Use a Step-by-Step Approach to Help Manage Patients With Bloating

Philadelphia—A stepwise approach to management of patients with bloating can facilitate identification of likely causes and uncover optimal treatment strategies, according to a presentation at the 2018 annual meeting of the American College of Gastroenterology.

Bloating affects up to 30% of the U.S. population and is a common complaint in GI clinics, said Amy S. Oxentenko, MD, from Mayo Clinic’s Division of Gastroenterology and Hepatology in Rochester, Minn. Approximately 75% of such patients, Dr. Oxentenko said, have moderate symptoms that can adversely affect their quality of life.

Some patients will have a discernable organic basis of bloating, but others have functional abdominal bloating. Overall, the Rome IV criteria for a diagnosis of functional abdominal bloating/distention requires recurrent bloating/distention that occurs, on average, at least one day per week, has been present the last three months and started at least six months prior, in a patient who does not meet the criteria for irritable bowel syndrome (IBS), functional constipation, functional diarrhea or postprandial distress syndrome (Gastroenterology 2016;150[6]:1393-1407.e5).

Uncovering the Predominant Symptom And Its Timing

An important first step in the workup of patients who present with bloating is to have patients explain what they mean when they state they are “bloated.” About half of patients present with both distention and bloating, but others present with just one or the other, Dr. Oxentenko said. Thus, she said the workup for patients presenting with bloating and/or distention should start with identification of the predominant symptom (Figure). Is it belching, with the patient frequently expelling gas from the stomach or esophagus; bloating, with the patient presenting with a feeling of gassiness or abdominal pressure; or distention, with the patient presenting with an objective enlargement of the waist? Patients should also be assessed for risk factors for “pseudobloat,” which can be ruled out by evaluating for the three F’s—fluid (are risk factors for ascites present?), fat (has there been recent weight gain/adiposity?), and fetus (when was the patient’s last menstrual period?).

As important as homing in on the primary symptom, Dr. Oxentenko said, is pinning down the onset of symptoms. The workup should include a determination of whether the symptoms occur shortly after eating (within 30 minutes), which may suggest a gastric etiology, or later (several hours after eating), which may suggest a small-bowel or dietary etiology. It’s also important to find out whether the symptoms are related to the patient’s stool pattern, so “sorting out the baseline bowel pattern (constipation versus diarrhea) can be incredibly helpful in narrowing down the differential,” Dr. Oxentenko told Gastroenterology & Endoscopy News.

Evaluating Diet, Medications And Comorbidities

The next step, she said, is a full dietary evaluation that assesses the volume and frequency of meals, the speed at which the patient ingests their food, their intake of carbonated and/or caffeinated beverages and lactose, gluten, fructose and gas-producing foods and artificial sweeteners that may provoke symptoms.

Evaluation of other gastrointestinal symptoms also is essential, according to Dr. Oxentenko. This includes asking the patient whether their excess gas is accompanied by abdominal pain as well as whether their stool has changed in form or frequency. Constipation, incomplete evacuation, diarrhea and weight loss are other GI symptoms to assess.

Considering medical comorbidities is another crucial step. She listed important confounders including risk factors for small intestinal bacterial overgrowth (SIBO), such as Roux-en-Y gastric bypass, radiation therapy, Crohn’s disease, small-bowel strictures, ileocecal valve resection, motility disorders and achlorhydria. Other things to note include a history of abdominal surgery (which could result in adhesions/obstruction), Nissen fundoplication (which can lead to gas and bloating), and use of continuous positive airway pressure devices (which can result in the swallowing of excess air).

A review of medications and supplements should tease out any use of opioids, metformin, lactulose, other osmotic agents (e.g., magnesium), sorbitol, as well as multivitamins, iron, psyllium and fiber, Dr. Oxentenko said.

Treatment Algorithms

Several treatment algorithms are available to guide management of patients with bloating, belching and distention. Cotter et al recommended an evaluation based on the predominant symptom (belching, bloating and distention) and the timing in relation to meals, breaking patients into four categories—gastric bloaters, small-bowel bloaters, constipated bloaters and belchers—listing potential etiologies and offering management strategies for each category (Mayo Clin Proc 2016;91[8]:1105-1113). Dr. Oxentenko and her colleague Amrit K Kamboj, MD, published an alternative algorithm that factors in GI features of diarrhea, constipation, and the presence or absence of a mechanical disturbance, with less emphasis on timing (Clin Gastroenterol Hepatol 2018;16[7]:1030-1033). For example, in managing a patient with bloating and diarrhea, Drs. Kamboj and Oxentenko recommend reviewing dietary intake and medications, as well as considering breath testing, celiac serologies, enterography and colonoscopy, as indicated, considering that the patient’s symptoms may be related to dietary issues, SIBO, celiac disease, inflammatory bowel disease, diarrhea-predominant IBS, and/or medications. In contrast, for a patient with bloating and abdominal pain and complaints that raise the concern for a mechanical issue (such as obstruction or pseudoobstruction with pain, nausea, vomiting), they recommend a careful review of surgical history, with consideration for abdominal imaging and/or esophagogastroduodenoscopy, recognizing that the patient may have a small or large bowel obstruction or gastric outlet obstruction.

Treatment Remains Challenging

Braden Kuo, MD, a motility specialist and the director of the Center for Neurointestinal Health at Massachusetts General Hospital and Harvard Medical School in Boston, complimented Dr. Oxentenko on “a thoughtful evaluation in terms of a rule-out process” for bloating and distention. But he stressed the ongoing challenge of treating patients with these conditions. “It boils down to … what the heck are we going to do for these people?” once you complete a comprehensive workup which ends up being negative.

At Mass General, he said, after a reasonable evaluation, they offer review of the concept of visceral hypersensitivity, which factors heavily into functional dyspepsia, IBS and chronic abdominal pain. He said he explains to patients that they have either visceral hypersensitivity, leading to an abnormal sensation of bloating, or an abnormal visceral reflex response that results in a dilated bowel response or altered abdominal wall response, leading, in turn, to abdominal distention. To treat visceral hypersensitivity, they may use neuromodulators such as gabapentin or tricyclic antidepressants, depending on patient medical tolerance and side effects to medications. To treat an abnormal visceral reflex response, they also may use gabapentin and other neuromodulators, possibly along with abdominal physical therapy focusing on the pelvic floor, diaphragm and abdominal wall to try to attenuate the abnormal visceral reflex.

But Dr. Kuo said the science is early, and much of their approach is based on “conjecture” with much more work needed in the area.

The “closest anyone has gotten” to showing support for these ideas, he said, is a small study by a group from Barcelona, Spain, that showed some benefit from biofeedback (Am J Gastroenterol 2017;112[8]:1221-1231). The authors of that study, led by J.R. Malagelada, concluded that potential therapies “include dietary modification, microbiome modulation, promoting gas evacuation, attenuating visceral perception, and controlling abdominal wall muscle activity via biofeedback.” They also recommended that for “severe, protracted cases it may be appropriate to refer the patient to a specialized center where motility, visceral sensitivity, and abdominal muscle activity in response to intraluminal stimuli may be measured.”

—Sarah Tilyou