Description
Belching , bloating, and bloating are highly prevalent gastrointestinal symptoms and represent some of the most common reasons for patient visits to outpatient gastroenterology practices. These symptoms are often debilitating, impact patients’ quality of life, and contribute to work absenteeism.
Belching and bloating differ in their pathophysiology, diagnosis and treatment, and limited evidence is available for their various treatments. Therefore, the purpose of this American Gastroenterological Association (AGA) Clinical Practice Update is to provide best practice advice based on both controlled trials and observational data for clinicians covering characteristics clinical, diagnostic, and management considerations including diet, gut-directed behavior, and pharmacologic therapies.
Methods
This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of great clinical importance to AGA members, and underwent internal review by the Practice Updates Committee. These best practice advice statements were drawn from a review of published literature based on clinical trials, the most robust observational studies, and expert opinion. Because no systematic reviews were conducted, these best practice advice statements do not carry formal qualifications regarding the quality of the evidence or the strength of the considerations presented.
This American Gastroenterological Association clinical practice update and best practice advice statements describe the definition, clinical features, and treatment for the 3 common symptoms of belching, abdominal bloating, and bloating . When these symptoms are frequent or severe enough to affect daily activities, they are classified as disorders of gut-brain interaction (DGBI).
The clinical advice presented in this document is based on evidence where data were available, but where available data were insufficient, level 5 evidence is provided on the basis of expert opinion and is empirically based on the data. of observation and expert consensus of the authors.
Why is this question important in clinical practice?
These symptoms are highly prevalent and possibly affect the patient’s quality of life (QoL), work productivity, and visits to emergency and outpatient services. There is limited information available for gastroenterologists to find expert advice on diagnosing and managing these symptoms of disorders of the gut-brain interaction (DIBID), as we lack strong evidence because much of the existing data is single-centre and, sometimes controversial.
How much is known about this topic?
Few studies address the pathophysiology or risk factors for belching and bloating, and their treatment options remain suboptimal. Furthermore, these disorders overlap with other common DGBIs, and their mechanisms involve both central and peripheral processes. In this expert review, we separate belching from bloating and distension, given their different locations, pathophysiology, and avenues for diagnosis and treatment.
Bloating and distension
Definition
Abdominal bloating ( bloating ) is a subjective sensation in any abdominal region experienced by patients as fullness, bloating, trapped gas or gassiness, or tightness, and is described as "bloated" in some cultures.
In contrast, bloating is a visible increase in abdominal circumference, often described as "like a balloon" or "like being pregnant."
These conditions have interrelated pathophysiologies, and coexisting treatment strategies are often difficult to separate. The Rome IV criteria define functional bloating and distension as disorders of the gut-brain interaction (DGBI) with recurrent symptoms of abdominal fullness or pressure or a visible increase in abdominal circumference with symptoms at least 1 day per week and active for 3 months, with onset of 6 months, and without predominance of pain and alteration of intestinal habits.
Rome IV has a category of abdominal bloating and distension that is separate from other DGBIs, recognizing that this may be a primary disorder in some patients. A large global population-based study found a prevalence of functional swelling and distension as high as 3.5% (4.6% in women and 2.4% in men). However, swelling and distension are much more common. common (>50%) when associated with other DGBIs, including irritable bowel syndrome (IBS), constipation, and functional dyspepsia.
Best Practice Advice Statements Best Practice Tips 1 History and physical examination findings and impedance pH monitoring can help differentiate between gastric and supragastric belching. Best Practice Tips 2 Treatment options for supragastric belching may include brain-gut behavioral therapies , either separately or in combination, such as cognitive behavioral therapy, diaphragmatic breathing, speech therapy, and central neuromodulators. Best Practice Tips 3 The Rome IV criteria should be used to diagnose primary abdominal distension and distention. Best Practice Tips 4 Carbohydrate enzyme deficiencies can be ruled out with dietary restriction and/or breath testing. In a small subset of at-risk patients, small intestinal aspiration and glucose- or lactulose-based hydrogen breath testing can be used to evaluate bacterial overgrowth in the small intestine. 5 Best Practice Tips Serological testing can rule out celiac disease in patients with abdominal distention, and if serologies are positive, a small bowel biopsy should be performed to confirm the diagnosis. A gastroenterologist dietitian should be part of the multidisciplinary approach to the care of patients with celiac disease and non-celiac gluten sensitivity. Best Practice Tips 6 Abdominal imaging and upper endoscopy should be ordered in patients with red flag features , recent worsening of symptoms, or only an abnormal physical examination. Best Practice Tips 7 Gastric emptying studies should not be routinely ordered for bloating and distension, but may be considered if nausea and vomiting are present. Total intestinal motility and radiopaque transit studies should not be ordered unless there are other refractory lower gastrointestinal symptoms that warrant testing for neuromyopathic disorders. Best Practice Tips 8 In patients with bloating and bloating believed to be related to constipation or difficult bowel movements, anorectal physiology testing is suggested to rule out a pelvic floor disorder. Best Practice Tips 9 When dietary modifications are needed (e.g., diet with oligosaccharides, disaccharides, monosaccharides, and low-fermenting polyols), it is preferable for treatment to be monitored by a gastroenterology dietitian. 10 Best Practice Tips Probiotics should not be used to treat bloating and bloating. Best Practice Tips 11 Biofeedback therapy can be effective for bloating and distension when a pelvic floor disorder is identified. Best Practice Tips 12 Central neuromodulators (e.g., antidepressants) are used to treat bloating and abdominal distension by reducing visceral hypersensitivity, raising the threshold of sensation, and improving psychological comorbidities. Best Practice Tips 13 Medications used to treat constipation should be considered to treat bloating if symptoms of constipation occur. Best Practice Tips 14 Psychological therapies, such as hypnotherapy, cognitive behavioral therapy, and other brain and gut behavioral therapies can be used to treat patients with bloating and distension. Best Practices 15 Diaphragmatic breathing and central neuromodulators are used to treat abdominophrenic dyssynergia. |
