IBS.18,19 The Rome III diagnostic criteria for functional abdominal pain disorder are: Continuous or nearly continuous abdominal pain. No, or only an occasional, relationship between pain and physiological events (eg, eating, defecation, or menses). Some loss of everyday functioning. The pain is not feigned. There are insufficient symptoms to meet the criteria for another FGID that would explain the pain. The criteria have been fulfilled for the previous 3 months, with symptom onset at least 6 months before diagnosis. Differential Diagnosis (Tables 1, 2) There are many possible causes of abdominal pain. The focus here will be on common causes of chronic abdominal pain, with pain/discomfort as the main presenting feature. However, it must be borne in mind that specific GI conditions may cause severe, acute abdominal pain, including: appendicitis, perforated peptic ulcer, strangulated hernia, diverticulitis, small-bowel and large-bowel obstruction, superior mesenteric arterial thrombosis, pancreatitis, and cholecystitis. IBS—abdominal pain is associated with bowel movements and leads to frequent, loose(r) stools or infrequent hard(er) stools with relief from defecation. Enteric infections—diarrhea and vomiting are prominent symptoms; pain, typically cramping in nature, may also feature. Specific food intolerance—FODMAPs, lactose.9,20,21 FODMAPs are poorly absorbed short-chain carbohydrates and monosaccharides and include fructans, galactans, fructose, and polyols; the acronym stands for “fermentable, oligosaccharides, disaccharides, monosaccharides, and polyols.” Functional dyspepsia or epigastric pain disorder: pain is localized to the epigastrium, is intermittent, and does not meet the criteria for gallbladder disease or sphincter of Oddi dysfunction. Peptic ulcer disease: the rates remain high in many countries, because of H. pylori infection and use of acetylsalicylic acid and NSAIDs. Unrecognized constipation. Celiac disease. Hepatic congestion/swelling of any cause—for example, right-sided heart failure, steatosis, hepatitis. IBD, especially Crohn’s disease. Chronic mesenteric ischemia (older patients): pain is exacerbated by eating (intestinal angina) and is out of proportion to the physical examination; new onset in older patients, history of vascular disease, symptoms of nausea, vomiting, and prominent weight loss; diarrhea may be present. Gynecologic pathology—pain associated with, and worsened by, menses; it should be remembered that IBS is often worse with menstruation. Gynecologic causes of chronic/recurrent abdominal pain/discomfort are: endometriosis, dysfunctional uterine bleeding, pelvic inflammatory disease, and ovarian cancer (may mimic IBS or dyspepsia and be difficult to detect). Ruptured ovarian cyst and ectopic pregnancy present with acute abdominal pain. A pelvic examination should be carried out, and one should consider pelvic ultrasound and/or referral to a gynecologist. TABLE 1: Pain Location and Differential DiagnosisTABLE 2: Pain Trigger/Relief and Differential DiagnosisAlarm Features Abnormal findings on physical examination. Unintentional progressive weight loss. Age at onset. GI bleeding. Family history of abdominal cancer. Laboratory abnormalities: anemia, hypoalbuminemia, abnormal liver function tests, elevated ESR or CRP, positive fecal occult blood test. New onset of symptoms without obvious trigger(s). Abdominal Pain/Discomfort—Management Cascade The community prevalence, severity, health care seeking, and medication use related to abdominal cramping/pain are high overall, but vary considerably between countries.4 In the United States and Latin America, greater use of medications for abdominal pain has been reported than in Europe (90% vs. 72%). Antispasmodic drugs have been most popular in Latin America and Italy, antacids in Germany and the United Kingdom. Drug therapy has reduced the duration of episodes (by up to 81% in Brazil). Medication is mainly taken on demand to relieve a pain episode. In a report on expectations of treatment, “fast onset of action” was ranked as the most important aspect, followed by “highly effective” and “well tolerated.” The choice of drug was mostly determined by a physician (approx. 50%), followed by friends, relatives, or fellow sufferers. Advertising appeared to play a minor role (0% to 6%), except in the United States (18%).5 A matter of great concern is that during the 10-year period from 1997 to 2008, opioid prescriptions for chronic abdominal pain more than doubled in the United States.22 No study has shown that opioids are effective for treating chronic abdominal pain; long-term use of opioids may worsen other GI symptoms, particularly constipation, nausea, and vomiting, and may lead to addiction. Abdominal Pain/Discomfort Self-help Warning signals to seek medical care rather than self-help: Continuing symptoms despite a full course of prescription or OTC medications. Vomiting. Unintentional weight loss. Symptoms increase over time and interfere with daily activities. Alarm signals to consult a doctor immediately: Pain that starts all over the abdomen but settles into one area, especially the right lower quadrant. Pain accompanied by fever over 38.3°C or 101°F. Pain with inability to urinate, move the bowels, or pass gas. Severe pain, fainting, inability to move. Pain that seems to come from the testicles. Chest pain accompanied by pain radiating up into the neck, jaw, arms, with shortness of breath, weakness, irregular pulse, or sweating. Continuous nausea, vomiting, or diarrhea. Extreme discomfort/pain in abdomen. Vomiting of blood or black material. Black or bloody bowel movements. Self-medication/self-help When appropriate: OTC medication for diarrhea and constipation. Lifestyle changes and dietary interventions. Pharmacist Management: The current standard treatment for IBS generally consists of a symptom-directed approach, with medication aimed at alleviating pain, constipation, and/or diarrhea.17,18 Evidence is now beginning to suggest that specific dietary intolerances should be considered.9,20,21 Other dietary strategies may also be of benefit, such as increasing fiber in the diet in the presence of constipation or probiotic with evidence of efficacy in IBS. Antacids and PPIs are probably inappropriate for treating abdominal cramping and pain5—although laxatives may cause cramps, they can actually reduce pain in more severely constipated patients. Primary Care Doctor Alarm signals: Refer for upper and/or lower endoscopy (as appropriate) in patients aged >50 years with alarm symptoms: weight loss, anemia, hematemesis, melena, bright red, bloody stools. Diagnosis: Patient history. Physical examination—light and deep palpation, auscultation, percussion, rectal, or pelvic examination, penis and testicles, check for dehydration and jaundice. Psychosocial assessment—history of posttraumatic stress disorder, physical or psychosocial abuse, somatization, anxiety, depression, family relationships and functioning. Standard laboratory tests—complete blood count to screen for anemia and infection, serum electrolytes, glucose, creatinine and urea for metabolic causes; liver function tests, lipase, and amylase, particularly in patients with upper abdominal pain; inflammatory markers; urinalysis and urine culture to help exclude urinary tract infection and interstitial cystitis; fecal occult blood (patient over 50 y of age); celiac serology; calprotectin test. Additional tests—stool tests for culture, ova, and parasites, and Giardia antigen to screen for bacterial, parasitic, or protozoal causes; it should be noted, however, that the association of IBS with prior parasitic infections is far from clear-cut and needs to be studied more definitively23; urine or serum pregnancy test; testing for H. pylori infection in patients with upper GI symptoms (test type depending on prevalence and test availability—eg, urea breath test, fecal antigen, or serology); in certain cases with pelvic and lower abdominal pain: vaginal swabs, pap smears, β-human chorionic gonadotropin, prostate-specific antigen, and urine cytology. Management: Symptomatic treatment: Antimuscarinic agents. Peppermint. Dietary manipulation—FODMAPs, lactose, fructose-free diets. Other pharmacologic agents: TCAs or serotonin-specific reuptake inhibitor therapy. The use of narcotic agents in patients with functional abdominal pain disorder may lead to the development of narcotic bowel syndrome—characterized by increasing use of narcotic medications for pain relief and, paradoxically, with the development of hyperalgesia. Follow-up action: Reassessment after 3 to 6 weeks of symptomatic treatment. Consider the Rome III Psychosocial Alarm Questionnaire for Functional Gastrointestinal Disorders to identify markers of serious psychosocial disturbance.24 Additional diagnostic procedures—laboratory and radiologic examinations. Referral to GI specialist,25 pain clinic. BLOATING Definition and Description Bloating, postprandial abdominal fullness, and distension are rather vague entities and difficult to define, with bloating described as a “feeling of increased pressure within the abdomen.” Language issues: In English, bloating and distension are differentiated: bloating is a symptom and distension is an observable and measurable expansion of the abdomen. This distinction is not possible in several other languages, such as Spanish. In Western countries, “ea" @default.
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W2315810040 title "Coping With Common Gastrointestinal Symptoms in the Community" @default.
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