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Saturday, August 23, 2025

Bloating


Introduction

Bloating refers to the subjective sensation of abdominal fullness, tightness, or distension. It may be accompanied by excessive gas, belching, flatulence, or abdominal pain.

  • Up to 20–30% of the general population report bloating symptoms.

  • More common in women (hormonal influence, IBS prevalence).

  • Often benign, but persistent or severe bloating requires evaluation.

Pathophysiology

Bloating may result from:

  1. Excessive gas production (fermentation of poorly digested food).

  2. Altered gut motility (slowed transit, constipation).

  3. Visceral hypersensitivity (gut more sensitive to normal gas levels, as in IBS).

  4. Fluid retention or ascites (in systemic illness).

  5. Mechanical obstruction (tumors, strictures).

Causes of Bloating

1. Dietary Causes

  • Overeating, eating too quickly.

  • Carbonated drinks, chewing gum, drinking through a straw (swallowed air).

  • High-FODMAP foods (beans, cabbage, onions, garlic, apples, wheat, lactose).

  • Food intolerances:

    • Lactose intolerance.

    • Fructose intolerance.

    • Gluten sensitivity / celiac disease.

2. Functional Gastrointestinal Disorders

  • Irritable bowel syndrome (IBS).

  • Functional dyspepsia.

  • Chronic constipation.

3. Organic Gastrointestinal Disease

  • Small intestinal bacterial overgrowth (SIBO).

  • Gastroparesis (delayed stomach emptying).

  • Gastroesophageal reflux disease (GERD).

  • Peptic ulcer disease.

  • Intestinal obstruction (tumor, adhesions, hernia).

  • Inflammatory bowel disease (Crohn’s, ulcerative colitis).

  • Colorectal cancer.

4. Gynecological Conditions (in women)

  • Premenstrual syndrome (PMS).

  • Ovarian cysts or tumors.

  • Endometriosis.

5. Systemic / Other Causes

  • Cirrhosis with ascites.

  • Heart failure (fluid retention).

  • Pancreatic insufficiency (fat malabsorption).

  • Hypothyroidism (slowed motility).

  • Medications:

    • Iron supplements.

    • Opioids.

    • Antidepressants.

    • Metformin.

Clinical Features

  • Subjective fullness, tightness, heaviness.

  • Visible abdominal distension.

  • Excessive belching, flatulence.

  • Abdominal pain or cramping.

  • Constipation or diarrhea (depending on cause).

  • Systemic red flags:

    • Weight loss.

    • Blood in stool.

    • Persistent vomiting.

    • Night sweats or fever.

Diagnostic Approach

1. History

  • Onset, duration, pattern (daily, intermittent).

  • Relation to food intake, menstrual cycle, bowel movements.

  • Associated symptoms (diarrhea, constipation, pain, weight loss).

  • Diet, medications, alcohol use.

  • Family history of GI or gynecological cancers.

2. Examination

  • Abdominal distension, tenderness, bowel sounds.

  • Signs of ascites (fluid wave).

  • Rectal exam (occult blood, masses).

  • Gynecological exam in women (if indicated).

3. Investigations

  • Basic tests: CBC, ESR/CRP, renal/liver function, thyroid function.

  • Stool studies: Culture, ova/parasites, fecal calprotectin (IBD).

  • Breath tests: Hydrogen/methane breath test for lactose intolerance or SIBO.

  • Celiac serology: Tissue transglutaminase antibodies.

  • Imaging:

    • Abdominal ultrasound (cysts, ascites, tumors).

    • CT/MRI if obstruction or cancer suspected.

  • Endoscopy / Colonoscopy: Rule out ulcers, IBD, colorectal cancer.

Management and Treatment

Treatment depends on cause.

A. General Lifestyle & Dietary Measures

  • Eat smaller, frequent meals.

  • Avoid carbonated drinks, chewing gum.

  • Eat slowly, avoid swallowing air.

  • Low-FODMAP diet (reduce fermentable carbohydrates).

  • Identify and eliminate food triggers (keep a food diary).

  • Adequate hydration, fiber intake (for constipation).

  • Regular exercise (stimulates gut motility).

B. Pharmacological Treatment

1. For Gas & Bloating Relief

  • Simethicone 80–125 mg orally after meals and at bedtime.

  • Activated charcoal tablets may help some patients.

2. For Constipation-Related Bloating

  • Psyllium husk 3.4 g orally 1–2 times daily with water.

  • Polyethylene glycol (PEG) 17 g dissolved in water once daily.

  • Lactulose 15–30 mL orally once daily.

3. For Diarrhea-Predominant IBS

  • Loperamide 2–4 mg orally after each loose stool (max 16 mg/day).

  • Rifaximin 400 mg orally three times daily × 14 days (for IBS with SIBO component).

4. For Pain-Predominant IBS / Dyspepsia

  • Antispasmodics:

    • Hyoscine butylbromide 10 mg orally three times daily.

    • Mebeverine 135 mg orally three times daily.

  • Peppermint oil capsules may help bloating and pain.

5. For GERD-Related Bloating

  • Omeprazole 20–40 mg orally once daily.

6. For SIBO

  • Rifaximin 550 mg orally twice daily × 14 days.

7. For Gynecological Causes

  • Hormonal therapy (combined oral contraceptives) for endometriosis-related bloating.

8. For Ascites / Fluid Retention

  • Spironolactone 100 mg orally once daily, titrate as needed.

  • Furosemide 20–40 mg orally daily (in combination if needed).

C. Procedural / Surgical Treatment

  • Removal of bowel obstruction, tumors, or large ovarian cysts.

  • Endoscopic removal of strictures.

  • Paracentesis for large ascites.

  • Surgery for refractory endometriosis or cancer.

Complications

  • Anxiety, reduced quality of life.

  • Malnutrition (if due to malabsorption).

  • Missed diagnosis of cancer if ignored.

  • Severe distension causing discomfort or respiratory compromise (in ascites, obstruction).

Prognosis

  • Functional bloating (IBS, diet-related): Good with dietary changes and medications.

  • Infections/SIBO: Treatable with antibiotics.

  • Chronic diseases (IBD, celiac): Controlled with long-term management.

  • Cancer-related bloating: Prognosis depends on stage and treatment.

Patient Education

  • Bloating is common and often benign.

  • Track diet and symptoms to identify triggers.

  • Avoid excessive gas-forming foods and carbonated drinks.

  • Seek medical care if bloating is persistent, painful, associated with weight loss, blood in stool, or vomiting.

  • Regular check-ups for those with family history of GI or gynecological cancers.




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