Bloating resident survival guide

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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:

Bloating resident survival guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
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 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.

Causes

The causes of abdominal bloating are numerous and are managed according to the etiology.[1]

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 American College of Gastroenterology guidelines.[2][3]

 
 
 
Patient with abdominal bloating and Distention
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Look for the
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
* Reassurance the patient, recommend diaphragmatic breathing
 
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.[4]

 
 
 
 
 
 
 
Treatment of bloating is based on 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
    [5]
  • Treat constipation aggressively and minimize bowel distention
  • Consider the use of Rifaximin
  • Consider probiotics, Psychological therapy, CBT, and/or antidepressants
  • Consider Biodfeedback neuromodulation
 
 
 
 
 

Do's

  • 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.[6]
  • Hypnotherapy has been reported to be useful in reducing symptoms of bloating.
  • Bowel training and diaphragmatic breathing have been useful in the management of bloating however the data is unclear.

Don'ts

References

  1. Lacy, BE; Gabbard, SL; Crowell, MD (2011). "Pathophysiology, evaluation, and treatment of bloating: hope, hype, or hot air?". Gastroenterology & hepatology. 7 (11): 729–39. ISSN 1554-7914. PMC 3264926. PMID 22298969.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.