1) The document outlines a 6-step approach to evaluating patients with gas-related symptoms, including clarifying the predominant symptom, timing relative to meals, dietary factors, associated GI symptoms, medications/supplements, and risk factors. 2) Potential causes are discussed depending on symptom onset, such as gastric issues for soon after eating and small bowel issues for over 1 hour later. 3) Treatment focuses on identifying and

1. Kurdistan Board GEH J Club
Supervised by:
Dr. Mohamed Alshekhani
Professor in Medicine
MBChB-CABM-FRCP-EBGH 2016
1

2. Introduction:
• Gas-related symptoms (GRSs) as bloating, belching, flatulence are
common & are a consequence of an incompletely understood
interaction between GI motility & gas production.
• Bloating : a sense of gassiness or being distended, but abd
distention, is an objective increase in abd girth, occurs in only 50%
of patients who experience bloating
• Belching (eructation): the expulsion of excess gas from the
esophagus or stomach, may or may not occur iwith bloating.
• Flatulence(passing air down)& belching after meals is not
considered abnormal, but can be bothersome, sp when in excess.
• The threshold for a patient to seek medical evaluation is affected by
their perception of what is “ normal.”
• A careful evaluation is exclude an organic disorder.

3. Introduction:
• All occur in both functional GI disorders, as IBS& in the general
population.
• 1/3 met Rome criteria for functional bloating.
• GRS can markedly impair the health-related QOL.
• Despite the increasing number of promising pharmacotherapies &
dietary interventions, an effective management strategy can be
hard to elucidate, frustrating both patients&clinicians.

4. Clin history: A SIMPLIFIED 6-STEP
• 1.Clarify the Predominant Symptom:
• The predominant symptom, be it belching ,flatulence or bloating,
should be ascertained initially to help direct questioning.

5. Clin history: A SIMPLIFIED 6-STEP
• 2.Timing of the onset of symptoms relative to food ingestion should
also be clarified.:
• The onset soon after eating suggests a gastric etiology, whereas
delayed symptoms may suggest a small bowel origin.
• Perform a thorough Dietary Evaluation, patient’s eating pattern &
relationship of symptoms:

6. Clin history: A SIMPLIFIED 6-STEP
• 3.The patient should be asked to describe how much & how
frequently they eat.
• Eating large meals less frequently may contribute to PP discomfort.
• Eating meals quickly, without thorough chewing& gulping food may
contribute to GRSs.
• Ingestion of foods associated with increased intestinal gas
production: onions, beans, legumes,Intolerance of food containing
lactose, gluten, fructose, large quantities of caffeine or carbonated
drinks,artificial sweeteners, specifically sugar alcohols such as
sorbitol, mannitol, glycerol.,often contained in chewing gum, even if
“sugar-free.”
• Any improvement with prior dietary modification.
• Belching, can be associated with caffeine causing TLESR.

7. Clin history: A SIMPLIFIED 6-STEP
• 4.Ask About Associated GI Symptoms, Specifically Abd Pain,
Diarrhea,Constipation, Weight Loss
• The coexistence of abdominal pain, alteration in bowel habit&
abdominal bloating suggests a potential IBS.
• Many other conditions leading to GRSs may also cause abd pain.
• Ask about form&frequency of stool,the ease of stool passage, as
constipation can induce GRSs.
• Presence of incomplete evacuation, straining with defecation, or
manual removal of stool suggests pelvic floor dysfunction.
• Diarrhea should prompt consideration of (SIBO) & celiac disease.
• Wt loss suggests neoplasm or malabsorptives,as celiac disease.
• Patients with severely restricted intake, due to dietary intolerance
or even functional dyspepsia, may also report marked weight loss.

8. Clin history: A SIMPLIFIED 6-STEP
• 5.Review the Patient’ s Medications&Supplements:
• Medication review is necessary, specially psyllium-containing
products, ,metformin&opiates.

9. Clin history: A SIMPLIFIED 6-STEP
• 6.Explore the Patient’ s Comorbidities&ask about RFs for SIBO:
• CPAP for OSA is associated with GRSs, typically with morning
symptoms following overnight use.
• Patients receiving home oxygen therapy can also experience
gaseous symptoms.
• 25% of patients experience gas-bloat syndrome after Nissen
fundoplication surgery.
• Risk for for SIBO should be sought:
• 1. Structural: SB diverticula&CD strictures, radiation, or NSAIDs.
• 2. Surgical: R-en-Y surgery (blind&afferent loops) &ICV resection
• 3. Dysmotility: scleroderma, narcotics, DM,amyloidosis
• 4. Reduced acid (achlorhydria): acid suppressive, gastric resection,
atrophic gastritis, advancing age
• 5. Miscellaneous: celiac, cirrhosis, immunodefi ciency, panc insuff.

10. Exams:
• The observations suggest a diagnosis of supragastric belching, a
learned behavior often associated with anxiety disorders:
• A patient excessively belch when attention is focused on this
symptom&may even volunteer a demonstration of “ belching”
during the interview process.
• Improvement in belching may also be observed as the patient is
distracted.
• Exam of the abd may reveal distention related to small bowel ileus
or mechanical obstruction or less likely gastric outlet obstruction
(GOO), whereby patients may also manifest a succussion splash.
• Nongaseous etiologies for abd distension should also be considered,
including ascites, organomegaly,increased adiposity.
• Bowel sounds carefully auscultated, with of high-pitched BSs
suggesting mechanical obstruction whereas reduced or absent
bowel sounds could suggest GI ileus or dysmotility.

11. Exams:
• A detailed DRE looking for evidence of fecal impaction or signs of
pelvic floor dysfunction.
• Signs of pelvic floor dysfunction:
• Increased perineal descent (ie, descending perineum syndrome),
• Decreased perineal descent.
• Abnormal sphincter tone.
• Failed relaxation of the puborectalis muscle with simulated
defecation.

15. The Gastric Bloater:
• The epigastric discomfort & upper abd bloating soon after eating
suggests gastric origin.
• Potential causess: GOO, gastroparesis, abn gastric accommodation ,
Post-infectious &functional (nonulcer) dyspepsia.
• GOO may be caused by neoplasm, chronic PUD, or pancreatitis
often with vomiting of undigested or partially digested food.
• If suspected, EGD is the appropriate investigation, with a normal
study effectively excluding GOO.
• Gastroparesis: delayed gastric emptying without mechanical GOO ,
diagnosis by abn gastric emptying ,most frequently with diabetes.
• Functional dyspepsia:chronic upper abd pain, bloating, or
discomfort, usually for 6 months or more, without alternative
explanation or organic disease (including normal EGD).

16. The Gastric Bloater”:
• The management is tailored to the underlying etiology.
• Gastropariesis should receive formal instruction from an
experienced GI dietician with respect to a gastroparesis diet (eating
small meals frequently or reducing dietary fat intake).
• Postinfectious gastroparesis is usually selflimiting&should improve
with time.
• Those related to a systemic condition such as DM or connective
tissue disease (eg, scleroderma) should have targeted treatment of
their underlying condition.
• A prokinetic, such as metoclopramide, may be considered in cases
refractory to dietary modification,liquid formulation at a dose of 5 -
10 mL, 30 minutes before meals&at bedtime, may optimize the
clinical response.

17. The Gastric Bloater”:
• Abnormal gastric accommodation may also benefit from
gastroparesis diet. Buspirone 5 - 10 mg, 30 minutes before meals.
• If GOO is found, this will usually require surgical intervention.
• Functional dyspepsia, a diagnosis of exclusion.
• Similar dietary instruction should occur, as well as avoidance of
other precipitants, identified by a diet & symptom diary.
• If symptoms persist&local prevalence of Helicobacter pylori is
>10%, this diagnosis should be sought (H pylori breath test, stool
antigen, or biopsy at EGD) & treated if present.
• A trial of acid suppressive therapy may be of benefit, especially if
the primary symptom is epigastric pain.
• Amitriptyline shown to be beneficial starting 25 mg at nighttime,
increasing in 25-mg every 2 weeks.

18. The SB Bloater”:
• Upper abdominal bloating that occurs >1 hour after eating.
• DD: dietary-related ingestion (foods, lactose, gluten, FODMAPs
[fermentable oligo-, di-, monosaccharides,polyols]), CD, SIBO,
(SBO), or IBS.
• A focused history help to rule out the usual diet-related causes.
• Normal celiac serology, normal abd radio, make SBO less likely.
• Previous abd surgery predisposes to SBO due to adhesions&should
always be sought in the history of patients presenting with GRSs,
increases with multiple abdominal operations &history of SBO
secondary to adhesions.
• Patients with SIBO will often have concomitant diarrhea.
• Although no perfect test exists for diagnosing SIBO, the normal
hydrogen breath test combined with the absence of risk factors
makes it unlikely.

19. The SB Bloater”:
• SIBO diagnosis: EGD, with SB aspirate culture revealing >100,000
organisms/mL.
• A noninvasive alternative test is the hydrogen breath test, which
involves ingestion of substrate with monitoring of hydrogen in
exhaled breath every 15 to 30 minutes.
• In nondiabetics, glucose used&a positive test involves an increase in
hydrogen by 12 ppm.
• In diabetics, lactulose used, with an increase by 20 ppm indicative
of a positive test.
• Management of SIBO: treatment of identifiable risk factors,
replacement of nutritional deficiencies (eg, vitamin B12 ),
antibiotics, such as ciprofloxacin 250 mg twice a day for 7- 10 days.
• A cyclic antibiotic for the first 7 to 10 days each month can also be
used for some cases with high risk of persistent or recurrent SIBO
(eg, patients with scleroderma).

20. The SB Bloater”:
• Positive Rome criteria suggests IBS.
• Dietary interventions, often overlooked, 60% of patients with IBS
associate symptoms with eating a meal,may be due to food
intolerances, gastrocolic response, microbiome/fermentation, gas
handling, or psychological factors.
• Reassurance/education are critical initial steps.
• The traditional IBS diet emphasizes a greater focus on how/when to
eat rather than on what foods to ingestd as 3 meals / 3 snacks a
day; reduced intake of fatty foods, spicy foods, coffee,alcohol&
avoidance of carbonated drinks, gums, and sweeteners.
• Other recommended diets include the low FODMAP diet,shown to
reduce ,a gluten-free diet, irrespective of the presence of celiac
disease, sp with IBS-D &HLA-DQ2 or -DQ8 positive.

21. The SB Bloater”:
• For episodic pain, hyoscyamine considered.
• For patients with continuous pain, amitriptyline more beneficial.
• CBT helpful in certain patients.
• The complementary medicine, STW have some benefit.
• IBS-D, 25% may have bile acid malabsorption, and thus a trial of a
bile acid sequestrant may be worthwhile.
• Rifaximin, a gut-selective antibiotic that is not systemically
absorbed,effective in IBS-D.
• Eluxadoline, a new oral agent with mixed opioid effects, for the
treatment of IBS-D.

22. The Constipated Bloater”:
• Constipation is a common cause of GRSs.
• Common causes: IBS-C,simple constipation, or constipation with
pelvic floor dysfunction,inadequate fiber / fluid/physical activity,
,motility disorders or colonic pathology.
• Systemic conditions such as hypothyroidism or hypercalcemia ,
medication use (eg, narcotics /CCB).
• most patients with uncomplicated constipation do not require
investigation, the clinical presentation can identify a subset of
patients in whom investigations are indicated.
• Colonoscopy should be pursued when marked alteration in bowel
habit is associated with unexplained concerning symptoms such as
hematochezia or weight loss.
• Anorectal manometry is indicated for patients with symptoms or
signs suggestive of pelvic floor dysfunction.

23. The Constipated Bloater”:
• Most benefit from ensuring dietary fiber intake of approximately
20g/d, maintaining excellent hydration, increasing physical activity
&in some cases initiation of supplementary fiber (eg,
methylcellulose, 2 heaped tablespoons per day).
• Patients with constipation associated with excess gas or bloating
may have worsening of their symptoms with psyllium products so if
fi ber supplementation is being pursued, this group of patients may
see more benefit from a none psyllium-containing product such as
methycellulose.
• For those patients not responding to these measures, an osmotic
laxative such as polyethylene glycol should be pursued.
• Worsening of GRSs after fiber supplementation or osmotic laxatives
may be a clue to the underlying pelvic floor dysfunction.

24. The Constipated Bloater”:
• The most effective intervention for dysynergic defecation is pelvi fl
oor retraining using biofeedback therapy, with 80% improvement at
6 months after a 2-week program.
• Stimulant laxatives are usually reserved for patients with
dysmotility disorders, those on narcotic pain medications&those
unresponsive to other interventions for constipation.
• For those patients with GRSs due to narcotic-induced constipation,
measures should be taken to reduce or discontinue narcotic dose.
• Two novel agentsd lubiprostone/linaclotided have been approved
for the treatment of chronic idiopathic constipation & IBS-C but
relatively small response rates&higher costs will likely make these
medications second-line therapy, for now.

25. The belcher”:
• Belching reflect normal physiology or may be pathological, a from
aerophagia or supragastric belching.
• During eating, ingestion of small quantities of air is normal.
• Gas is also produced within the GI tract,contribute to intestinal gas
&may ultimately be passed as flatus or may rise into the fundus of
the stomach, leading to TLESR.
• TLESRs occur approximately 25 to 30 times/d in normal individuals,
represent the mechanism for “ physiologic” belching.
• Supragastric belching usually occurs as a result of diaphragmatic
contraction, decreased intrathoracic pressure, or air entering the
esophagus & then being expelled as the diaphragm relaxes.
• This is an abnormal learned behavior may lead to multiple “
belches” / minute,espe when attention is focused on the symptom
or when the patient is anxious.

26. The belcher”:
• Aerophagia (air swallowing ):swallowing excessive amounts of air
may be seen in patients who eat in a hurried manner, do not chew
their food thoroughly&gulp during eating,also an association with
anxiety disorders, but symptom is generally not reproduced.

27. The belcher”:
• Many patients with excess belching will benefit from dietary
reduction of high gas forming foods such as onions, beans, legumes.
• Eating small meals, chewing food thoroughly, minimizing
carbonated drinks.
• Occasionally, with more difficult to control physiologic belching,
baclofen can be prescribed in short-term (reduces TLESRs).
• Patients with suspected aerophagia should also be advised to eat
slowly, deliberately chewing their food & not gulping.
• This group & supragastric belching will usually benefit most from
behavioral therapy consultation and specifically instruction with
respect to the potential benefi ts of diaphragmatic to decreasing
aerophagia & supragastric belching.

28. Abstract:
• The evaluation of the patient with gas & bloating can be complex &
the treatment extremely challenging.
• A simplified approach to the history & relevant physical
examination is presented &applied in a case-oriented manner,
suitable for application in the primary care setting.
• Evaluation of the patient with GRSs can often be complex&time-
consuming.
• A methodical approach can facilitate diagnosis&management.
• This aproach should help with limiting the differential diagnosis
&directing testing&should help primary care physicians evaluate /
treat a large percentage of patients with GRSs.
• Referral to a gastroenterologist should be considered in more
complex or refractory cases.

29. BO5s:
• 1. A 40-year-old man with longstanding irritable bowel syndrome
(IBS) symptoms has recently been restricting his diet in an attempt
to improve symptom control. He has significant abdominal bloating
and pain, which is relieved somewhat by defecation. He does not
ingest excess caffeine, carbonation, gum, or artificial sweeteners.
He has not had abdominal surgery. Prior testing has included
normal results on celiac serology testing. What dietary change
is least likely to benefit this patient?
• a. The traditional IBS diet
• b. Lactose-free diet
• c. Gluten-free diet
• d. FODMAPs diet
• e. The Paleo diet

30. BO5s:
• 2. A 30-year-old man presents for evaluation of immediate post-
prandial epigastric discomfort and bloating. He recently
experienced a self-limiting episode of viral gastroenteritis. A trial of
a proton pump inhibitor was not helpful. Upper endoscopy and
ultrasound of gallbladder were normal. What is the next step in
treatment of this patient?
• a. Surgical consult for laparoscopic cholecystectomy
• b. Gastric emptying study
• c. Computerized tomographic scan of abdomen
• d. Dietary modification
• e. 24-hour PH and impedance study

31. BO5s:
• 3. A 60-year-old woman presents for evaluation of chronic
abdominal pain and bloating. She reports a longstanding history of
constipation, which has worsened in recent months. Symptoms
have proved refractory to methylcellulose (Citrucel) and
exacerbated by polyethylene glycol (MiraLAX). The patient reports
straining to have a bowel movement, and having to manually
remove stool on occasion. What’s the next step in treatment for this
patient?
• a. Colon transit studies
• b. Computerized tomography of abdomen and pelvis
• c. Anorectal manometry
• d. Stimulant laxative
• e. Linaclotide

32. BO5s:
• 4. A 45-year-old woman presents for evaluation of a 6-month
history of bloating and loose stools, generally worse an hour after
meals. Her only past medical history is gastroesophageal reflux
disease for which she takes omeprazole. She states that in the
morning she has little bloating and gets worse as the day goes by.
She has had a normal complete blood count (CBC) and celiac
serology. She was found to have a low vitamin B12 level. What is
the next step in treatment of this patient?
• a. Hydrogen breath test for bacterial overgrowth
• b. Rifaximin 550 mg bid for 10 days
• c. Metronidazole 500 mg tid for 10 days
• d. A probiotic
• e. Psychology consultation

33. BO5s:
• 5. A 28-year-old woman with a history of anxiety presents for
evaluation of belching. The patient states that at times she will
belch multiple times per minute, usually after eating. It is not
present at weekends, or while on vacation. She describes gulping
food in a hurried manner during the weekdays. She has not had
breakfast prior to the consultation, and does not belch during the
entire interview. What’s the most likely diagnosis?
• a. Gastric belching
• b. Aerophagia
• c. Supragastric belching
• d. Small intestinal bacterial overgrowth
• e. Celiac disease
•