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bloat

Feelings of diffuse abdominal pain. Etiology: 1) irritable bowel syndrome 2) bacterial overgrowth syndrome 3) giardiasis (Giardia lamblia) 4) carbohydrate enzyme deficiency 5) celiac disease [4] 6) pelvic floor dysfunction [4] 7) dyspepsia (MKSAP19) 8) cholinesterase inhibitors Pathology: 1) intestinal gas may be normal in quantity 2) intestinal motility disturbance 3) visceral hypersensitivity 4) gas produced in the colon by bacterial fermentation (also see flatulence) Laboratory: - hydrogen breath test for carbohydrate enzyme deficiency [4] - tissue transglutaminase IgA in serum to evaluated for celiac disease [4] Special laboratory: - upper GI endoscopy with small bowel biopsy - confirm celiac disease [4] - worsening symptoms - gastric emptying study only if nausea/vomiting [4] - anorectal physiology testing if constipation, difficulty with defectation [4] Diagnostic criteria: - Rome IV criteria should be used to diagnose primary abdominal bloating & abdominal distension & irritable bowel syndrome [4] Radiology: - plain abdominal radiograph Differential diagnosis: - dyspepsia* - postprandial bloating, early satiety & minimal epigastric tenderness Management: 1) pharmacologic agents* a) simethicone is indicated for treatment of gas retention in the GI tract - may alter elasticity of gas bubbles b) anticholinergics - dicyclomine (Bentyl) 10-30 mg 30 min before meals - hyoscyamine b) antidepressants: begin at lower dose - amitriptyline (Elavil) 25-150 mg QHS - doxepin (Sinequan) 25-150 mg QHS - fluoxetine (Prozac) 20 mg QD - nortriptyline (prokinetic agent according to NEJM) d) prokinetic agent: - metoclopramide - cisapride (Propulsid) 10-20 mg BID (removed from US market) 2) behavioral modification/biofeedback especially with pelvic floor dysfunction [4] 3) low FODMAP diet with GI dietician oversight if carbohydrate enzyme deficiency [4] 4) do not use probiotics [4] 5) Iberogast ? * treat dyspepsia with proton pump inhibitor prior to treating bloat (MKSAP19)

Related

bacterial overgrowth syndrome flatulence

General

intestinal disease

References

  1. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
  2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 234
  3. Medical Knowledge Self Assessment Program (MKSAP) 18, American College of Physicians, Philadelphia 2018
  4. American Gastroenterological Association Clinical practice update focuses on belching, bloating, distension. https://gastroenterology.acponline.org/archives/2023/07/28/1.htm - Moshiree B, Drossman D, Shaukat A. AGA Clinical Practice Update on Evaluation and Management of Belching, Abdominal Bloating, and Distension: Expert Review. Gastroenterology. 2023. July 13 PMID: 37452811 Free article Review. https://www.gastrojournal.org/article/S0016-5085(23)00823-5/fulltext
  5. NEJM Knowledge+