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|[[Bloating resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{Infobox_Disease |
  Name          = {{PAGENAME}} |
  Image          = |
  Caption        = |
  DiseasesDB    = |
  ICD10          = {{ICD10|R|14|r|10}}|
  ICD9          = {{ICD9|787.3}}|
  ICDO          = |
  OMIM          = |
  MedlinePlus    = |
  eMedicineSubj  = |
  eMedicineTopic = |
  MeshID        = |
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{{CMG}} '''Associate Editor-In-Chief:''' {{Ibtisam}}
{{CMG}} '''Associate Editor-In-Chief:''' {{Ibtisam}}


{{SK}} Post-prandial abdominal fullness
==Overview==
==Overview==
Bloating is described as a sensation of elevated abdominal pressure that may or may not be accompanied by objective abdominal distension, i.e. noticeable enlargement of the waist. Bloating and abdominal distension may be symptoms of organic disease and possible causes should be considered first in the differential diagnosis. It is one of the most frequent problems in a wide proportion of patients with gastrointestinal disorders, but the most common cause is constipation. Aside from constipation, other causes of bloating include Irritable bowel syndrome, small intestinal bacterial overgrowth, gastroparesis, and gynecological conditions. The pathophysiology of bloating is not well understood and suggested underlying causes include visceral hypersensitivity, behavioral mediated irregular abdominal wall-phrenic reflexes, the influence of poorly ingested fermentable carbohydrates, and microbiome modification. Usually, patients are evaluated with a thorough history and physical examination, but organic disorders should be ruled out. The management strategy includes dietary modification, behavioral therapy, microbiome modulation, and medical therapy.
Bloating is described as a sensation of elevated [[abdominal]] pressure that may or may not be accompanied by objective [[abdominal distension]], i.e. noticeable enlargement of the waist. Bloating and abdominal distension may be symptoms of organic disease and possible causes should be considered first in the differential diagnosis. It is one of the most frequent problems in a wide proportion of patients with gastrointestinal disorders, but the most common cause is [[constipation]]. Bloating also results from [[irritable bowel syndrome]], [[Gastroparesis|gastroparesis,]] [[small intestinal bacterial overgrowth]] and [[Gynecological|gynecological conditions]]. The pathophysiology of bloating is not well understood and suggested underlying causes include [[visceral]] [[hypersensitivity]], behavioral mediated irregular abdominal wall-[[phrenic]] reflexes, poorly ingested fermentable carbohydrates, and [[microbiome]] modification. Usually, patients are evaluated with a thorough history and physical examination, but organic disorders should be ruled out. The management strategy includes dietary modification, behavioral therapy, microbiome modulation, and medical therapy.


==Historical Perspective==
==Historical Perspective==


*Bernheim in 1891 described a woman who said, "I go up and down like an accordion."<ref name="pmid6378725">{{cite journal |vauthors=Schott H |title=[Mesmer, Braid and Bernheim: on the history of the development of hypnotism] |language=German |journal=Gesnerus |volume=41 |issue=1-2 |pages=33–48 |date=1984 |pmid=6378725 |doi= |url=}}</ref> and Later on in 1900 Kaplan, wrote on ventre en accordéon.<ref name="pmid18138437">{{cite journal |vauthors=ALVAREZ WC |title=Hysterical type of nongaseous abdominal bloating |journal=Arch Intern Med (Chic) |volume=84 |issue=2 |pages=217–45 |date=August 1949 |pmid=18138437 |doi=10.1001/archinte.1949.00230020020002 |url=}}</ref>
*Bernheim in 1891 described a woman who said, "I go up and down like an accordion."<ref name="pmid6378725">{{cite journal |vauthors=Schott H |title=[Mesmer, Braid and Bernheim: on the history of the development of hypnotism] |language=German |journal=Gesnerus |volume=41 |issue=1-2 |pages=33–48 |date=1984 |pmid=6378725 |doi= |url=}}</ref> Later, in 1900, Kaplan wrote on ventre en accordéon.<ref name="pmid18138437">{{cite journal |vauthors=ALVAREZ WC |title=Hysterical type of nongaseous abdominal bloating |journal=Arch Intern Med (Chic) |volume=84 |issue=2 |pages=217–45 |date=August 1949 |pmid=18138437 |doi=10.1001/archinte.1949.00230020020002 |url=}}</ref>
*Sir James Y. Simpson described it and demonstrated nongaseous bloating. <ref name="pmid11978757">{{cite journal |vauthors=Dunn PM |title=Sir James Young Simpson (1811-1870) and obstetric anaesthesia |journal=Arch. Dis. Child. Fetal Neonatal Ed. |volume=86 |issue=3 |pages=F207–9 |date=May 2002 |pmid=11978757 |pmc=1721404 |doi=10.1136/fn.86.3.f207 |url=}}</ref>
*Nongaseous form of bloating was first described by Sir James Y. Simpson. <ref name="pmid11978757">{{cite journal |vauthors=Dunn PM |title=Sir James Young Simpson (1811-1870) and obstetric anaesthesia |journal=Arch. Dis. Child. Fetal Neonatal Ed. |volume=86 |issue=3 |pages=F207–9 |date=May 2002 |pmid=11978757 |pmc=1721404 |doi=10.1136/fn.86.3.f207 |url=}}</ref>
*According to Kaplan, in the 19th century in Europe, the intestines of the patient were punctured with a trocar in cases of suspected intestinal obstruction. In this way, it was discovered that there was no gas involved in cases of hysteric bloating.
*According to Kaplan, in the 19th century in Europe, the intestines of the patient were punctured with a trocar in cases of suspected [[intestinal obstruction]]. In this way, it was discovered that there was no gas involved in cases of hysteric bloating.
*It was also considered a "tumor" that vanished when the patient was anesthetized and returned when they were conscious.<ref name="urlFebruary 1887 - Volume 14 - Issue 2 : The Journal of Nervous and Mental Disease">{{cite web |url=https://journals.lww.com/jonmd/toc/1887/02000 |title=February 1887 - Volume 14 - Issue 2 : The Journal of Nervous and Mental Disease |format= |work= |accessdate=}}</ref>
*It was also considered a "tumor" that vanished when the patient was anesthetized and returned when they were conscious.<ref name="urlFebruary 1887 - Volume 14 - Issue 2 : The Journal of Nervous and Mental Disease">{{cite web |url=https://journals.lww.com/jonmd/toc/1887/02000 |title=February 1887 - Volume 14 - Issue 2 : The Journal of Nervous and Mental Disease |format= |work= |accessdate=}}</ref>
*Lordosis association with bloating was described by Krukenberg in 1884. <ref name="pmid18138437">{{cite journal |vauthors=ALVAREZ WC |title=Hysterical type of nongaseous abdominal bloating |journal=Arch Intern Med (Chic) |volume=84 |issue=2 |pages=217–45 |date=August 1949 |pmid=18138437 |doi=10.1001/archinte.1949.00230020020002 |url=}}</ref>
*[[Lordosis]] association with bloating was described by Krukenberg in 1884. <ref name="pmid18138437">{{cite journal |vauthors=ALVAREZ WC |title=Hysterical type of nongaseous abdominal bloating |journal=Arch Intern Med (Chic) |volume=84 |issue=2 |pages=217–45 |date=August 1949 |pmid=18138437 |doi=10.1001/archinte.1949.00230020020002 |url=}}</ref>
*Bloating was first described by Alvarez of the Mayo Clinic in 1949 in a woman with a psychiatric problem.<ref name="pmid18138437">{{cite journal |vauthors=ALVAREZ WC |title=Hysterical type of nongaseous abdominal bloating |journal=Arch Intern Med (Chic) |volume=84 |issue=2 |pages=217–45 |date=August 1949 |pmid=18138437 |doi=10.1001/archinte.1949.00230020020002 |url=}}</ref>
*Bloating was first described by Alvarez of the Mayo Clinic in 1949 in a woman with a psychiatric problem.<ref name="pmid18138437">{{cite journal |vauthors=ALVAREZ WC |title=Hysterical type of nongaseous abdominal bloating |journal=Arch Intern Med (Chic) |volume=84 |issue=2 |pages=217–45 |date=August 1949 |pmid=18138437 |doi=10.1001/archinte.1949.00230020020002 |url=}}</ref>


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==Classification==
==Classification==
There is no established system for the classification of [disease name].
There is no established system for the classification of bloating.
 
OR
 
[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].
 
OR
 
[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3].
[Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].
 
OR
 
Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.
 
OR
 
If the staging system involves specific and characteristic findings and features:
According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].
 
OR
 
The staging of [malignancy name] is based on the [staging system].
 
OR
 
There is no established system for the staging of [malignancy name].


==Pathophysiology==
==Pathophysiology==
===Abnormal Gut Microbiota===
===Abnormal Gut Microbiota===
There is a relationship between the types of gas produced by colonic [[microflora]] and bloating. The low producers of [[methane]] reported significantly increased bloating and [[cramping]] after the ingestion of [[sorbitol]] and fiber, and the high producers of methane revealed a lower prevalence of severe [[lactose intolerance]] than low producers. Hence, the role of methanogenic [[flora]] may be important in the pathogenesis of bloating. <ref name="pmid8995944">{{cite journal |vauthors=Kajs TM, Fitzgerald JA, Buckner RY, Coyle GA, Stinson BS, Morel JG, Levitt MD |title=Influence of a methanogenic flora on the breath H2 and symptom response to ingestion of sorbitol or oat fiber |journal=Am. J. Gastroenterol. |volume=92 |issue=1 |pages=89–94 |date=January 1997 |pmid=8995944 |doi= |url=}}</ref>
There is a relationship between the types of gas produced by colonic [[microflora]] and bloating. The role of [[Methanogen|methanogenic flora]] has always been in question when the pathogenesis of bloating is discussed. During the experiments involving the ingestion of [[sorbitol]] and fiber, it was determined that there was a significant increase in bloating in individuals with low producers of [[methane]] vs high producers. <ref name="pmid8995944">{{cite journal |vauthors=Kajs TM, Fitzgerald JA, Buckner RY, Coyle GA, Stinson BS, Morel JG, Levitt MD |title=Influence of a methanogenic flora on the breath H2 and symptom response to ingestion of sorbitol or oat fiber |journal=Am. J. Gastroenterol. |volume=92 |issue=1 |pages=89–94 |date=January 1997 |pmid=8995944 |doi= |url=}}</ref>


===Small Intestinal Bacterial Overgrowth===
===Small Intestinal Bacterial Overgrowth===
Patients with [[IBS]] who explicitly complain of bloating have been reported to have elevated gas production from bacterial [[fermentation]] due to [[small intestinal bacterial overgrowth]] (SIBO).<ref name="pmid17043337">{{cite journal |vauthors=Pimentel M, Park S, Mirocha J, Kane SV, Kong Y |title=The effect of a nonabsorbed oral antibiotic (rifaximin) on the symptoms of the irritable bowel syndrome: a randomized trial |journal=Ann. Intern. Med. |volume=145 |issue=8 |pages=557–63 |date=October 2006 |pmid=17043337 |doi=10.7326/0003-4819-145-8-200610170-00004 |url=}}</ref>
Bacterial [[fermentation]] and the subsequent gas production is the potential cause of bloating in patients with [[irritable bowel syndrome]].<ref name="pmid17043337">{{cite journal |vauthors=Pimentel M, Park S, Mirocha J, Kane SV, Kong Y |title=The effect of a nonabsorbed oral antibiotic (rifaximin) on the symptoms of the irritable bowel syndrome: a randomized trial |journal=Ann. Intern. Med. |volume=145 |issue=8 |pages=557–63 |date=October 2006 |pmid=17043337 |doi=10.7326/0003-4819-145-8-200610170-00004 |url=}}</ref>


===Intestinal Gas Accumulation===
===Intestinal Gas Accumulation===
In fasting conditions, the healthy GI tract produces just about 100 mL of gas spread almost equally between 6 compartments the [[liver]], [[small intestine]], [[ascending colon]], [[transverse colon]], [[descending colon]], and distal (pelvic) colon. The [[postprandial]] gas volume rises by around 65 percent, mainly in the pelvic colon. Excessive levels of intestinal gas have been suggested as the possible source of bloating and distension.<ref name="urlSleisenger and Fordtrans Gastrointestinal and Liver Disease- 2 Volume Set - 9th Edition">{{cite web |url=https://www.elsevier.com/books/sleisenger-and-fordtrans-gastrointestinal-and-liver-disease-2-volume-set/feldman/978-1-4160-6189-2 |title=Sleisenger and Fordtran's Gastrointestinal and Liver Disease- 2 Volume Set - 9th Edition |format= |work= |accessdate=}}</ref>
Increase levels of intestinal gas has been linked with bloating. After consuming a large meal, there is 65% increase in postprandial gas volume in pelvic colon. Whereas during fasting, GI tract produces about 100ml of gas which spreads between the [[liver]], [[small intestine]], [[ascending colon]], [[transverse colon]], [[descending colon]], and distal (pelvic) colon.<ref name="urlSleisenger and Fordtrans Gastrointestinal and Liver Disease- 2 Volume Set - 9th Edition">{{cite web |url=https://www.elsevier.com/books/sleisenger-and-fordtrans-gastrointestinal-and-liver-disease-2-volume-set/feldman/978-1-4160-6189-2 |title=Sleisenger and Fordtran's Gastrointestinal and Liver Disease- 2 Volume Set - 9th Edition |format= |work= |accessdate=}}</ref>


===Altered Gut Motility and Impaired Gas Handling===
===Altered Gut Motility===
Ineffective [[anorectal]] evacuation and impaired gas processing could also be the potential causes of abdominal distension and bloating.
Gut motility is affected in many disorders mainly labeled as Intestinal dysmotility. It affects the evacuation of excessive gas produced in the GI tract during fasting as well as post-prandial.  


===Abnormal Abdominal-diaphragmatic Reflexes===
===Abnormal Abdominal-diaphragmatic Reflexes===
In healthy adults, colonic gas infusion increases anterior wall tone and relaxes the [[diaphragm]] at the same time. On the contrary, patients with bloating have shown diaphragmatic contraction (descent) and relaxation of the [[internal oblique muscle]] with the same gas load. <ref name="pmid19208364">{{cite journal |vauthors=Accarino A, Perez F, Azpiroz F, Quiroga S, Malagelada JR |title=Abdominal distention results from caudo-ventral redistribution of contents |journal=Gastroenterology |volume=136 |issue=5 |pages=1544–51 |date=May 2009 |pmid=19208364 |doi=10.1053/j.gastro.2009.01.067 |url=}}</ref>
Mechanism which leads to bloating are not well understood but studies have shown a role of abdominal-diaphragmatic reflexes, which are involves the combination of increase in the anterior wall tone and diaphragm relaxation. These reflexes are abnormal in individuals with bloating.<ref name="pmid19208364">{{cite journal |vauthors=Accarino A, Perez F, Azpiroz F, Quiroga S, Malagelada JR |title=Abdominal distention results from caudo-ventral redistribution of contents |journal=Gastroenterology |volume=136 |issue=5 |pages=1544–51 |date=May 2009 |pmid=19208364 |doi=10.1053/j.gastro.2009.01.067 |url=}}</ref>


===Visceral Hypersensitivity===
===Visceral Hypersensitivity===
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===Food Intolerance and Carbohydrate Malabsorption===
===Food Intolerance and Carbohydrate Malabsorption===
A high FODMAP diet has demonstrated prolonged hydrogen production in the [[intestine]], colonic distension by [[fermentation]], increased colonic fluid delivery by osmotic load within the bowel lumen, and GI symptom generation. <ref name="pmid20102355">{{cite journal |vauthors=Barrett JS, Gearry RB, Muir JG, Irving PM, Rose R, Rosella O, Haines ML, Shepherd SJ, Gibson PR |title=Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon |journal=Aliment. Pharmacol. Ther. |volume=31 |issue=8 |pages=874–82 |date=April 2010 |pmid=20102355 |doi=10.1111/j.1365-2036.2010.04237.x |url=}}</ref>
A high FODMAP diet has demonstrated prolonged hydrogen production in the [[intestine]], colonic distension by [[fermentation]], increased colonic fluid delivery by osmotic load within the bowel [[lumen]], and GI symptom generation. <ref name="pmid20102355">{{cite journal |vauthors=Barrett JS, Gearry RB, Muir JG, Irving PM, Rose R, Rosella O, Haines ML, Shepherd SJ, Gibson PR |title=Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon |journal=Aliment. Pharmacol. Ther. |volume=31 |issue=8 |pages=874–82 |date=April 2010 |pmid=20102355 |doi=10.1111/j.1365-2036.2010.04237.x |url=}}</ref>


===Hard stool/Constipation===
===Hard stool/Constipation===
Distension of the [[rectum]] by retained [[feces]] slows small intestinal transit as well as colonic transit, thus aggravating bloating in [[Constipation|constipated]] patients. Constipation or hard/lumpy stool induces alteration of gut motility and increases bacterial [[Fermentation (biochemistry)|fermentation]].
Distension of the [[rectum]] by retained [[feces]] induces alteration of gut motility and increases bacterial [[Fermentation (biochemistry)|fermentation]].


==Causes==
==Causes==
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*In the USA, 15-30% of the general population has been reported to experience bloating.<ref name="pmid18477677">{{cite journal |vauthors=Jiang X, Locke GR, Choung RS, Zinsmeister AR, Schleck CD, Talley NJ |title=Prevalence and risk factors for abdominal bloating and visible distention: a population-based study |journal=Gut |volume=57 |issue=6 |pages=756–63 |date=June 2008 |pmid=18477677 |pmc=2581929 |doi=10.1136/gut.2007.142810 |url=}}</ref>
*In the USA, 15-30% of the general population has been reported to experience bloating.<ref name="pmid18477677">{{cite journal |vauthors=Jiang X, Locke GR, Choung RS, Zinsmeister AR, Schleck CD, Talley NJ |title=Prevalence and risk factors for abdominal bloating and visible distention: a population-based study |journal=Gut |volume=57 |issue=6 |pages=756–63 |date=June 2008 |pmid=18477677 |pmc=2581929 |doi=10.1136/gut.2007.142810 |url=}}</ref>


*A telephone survey reported a prevalence of 16% in US adults who were asked about bloating or distention during the last month.<ref name="pmid10877233">{{cite journal |vauthors=Sandler RS, Stewart WF, Liberman JN, Ricci JA, Zorich NL |title=Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact |journal=Dig. Dis. Sci. |volume=45 |issue=6 |pages=1166–71 |date=June 2000 |pmid=10877233 |doi=10.1023/a:1005554103531 |url=}}</ref>
*A telephone [[Survey sampling|survey]] reported a [[prevalence]] of 16% in US adults who were asked about bloating or distention during the last month.<ref name="pmid10877233">{{cite journal |vauthors=Sandler RS, Stewart WF, Liberman JN, Ricci JA, Zorich NL |title=Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact |journal=Dig. Dis. Sci. |volume=45 |issue=6 |pages=1166–71 |date=June 2000 |pmid=10877233 |doi=10.1023/a:1005554103531 |url=}}</ref>


*Women were more likely than men to report bloating.<ref name="pmid18477677">{{cite journal |vauthors=Jiang X, Locke GR, Choung RS, Zinsmeister AR, Schleck CD, Talley NJ |title=Prevalence and risk factors for abdominal bloating and visible distention: a population-based study |journal=Gut |volume=57 |issue=6 |pages=756–63 |date=June 2008 |pmid=18477677 |pmc=2581929 |doi=10.1136/gut.2007.142810 |url=}}</ref>
*Women were more likely than men to report bloating.<ref name="pmid18477677">{{cite journal |vauthors=Jiang X, Locke GR, Choung RS, Zinsmeister AR, Schleck CD, Talley NJ |title=Prevalence and risk factors for abdominal bloating and visible distention: a population-based study |journal=Gut |volume=57 |issue=6 |pages=756–63 |date=June 2008 |pmid=18477677 |pmc=2581929 |doi=10.1136/gut.2007.142810 |url=}}</ref>
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==Risk Factors==
==Risk Factors==
Risk factors include chewing gum, hard candy, and carbonated beverages such as soda or beer. Additionally, people may swallow excess air if they are [[anxious]] or have an [[upper respiratory infection]]. Foods that can produce excess bowel gas include leafy greens, beans, and bran foods. Dairy products can lead to [[bloating]] and [[flatulence]] in people who are [[lactose intolerant]].
Risk factors include chewing gum, hard candy, and carbonated beverages such as soda or beer. Foods that can produce excess bowel gas include leafy greens, beans, and bran foods. Dairy products can lead to [[bloating]] and [[flatulence]] in people who are [[lactose intolerant]].


==Screening==
==Screening==
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==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
The sensation of abdominal bloating is often attributed to excessive gas in patients. However, the relationship between the volume of intestinal gas and the effects is not clear. Patients with chronic complaints of bloating and distension have heightened sensitivity to gaseous distension or exaggerated motor response to normal amounts of gas. Pains that are due to bloating will feel sharp and cause the [[stomach]] to cramp. These pains may occur anywhere in the body and can change locations quickly.


OR
Bloating is typically [[benign]], although it can be due to severe conditions such as [[intestinal obstruction]] and [[Malignancy|malignancy.]]


Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
Patients with mild functional bloating may need merely reassurance that the condition is benign. <ref name="pmid30879252">{{cite journal |vauthors=Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R |title=Bloating and Abdominal Distension: Clinical Approach and Management |journal=Adv Ther |volume=36 |issue=5 |pages=1075–1084 |date=May 2019 |pmid=30879252 |pmc=6824367 |doi=10.1007/s12325-019-00924-7 |url=}}</ref>
 
OR
 
Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
[[Rome IV criteria]] for establishing the diagnosis of functional bloating include both of the following (for at least three months with symptom onset at least six months prior to diagnosis).<ref name="pmid27144627">{{cite journal |vauthors=Mearin F, Lacy BE, Chang L, Chey WD, Lembo AJ, Simren M, Spiller R |title=Bowel Disorders |journal=Gastroenterology |volume= |issue= |pages= |date=February 2016 |pmid=27144627 |doi=10.1053/j.gastro.2016.02.031 |url=}}</ref>


OR
●Recurrent bloating or distension, on average, at least one day per week; abdominal bloating and/or distension predominates over other symptoms


The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
●Insufficient criteria for a diagnosis of IBS, functional [[constipation]], functional [[diarrhea]], or postprandial distress syndrome
 
OR
 
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
 
OR
 
There are no established criteria for the diagnosis of [disease name].


===History and Symptoms===
===History and Symptoms===
The majority of patients with [disease name] are asymptomatic.
History includes the onset of symptoms, the relationship to diet (eg, wheat, dairy, fructose, fiber, nonabsorbable sugars) diurnal variation, and the presence of symptoms suggestive of other functional gastrointestinal disorders, including [[constipation]], diarrhea, and abdominal pain or postprandial fullness. Functional bloating usually have a [[diurnal]] pattern which may accompany the consumption of such foods, frequently accompanied by excessive [[burping]] or flattening. Patients may complain about deteriorating symptoms as the day progresses, particularly after meals, but they may be relieved overnight.<ref name="pmid16678560">{{cite journal |vauthors=Tack J, Talley NJ, Camilleri M, Holtmann G, Hu P, Malagelada JR, Stanghellini V |title=Functional gastroduodenal disorders |journal=Gastroenterology |volume=130 |issue=5 |pages=1466–79 |date=April 2006 |pmid=16678560 |doi=10.1053/j.gastro.2005.11.059 |url=}}</ref>
 
OR
 
The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].


===Physical Examination===
===Physical Examination===
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
Common physical examination findings of bloating include abdominal distention with or without altered [[bowel sounds]]. However, if [[Occult Blood|occult fecal blood]], cutaneous findings [[Sclerodactyly|(sclerodactyly]] with [[scleroderma]], [[dermatitis herpetiformis]] in [[celiac disease]]), peripheral or autonomic [[neuropathy]], [[cachexia]], [[jaundice]], or palpable masses is present then it suggests underlying organic disease. <ref name="pmid28316536">{{cite journal |vauthors=Hasler WL |title=Gas and Bloating |journal=Gastroenterol Hepatol (N Y) |volume=2 |issue=9 |pages=654–662 |date=September 2006 |pmid=28316536 |pmc=5350578 |doi= |url=}}</ref>
 
OR
 
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].


===Laboratory Findings===
===Laboratory Findings===
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
====Complete blood count====
To evaluate for [[anemia]]  


OR
====Serologies for Celiac Sprue<ref name="pmid308792522">{{cite journal |vauthors=Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R |title=Bloating and Abdominal Distension: Clinical Approach and Management |journal=Adv Ther |volume=36 |issue=5 |pages=1075–1084 |date=May 2019 |pmid=30879252 |pmc=6824367 |doi=10.1007/s12325-019-00924-7 |url=}}</ref>====


Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
*anti-tissue transglutaminase (tTG) antibodies
*endomysial antibodies (EMA)
*deamidated gliadin peptide (DGP) antibodies


OR
====Hydrogen Breath Test====
For the evaluation of [[small intestinal bacterial overgrowth]] and [[lactose intolerance]].


[Test] is usually normal among patients with [disease name].
====Thyroid Function tests<ref name="pmid308792523">{{cite journal |vauthors=Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R |title=Bloating and Abdominal Distension: Clinical Approach and Management |journal=Adv Ther |volume=36 |issue=5 |pages=1075–1084 |date=May 2019 |pmid=30879252 |pmc=6824367 |doi=10.1007/s12325-019-00924-7 |url=}}</ref>====


OR
====Fasting Cortisol Levels<ref name="pmid308792524">{{cite journal |vauthors=Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R |title=Bloating and Abdominal Distension: Clinical Approach and Management |journal=Adv Ther |volume=36 |issue=5 |pages=1075–1084 |date=May 2019 |pmid=30879252 |pmc=6824367 |doi=10.1007/s12325-019-00924-7 |url=}}</ref>====


Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
====Antinuclear antibodies and Scleroderma antibodies<ref name="pmid308792525">{{cite journal |vauthors=Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R |title=Bloating and Abdominal Distension: Clinical Approach and Management |journal=Adv Ther |volume=36 |issue=5 |pages=1075–1084 |date=May 2019 |pmid=30879252 |pmc=6824367 |doi=10.1007/s12325-019-00924-7 |url=}}</ref>====
To evaluate for [[collagen]] [[vascular]] disease


OR
====Antinuclear neuronal antibodies<ref name="pmid308792526">{{cite journal |vauthors=Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R |title=Bloating and Abdominal Distension: Clinical Approach and Management |journal=Adv Ther |volume=36 |issue=5 |pages=1075–1084 |date=May 2019 |pmid=30879252 |pmc=6824367 |doi=10.1007/s12325-019-00924-7 |url=}}</ref>====
To screen for [[Paraneoplastic syndrome|paraneoplastic]] [[visceral]] [[neuropathy]]


There are no diagnostic laboratory findings associated with [disease name].
====Stool analysis====
Antigen testing for ''[[Giardia lamblia|Giardia]]''


===Electrocardiogram===
===Electrocardiogram===
There are no ECG findings associated with [disease name].
There are no ECG findings associated with bloating.
 
OR
 
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


===X-ray===
===X-ray===
There are no x-ray findings associated with [disease name].
An abdominal x-ray may be helpful to rule out [[Intestinal obstruction|intestinal obstruction.]]
 
OR
 
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
There are no echocardiography/ultrasound  findings associated with [disease name].
Abdominal/Pelvic Ultrasound to look for [[ascites]] and rule out [[Ovarian cancer|ovarian cancer.]]
 
OR
 
Echocardiography/ultrasound  may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no echocardiography/ultrasound  findings associated with [disease name]. However, an echocardiography/ultrasound  may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===CT scan===
===CT scan===
There are no CT scan findings associated with [disease name].
There are no CT scan findings associated with bloating. However, it can be used to rule out [[Intestinal obstruction|intestinal obstruction.]]
 
OR
 
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===MRI===
===MRI===
There are no MRI findings associated with [disease name].
There are no MRI findings associated with bloating.
 
OR
 
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===Other Imaging Findings===
===Other Imaging Findings===
There are no other imaging findings associated with [disease name].
====Upper GI Endoscopy====
 
The presence of alarm features including [[weight loss]], abdominal pain, [[dysphagia]], [[heartburn]], and [[regurgitation]] are an indication for a diagnostic evaluation with upper [[endoscopy]].
OR
 
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


===Other Diagnostic Studies===
===Other Diagnostic Studies===
There are no other diagnostic studies associated with [disease name].
There are no other diagnostic studies associated with bloating.
 
OR
 
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
====Education, treatment of associated disorders, and behavioral therapy====
 
Management requires instruction to minimize air swallowing and reassurance that belching is a [[benign]] condition. Relevant behavioural interventions include the avoidance of gum chewing, smoking, consuming carbonated drinks, and gulping of food and liquids. Treatment should be started in people with persistent [[depression]] or [[anxiety]].<ref name="pmid288397572">{{cite journal |vauthors=Disney B, Trudgill N |title=Managing a patient with excessive belching |journal=Frontline Gastroenterol |volume=5 |issue=2 |pages=79–83 |date=April 2014 |pmid=28839757 |pmc=5369716 |doi=10.1136/flgastro-2013-100355 |url=}}</ref> Patients with co-existing acid reflux may need an acid reduction treatment for the control of [[GERD]].
OR
 
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
 
OR
 
The majority of cases of [disease name] are self-limited and require only supportive care.
 
OR


[Disease name] is a medical emergency and requires prompt treatment.
Effective management with excessive belching by a therapist (e.g. cognitive behavioral therapy or speech therapist)<ref name="pmid19650772">{{cite journal |vauthors=Hemmink GJ, Ten Cate L, Bredenoord AJ, Timmer R, Weusten BL, Smout AJ |title=Speech therapy in patients with excessive supragastric belching--a pilot study |journal=Neurogastroenterol. Motil. |volume=22 |issue=1 |pages=24–8, e2–3 |date=January 2010 |pmid=19650772 |doi=10.1111/j.1365-2982.2009.01371.x |url=}}</ref> with specific experience of diaphragmatic relaxation exercises has been linked with a decrease of symptoms.   [[Diaphragmatic breathing|Diaphragmatic]] breathing decreases postprandial intragastric pressure and raises the pressure of the esophagogastric junction region, restoring the gradient of the gastroesophageal pressure.


OR
====Reflux inhibitors for refractory symptoms====
[[Baclofen]] 10 mg three times daily can be prescribed to reduce transient lower [[esophageal]] [[sphincter]] relaxations and centrally suppress the swallowing rate, and may decrease both supragastric and gastric [[belching]].<ref name="pmid22079512">{{cite journal |vauthors=Blondeau K, Boecxstaens V, Rommel N, Farré R, Depeyper S, Holvoet L, Boeckxstaens G, Tack JF |title=Baclofen improves symptoms and reduces postprandial flow events in patients with rumination and supragastric belching |journal=Clin. Gastroenterol. Hepatol. |volume=10 |issue=4 |pages=379–84 |date=April 2012 |pmid=22079512 |doi=10.1016/j.cgh.2011.10.042 |url=}}</ref>


The mainstay of treatment for [disease name] is [therapy].


OR
{{familytree/start |summary=PE diagnosis Algorithm.}}
 
{{familytree | | | | | | | | A01 |A01='''Abdominal Bloating <br> and <br> Distension''' <ref name="pmid30879252">{{cite journal |vauthors=Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R |title=Bloating and Abdominal Distension: Clinical Approach and Management |journal=Adv Ther |volume=36 |issue=5 |pages=1075–1084 |date=May 2019 |pmid=30879252 |pmc=6824367 |doi=10.1007/s12325-019-00924-7 |url=}}</ref> }}
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
{{familytree | | | | | | | | |!| | | | | | }}
 
{{familytree | | | | | | | | A'01| | | | | | A'01= Evaluate for: <br> ●Alarm Signs <br> ●Overlapping FGID <br> (FG,FD,IBS) <br> ●[[Bacterial Overgrowth]] <br> ●Dietary Intolerance <br> [[Celiac Disease]] <br> ●Recent Weight Gain <br> [[Constipation]] <br> ●Psychological disorder  }}
OR
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
 
{{familytree | | | B01 | | | | | | | | B02 | | |B01=No  |B02=Yes }}
[Therapy] is recommended among all patients who develop [disease name].
{{familytree | | | |!| | | | | | | | | |!| }}
 
{{familytree | | | D01 | | | | | | | | D02 |D01= ●Reassurance <br> ●Recommend <br> [[Diaphragmatic]] <br> Breathing <br> ●Diet Intervention: <br> Low FODMAP diet <br> ●Symptomatic <br> medical therapy: <br> [[Peppermint oil]], <br> Simethicone etc  |D02= Treat <br> Accordingly }}
OR
{{familytree | | | |!| | | | | | | | | | | | | }}
 
{{familytree | | | E01 | | | | | | | | | | | | |E01= '''''No Response''''' }}
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
{{familytree | | | |!| | | | | | | | | | | | | }}
 
{{familytree | | | E02 | | | | | | | | | | | | |E02= ●Trial of <br> [[Rifixamin]]/[[Probiotics]] }}
OR
{{familytree | | | |!| | | | | | | | | | | | | }}
 
{{familytree | | | F01 | | | | | | | | | | | | |F01= '''''No Response''''' }}
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
{{familytree | | | |!| | | | | | | | | | | | | }}
 
{{familytree | | | G01 | | | | | | | | | | | | |G01= ●Antidepressants <br> ●Psychological therapy <br> ●[[Hypnotherapy]], <br> [[CBT]] }}
OR
{{familytree | | | |!| | | | | | | | | | | | | }}
 
{{familytree | | | F02 | | | | | | | | | | | | |F02= '''''No Response''''' }}
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
{{familytree | | | |!| | | | | | | | | | | | | }}
 
{{familytree | | | H01 | | | | | | | | | | | | |H01= ●Refer to <br> [[Neurogastroenterology]] <br> center <br> ●Refer to [[CT]] <br> or <br> [[MRI]] [[Electromyography]] <br> ●Refer to Abdominal <br> Biofeedback <br> therapy }}
OR
{{familytree/end}}
 
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].


===Surgery===
===Surgery===
Surgical intervention is not recommended for the management of [disease name].
Surgical intervention is not recommended for the management of bloating.
 
OR
 
Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
 
OR
 
The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
 
OR
 
The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
 
OR
 
Surgery is the mainstay of treatment for [disease or malignancy].


===Primary Prevention===
===Primary Prevention===
There are no established measures for the primary prevention of [disease name].
There are no established measures for the primary prevention of bloating.
 
OR
 
There are no available vaccines against [disease name].
 
OR
 
Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
 
OR
 
[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].


===Secondary Prevention===
===Secondary Prevention===
There are no established measures for the secondary prevention of [disease name].
There are no established measures for the secondary prevention of bloating.
 
OR
 
Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].


==References==
==References==
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[[Category:Digestive disease symptoms]]
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[[Category:Gastroenterology]]
 
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Ibtisam Ashraf, M.B.B.S.[2]

Synonyms and keywords: Post-prandial abdominal fullness

Overview

Bloating is described as a sensation of elevated abdominal pressure that may or may not be accompanied by objective abdominal distension, i.e. noticeable enlargement of the waist. Bloating and abdominal distension may be symptoms of organic disease and possible causes should be considered first in the differential diagnosis. It is one of the most frequent problems in a wide proportion of patients with gastrointestinal disorders, but the most common cause is constipation. Bloating also results from irritable bowel syndrome, gastroparesis, small intestinal bacterial overgrowth and gynecological conditions. The pathophysiology of bloating is not well understood and suggested underlying causes include visceral hypersensitivity, behavioral mediated irregular abdominal wall-phrenic reflexes, poorly ingested fermentable carbohydrates, and microbiome modification. Usually, patients are evaluated with a thorough history and physical examination, but organic disorders should be ruled out. The management strategy includes dietary modification, behavioral therapy, microbiome modulation, and medical therapy.

Historical Perspective

  • Bernheim in 1891 described a woman who said, "I go up and down like an accordion."[1] Later, in 1900, Kaplan wrote on ventre en accordéon.[2]
  • Nongaseous form of bloating was first described by Sir James Y. Simpson. [3]
  • According to Kaplan, in the 19th century in Europe, the intestines of the patient were punctured with a trocar in cases of suspected intestinal obstruction. In this way, it was discovered that there was no gas involved in cases of hysteric bloating.
  • It was also considered a "tumor" that vanished when the patient was anesthetized and returned when they were conscious.[4]
  • Lordosis association with bloating was described by Krukenberg in 1884. [2]
  • Bloating was first described by Alvarez of the Mayo Clinic in 1949 in a woman with a psychiatric problem.[2]

Classification

There is no established system for the classification of bloating.

Pathophysiology

Abnormal Gut Microbiota

There is a relationship between the types of gas produced by colonic microflora and bloating. The role of methanogenic flora has always been in question when the pathogenesis of bloating is discussed. During the experiments involving the ingestion of sorbitol and fiber, it was determined that there was a significant increase in bloating in individuals with low producers of methane vs high producers. [5]

Small Intestinal Bacterial Overgrowth

Bacterial fermentation and the subsequent gas production is the potential cause of bloating in patients with irritable bowel syndrome.[6]

Intestinal Gas Accumulation

Increase levels of intestinal gas has been linked with bloating. After consuming a large meal, there is 65% increase in postprandial gas volume in pelvic colon. Whereas during fasting, GI tract produces about 100ml of gas which spreads between the liver, small intestine, ascending colon, transverse colon, descending colon, and distal (pelvic) colon.[7]

Altered Gut Motility

Gut motility is affected in many disorders mainly labeled as Intestinal dysmotility. It affects the evacuation of excessive gas produced in the GI tract during fasting as well as post-prandial.

Abnormal Abdominal-diaphragmatic Reflexes

Mechanism which leads to bloating are not well understood but studies have shown a role of abdominal-diaphragmatic reflexes, which are involves the combination of increase in the anterior wall tone and diaphragm relaxation. These reflexes are abnormal in individuals with bloating.[8]

Visceral Hypersensitivity

The sensation of bloating may originate from abdominal viscera in patients with a functional gastrointestinal disorder, in whom normal stimuli or small variations of gas content within the gut may be perceived as bloating. The autonomic nervous system may also contribute to the modulation of visceral sensitivity and sympathetic activation is known to increase the perception of intestinal distention in these patients.

Food Intolerance and Carbohydrate Malabsorption

A high FODMAP diet has demonstrated prolonged hydrogen production in the intestine, colonic distension by fermentation, increased colonic fluid delivery by osmotic load within the bowel lumen, and GI symptom generation. [9]

Hard stool/Constipation

Distension of the rectum by retained feces induces alteration of gut motility and increases bacterial fermentation.

Causes

The most common cause of bloating is Constipation, Pregnancy, IBS, Celiac disease, Lactose, fructose, and other carbohydrates intolerance, Pancreatic insufficiency, Gastroparesis, Diabetes mellitus, Hypothyroidism, Scleroderma, Chronic idiopathic pseudo-obstruction, Small bowel bacterial overgrowth, Acute gastroenteritis, Gastric malignancy, Ovarian malignancy, and Ascites.[10]

Differentiating bloating from other Diseases

Bloating must be differentiated from Lactose intolerance, Fructose intolerance, Celiac disease, Pancreatic insufficiency, Irritable bowel syndrome, Functional dyspepsia, Functional bloating, Constipation, Diabetes, Scleroderma, Pseudo-obstruction: acute or chronic, Gastroparesis, Acute adynamic ileus, Gastric outlet obstruction, Small bowel obstruction, SMA syndrome, Colonic obstruction, Volvulus, Gastrointestinal/Ovarian Malignancy, Ascites, Pregnancy, and Obesity/adiposity.[11]

Epidemiology and Demographics

  • In the USA, 15-30% of the general population has been reported to experience bloating.[12]
  • A telephone survey reported a prevalence of 16% in US adults who were asked about bloating or distention during the last month.[13]
  • Women were more likely than men to report bloating.[12]
  • There is no racial predilection to bloating.[14]

Risk Factors

Risk factors include chewing gum, hard candy, and carbonated beverages such as soda or beer. Foods that can produce excess bowel gas include leafy greens, beans, and bran foods. Dairy products can lead to bloating and flatulence in people who are lactose intolerant.

Screening

There is insufficient evidence to recommend routine screening for bloating.

Natural History, Complications, and Prognosis

The sensation of abdominal bloating is often attributed to excessive gas in patients. However, the relationship between the volume of intestinal gas and the effects is not clear. Patients with chronic complaints of bloating and distension have heightened sensitivity to gaseous distension or exaggerated motor response to normal amounts of gas. Pains that are due to bloating will feel sharp and cause the stomach to cramp. These pains may occur anywhere in the body and can change locations quickly.

Bloating is typically benign, although it can be due to severe conditions such as intestinal obstruction and malignancy.

Patients with mild functional bloating may need merely reassurance that the condition is benign. [10]

Diagnosis

Diagnostic Study of Choice

Rome IV criteria for establishing the diagnosis of functional bloating include both of the following (for at least three months with symptom onset at least six months prior to diagnosis).[15]

●Recurrent bloating or distension, on average, at least one day per week; abdominal bloating and/or distension predominates over other symptoms

●Insufficient criteria for a diagnosis of IBS, functional constipation, functional diarrhea, or postprandial distress syndrome

History and Symptoms

History includes the onset of symptoms, the relationship to diet (eg, wheat, dairy, fructose, fiber, nonabsorbable sugars) diurnal variation, and the presence of symptoms suggestive of other functional gastrointestinal disorders, including constipation, diarrhea, and abdominal pain or postprandial fullness. Functional bloating usually have a diurnal pattern which may accompany the consumption of such foods, frequently accompanied by excessive burping or flattening. Patients may complain about deteriorating symptoms as the day progresses, particularly after meals, but they may be relieved overnight.[16]

Physical Examination

Common physical examination findings of bloating include abdominal distention with or without altered bowel sounds. However, if occult fecal blood, cutaneous findings (sclerodactyly with scleroderma, dermatitis herpetiformis in celiac disease), peripheral or autonomic neuropathy, cachexia, jaundice, or palpable masses is present then it suggests underlying organic disease. [11]

Laboratory Findings

Complete blood count

To evaluate for anemia

Serologies for Celiac Sprue[17]

  • anti-tissue transglutaminase (tTG) antibodies
  • endomysial antibodies (EMA)
  • deamidated gliadin peptide (DGP) antibodies

Hydrogen Breath Test

For the evaluation of small intestinal bacterial overgrowth and lactose intolerance.

Thyroid Function tests[18]

Fasting Cortisol Levels[19]

Antinuclear antibodies and Scleroderma antibodies[20]

To evaluate for collagen vascular disease

Antinuclear neuronal antibodies[21]

To screen for paraneoplastic visceral neuropathy

Stool analysis

Antigen testing for Giardia

Electrocardiogram

There are no ECG findings associated with bloating.

X-ray

An abdominal x-ray may be helpful to rule out intestinal obstruction.

Echocardiography or Ultrasound

Abdominal/Pelvic Ultrasound to look for ascites and rule out ovarian cancer.

CT scan

There are no CT scan findings associated with bloating. However, it can be used to rule out intestinal obstruction.

MRI

There are no MRI findings associated with bloating.

Other Imaging Findings

Upper GI Endoscopy

The presence of alarm features including weight loss, abdominal pain, dysphagia, heartburn, and regurgitation are an indication for a diagnostic evaluation with upper endoscopy.

Other Diagnostic Studies

There are no other diagnostic studies associated with bloating.

Treatment

Medical Therapy

Education, treatment of associated disorders, and behavioral therapy

Management requires instruction to minimize air swallowing and reassurance that belching is a benign condition. Relevant behavioural interventions include the avoidance of gum chewing, smoking, consuming carbonated drinks, and gulping of food and liquids. Treatment should be started in people with persistent depression or anxiety.[22] Patients with co-existing acid reflux may need an acid reduction treatment for the control of GERD.

Effective management with excessive belching by a therapist (e.g. cognitive behavioral therapy or speech therapist)[23] with specific experience of diaphragmatic relaxation exercises has been linked with a decrease of symptoms.   Diaphragmatic breathing decreases postprandial intragastric pressure and raises the pressure of the esophagogastric junction region, restoring the gradient of the gastroesophageal pressure.

Reflux inhibitors for refractory symptoms

Baclofen 10 mg three times daily can be prescribed to reduce transient lower esophageal sphincter relaxations and centrally suppress the swallowing rate, and may decrease both supragastric and gastric belching.[24]


 
 
 
 
 
 
 
Abdominal Bloating
and
Distension [10]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate for:
●Alarm Signs
●Overlapping FGID
(FG,FD,IBS)
●Bacterial Overgrowth
●Dietary Intolerance
Celiac Disease
●Recent Weight Gain
Constipation
●Psychological disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
●Reassurance
●Recommend
Diaphragmatic
Breathing
●Diet Intervention:
Low FODMAP diet
●Symptomatic
medical therapy:
Peppermint oil,
Simethicone etc
 
 
 
 
 
 
 
Treat
Accordingly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No Response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
●Trial of
Rifixamin/Probiotics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No Response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
●Antidepressants
●Psychological therapy
●Hypnotherapy,
CBT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No Response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
●Refer to
Neurogastroenterology
center
●Refer to CT
or
MRI Electromyography
●Refer to Abdominal
Biofeedback
therapy
 
 
 
 
 
 
 
 
 
 
 
 

Surgery

Surgical intervention is not recommended for the management of bloating.

Primary Prevention

There are no established measures for the primary prevention of bloating.

Secondary Prevention

There are no established measures for the secondary prevention of bloating.

References

  1. ↑ Schott H (1984). "[Mesmer, Braid and Bernheim: on the history of the development of hypnotism]". Gesnerus (in German). 41 (1–2): 33–48. PMID 6378725.
  2. ↑ 2.0 2.1 2.2 ALVAREZ WC (August 1949). "Hysterical type of nongaseous abdominal bloating". Arch Intern Med (Chic). 84 (2): 217–45. doi:10.1001/archinte.1949.00230020020002. PMID 18138437.
  3. ↑ Dunn PM (May 2002). "Sir James Young Simpson (1811-1870) and obstetric anaesthesia". Arch. Dis. Child. Fetal Neonatal Ed. 86 (3): F207–9. doi:10.1136/fn.86.3.f207. PMC 1721404. PMID 11978757.
  4. ↑ "February 1887 - Volume 14 - Issue 2 : The Journal of Nervous and Mental Disease".
  5. ↑ Kajs TM, Fitzgerald JA, Buckner RY, Coyle GA, Stinson BS, Morel JG, Levitt MD (January 1997). "Influence of a methanogenic flora on the breath H2 and symptom response to ingestion of sorbitol or oat fiber". Am. J. Gastroenterol. 92 (1): 89–94. PMID 8995944.
  6. ↑ Pimentel M, Park S, Mirocha J, Kane SV, Kong Y (October 2006). "The effect of a nonabsorbed oral antibiotic (rifaximin) on the symptoms of the irritable bowel syndrome: a randomized trial". Ann. Intern. Med. 145 (8): 557–63. doi:10.7326/0003-4819-145-8-200610170-00004. PMID 17043337.
  7. ↑ "Sleisenger and Fordtran's Gastrointestinal and Liver Disease- 2 Volume Set - 9th Edition".
  8. ↑ Accarino A, Perez F, Azpiroz F, Quiroga S, Malagelada JR (May 2009). "Abdominal distention results from caudo-ventral redistribution of contents". Gastroenterology. 136 (5): 1544–51. doi:10.1053/j.gastro.2009.01.067. PMID 19208364.
  9. ↑ Barrett JS, Gearry RB, Muir JG, Irving PM, Rose R, Rosella O, Haines ML, Shepherd SJ, Gibson PR (April 2010). "Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon". Aliment. Pharmacol. Ther. 31 (8): 874–82. doi:10.1111/j.1365-2036.2010.04237.x. PMID 20102355.
  10. ↑ 10.0 10.1 10.2 Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R (May 2019). "Bloating and Abdominal Distension: Clinical Approach and Management". Adv Ther. 36 (5): 1075–1084. doi:10.1007/s12325-019-00924-7. PMC 6824367 Check |pmc= value (help). PMID 30879252.
  11. ↑ 11.0 11.1 Hasler WL (September 2006). "Gas and Bloating". Gastroenterol Hepatol (N Y). 2 (9): 654–662. PMC 5350578. PMID 28316536.
  12. ↑ 12.0 12.1 Jiang X, Locke GR, Choung RS, Zinsmeister AR, Schleck CD, Talley NJ (June 2008). "Prevalence and risk factors for abdominal bloating and visible distention: a population-based study". Gut. 57 (6): 756–63. doi:10.1136/gut.2007.142810. PMC 2581929. PMID 18477677.
  13. ↑ Sandler RS, Stewart WF, Liberman JN, Ricci JA, Zorich NL (June 2000). "Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact". Dig. Dis. Sci. 45 (6): 1166–71. doi:10.1023/a:1005554103531. PMID 10877233.
  14. ↑ Ho KY, Kang JY, Seow A (October 1998). "Prevalence of gastrointestinal symptoms in a multiracial Asian population, with particular reference to reflux-type symptoms". Am. J. Gastroenterol. 93 (10): 1816–22. doi:10.1111/j.1572-0241.1998.00526.x. PMID 9772037.
  15. ↑ Mearin F, Lacy BE, Chang L, Chey WD, Lembo AJ, Simren M, Spiller R (February 2016). "Bowel Disorders". Gastroenterology. doi:10.1053/j.gastro.2016.02.031. PMID 27144627.
  16. ↑ Tack J, Talley NJ, Camilleri M, Holtmann G, Hu P, Malagelada JR, Stanghellini V (April 2006). "Functional gastroduodenal disorders". Gastroenterology. 130 (5): 1466–79. doi:10.1053/j.gastro.2005.11.059. PMID 16678560.
  17. ↑ Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R (May 2019). "Bloating and Abdominal Distension: Clinical Approach and Management". Adv Ther. 36 (5): 1075–1084. doi:10.1007/s12325-019-00924-7. PMC 6824367 Check |pmc= value (help). PMID 30879252.
  18. ↑ Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R (May 2019). "Bloating and Abdominal Distension: Clinical Approach and Management". Adv Ther. 36 (5): 1075–1084. doi:10.1007/s12325-019-00924-7. PMC 6824367 Check |pmc= value (help). PMID 30879252.
  19. ↑ Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R (May 2019). "Bloating and Abdominal Distension: Clinical Approach and Management". Adv Ther. 36 (5): 1075–1084. doi:10.1007/s12325-019-00924-7. PMC 6824367 Check |pmc= value (help). PMID 30879252.
  20. ↑ Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R (May 2019). "Bloating and Abdominal Distension: Clinical Approach and Management". Adv Ther. 36 (5): 1075–1084. doi:10.1007/s12325-019-00924-7. PMC 6824367 Check |pmc= value (help). PMID 30879252.
  21. ↑ Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, Dickman R (May 2019). "Bloating and Abdominal Distension: Clinical Approach and Management". Adv Ther. 36 (5): 1075–1084. doi:10.1007/s12325-019-00924-7. PMC 6824367 Check |pmc= value (help). PMID 30879252.
  22. ↑ Disney B, Trudgill N (April 2014). "Managing a patient with excessive belching". Frontline Gastroenterol. 5 (2): 79–83. doi:10.1136/flgastro-2013-100355. PMC 5369716. PMID 28839757.
  23. ↑ Hemmink GJ, Ten Cate L, Bredenoord AJ, Timmer R, Weusten BL, Smout AJ (January 2010). "Speech therapy in patients with excessive supragastric belching--a pilot study". Neurogastroenterol. Motil. 22 (1): 24–8, e2–3. doi:10.1111/j.1365-2982.2009.01371.x. PMID 19650772.
  24. ↑ Blondeau K, Boecxstaens V, Rommel N, Farré R, Depeyper S, Holvoet L, Boeckxstaens G, Tack JF (April 2012). "Baclofen improves symptoms and reduces postprandial flow events in patients with rumination and supragastric belching". Clin. Gastroenterol. Hepatol. 10 (4): 379–84. doi:10.1016/j.cgh.2011.10.042. PMID 22079512.


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