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

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

• The causes of abdominal bloating are numerous and are managed according to the underlying etiology:

Causes of Abdominal Bloating

Intestinal Disorders	Motility Disorders	Malabsorption disorders	Infectious causes	Dietary causes	Misc.
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

• Shown below is an algorithm summarizing the diagnosis of abdominal bloating according to the American College of Gastroenterology Guidelines:

Patient with abdominal bloating and distension

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

• Shown below is an algorithm summarizing the treatment of abdominal bloating according the the American College of Gastroenterology Guidelines:

Treatment of bloating is based on the underlying etiology of bloating

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 Treat constipation aggressively and minimize bowel distension Consider the use of Rifaximin Consider Probiotics, Psychological therapy, CBT, and/or Antidepressants Consider Biofeedback neuromodulation

Dos

• 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.
• 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

• Artificial sweeteners containing sorbitol, mannitol, and xylitol should be avoided.
• Medications such as anticholinergics, opiates, calcium channel blockers, and antidepressants should also be avoided as they have an effect on bloating.
• 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.