bloat

Introduction

Feelings of diffuse abdominal pain.

Etiology

• irritable bowel syndrome
• bacterial overgrowth syndrome
• giardiasis (Giardia lamblia)
• carbohydrate enzyme deficiency
• celiac disease
• pelvic floor dysfunction
• dyspepsia (MKSAP19)
• cholinesterase inhibitors

Pathology

• intestinal gas may be normal in quantity
• intestinal motility disturbance
• visceral hypersensitivity
• gas produced in the colon by bacterial fermentation (also see flatulence)

Diagnostic criteria

• Rome IV criteria should be used to diagnose primary abdominal bloating & abdominal distention & irritable bowel syndrome

Laboratory

• hydrogen breath test for carbohydrate enzyme deficiency
• tissue transglutaminase IgA in serum to evaluated for celiac disease

Diagnostic procedures

• upper GI endoscopy with small bowel biopsy
  • confirm celiac disease
  • worsening symptoms
• gastric emptying study only if nausea/vomiting
• anorectal physiology testing if constipation, difficulty with defectation

Radiology

• plain abdominal radiograph

Differential diagnosis

• dyspepsia*
  • postprandial bloating, early satiety & minimal epigastric tenderness

Management

• pharmacologic agents*
  • anticholinergics
    • dicyclomine (Bentyl) 10-30 mg 30 min before meals
    • hyoscyamine
  • antidepressants: begin at lower dose
    • amitriptyline (Elavil) 25-150 mg QHS
    • doxepin (Sinequan) 25-150 mg QHS
    • fluoxetine (Prozac) 20 mg QD
    • nortriptyline (prokinetic agent according to NEJM)
  • prokinetic agent:
    • metoclopramide
    • cisapride (Propulsid) 10-20 mg BID (removed from US market)
• behavioral modification/biofeedback especially with pelvic floor dysfunction
• low FODMAP diet with GI dietician oversight if carbohydrate enzyme deficiency
• do not use probiotics

* treat dyspepsia with proton pump inhibitor prior to treating bloat (MKSAP19)

More general terms

• intestinal disease

Additional terms

• bacterial overgrowth syndrome
• flatulence