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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] - Helicobacter pylori antigen in stool for postprandial bloating (dyspepsia) [3] 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) [3] * check Helicobacter pylori antigen in stool (MKSAP20) [3]

Related

bacterial overgrowth syndrome dyspepsia (indigestion, postprandial bloating) 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 - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  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+