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• W2782492783 abstract "Bloating is a common presenting complaint to health care providers, but is often difficult to evaluate and manage. Bloating is defined as a sensation of increased abdominal pressure that may or may not be accompanied by visible abdominal distention.1Malagelada J.R. Accarino A. Azpiroz F. Bloating and abdominal distension: old misconceptions and current knowledge.Am J Gastroenterol. 2017; 112: 1221-1231Crossref PubMed Scopus (45) Google Scholar In fact, objective abdominal distention occurs only in half the patients with bloating.2Houghton L.A. Lea R. Agrawal A. et al.Relationship of abdominal bloating to distention in irritable bowel syndrome and effect of bowel habit.Gastroenterology. 2006; 131: 1003-1010Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar Although bloating affects 16%–19% of the general population, its associated morbidity and impact on everyday life varies dramatically between individuals.3Sandler R.S. Stewart W.F. Liberman J.N. et al.Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact.Dig Dis Sci. 2000; 45: 1166-1171Crossref PubMed Scopus (191) Google Scholar, 4Jiang X. Locke G.R. Choung R.S. et al.Prevalence and risk factors for abdominal bloating and visible distention: a population-based study.Gut. 2008; 57: 756-763Crossref PubMed Scopus (90) Google Scholar Although some patients may have mild symptoms that resolve without any treatment, others may experience severe and debilitating symptoms that cause them to visit multiple health care providers in outpatient clinics or even the emergency department. The differential for bloating is broad and includes organic and functional causes. Organic disorders may have infectious, inflammatory, ischemic, autoimmune, malabsorptive, or neoplastic causes. In cases where an organic cause is not identified, functional causes should be considered. Functional abdominal bloating/distention is defined by the Rome IV criteria as follows: recurrent bloating and/or distention occurring, on average, at least 1 day per week with abdominal bloating/distention predominating over other complaints, and there are insufficient criteria for a diagnosis of irritable bowel syndrome (IBS), functional constipation, functional diarrhea, or postprandial distress syndrome.5Mearin F. Lacy B.E. Chang L. et al.Bowel disorders.Gastroenterology. 2016; 150: 1393-1407Abstract Full Text Full Text PDF Scopus (1515) Google Scholar Additionally, both criteria must be present for the last 3 months with symptom onset at least 6 months before diagnosis.5Mearin F. Lacy B.E. Chang L. et al.Bowel disorders.Gastroenterology. 2016; 150: 1393-1407Abstract Full Text Full Text PDF Scopus (1515) Google Scholar Notably, approximately one-third of the general adult population fulfills criteria for a functional gastrointestinal disorder.6Aziz I. Palsson O.S. Törnblom H. et al.The prevalence and impact of overlapping Rome IV-diagnosed functional gastrointestinal disorders on somatization, quality of life, and healthcare utilization: a cross-sectional general population study in three countries.Am J Gastroenterol. 2018; 113: 86-96Crossref PubMed Scopus (98) Google Scholar Numerous mechanisms of bloating exist and these can be captured using the acronym BLOATING (Bowel disturbance, Liquid, Obstruction, Adiposity, Thoracic, Increased sensitivity, Neuromuscular, Gas) (Figure 1). Constipation, small intestinal bacterial overgrowth (SIBO), celiac disease, and inflammatory bowel disease can all result in abdominal distention. Nonintestinal distention can occur with ascites and obesity. In patients presenting with abdominal pain, nausea, emesis, and obstipation, bowel obstruction should be considered. Common causes of gastric outlet obstruction include neoplasm and peptic ulcer disease. Small bowel obstruction classically occurs because of adhesions from prior abdominal surgeries. When healthy individuals are faced with intestinal gas distention, they reflexively have contraction of anterior abdominal muscles and relaxation of the diaphragm.1Malagelada J.R. Accarino A. Azpiroz F. Bloating and abdominal distension: old misconceptions and current knowledge.Am J Gastroenterol. 2017; 112: 1221-1231Crossref PubMed Scopus (45) Google Scholar In contrast, abnormal thoracic accommodation is defined as thoracic expansion with diaphragm contraction, leading to further distention. Additionally, abnormal gastric accommodation can be seen in those with functional bloating, diabetic gastroparesis, postgastric surgery, gastroesophageal reflux disease, and infiltrative processes, such as malignancy. Some patients with bloating may have an altered perception of pain. Functional bloating, IBS, dyspepsia, depression, anxiety, stress, obesity, and premenstrual syndrome have all been associated with visceral hyperalgesia to varying degrees.1Malagelada J.R. Accarino A. Azpiroz F. Bloating and abdominal distension: old misconceptions and current knowledge.Am J Gastroenterol. 2017; 112: 1221-1231Crossref PubMed Scopus (45) Google Scholar Neuromuscular causes of bloating may occur with motility disorders, such as gastroparesis, or because of medications, such as narcotics. Flatulence or increased intestinal gas leading to bloating may occur with aerophagia, IBS, or from dietary sources, including but not limited to carbohydrates, lactose, gluten, or high-FODMAP foods. A systematic approach is crucial in the workup and management of patients with bloating (Figure 2). This requires carefully eliciting a detailed history regarding the predominant complaint, timing of symptoms, other associated gastrointestinal features, and reviewing medical comorbidities, medications, supplements, and dietary habits.1Malagelada J.R. Accarino A. Azpiroz F. Bloating and abdominal distension: old misconceptions and current knowledge.Am J Gastroenterol. 2017; 112: 1221-1231Crossref PubMed Scopus (45) Google Scholar, 7Cotter T.G. Gurney M. Loftus C.G. Gas and bloating-controlling emissions: a case-based review for the primary care provider.Mayo Clin Proc. 2016; 91: 1105-1113Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The patient history and description of bloating should be used to guide the physical examination, laboratory studies, and imaging tests. When approaching a patient with bloating, an important first step is to exclude causes of pseudobloat or nonintestinal distention, which include fluid (ascites), fat (adiposity), and fetus (pregnancy), or the “3 Fs.” If these etiologies are ruled out, focusing on the predominant associated symptom, such as diarrhea, constipation, or possible mechanical disturbance, is most helpful. Conditions with diarrhea and bloating may be related to diet (carbohydrate malabsorption, osmotically rich sugars, enteral formulas, or high-fiber foods), medications (osmotic laxatives), small intestinal bacterial overgrowth (SIBO), celiac disease, inflammatory bowel disease, or diarrhea-predominant IBS. Management of such patients may include dietary or medication modifications, hydrogen breath test, celiac serologies, computed tomography enterography, or endoscopic procedures with mucosal biopsies. Additionally, bloating may be the primary symptom in more than 60% of patients with underlying constipation.8Mertz H. Naliboff B. Mayer E.A. Symptoms and physiology in severe chronic constipation.Am J Gastroenterol. 1999; 94: 131-138Crossref PubMed Scopus (96) Google Scholar Constipation-related bloating may occur in patients with simple constipation; pelvic floor dysfunction, constipation-predominant IBS, or those taking certain medications, particularly narcotics. Management of such patients almost always includes ensuring adequate hydration and initiating a bowel regimen. Additional workup may include calcium, thyroid function tests, colonoscopy, anorectal manometry, or transit studies. Mechanical disturbance is suspected in patients with symptoms suggestive of gastric outlet or bowel obstruction and usually requires additional imaging or testing for definitive diagnosis. In patients with bloating but without concomitant diarrhea, constipation, or mechanical disturbance, other etiologies, such as aerophagia, gastroparesis, or functional dyspepsia, should be considered. An alternative approach to bloating relies on the presence or absence of concomitant constipation and timing of symptoms in relationship to food.7Cotter T.G. Gurney M. Loftus C.G. Gas and bloating-controlling emissions: a case-based review for the primary care provider.Mayo Clin Proc. 2016; 91: 1105-1113Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar If patients have concomitant constipation, this symptom should be further investigated and treated as outlined in Figure 2. Otherwise, patients should be classified either as a “gastric bloater” if symptoms occur within 30 minutes of eating or a “small bowel bloater” if symptoms occur 30 minutes to 2 hours after eating.7Cotter T.G. Gurney M. Loftus C.G. Gas and bloating-controlling emissions: a case-based review for the primary care provider.Mayo Clin Proc. 2016; 91: 1105-1113Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Gastric bloating may occur because of gastric outlet obstruction, gastroparesis, abnormal accommodation, or functional dyspepsia, whereas small bowel bloating may occur from dietary causes, SIBO, celiac disease, small bowel obstruction, or IBS.7Cotter T.G. Gurney M. Loftus C.G. Gas and bloating-controlling emissions: a case-based review for the primary care provider.Mayo Clin Proc. 2016; 91: 1105-1113Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar An extensive dietary evaluation should be performed noting the size and frequency of meals and intake of fructose, lactose, and gluten-containing products, along with carbonated and caffeinated beverages.7Cotter T.G. Gurney M. Loftus C.G. Gas and bloating-controlling emissions: a case-based review for the primary care provider.Mayo Clin Proc. 2016; 91: 1105-1113Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar A thorough medication and supplement review should be conducted. In particular, patients should be asked about consumption of opioids, psyllium, iron, metformin, magnesium, laxatives, and antidiarrheal agents.7Cotter T.G. Gurney M. Loftus C.G. Gas and bloating-controlling emissions: a case-based review for the primary care provider.Mayo Clin Proc. 2016; 91: 1105-1113Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Medical comorbidities should be explored including risk factors for SIBO (Roux-en-Y gastric bypass, abdominal radiation, Crohn’s disease, strictures, ileocecal valve resection, dysmotility, achlorhydria), obstruction (prior abdominal surgeries), aerophagia (obstructive sleep apnea with continuous positive airway pressure use at night, poorly fitting dentures, rapid food eating habits, carbonated beverage consumption), and gas-bloat syndrome (post-Nissen fundoplication). The treatment of bloating should be directed at the underlying mechanism or cause as outlined previously. Treatment options may include, but are not limited to, simple reassurance, diet modification, laxatives, antibiotics, probiotics, antispasmodics, visceral antinociceptives, and biofeedback.1Malagelada J.R. Accarino A. Azpiroz F. Bloating and abdominal distension: old misconceptions and current knowledge.Am J Gastroenterol. 2017; 112: 1221-1231Crossref PubMed Scopus (45) Google Scholar In mild cases of bloating, a simple explanation of the problem and reassurance may be sufficient for patients. Dietary modification may consist of avoiding food triggers and reducing consumption of fermentable food products.1Malagelada J.R. Accarino A. Azpiroz F. Bloating and abdominal distension: old misconceptions and current knowledge.Am J Gastroenterol. 2017; 112: 1221-1231Crossref PubMed Scopus (45) Google Scholar Relieving constipation, if present, with adequate hydration, laxatives, stimulants, or pelvic floor biofeedback therapy may facilitate gas evacuation. In some patients, microbiome modulation may be necessary with antibiotics or probiotics. However, certain conditions, such as SIBO, may be overdiagnosed in clinical practice leading to inappropriate use of antibiotics, such as rifaxamin. Moreover, although research on probiotics remains limited and ongoing, they may have a role in certain disorders of gastrointestinal inflammation and infectious diarrheal illness. In other patients, particularly those with visceral hyperalgesia, antispasmodic agents, antidepressants, anxiolytics, or cognitive behavioral therapy may be useful.7Cotter T.G. Gurney M. Loftus C.G. Gas and bloating-controlling emissions: a case-based review for the primary care provider.Mayo Clin Proc. 2016; 91: 1105-1113Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Lastly, abdominal biofeedback treatment can help alleviate bloating in patients with an abnormal viscerosomatic reflex.1Malagelada J.R. Accarino A. Azpiroz F. Bloating and abdominal distension: old misconceptions and current knowledge.Am J Gastroenterol. 2017; 112: 1221-1231Crossref PubMed Scopus (45) Google Scholar Bloating is a common presenting complaint in gastroenterology and primary care medicine. The differential for bloating is broad and includes organic and functional causes. It is imperative to consider and rule out organic causes before considering functional causes. We propose an innovative acronym BLOATING to capture the various mechanisms responsible for bloating, including bowel disturbance, liquid, obstruction, adiposity, thoracic, increased sensitivity, neuromuscular, and gas. Workup and management relies on identifying the predominant complaint, noting the timing of onset of symptoms, reviewing dietary habits, medications, and supplements, and exploring other medical comorbidities. Numerous therapeutic options exist and should be directed at the underlying mechanism, symptom, or cause. A systematic approach is therefore essential in the workup and management of patients with bloating." @default.
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