APPROACH TO BLOATING Epidemiology Very common symptom in primary - PowerPoint PPT Presentation

Dr Juanda Leo Hartono Associate Consultant Div Gastroenterology and Hepatology National University Hospital, Singapore APPROACH TO BLOATING

Epidemiology  Very common symptom in primary care (10- 30% in population based studies)  Most are benign  Majority present as part of other Functional GI Disorder, esp Functional Dyspepsia and IBS  Bloating as the only symptom (Functional Bloating) is uncommon

Patient’s Possible Range of Symptoms  Bloatedness  Abdominal fullness  Abdominal Tightness  Distension  Increased burping / belching  Increase flatulence Bloating NOT THE SAME AS Distension

Before you label ‘Functional…’ make sure it is not physiological

Consider Possible Organic Etiology Foley et al. Gastroenterol & Hepatol 2014;10(9):561-71

Red Flag Features  Age >50 years old  Family history of GI malignancy in a first degree relative  Unintended weight loss  GI bleeding or iron deficiency anemia  Dysphagia  Worsening or change in character of symptoms despite usual measures

Basic Investigation  FBC, LFT, Renal Panel  ESR (especially in diarrhea)  Ultrasound (HBS or pelvic depending on suspicion)

Dyspepsia Algorithm ASGE guideline 2015

Rome III Criteria : FD

Rome III Criteria : IBS

Rome III Criteria : Functional Bloating Only small proportion of patients will fall into this group

Putative Mechanism

Abdominal Wall displacement theory

Visceral Hypersensitivity ‘ What do you mean I am not being sensitive inw(n)ardly ? ‘

Non-medical therapy for Bloating  Low FODMAP diet (50-75% response in RCT)  Physical activity promote gas transit  Biofeedback for  Constipation with pelvic floor dysfunction  Abdominal wall displacement correction (preliminary)

What is FODMAP?  Fermentable  Oligosaccharides  Inulin & fructo-oligosaccharides (eg: wheat, onion)  Galacto-oligosacharrides (eg: legumes: beans, peas)  Disaccharides (eg lactose in dairy products)  Monosaccharides  Free fructose (excess fructose relative to glucose)  And Polyols ( sorbitols, mannitols) : artificial sweeteners

Management : low FODMAP diet

RCTs of Medications used to relieve bloating Ionivo P et al. World J Gastroenterol 2014;20(39):14407-19

Algorithm Foley et al. Gastroenterol & Hepatol 2014;10(9):561-71

Algorithm Foley et al. Gastroenterol & Hepatol 2014;10(9):561-71

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