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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 -
Translational Lung Cancer Research Feb 2020Malignant peritoneal mesothelioma (MPM) is a rare and lethal disease of the peritoneal lining, with high variability in biologic aggressiveness. Morbidity and mortality... (Review)
Review
Malignant peritoneal mesothelioma (MPM) is a rare and lethal disease of the peritoneal lining, with high variability in biologic aggressiveness. Morbidity and mortality of the disease are related to progressive locoregional effects within the abdominal cavity, such as distention, pain, early satiety, and decreased oral intake that can ultimately lead to bowel obstruction and cachexia. The standard of care for patients with resectable disease remains cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), with potential survival outcomes greater than 5 years in appropriately selected patients. Patients with inoperable MPM can be offered systemic treatment, although the disease is usually refractory to standard chemotherapic regimens. Patients with MPM should be treated at high volume centers with strong consideration for inclusion in tumor registries and clinical trials. In 2020, research will continue to explore promising genetic and immunologic targets and focus on refinement of surgical methods to optimize CRS-HIPEC approaches.
PubMed: 32206577
DOI: 10.21037/tlcr.2019.12.15 -
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 -
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 -
Journal of Kidney Cancer and VHL 2023Renal leiomyomas are rare benign mesenchymal tumors of kidney that affect adults of second to sixth decade. They can present as small asymptomatic multifocal lesions...
Renal leiomyomas are rare benign mesenchymal tumors of kidney that affect adults of second to sixth decade. They can present as small asymptomatic multifocal lesions that are identified only in autopsy, or as large solitary lesions that cause pain and abdominal distention. Histomorphologically it appears exactly like its counterpart in other soft tissues. Differentiating renal leiomyoma from the lipid-poor angiomyolipoma is difficult by morphology, hence immunohistochemical studies are recommended. The case described is that of a female patient aged 74 years with a small solitary lesion in right kidney, who presented with history of pain and abdominal distention. She underwent wedge resection, histopathologically and immunohistochemically diagnosed as renal leiomyoma.
PubMed: 37398509
DOI: 10.15586/jkcvhl.v10i2.264 -
Diseases of the Colon and Rectum Sep 2021A 46-year-old man with no significant medical or surgical history presented to the emergency department with a 1-week history of worsening constipation, abdominal...
A 46-year-old man with no significant medical or surgical history presented to the emergency department with a 1-week history of worsening constipation, abdominal distension, nausea, and nonbloody, nonbilious emesis. Workup included a CT scan that was notable for a 5.3 × 3.9 cm "apple core-type" mass located within the sigmoid colon with proximal large-bowel dilation. Carcinoembryonic antigen was 1.4. No metastatic disease was seen on chest, abdominal, or pelvic CT scans. Flexible sigmoidoscopy identified a sigmoid colon mass 30 cm from the anal verge with near complete obstruction. Biopsies of the mass did not show evidence of dysplasia or malignancy. The Gastroenterology service declined to place a stent without a malignancy diagnosis. The patient subsequently underwent exploratory laparotomy, sigmoid colectomy, and end colostomy. Recovery was uneventful. Final pathology showed diverticulitis with abscess formation and no evidence of malignancy. A completion colonoscopy was unremarkable, and the patient underwent colostomy reversal 3 months later.
Topics: Abdominal Abscess; Algorithms; Biopsy; Colectomy; Colon, Sigmoid; Constriction, Pathologic; Diagnosis, Differential; Dilatation; Diverticulitis, Colonic; Humans; Male; Middle Aged; Sigmoid Diseases; Sigmoidoscopy; Stents; Tomography, X-Ray Computed
PubMed: 34108366
DOI: 10.1097/DCR.0000000000002179