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'''For patient information click [[Abdominal distension (patient information)|here]]'''
{{Search infobox}}
{{CMG}}


{{SI}}
{{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]]. 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==
*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>
*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.
*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>
*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>
*
==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 [[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===
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===
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===
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.<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===
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.


'''Bloating''' is any abnormal general [[swelling]], or increase in diameter of the [[abdomen|abdominal]] area. As a [[symptom]], the patient feels a full and tight abdomen, which may cause [[abdominal pain]] sometimes accompanied by [[borborygmus]].  
===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>
 
===Hard stool/Constipation===
Distension of the [[rectum]] by retained [[feces]] induces alteration of gut motility and increases bacterial [[Fermentation (biochemistry)|fermentation]].


==Causes==
==Causes==
Bloating may have several causes, the most common being accumulation of liquids and [[intestine|intestinal]] gas. [[Ascites]] is the proper medical term for abdominal bloating caused by excessive accumulation of liquid inside the cavity.
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]].<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>
 
==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|Functional bloating,]] [[Constipation]], [[Diabetes]], [[Scleroderma]], [[Pseudo-obstruction-intestinal|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]].<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>
 
==Epidemiology and Demographics==


Common causes for abdominal bloating are: <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</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>


* Overeating ([[gastric distension]])
*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>
* [[Lactose intolerance]], [[fructose intolerance]] and other [[food intolerance]]s
* [[Food allergy]]
* [[Aerophagia]] (air swallowing, a nervous habit)
* [[Irritable bowel syndrome]]
* Partial [[bowel obstruction]]
* [[Gastric dumping syndrome]] or rapid gastric emptying
* Gas-producing foods
* [[Constipation]]
* [[Visceral fat]]
* [[Splenic-flexure syndrome]]
* [[Menstruation]], [[dysmenorrhea]] and [[premenstrual stress syndrome]]
* [[Polycystic ovary syndrome]] and [[ovarian cyst]]s
* [[Alvarez' syndrome]], hysterical or neurotic abdominal bloating without excess of gas in the digestive tract
* Massive infestation with [[intestinal parasite]]s, such as worms (e.g, [[Ascaris lumbricoides]])
* [[Diverticulosis]]


Important but uncommon causes of abdominal bloating include large intra-abdominal [[tumor]]s, such as those arising from [[ovarian cancer|ovarian]], [[liver cancer|liver]], [[uterine cancer|uterus]] and [[stomach cancer]]; and [[megacolon]], an abnormal dilation of the [[Colon (anatomy)|colon]], due to some diseases, such as [[Chagas disease]], a [[parasite|parasitic]] infection. Gaseous bloating may be a consequence of [[cardiopulmonary resuscitation]] procedures, due to the artificial mouth-to-mouth insufflation of air. In some animals, like cats, dogs and cattle, gastric dilatation-[[volvulus]], or bloat also occurs when gas is trapped inside the stomach and a gastric torsion or volvulus prevents it from escaping.
*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>


Bloating from [[irritable bowel syndrome]] (IBS) is of unknown origin but often results from an insult to the gut, and as such can overlap with infective diarrhea, celiac, and inflammatory bowel diseases. IBS is a brain-gut dysfunction that causes visceral hypersensitivity and results in bloating in association with recurrent diarrhea (or constipation) and abdominal pain.  
*There is no racial predilection to bloating.<ref name="pmid9772037">{{cite journal |vauthors=Ho KY, Kang JY, Seow A |title=Prevalence of gastrointestinal symptoms in a multiracial Asian population, with particular reference to reflux-type symptoms |journal=Am. J. Gastroenterol. |volume=93 |issue=10 |pages=1816–22 |date=October 1998 |pmid=9772037 |doi=10.1111/j.1572-0241.1998.00526.x |url=}}</ref>


While there is no direct treatment for the underlying [[pathology]] of IBS, the symptom of bloating can be well managed through dietary changes that prevent the over-reaction of the gastrocolic reflex. Having soluble [[dietary fiber|fiber]] foods and supplements, substituting [[dairy product|dairy]] with soy or rice products, being careful with fresh fruits and vegetables that are high in insoluble fiber, and eating regular small amounts can all help to lessen the symptoms of IBS (Van Vorous 2000).  
==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]].


Foods and beverages to be avoided or minimized include red meat, oily, fatty and fried products, dairy (even when there is no lactose intolerance), solid chocolate, coffee (regular and decaffeinated), [[alcoholic beverage|alcohol]], carbonated beverages, especially those also containing [[sorbitol]], and artificial sweeteners (Van Vorous 2000).  
==Screening==
There is insufficient evidence to recommend routine screening for bloating.


Postmortem bloating occurs in cadavers, due to the formation of gases by [[bacteria]]l action and [[putrefaction]] of the internal tissues of the abdomen and the inside of the intestines.
==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.


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


* [[Lactulose]]
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>
* [[Norgestrel and Ethinyl estradiol]]
* [[ Polyethylene glycol-electrolyte solution (PEG-ES)]]


==See also==
==Diagnosis==
* [[Abdominal distension]]
===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).<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>


==Source==
●Recurrent bloating or distension, on average, at least one day per week; abdominal bloating and/or distension predominates over other symptoms
* Partly based on [http://www.nlm.nih.gov/medlineplus/ency/article/003123.htm Abdominal bloating]. MedlinePlus (US public domain Medical Encyclopedia). Update Date: 10 November 2004. Updated by: Christian Stone, M.D., Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, MO. Review provided by VeriMed Healthcare Network.


* Van Vorous, Heather. ''Eating for IBS''. 2000. ISBN 1-56924-600-9. Excerpted with author's permission at [http://www.HelpForIBS.com/ Help for Irritable Bowel Syndrome] (see IBS Diet Section)
●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.<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>
 
===Physical Examination===
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>
 
===Laboratory Findings===
====Complete blood count====
To evaluate for [[anemia]]
 
====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>====
 
*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<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>====
 
====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>====
 
====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
 
====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]]
 
====Stool analysis====
Antigen testing for ''[[Giardia lamblia|Giardia]]''
 
===Electrocardiogram===
There are no ECG findings associated with bloating.
 
===X-ray===
An abdominal x-ray may be helpful to rule out [[Intestinal obstruction|intestinal obstruction.]]
 
===Echocardiography or Ultrasound===
Abdominal/Pelvic Ultrasound to look for [[ascites]] and rule out [[Ovarian cancer|ovarian cancer.]]
 
===CT scan===
There are no CT scan findings associated with bloating. However, it can be used to rule out [[Intestinal obstruction|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]].<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]].
 
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.
 
====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>
 
 
{{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> }}
{{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  }}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | B01 | | | | | | | | B02 | | |B01=No  |B02=Yes }}
{{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 }}
{{familytree | | | |!| | | | | | | | | | | | | }}
{{familytree | | | E01 | | | | | | | | | | | | |E01= '''''No Response''''' }}
{{familytree | | | |!| | | | | | | | | | | | | }}
{{familytree | | | E02 | | | | | | | | | | | | |E02= ●Trial of <br> [[Rifixamin]]/[[Probiotics]]  }}
{{familytree | | | |!| | | | | | | | | | | | | }}
{{familytree | | | F01 | | | | | | | | | | | | |F01= '''''No Response''''' }}
{{familytree | | | |!| | | | | | | | | | | | | }}
{{familytree | | | G01 | | | | | | | | | | | | |G01= ●Antidepressants <br> ●Psychological therapy <br> ●[[Hypnotherapy]], <br> [[CBT]] }}
{{familytree | | | |!| | | | | | | | | | | | | }}
{{familytree | | | F02 | | | | | | | | | | | | |F02= '''''No Response''''' }}
{{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 }}
{{familytree/end}}
 
===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==
==References==
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Latest revision as of 13:47, 5 November 2020


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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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