Bloating resident survival guide: Difference between revisions

Bloating resident survival guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Dos
Don'ts

VisualWikitext

Latest revision as of 18:58, 19 February 2021

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.

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:^[1]^[2]

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:^[3]^[4]

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

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:^[5]

Treatment of bloating is based on the underlying etiology of bloating

Dietary changes are suggested for bloating

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

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

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

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

↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.

[Lacy_Gabbard_Crowell_2011_pp._729–39-1] 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.

[Malagelada_Accarino_Azpiroz_2017_pp._1221–1231-2] 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.

[Foley_Burgell_Barrett_Gibson_2014_pp._561–571-3] 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.

[Lacy_Cangemi_Vazquez-Roque_2021_pp._219–231.e1-4] 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.

[Schmulson_Chang_pp._1071–1086-5] 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.

[Altobelli_Del_Negro_Angeletti_Latella_p=940-6] 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.

[Seo_Kim_Oh_pp._433–453-7] 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.

[Kamphuis_Guiard_Leveque_Olier_2020_pp._652–663.e6-8] 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.

[Mari_Abu_Backer_Mahamid_Amara_pp._1075–1084-9] 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.

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[3]

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@@ Line 3: / Line 3: @@
 {{CMG}} {{AE}} {{Usman Ali Akbar}}
-{{SK}}Approach to abdominal bloating, Approach to abdominal belching, Approach to flatulence, Use of FODMAPs.
+{{SK}}Approach to [[abdominal]] [[bloating]], Approach to [[abdominal]] [[belching]], Approach to [[flatulence]], Use of [[FODMAP|FODMAPs]].
 {| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0" ;
@@ Line 19: / Line 19: @@
 ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Bloating resident survival guide#Treatment|Treatment]]
 |-
-! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Bloating resident survival guide#Do's|Do's]]
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Bloating resident survival guide#Dos|Dos]]
 |-
 ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Bloating resident survival guide#Don'ts|Don'ts]]
@@ Line 25: / Line 25: @@
 ==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 distention. Primary functional abdominal distention (FABD) should be diagnosed as a single entity and it doesn't overlap with other functional gastrointestinal disorders. Rome IV diagnostic criteria mention 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 counter the dietary interventions, [[microbiome]] modulation, and medical therapy in the management of FABD.
+[[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 [[Diagnose|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 movement|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 etiology.<ref name="Lacy Gabbard Crowell 2011 pp. 729–39">{{cite journal | last=Lacy | first=BE | last2=Gabbard | first2=SL | last3=Crowell | first3=MD | title=Pathophysiology, evaluation, and treatment of bloating: hope, hype, or hot air? | journal=Gastroenterology & hepatology | volume=7 | issue=11 | year=2011 | issn=1554-7914 | pmid=22298969 | pmc=3264926 | pages=729–39}}</ref><ref name="Malagelada Accarino Azpiroz 2017 pp. 1221–1231">{{cite journal | last=Malagelada | first=Juan R | last2=Accarino | first2=Anna | last3=Azpiroz | first3=Fernando | title=Bloating and Abdominal Distension: Old Misconceptions and Current Knowledge | journal=The American journal of gastroenterology | publisher=Ovid Technologies (Wolters Kluwer Health) | volume=112 | issue=8 | year=2017 | issn=0002-9270 | pmid=28508867 | doi=10.1038/ajg.2017.129 | pages=1221–1231}}</ref>
+*The [[causes]] of [[abdominal]] [[bloating]] are numerous and are managed according to the underlying [[etiology]]:<ref name="Lacy Gabbard Crowell 2011 pp. 729–39">{{cite journal | last=Lacy | first=BE | last2=Gabbard | first2=SL | last3=Crowell | first3=MD | title=Pathophysiology, evaluation, and treatment of bloating: hope, hype, or hot air? | journal=Gastroenterology & hepatology | volume=7 | issue=11 | year=2011 | issn=1554-7914 | pmid=22298969 | pmc=3264926 | pages=729–39}}</ref><ref name="Malagelada Accarino Azpiroz 2017 pp. 1221–1231">{{cite journal | last=Malagelada | first=Juan R | last2=Accarino | first2=Anna | last3=Azpiroz | first3=Fernando | title=Bloating and Abdominal Distension: Old Misconceptions and Current Knowledge | journal=The American journal of gastroenterology | publisher=Ovid Technologies (Wolters Kluwer Health) | volume=112 | issue=8 | year=2017 | issn=0002-9270 | pmid=28508867 | doi=10.1038/ajg.2017.129 | pages=1221–1231}}</ref>
 *
@@ Line 42: / Line 43: @@
 ! style="background:#4479BA; color: #FFFFFF;" align="center" + |Misc.
 |-
-|[[Adhesions]]
+|
-[[Malignancy]]
+*[[Adhesions]]
-|[[Diabetes]]
-[[Scleroderma]]
+*[[Malignancy]]
+|
-Pseudo-obstruction
+*[[Diabetes]]
+*[[Scleroderma]]
-Medications
+*Pseudo-[[obstruction]]
-|[[Lactose intolerance]]
+*[[Medications]]
-[[Fructose intolerance]]
+|
+*[[Lactose intolerance]]
-[[Celiac disease]]
+*[[Fructose intolerance]]
+*[[Celiac Disease]]
-[[Pancreatic insufficiency]]
+*[[Pancreatic insufficiency]]
-|[[Small intestinal bacterial overgrowth]]
+|
-[[Giardiasis]]
+*[[Small intestinal bacterial overgrowth]]
-|Gas-producing foods
+*[[Giardiasis]]
-FODMAPs
+|
-|[[Irritable bowel syndrome]] <br />
+*[[Gas]]-producing [[Food|foods]]
+*[[FODMAP]]<nowiki/>s
+|
+*[[Irritable bowel syndrome]] <br />
 |}
@@ Line 67: / Line 70: @@
 ==Complete Diagnostic Approach==
-Shown below is an algorithm summarizing the diagnosis of abdominal bloating according to American College of Gastroenterology guidelines.<ref name="Foley Burgell Barrett Gibson 2014 pp. 561–571">{{cite journal | last=Foley | first=A | last2=Burgell | first2=R | last3=Barrett | first3=JS | last4=Gibson | first4=PR | title=Management Strategies for Abdominal Bloating and Distension | journal=Gastroenterology & Hepatology | volume=10 | issue=9 | year=2014 | pmid=27551250 | pmc=4991532 | pages=561–571}}</ref><ref name="Lacy Cangemi Vazquez-Roque 2021 pp. 219–231.e1">{{cite journal | last=Lacy | first=Brian E. | last2=Cangemi | first2=David | last3=Vazquez-Roque | first3=Maria | title=Management of Chronic Abdominal Distension and Bloating | journal=Clinical Gastroenterology and Hepatology | publisher=Elsevier BV | volume=19 | issue=2 | year=2021 | issn=1542-3565 | doi=10.1016/j.cgh.2020.03.056 | pages=219–231.e1}}</ref>
+*Shown below is an [[algorithm]] summarizing the [[diagnosis]] of [[abdominal]] [[bloating]] according to the [[American College of Gastroenterology Guidelines]]:<ref name="Foley Burgell Barrett Gibson 2014 pp. 561–571">{{cite journal | last=Foley | first=A | last2=Burgell | first2=R | last3=Barrett | first3=JS | last4=Gibson | first4=PR | title=Management Strategies for Abdominal Bloating and Distension | journal=Gastroenterology & Hepatology | volume=10 | issue=9 | year=2014 | pmid=27551250 | pmc=4991532 | pages=561–571}}</ref><ref name="Lacy Cangemi Vazquez-Roque 2021 pp. 219–231.e1">{{cite journal | last=Lacy | first=Brian E. | last2=Cangemi | first2=David | last3=Vazquez-Roque | first3=Maria | title=Management of Chronic Abdominal Distension and Bloating | journal=Clinical Gastroenterology and Hepatology | publisher=Elsevier BV | volume=19 | issue=2 | year=2021 | issn=1542-3565 | doi=10.1016/j.cgh.2020.03.056 | pages=219–231.e1}}</ref>
 {{familytree/start |summary=PE diagnosis Algorithm.}}
-{{familytree | | | | A01 | | | A01= Patient with abdominal bloating and Distention }}
+{{familytree | | | | A01 | | | A01= [[Patient]] with [[abdominal]] [[bloating]] and [[distension]] }}
 {{familytree | | | | |!| | | | }}
 {{familytree | | | | B01 | | | B01= Look for the <br>
-* Alarm signs
+*Warning signs
-*Overlapping functional gastrointestinal disorders
+*Overlapping functional [[gastrointestinal]] [[disorders]]
 *[[Bacterial overgrowth]] (Small intestine bacterial overgrowth)
-* Dietary intolerances
+*[[Dietary]] intolerances
 *[[Celiac Disease]]
-* Weight gain
+*[[Weight gain]]
 *[[Constipation]]
 *[[Hydrogen breath test]]
-*Any pyschological comorbidities}}
+*Any [[psychological]] [[comorbidities]]}}
 {{familytree | | |,|-|^|-|.| | }}
 {{familytree | | C01 | | C02 | C01= Yes | C02=No}}
 {{familytree | | |!| | | |!| | }}
 {{familytree | | C01 | | C02 | C01=
-* Reassurance the patient, recommend [[diaphragmatic breathing]]
+*[[Reassure]] the [[patient]], recommend [[diaphragmatic breathing]]
-*Diet intervention: Low FODMAP (fermentable oligo-, di-, mono-saccharides and polyols) diet
+*[[Diet]] [[intervention]]: Low FODMAP (fermentable oligo-, di-, [[monosaccharides]], and [[polyols]]) [[diet]]
-*Iniate sympotmatic treatment such as [[peppermint oil]] or [[Simethicone]]   | C02= Treat Accordingly}}
+*Initiate [[symptomatic]] treatment such as [[peppermint oil]] or [[Simethicone]]   | C02= Treat Accordingly}}
 {{familytree | | |!| | | | | | }}
-{{familytree | | C01 | | | C01= *Trial of [[Rifaximin]]/[[Probiotics]] }}
+{{familytree | | C01 | | | C01= Trial of [[Rifaximin]]/[[Probiotics]] }}
 {{familytree | | |!| | | | | | }}
 {{familytree | | C01 | | | C01= No Response }}
 {{familytree | | |!| | | | | | }}
 {{familytree | | C01 | | | C01= [[Antidepressants]]
-*[[Psychological therapy]]
+*[[Psychological]] [[therapy]]
-*Hypnotherapy, [[Cognitive behavioral therapy]] (CBT)}}
+*[[Hypnotherapy]], [[Cognitive behavioral therapy]] ([[CBT]])}}
 {{familytree | | |!| | | | | | }}
 {{familytree | | C01 | | | C01= No Response }}
 {{familytree | | |!| | | | | | }}
 {{familytree | | C01 | | | C01=
-*Referral to specialized Neurogastroenterology center
+*Referral to specialized [[Neurogastroenterology]] center
-*Referral for the CT/MRI [[Electromyography]]
+*Referral for the [[CT]]/[[MRI]] [[Electromyography]]
-*Referral for the abdominal biofeedback therapy)}}
+*Referral for the [[abdominal]] [[biofeedback]] [[therapy]]}}
 {{familytree/end}}
 ==Treatment==
-Shown below is an algorithm summarizing the treatment of abdominal bloating according the the American College of Gastroenterology guidelines.<ref name="Schmulson Chang pp. 1071–1086">{{cite journal | last=Schmulson | first=M. | last2=Chang | first2=L. | title=Review article: the treatment of functional abdominal bloating and distension | journal=Alimentary Pharmacology & Therapeutics | publisher=Wiley | volume=33 | issue=10 | date=2011-03-29 | issn=0269-2813 | doi=10.1111/j.1365-2036.2011.04637.x | pages=1071–1086}}</ref>
+* Shown below is an [[algorithm]] summarizing the [[treatment]] of [[abdominal]] [[bloating]] according the the [[American College of Gastroenterology Guidelines]]:<ref name="Schmulson Chang pp. 1071–1086">{{cite journal | last=Schmulson | first=M. | last2=Chang | first2=L. | title=Review article: the treatment of functional abdominal bloating and distension | journal=Alimentary Pharmacology & Therapeutics | publisher=Wiley | volume=33 | issue=10 | date=2011-03-29 | issn=0269-2813 | doi=10.1111/j.1365-2036.2011.04637.x | pages=1071–1086}}</ref>
 {{familytree/start |summary=PE diagnosis Algorithm.}}
-{{familytree | | | | | | | | A01 |A01= Treatment of bloating is based on etiology of bloating.}}
+{{familytree | | | | | | | | A01 |A01= [[Treatment]] of [[bloating]] is based on the underlying [[etiology]] of [[bloating]]}}
 {{familytree | | | | | | | | |!| | | | | |}}
-{{familytree | | | | | | | |C01| | | | | |C01= Dietary changes are suggested for bloating
+{{familytree | | | | | | | |C01| | | | | |C01= [[Dietary]] changes are suggested for [[bloating]]
-*Diet
+*[[Diet]]
 *[[Exercise]] and [[posture]]
-*Over-the-counter medications
+*Over-the-counter [[medications]]
 *[[Probiotics]]
 *[[Antibiotics]]
-*Smooth muscle [[antispasmodics]]
+*[[Smooth muscle]] [[antispasmodics]]
-*Osmotic laxatives
+*[[Osmotic]] [[laxatives]]
-*Prokinetic agents
+*[[Prokinetic]] agents
-*Chloride channel activators
+*[[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. }}
+*[[Anemia]], [[GI bleeding]], [[weight loss]] >10% of the [[body weight]], and [[family history]] of [[GI]] [[malignancy]]}}
 {{familytree | | | | | | | | |!| | | | | | }}
 {{Family tree | | | | | |,|-|-|^|-|-|.| | }}
@@ Line 131: / Line 135: @@
 *Labs
 *[[Endoscopy]]
-*Imaging|F02=Functional?}}
+*[[Imaging]]|F02=Functional?}}
 {{familytree | | | | | | | | | | | | |!| | | }}
 {{familytree | | | | | | | | | | | | |!| | | | | | | }}
 {{familytree | | | |,|-|-|-|v|-|-|-|-|+|-|.| | }}
 {{familytree | | | |!| | | |!| | | | |!| |!| | }}
-{{familytree | | | D01 | | D02 | | D03 | | D04 | |D01=[[Constipation]]|D02=Functional dyspepsia|D03=Non-constipation IBS|D04=Bloating alone}}
+{{familytree | | | D01 | | D02 | | D03 | | D04 | |D01=[[Constipation]]|D02=Functional [[dyspepsia]]|D03=Non-[[constipation]] [[IBS]]|D04=[[Bloating]] alone}}
 {{familytree | | | |`|-|-|-|^|-|-|+|-|-|-|-|-|'|}}
 {{familytree | | | | | | | | | | |!| | | | | | | | | }}
-{{familytree | | | | | | | | | | A02 | | | | | |A02= Lifestyle and nonspecific dietary advice.<br>
+{{familytree | | | | | | | | | | A02 | | | | | |A02= *[[Lifestyle]] and nonspecific [[dietary]] advice<br>
-*Education about low FODMAP diet <br><ref name="Altobelli Del Negro Angeletti Latella p=940">{{cite journal | last=Altobelli | first=Emma | last2=Del Negro | first2=Valerio | last3=Angeletti | first3=Paolo | last4=Latella | first4=Giovanni | title=Low-FODMAP Diet Improves Irritable Bowel Syndrome Symptoms: A Meta-Analysis | journal=Nutrients | publisher=MDPI AG | volume=9 | issue=9 | date=2017-08-26 | issn=2072-6643 | doi=10.3390/nu9090940 | page=940}}</ref>
+*[[Education]] about low [[FODMAP]] [[diet]]<ref name="Altobelli Del Negro Angeletti Latella p=940">{{cite journal | last=Altobelli | first=Emma | last2=Del Negro | first2=Valerio | last3=Angeletti | first3=Paolo | last4=Latella | first4=Giovanni | title=Low-FODMAP Diet Improves Irritable Bowel Syndrome Symptoms: A Meta-Analysis | journal=Nutrients | publisher=MDPI AG | volume=9 | issue=9 | date=2017-08-26 | issn=2072-6643 | doi=10.3390/nu9090940 | page=940}}</ref>
-* Treat constipation aggressively and minimize bowel distention<br>
+* Treat [[constipation]] aggressively and minimize [[bowel]] [[distension]]<br>
 *Consider the use of [[Rifaximin]]
-*Consider probiotics, Psychological therapy, [[CBT]], and/or [[antidepressants]]<br>
+*Consider [[Probiotics]], [[Psychological]] [[therapy]], [[CBT]], and/or [[Antidepressants]]<br>
-*Consider Biodfeedback neuromodulation }}
+*Consider Biofeedback [[neuromodulation]] }}
 {{familytree/end}}
-==Do's==
+==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.<ref name="Seo Kim Oh pp. 433–453">{{cite journal | last=Seo | first=A Young | last2=Kim | first2=Nayoung | last3=Oh | first3=Dong Hyun | title=Abdominal Bloating: Pathophysiology and Treatment | journal=Journal of Neurogastroenterology and Motility | publisher=The Korean Society of Neurogastroenterology and Motility | volume=19 | issue=4 | date=2013-10-31 | issn=2093-0879 | doi=10.5056/jnm.2013.19.4.433 | pages=433–453}}</ref>
+*[[Antidepressants]] can help to [[Reduced|reduce]] the [[symptoms]] of [[IBS]] but the [[data]] is unclear over the [[reduction]] of [[bloating]].<ref name="Seo Kim Oh pp. 433–453">{{cite journal | last=Seo | first=A Young | last2=Kim | first2=Nayoung | last3=Oh | first3=Dong Hyun | title=Abdominal Bloating: Pathophysiology and Treatment | journal=Journal of Neurogastroenterology and Motility | publisher=The Korean Society of Neurogastroenterology and Motility | volume=19 | issue=4 | date=2013-10-31 | issn=2093-0879 | doi=10.5056/jnm.2013.19.4.433 | pages=433–453}}</ref>
-*[[Hypnotherapy]] has been reported to be useful in reducing symptoms of bloating.
+*[[Hypnotherapy]] has been reported to be useful in [[Reduction|reducing]] the [[symptoms]] of [[bloating]].
-*Bowel training and [[diaphragmatic breathing]] have been useful in the management of [[bloating]] however the data is unclear.
+*[[Bowel training problem|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]], [[xylitol]] should be avoided.<ref name="Kamphuis Guiard Leveque Olier 2020 pp. 652–663.e6">{{cite journal | last=Kamphuis | first=Jasper B.J. | last2=Guiard | first2=Bruno | last3=Leveque | first3=Mathilde | last4=Olier | first4=Maiwenn | last5=Jouanin | first5=Isabelle | last6=Yvon | first6=Sophie | last7=Tondereau | first7=Valerie | last8=Rivière | first8=Pauline | last9=Guéraud | first9=Françoise | last10=Chevolleau | first10=Sylvie | last11=Noguer-Meireles | first11=Maria-Helena | last12=Martin | first12=Jean- François | last13=Debrauwer | first13=Laurent | last14=Eutamène | first14=Helene | last15=Theodorou | first15=Vassilia | title=Lactose and Fructo-oligosaccharides Increase Visceral Sensitivity in Mice via Glycation Processes, Increasing Mast Cell Density in Colonic Mucosa | journal=Gastroenterology | publisher=Elsevier BV | volume=158 | issue=3 | year=2020 | issn=0016-5085 | doi=10.1053/j.gastro.2019.10.037 | pages=652–663.e6}}</ref>
+*[[Artificial sweetener|Artificial sweeteners]] containing [[sorbitol]], [[mannitol]], and [[xylitol]] should be avoided.<ref name="Kamphuis Guiard Leveque Olier 2020 pp. 652–663.e6">{{cite journal | last=Kamphuis | first=Jasper B.J. | last2=Guiard | first2=Bruno | last3=Leveque | first3=Mathilde | last4=Olier | first4=Maiwenn | last5=Jouanin | first5=Isabelle | last6=Yvon | first6=Sophie | last7=Tondereau | first7=Valerie | last8=Rivière | first8=Pauline | last9=Guéraud | first9=Françoise | last10=Chevolleau | first10=Sylvie | last11=Noguer-Meireles | first11=Maria-Helena | last12=Martin | first12=Jean- François | last13=Debrauwer | first13=Laurent | last14=Eutamène | first14=Helene | last15=Theodorou | first15=Vassilia | title=Lactose and Fructo-oligosaccharides Increase Visceral Sensitivity in Mice via Glycation Processes, Increasing Mast Cell Density in Colonic Mucosa | journal=Gastroenterology | publisher=Elsevier BV | volume=158 | issue=3 | year=2020 | issn=0016-5085 | doi=10.1053/j.gastro.2019.10.037 | pages=652–663.e6}}</ref>
-*Medications ([[anticholinergics]], [[opiates]], [[calcium channel blockers]], antidepressants) should also be avoided as they have an effect on [[bloating]].<ref name="Mari Abu Backer Mahamid Amara pp. 1075–1084">{{cite journal | last=Mari | first=Amir | last2=Abu Backer | first2=Fadi | last3=Mahamid | first3=Mahmud | last4=Amara | first4=Hana | last5=Carter | first5=Dan | last6=Boltin | first6=Doron | last7=Dickman | first7=Ram | title=Bloating and Abdominal Distension: Clinical Approach and Management | journal=Advances in Therapy | publisher=Springer Science and Business Media LLC | volume=36 | issue=5 | date=2019-03-16 | issn=0741-238X | doi=10.1007/s12325-019-00924-7 | pages=1075–1084}}</ref>
+*[[Medications]] such as [[anticholinergics]], [[opiates]], [[calcium channel blockers]], and [[antidepressants]] should also be avoided as they have an [[Effect size|effect]] on [[bloating]].<ref name="Mari Abu Backer Mahamid Amara pp. 1075–1084">{{cite journal | last=Mari | first=Amir | last2=Abu Backer | first2=Fadi | last3=Mahamid | first3=Mahmud | last4=Amara | first4=Hana | last5=Carter | first5=Dan | last6=Boltin | first6=Doron | last7=Dickman | first7=Ram | title=Bloating and Abdominal Distension: Clinical Approach and Management | journal=Advances in Therapy | publisher=Springer Science and Business Media LLC | volume=36 | issue=5 | date=2019-03-16 | issn=0741-238X | doi=10.1007/s12325-019-00924-7 | pages=1075–1084}}</ref>
-*20% of [[carbohydrates]] in baked beans and 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]].
+*20% of [[carbohydrates]] in baked [[beans]], 7–10% in [[wheat]], [[Oat|oats]], [[Potato|potatoes]], and [[Corn oil|corn]], and 1% in white rice are not [[Absorbed dose|absorbed]] well in the [[intestine]] and they can [[Predisposition|predispose]] to [[bloating]], hence it is advisable to avoid them in the [[patients]] with increased complaints of [[bloating]].
 ==References==
@@ Line 166: / Line 170: @@
 [[Category:Resident survival guide]]
 [[Category:Gastroenterology]]
+[[Category:Up-To-Date]]