Let's talk about something common, hard to treat, and often misunderstood: CHRONIC BLOATING AND DISTENSION!

A 🧵 summarizing from the excellent @AGA_CGH article cghjournal.org/article/S1542-…

#GI #GITwitter #motility #IBS #DGBI #FGID #microbiome #health #MedEd
🟢Bloating: subjective sensation of gassiness, trapped💨, or a feeling of pressure or being distended w/o obvious visible distension.

🟢Distension: objective physical manifestation of an⬆️in abdominal girth. Patients commonly say they look like 🎈 or 🤰
Bloating and distension are COMMON

🔴16-31% in the general population

🔴Women > men

🔴66-99% in #IBS

🔴IBS-C > IBS-D

🟢Bloating and distension are distressing to patients and ⬇️quality of life
Many patients believe their bloating/distension is caused by⬆️gas but this is very rarely true! 💨

CT scans show gas ⬆️ in only 25% of patients with #DGBI during an episode of abdominal distension or following consumption of a “high-flatulence” diet.

⬇️Normal #gas production Image
So what causes pathologic bloating/distension? Lots of things! And it's not always due to #GI dysfunction! Here's a nice list⬇️⬇️⬇️ ImageImage
Important factors
🟠#SIBO + carbohydrate (eg lactose, fructose) malabsorption
🟠Altered #gut #microbiome (❓⬇️Ruminococcaceae and Eubacteriaceae)
🟠dysmotility (gastroparesis, CIPO, scleroderma)
🟠pelvic floor dysfunction
🟠visceral hypersensitivity
🟠abdominophrenic dyssynergia
Abdominophrenic dyssynergia is *very common* in patients w bloating/distension, especially in functional bloating!

Normal:💨 ▶️diaphragm relaxes, and the anterior abdominal muscles contract

AD:💨 ▶️diaphragm contracts, and the anterior abdominal wall muscles relax Image
Don't forget the diagnosis of functional abdominal bloating and distension! This is common and underdiagnosed!

Biofeedback can be very helpful! Image
How should we work up chronic bloating and distension? Here's a start! ⬇️⬇️⬇️ Image
Treatments

Diet
🟢artificial sweeteners⬆️💨
🟢FODMAPs (fermentable oligo-, di-, and monosaccharides) are common culprits

Probiotics
🟢L. sporogens/Bacillus coagulans had and Bifidobacterium species have been shown to improve bloating in #IBS Image
Meds
🟢Rifaximin treats bloating in #IBS and #SIBO
🟢Antispasmodics (if sx are from💨)
🟢Secretagogues (lubiprostone, linaclotide, plecanatide) in #IBS-C
🟢Prokinetics: not much data, but🤔neostigmine, pyridostigmine, prucalopride, and tegaserod
Meds
🟢Neuromodulators/antidepressants: amitryptiline, escitalopram, and buspirone in #FD; citalopram in #IBS

Other
🟢Biofeedback
🟢Pelvic floor physical therapy
🟢Peppermint oil
🟢Rikkunshito
🟢Hypnosis
That's all folks! Some takeaways!
🎈bloating is COMMON
🎈MANY different causes
🎈Don't forget non-GI etiologies
🎈Pursue appropriate workup
🎈GIVE PTS A DIAGNOSIS! Don't forget functional B/D!
🎈Lots of treatment options including diet,💊, peppermint oil, and behavioral therapy

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More from @john_damianosMD

8 Mar
A little late but better late than never! ⌚️ Here's a recap of @AmCollegeGastro Virtual Grand Rounds by @ScottGabbardMD on...... FUNCTIONAL DYSPEPSIA!
🤢🤢🤢

This is a VERY common entity that is underdiagnosed! #MedTwitter take notice!

#GITwitter #GI #gut Image
DYSPEPSIA = epigastric #pain. (can be associated with any other upper #GI symptom such as epigastric fullness, nausea, vomiting, or heartburn).

Dyspepsia is COMMON, and most cases are FUNCTIONAL (i.e., caused by brain-gut axis dysfunction)! ImageImage
Like all disorders of gut-brain interactions FD pathophysiology is❌completely understood, but is thought to be complex+multifactorial. Components include
🤢disrupted duodenal barrier
🤢altered duodenal #microbiome
🤢dysmotility
🤢visceral hypersensitivity
🤢psychosocial stress Image
Read 21 tweets
15 Dec 20
🚨New @AmCollegeGastro guidelines for the treatment of irritable bowel syndrome! I will summarize in this🧵 ⬇️⬇️⬇️

journals.lww.com/ajg/Abstract/9…

Authors: #BrianLacy, @MarkPimentelMD, @dbrennerGIMD, @umfoodoc, @drlauriekeefer, @MLongMD, @BMoshiree

#GITwitter #GI #IBS #gut #MedEd
🔘In pts w diarrhea, rule out #celiac disease🍞
🔘In pts w diarrhea + no🚨features, check fecal calprotectin/fecal leukocytes AND CRP to rule out #IBD
🔘❌routine 💩testing for enteric pathogens in #IBS
🔘❌colonoscopy in IBS if <45 and no🚨s
🔘Make POSITIVE IBS dx (Rome), ❌DOE
🔘Identify #IBS subtype to target therapy
🔘❌testing for food allergies/sensitivities
🔘Test anorectal physiology in pts w IBS + symptoms suggestive of pelvic floor disorder +/or refractory #constipatoin
🔘Limited trial of low-#FODMAP #diet
🔘✅soluble fiber,❌insoluble fiber
Read 7 tweets
11 Dec 20
Very important and high-yield #AIBD2020 session with @UmaMahadevanIBD on #IBD in #pregnancy! 🤰🔥💩👶
⬇️⬇️⬇️

@IBDConference #GITwitter #GI #OBGYNtwitter #OBGYN
Management of a healthy pregnancy begins... before pregnancy!

#AIBD2020 @IBDConference @UmaMahadevanIBD #IBD
Start planning early!

Want 3 months of steroid-free remission before conception.

#AIBD2020 @IBDConference @UmaMahadevanIBD #IBD
Read 23 tweets
18 Sep 20
Recapping @AmCollegeGastro's #VirtualGrandRounds on #IBS! Let's begin!
🟣IBS can be diagnosed with the Rome criteria
🟣Making a positive diagnosis is very helpful to patients, many of whom have gone years without a name for their symptoms
#IBS is heterogeneous, and so are its pathogenesis and pathophysiology.
🟣Identifying underlying factors in patients can help target treatment!

@AmCollegeGastro
Important principles when diagnosing and treating #IBS.

@AmCollegeGastro
Read 34 tweets

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