-
Gastroenterology Sep 2023Belching, bloating, and abdominal distention are all highly prevalent gastrointestinal symptoms and account for some of the most common reasons for patient visits to... (Review)
Review
DESCRIPTION
Belching, bloating, and abdominal distention are all highly prevalent gastrointestinal symptoms and account for some of the most common reasons for patient visits to outpatient gastroenterology practices. These symptoms are often debilitating, affecting patients' quality of life, and contributing to work absenteeism. Belching and bloating differ in their pathophysiology, diagnosis, and management, and there is limited evidence 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 clinical features, diagnostics, and management considerations that include dietary, gut-directed behavioral, and drug 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 high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. These best practice advice statements were drawn from a review of the published literature based on clinical trials, the more robust observational studies, and from expert opinion. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Clinical history and physical examination findings and impedance pH monitoring can help to differentiate between gastric and supragastric belching. BEST PRACTICE ADVICE 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 ADVICE 3: Rome IV criteria should be used to diagnose primary abdominal bloating and distention. BEST PRACTICE ADVICE 4: Carbohydrate enzyme deficiencies may be ruled out with dietary restriction and/or breath testing. In a small subset of at-risk patients, small bowel aspiration and glucose- or lactulose-based hydrogen breath testing may be used to evaluate for small intestinal bacterial overgrowth. BEST PRACTICE ADVICE 5: Serologic testing may rule out celiac disease in patients with bloating and, if serologies are positive, a small bowel biopsy should be done to confirm the diagnosis. A gastroenterology dietitian should be part of the multidisciplinary approach to care for patients with celiac disease and nonceliac gluten sensitivity. BEST PRACTICE ADVICE 6: Abdominal imaging and upper endoscopy should be ordered in patients with alarm features, recent worsening symptoms, or an abnormal physical examination only. BEST PRACTICE ADVICE 7: Gastric emptying studies should not be ordered routinely for bloating and distention, but may be considered if nausea and vomiting are present. Whole gut motility and radiopaque transit studies should not be ordered unless other additional and treatment-refractory lower gastrointestinal symptoms exist to warrant testing for neuromyopathic disorders. BEST PRACTICE ADVICE 8: In patients with abdominal bloating and distention thought to be related to constipation or difficult evacuation, anorectal physiology testing is suggested to rule out a pelvic floor disorder. BEST PRACTICE ADVICE 9: When dietary modifications are needed (eg, low-fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet), a gastroenterology dietitian should preferably monitor treatment. BEST PRACTICE ADVICE 10: Probiotics should not be used to treat abdominal bloating and distention. BEST PRACTICE ADVICE 11: Biofeedback therapy may be effective for bloating and distention when a pelvic floor disorder is identified. BEST PRACTICE ADVICE 12: Central neuromodulators (eg, antidepressants) are used to treat bloating and abdominal distention by reducing visceral hypersensitivity, raising sensation threshold, and improving psychological comorbidities. BEST PRACTICE ADVICE 13: Medications used to treat constipation should be considered for treating bloating if constipation symptoms are present. BEST PRACTICE ADVICE 14: Psychological therapies, such as hypnotherapy, cognitive behavioral therapy, and other brain-gut behavior therapies may be used to treat patients with bloating and distention. BEST PRACTICE 15: Diaphragmatic breathing and central neuromodulators are used to treat abdominophrenic dyssynergia.
Topics: Female; Humans; United States; Eructation; Celiac Disease; Pelvic Floor Disorders; Quality of Life; Constipation; Flatulence; Dilatation, Pathologic
PubMed: 37452811
DOI: 10.1053/j.gastro.2023.04.039 -
Current Gastroenterology Reports Jun 2017This study aimed to systematically review small bowel obstruction (SBO), focusing on recent changes in diagnosis/therapy. (Review)
Review
PURPOSE OF REVIEW
This study aimed to systematically review small bowel obstruction (SBO), focusing on recent changes in diagnosis/therapy.
RECENT FINDINGS
SBO incidence is about 350,000/annum in the USA. Etiologies include adhesions (65%), hernias (10%), neoplasms (5%), Crohn's disease (5%), and other (15%). Bowel dilatation occurs proximal to obstruction primarily from swallowed air and secondarily from intraluminal fluid accumulation. Dilatation increases mural tension, decreases mucosal perfusion, causes bacterial proliferation, and decreases mural tensile strength that increases bowel perforation risks. Classical clinical tetrad is abdominal pain, nausea and emesis, abdominal distention, and constipation-to-obstipation. Physical exam may reveal restlessness, acute illness, and signs of dehydration and sepsis, including tachycardia, pyrexia, dry mucous membranes, hypotension/orthostasis, abdominal distention, and hypoactive bowel sounds. Severe direct tenderness, involuntary guarding, abdominal rigidity, and rebound tenderness suggest advanced SBO, as do marked leukocytosis, neutrophilia, bandemia, and lactic acidosis. Differential diagnosis includes postoperative ileus, narcotic bowel, colonic pseudo-obstruction, mesenteric ischemia, and large bowel obstruction. Medical resuscitation includes intravenous hydration, correcting electrolyte abnormalities, intravenous antibiotics, nil per os, and nasoenteral suction. Abdominal CT with oral and intravenous gastrografin contrast is highly sensitive and specific in detecting/characterizing SBO. SBO usually resolves with medical therapy but requires surgery, preferentially by laparoscopy, for unremitting total obstruction, bowel perforation, severe ischemia, or clinical deterioration with medical therapy. Overall mortality is 10% but increases to 30% with bowel necrosis/perforation. Key point in SBO is early diagnosis, emphasizing abdominal CT; aggressive medical therapy including rehydration, antibiotics, and nil per os; and surgery for failed medical therapy.
Topics: Abdominal Pain; Diagnosis, Differential; Dilatation, Pathologic; Humans; Ileus; Intestinal Obstruction; Intestine, Small; Laparoscopy; Nausea; Physical Examination; Postoperative Complications; Vomiting
PubMed: 28439845
DOI: 10.1007/s11894-017-0566-9 -
Circulation Research Jan 2021Blood eosinophil count and ECP (eosinophil cationic protein) associate with human cardiovascular diseases. Yet, whether eosinophils play a role in cardiovascular disease...
RATIONALE
Blood eosinophil count and ECP (eosinophil cationic protein) associate with human cardiovascular diseases. Yet, whether eosinophils play a role in cardiovascular disease remains untested. The current study detected eosinophil accumulation in human and murine abdominal aortic aneurysm (AAA) lesions, suggesting eosinophil participation in this aortic disease.
OBJECTIVE
To test whether and how eosinophils affect AAA growth.
METHODS AND RESULTS
Population-based randomized clinically controlled screening trials revealed higher blood eosinophil count in 579 male patients with AAA than in 5063 non-AAA control (0.236±0.182 versus 0.211±0.154, 10/L, <0.001). Univariate (odds ratio, 1.381, <0.001) and multivariate (odds ratio, 1.237, =0.031) logistic regression analyses indicated that increased blood eosinophil count in patients with AAA served as an independent risk factor of human AAA. Immunostaining and immunoblot analyses detected eosinophil accumulation and eosinophil cationic protein expression in human and murine AAA lesions. Results showed that eosinophil deficiency exacerbated AAA growth with increased lesion inflammatory cell contents, matrix-degrading protease activity, angiogenesis, cell proliferation and apoptosis, and smooth muscle cell loss using angiotensin-II perfusion-induced AAA in and eosinophil-deficient ΔdblGATA mice. Eosinophil deficiency increased lesion chemokine expression, muted lesion expression of IL (interleukin) 4 and eosinophil-associated-ribonuclease-1 (mEar1 [mouse EOS-associated-ribonuclease-1], human ECP homolog), and slanted M1 macrophage polarization. In cultured macrophages and monocytes, eosinophil-derived IL4 and mEar1 polarized M2 macrophages, suppressed CD11bLy6C monocytes, and increased CD11bLy6C monocytes. mEar1 treatment or adoptive transfer of eosinophil from wild-type and mice, but not eosinophil from mice, blocked AAA growth in ΔdblGATA mice. Immunofluorescent staining and immunoblot analyses demonstrated a role for eosinophil IL4 and mEar1 in blocking NF-κB (nuclear factor-κB) activation in macrophages, smooth muscle cells, and endothelial cells.
CONCLUSIONS
Eosinophils play a protective role in AAA by releasing IL4 and cationic proteins such as mEar1 to regulate macrophage and monocyte polarization and to block NF-κB activation in aortic inflammatory and vascular cells.
Topics: Adoptive Transfer; Aged; Angiotensin II; Animals; Aorta, Abdominal; Aortic Aneurysm, Abdominal; Cells, Cultured; Dilatation, Pathologic; Disease Models, Animal; Eosinophils; Female; Humans; Inflammation Mediators; Interleukin-10; Interleukin-4; Macrophages; Male; Mice, Inbred C57BL; Mice, Knockout, ApoE; Monocytes; NF-kappa B; Phenotype; Ribonucleases; Vascular Remodeling; Mice
PubMed: 33153394
DOI: 10.1161/CIRCRESAHA.120.318182 -
Masui. the Japanese Journal of... May 2017Point-of-care ultrasound (POCUS) in the diagnoses of postoperative complications is discussed. POCUS is useful in many situations such as abdominal distension, elevated...
Point-of-care ultrasound (POCUS) in the diagnoses of postoperative complications is discussed. POCUS is useful in many situations such as abdominal distension, elevated liver enzymes, abdominal pain, and fever, which are the common complications encountered after surgical operations. In the patients with abdominal distention, bowel distention or ascites can be easily detected by POCUS. Occasionally, congestive liver and milk of calcium bile caused by the administration of antibiotics cause elevated liver enzymes, and both of these can also be detected by POCUS. Although there are many complications which cause abdominal pain, POCUS is useful not only for the diagnosis of intraabdominal disorders but also the .diseases of other organs including the bone and muscle. Even the presence of NOMI (non-occlusive mesenteric ischemia) can be diagnosed by contrast ultrasound using Sonazoid®. In patients with fever, US is useful not only for the diagnosis of abdominal abscess but also for the drainage. By evaluating the colon with POCUS, we can detect the pseudomembranous colitis which often is overlooked. In conclusion, POCUS is an essential tool for the proper management of postoperative patients.
Topics: Abdomen; Abdominal Pain; Fever; Humans; Point-of-Care Systems; Ultrasonography
PubMed: 29693938
DOI: No ID Found -
World Journal of Gastrointestinal... Apr 2021Abdominal compartment syndrome (ACS) develops when organ failure arises secondary to an increase in intraabdominal pressure. The abdominal pressure is determined by... (Review)
Review
Abdominal compartment syndrome (ACS) develops when organ failure arises secondary to an increase in intraabdominal pressure. The abdominal pressure is determined by multiple factors such as blood pressure, abdominal compliance, and other factors that exert a constant pressure within the abdominal cavity. Several conditions in the critically ill may increase abdominal pressure compromising organ perfusion that may lead to renal and respiratory dysfunction. Among surgical and trauma patients, aggressive fluid resuscitation is the most commonly reported risk factor to develop ACS. Other conditions that have also been identified as risk factors are ascites, hemoperitoneum, bowel distention, and large tumors. All patients with abdominal trauma possess a higher risk of developing intra-abdominal hypertension (IAH). Certain surgical interventions are reported to have a higher risk to develop IAH such as damage control surgery, abdominal aortic aneurysm repair, and liver transplantation among others. Close monitoring of organ function and intra-abdominal pressure (IAP) allows clinicians to diagnose ACS rapidly and intervene with target-specific management to reduce IAP. Surgical decompression followed by temporary abdominal closure should be considered in all patients with signs of organ dysfunction. There is still a great need for more studies to determine the adequate timing for interventions to improve patient outcomes.
PubMed: 33968300
DOI: 10.4240/wjgs.v13.i4.330 -
The American Journal of Gastroenterology Aug 2017Bloating, as a symptom and abdominal distension, as a sign, are both common functional-type complaints and challenging to manage effectively. Individual patients may... (Review)
Review
Bloating, as a symptom and abdominal distension, as a sign, are both common functional-type complaints and challenging to manage effectively. Individual patients may weight differently the impact of bloating and distension on their well-being. Complaints may range from chronic highly distressing pain to simply annoying and unfashionable protrusion of the abdomen. To avoid mishaps, organic bloating, and distension should always be considered first and appropriated assessed. Functional bloating and distension often present in association with other manifestations of irritable bowel syndrome or functional dyspepsia and in that context patients tend to regard them as most troublesome. A mechanism-based management bloating and distension should be ideal but elucidating key operational mechanisms in individual patients is not always feasible. Some clues may be gathered through a detailed dietary history, by assessing bowel movement frequency and stool consistency and special imaging technique to measure abdominal shape during episodes of distension. In severe, protracted cases it may be appropriate to refer the patient to a specialized center where motility, visceral sensitivity, and abdominal muscle activity in response to intraluminal stimuli may be measured. Therapeutic resources focussed upon presumed or demonstrated pathogenetic mechanism include dietary modification, microbiome modulation, promoting gas evacuation, attenuating visceral perception, and controlling abdominal wall muscle activity via biofeedback.
Topics: Abdominal Wall; Constipation; Dilatation, Pathologic; Dyspepsia; Flatulence; Gastrointestinal Diseases; Humans; Irritable Bowel Syndrome
PubMed: 28508867
DOI: 10.1038/ajg.2017.129 -
Angiology Jul 2016We performed a systematic literature search and a meta-analysis to assess the association between diabetes mellitus (DM) and abdominal aortic aneurysm (AAA) growth.... (Meta-Analysis)
Meta-Analysis Review
We performed a systematic literature search and a meta-analysis to assess the association between diabetes mellitus (DM) and abdominal aortic aneurysm (AAA) growth. Databases including MEDLINE and EMBASE were searched through June 2015 using PubMed and OVID. For each study, data regarding AAA growth rates in both the DM and the non-DM groups were used to generate standardized mean differences (SMDs) and 95% confidence intervals (CIs). Our search identified 19 relevant studies including data on 9777 patients with AAA. Pooled analyses demonstrated a statistically significant slower growth rates in DM patients than in non-DM patients (unadjusted SMD, -0.32; 95% CI, -0.40 to -0.24; P < .00001; adjusted SMD, -0.29; 95% CI, -0.417 to -0.18; P < .00001). Despite possible publication bias in favor of DM based on funnel plot asymmetry, even adjustment of the asymmetry did not alter the beneficial effect of DM. In conclusion, on the basis of a meta-analysis of data on a total of 9777 patients (19 studies) identified through a systematic literature search, we confirmed the association of DM with slower growth rates of AAA.
Topics: Aged; Aged, 80 and over; Aorta, Abdominal; Aortic Aneurysm, Abdominal; Chi-Square Distribution; Diabetes Mellitus; Dilatation, Pathologic; Disease Progression; Female; Humans; Male; Middle Aged; Odds Ratio; Risk Factors; Time Factors
PubMed: 26311742
DOI: 10.1177/0003319715602414 -
Nutrition in Clinical Practice :... Feb 2016Early provision of enteral nutrition (EN) in critically ill and injured patients has become standard practice in surgical intensive care units (ICUs) due to its proven... (Review)
Review
Early provision of enteral nutrition (EN) in critically ill and injured patients has become standard practice in surgical intensive care units (ICUs) due to its proven role in reducing septic complications. Increasingly, intensivists are confronted with patients with an open abdomen due to the use of damage control surgery and the recognition of the abdominal compartment syndrome; the role and timing of EN in these challenging patients continue to be debated. Patients with an open abdomen are often among the sickest in the ICU and hence could benefit from early nutrition support. However, the exposed abdominal viscera can understandably create anxiety regarding the initiation of EN; there is theoretic concern over exacerbation of bowel distention with resultant inability to close the abdomen and an increased aspiration risk due to paralytic ileus. Recent studies have investigated the utility of EN in the patient with an open abdomen, addressing these clinical concerns. The goal of this clinical review is to provide guidance to physicians caring for these complex patients.
Topics: Abdomen; Abdominal Injuries; Critical Care; Enteral Nutrition; Humans; Intensive Care Units; Intra-Abdominal Hypertension; Time Factors; Treatment Outcome
PubMed: 26673199
DOI: 10.1177/0884533615620420 -
International Braz J Urol : Official... 2021This review aims to study the role of the abdominal wall in testicular migration process during the human fetal period. (Review)
Review
OBJECTIVES
This review aims to study the role of the abdominal wall in testicular migration process during the human fetal period.
MATERIALS AND METHODS
We performed a descriptive review of the literature about the role of the abdominal wall in testicular migration during the human fetal period.
RESULTS
The rise in intra-abdominal pressure is a supporting factor for testicular migration. This process has two phases: the abdominal and the inguinal-scrotal stages. The passage of the testis through the inguinal canal occurs very quickly between 21 and 25 WPC. Bilateral cryptorchidism in Prune Belly syndrome is explained by the impaired contraction of the muscles of the abdominal wall; mechanical obstruction due to bladder distention and structural alteration of the inguinal canal, which hampers the passage of the testis during the inguinoscrotal stage of testicular migration. Abdominal wall defects as gastroschisis and omphaloceles are associated with undescended testes in around 30 to 40% of the cases.
CONCLUSIONS
Abdominal pressure wound is an auxiliary force in testicular migration. Patients with abdominal wall defects are associated with undescendend testis in more than 30% of the cases probably due to mechanical factors; the Prune Belly Syndrome has anatomical changes in the anterior abdominal wall that hinder the increase of intra-abdominal pressure which could be the cause of cryptorchidism in this syndrome.
Topics: Cryptorchidism; Humans; Inguinal Canal; Male; Prune Belly Syndrome; Scrotum; Testis
PubMed: 32758302
DOI: 10.1590/S1677-5538.IBJU.2021.99.03 -
Rinsho Byori. the Japanese Journal of... Jun 2015In this paper, abdominal ultrasound examination as a point-of-care examination (POCUS) is discussed. POCUS is very useful in various clinical situations, especially for... (Review)
Review
In this paper, abdominal ultrasound examination as a point-of-care examination (POCUS) is discussed. POCUS is very useful in various clinical situations, especially for the diagnosis of critically ill patients with non-specific symptoms. In patients with an unknown fever origin, POCUS can detect unexpected infection foci such as liver abscesses. Pseudomembranous colitis, which is one of the important causes of fever during/after the use of broad-spectrum antibiotics and sometimes difficult to diagnose or even suspect as the cause of fever, can also be diagnosed with POCUS. Malignancies such as malignant lymphoma are also frequent causes of fever of unknown origin and, with POCUS, we have diagnosed many cases with malignant tumors presenting only with low-grade fever. Abdominal fullness is another common symptom of critically ill patients. POCUS is very useful for differentiation among several diseases causing abdominal fullness. Ascites is expressed as anechoic fluid in the abdominal cavity, while bowel obstruction as bowel distention presenting the so-called keyboard sign. Urinary retention, often misdiagnosed as bowel obstruction or an abdominal tumor, is also easily diagnosed by POCUS. It is very difficult to detect the occult causes of exacerbation of the general condition and/or markedly abnormal laboratory data in critically ill patients under endotracheal intubation or the influence of sedative agents, which make it difficult for the patients to complain of their symptoms. Attending physicians should make the best of POCUS as a useful diagnostic modality for these patients.
Topics: Abdomen; Fever of Unknown Origin; Humans; Lymphoma; Physical Examination; Physician's Role; Point-of-Care Systems; Ultrasonography
PubMed: 26548236
DOI: No ID Found