Bloating resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Usman Ali Akbar, M.B.B.S.[2]

Synonyms and keywords:Approach to abdominal bloating, Approach to abdominal belching, Approach to flatulence, Use of FODMAPs.

Bloating resident survival guide Microchapters

Overview
Causes
FIRE
Diagnosis
Treatment
Dos
Don'ts

## Overview[edit | edit source]

Bloating is one of the most common gastrointestinal complaints that is attributed by the patient as the subjective sensation of incorrectly perceived excess gas. There are multiple non-functional etiologies of abdominal bloating and distension. Primary functional abdominal distension (FABD) should be diagnosed as a single entity and doesn't overlap with other functional gastrointestinal disorders. Rome IV diagnostic criteria mentions the co-existence of mild abdominal pain and/or minor bowel movements. FABD can be treated with antispasmodic along with peppermint oil in randomized controlled trials. A stepwise approach is usually needed that includes the dietary interventions, microbiome modulation, and medical therapy in the management of FABD.

## Causes[edit | edit source]

* The causes of abdominal bloating are numerous and are managed according to the underlying etiology:[1][2]

Causes of Abdominal Bloating  Intestinal Disorders  | Motility Disorders  | Malabsorption disorders  | Infectious causes  | Dietary causes  | Misc.

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* Adhesions

* Malignancy

* Diabetes
* Scleroderma
* Pseudo-obstruction
* Medications

* Lactose intolerance
* Fructose intolerance
* Celiac Disease
* Pancreatic insufficiency

* Small intestinal bacterial overgrowth
* Giardiasis

* Gas-producing foods
* FODMAPs

* Irritable bowel syndrome

## Complete Diagnostic Approach[edit | edit source]

* Shown below is an algorithm summarizing the diagnosis of abdominal bloating according to the American College of Gastroenterology Guidelines:[3][4]

| Patient with abdominal bloating and distension|

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| Look for the

* Warning signs
* Overlapping functional gastrointestinal disorders
* Bacterial overgrowth (Small intestine bacterial overgrowth)
* Dietary intolerances
* Celiac Disease
* Weight gain
* Constipation
* Hydrogen breath test
* Any psychological comorbidities

| Yes|

| No

| *Reassure the patient, recommend diaphragmatic breathing

* Diet intervention: Low FODMAP (fermentable oligo-, di-, monosaccharides, and polyols) diet
* Initiate symptomatic treatment such as peppermint oil or Simethicone

| Treat Accordingly

| Trial of Rifaximin/Probiotics|

| No Response|

| Antidepressants

* Psychological therapy
* Hypnotherapy, Cognitive behavioral therapy (CBT)

| No Response|

| *Referral to specialized Neurogastroenterology center

* Referral for the CT/MRI Electromyography
* Referral for the abdominal biofeedback therapy

## Treatment[edit | edit source]

* Shown below is an algorithm summarizing the treatment of abdominal bloating according the the American College of Gastroenterology Guidelines:[5]

| Treatment of bloating is based on the underlying etiology of bloating

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| Dietary changes are suggested for bloating

* Diet
* Exercise and posture
* Over-the-counter medications
* Probiotics
* Antibiotics
* Smooth muscle antispasmodics
* Osmotic laxatives
* Prokinetic agents
* Chloride channel activators
* Tricyclic antidepressants

Are any warning signs present?

* Anemia, GI bleeding, weight loss >10% of the body weight, and family history of GI malignancy

| Yes|

| No

| Treat accordingly

* Labs
* Endoscopy
* Imaging

| Functional?|

| Constipation|

| Functional dyspepsia|

| Non-constipation IBS|

| Bloating alone|

| *Lifestyle and nonspecific dietary advice

* Education about low FODMAP diet[6]
* Treat constipation aggressively and minimize bowel distension

* Consider the use of Rifaximin
* Consider Probiotics, Psychological therapy, CBT, and/or Antidepressants

* Consider Biofeedback neuromodulation

## Dos[edit | edit source]

* Use of probiotics can help reduce bloating.
* Antidepressants can help to reduce the symptoms of IBS but the data is unclear over the reduction of bloating.[7]
* Hypnotherapy has been reported to be useful in reducing the symptoms of bloating.
* Bowel training and diaphragmatic breathing have been useful in the management of bloating, however the data is unclear.

## Don'ts[edit | edit source]

* Artificial sweeteners containing sorbitol, mannitol, and xylitol should be avoided.[8]
* Medications such as anticholinergics, opiates, calcium channel blockers, and antidepressants should also be avoided as they have an effect on bloating.[9]
* 20% of carbohydrates in baked beans, 7–10% in wheat, oats, potatoes, and corn, and 1% in white rice are not absorbed well in the intestine and they can predispose to bloating, hence it is advisable to avoid them in the patients with increased complaints of bloating.

## References[edit | edit source]

1. ↑ Lacy, BE; Gabbard, SL; Crowell, MD (2011). "Pathophysiology, evaluation, and treatment of bloating: hope, hype, or hot air?". Gastroenterology & hepatology. 7 (11): 729–39. ISSN 1554-7914. PMC 3264926. PMID 22298969.
2. ↑ Malagelada, Juan R; Accarino, Anna; Azpiroz, Fernando (2017). "Bloating and Abdominal Distension: Old Misconceptions and Current Knowledge". The American journal of gastroenterology. Ovid Technologies (Wolters Kluwer Health). 112 (8): 1221–1231. doi:10.1038/ajg.2017.129. ISSN 0002-9270. PMID 28508867.
3. ↑ Foley, A; Burgell, R; Barrett, JS; Gibson, PR (2014). "Management Strategies for Abdominal Bloating and Distension". Gastroenterology & Hepatology. 10 (9): 561–571. PMC 4991532. PMID 27551250.
4. ↑ Lacy, Brian E.; Cangemi, David; Vazquez-Roque, Maria (2021). "Management of Chronic Abdominal Distension and Bloating". Clinical Gastroenterology and Hepatology. Elsevier BV. 19 (2): 219–231.e1. doi:10.1016/j.cgh.2020.03.056. ISSN 1542-3565.
5. ↑ Schmulson, M.; Chang, L. (2011-03-29). "Review article: the treatment of functional abdominal bloating and distension". Alimentary Pharmacology & Therapeutics. Wiley. 33 (10): 1071–1086. doi:10.1111/j.1365-2036.2011.04637.x. ISSN 0269-2813.
6. ↑ Altobelli, Emma; Del Negro, Valerio; Angeletti, Paolo; Latella, Giovanni (2017-08-26). "Low-FODMAP Diet Improves Irritable Bowel Syndrome Symptoms: A Meta-Analysis". Nutrients. MDPI AG. 9 (9): 940. doi:10.3390/nu9090940. ISSN 2072-6643.
7. ↑ Seo, A Young; Kim, Nayoung; Oh, Dong Hyun (2013-10-31). "Abdominal Bloating: Pathophysiology and Treatment". Journal of Neurogastroenterology and Motility. The Korean Society of Neurogastroenterology and Motility. 19 (4): 433–453. doi:10.5056/jnm.2013.19.4.433. ISSN 2093-0879.
8. ↑ Kamphuis, Jasper B.J.; Guiard, Bruno; Leveque, Mathilde; Olier, Maiwenn; Jouanin, Isabelle; Yvon, Sophie; Tondereau, Valerie; Rivière, Pauline; Guéraud, Françoise; Chevolleau, Sylvie; Noguer-Meireles, Maria-Helena; Martin, Jean- François; Debrauwer, Laurent; Eutamène, Helene; Theodorou, Vassilia (2020). "Lactose and Fructo-oligosaccharides Increase Visceral Sensitivity in Mice via Glycation Processes, Increasing Mast Cell Density in Colonic Mucosa". Gastroenterology. Elsevier BV. 158 (3): 652–663.e6. doi:10.1053/j.gastro.2019.10.037. ISSN 0016-5085.
9. ↑ Mari, Amir; Abu Backer, Fadi; Mahamid, Mahmud; Amara, Hana; Carter, Dan; Boltin, Doron; Dickman, Ram (2019-03-16). "Bloating and Abdominal Distension: Clinical Approach and Management". Advances in Therapy. Springer Science and Business Media LLC. 36 (5): 1075–1084. doi:10.1007/s12325-019-00924-7. ISSN 0741-238X.