DYSPEPSIA , BLOATING, ABDOMINAL DISTENTION
AND FLATULENCE
DYSPEPSIA
- symptoms referred to the GI system in which a pathologic condition is not present, is
poorly established or, if present, does not entirely explain the clinical state
is divided according to
cause: : functional,
secondary
and
organic
localisation:
upper ( gastric)
lower (bowel)
pyrosis
meteorismus (bloating)
nausea, vomiting
flatulence
diskomfort (fullness weight, tension)
fullness, tension
ructus (belching)
borborygms
anorexia
problems with stool, defecation
functional:
patients with such complaints are common in the primary care setting and account for 30 to
50% of referrals to gastroenterologists
these ilnesses are considered difficult to understand and treat them, as they do not fit into
previously learned disease categories
dyspepsia with no evidence of underlying somatic disease usually calls first for reassurance
and symptomatic management with observation over time
Abdominal distension, meteorismus (bloating), flatulency - functional
complaints
GUT GAS
Gas is present in the gut as a result of swallowed air, production in the lumen, or difusion
from the blood into the lumen
Aerophagia : occurs normally in small amounts while eating and drinking
some people unconsciously swallow repeated boluses of air at other times, especially when
anxious.
Most of swallowed air is subsequently eructated (belched), only a small amount passes into
the small bowel, the quantity apparently beeing influenced by posture
e.g. when the person is supine, air trapped below the fluid in stomach tends to be propelled
into the duodenum
Excessive salivation may also lead to increased air swallowing( and may by associated with
GI disorders - peptic ulcer, ill-fitting denttures or with nausea of any etiology
chewing gum
Gas production in the lumen :
Gas is produced in the lumen by several mechanisms. Bacterial metabolism yields
significant volumes of hydrogen, methan and CO2
Hydrogen ( H2) of ingested fermentable materials ( carbohydrates and amino acids) in the
colon and therefore is negligible after a prolonged fast or after a meal that is completely
absorbed in the small bowel.
Hydrogen is produced in large quantities after eating certain fruits and vegetables ( eg. baked
beans ) containing indigestible carbohydrates and by patients with malabsorption syndromes
Patients with disaccharidase deficiencies ( most commonly lactose intolerance ) pass into the
colon large amounts of disaccharides that are fermented to hydrogen.
Lactase deficiency, sprue, pancreatic insuficiency
Even normal persons incompletly absorb carbohydrates in certain common foods e.g. wheat,
corn, potato flour. The normally indigestible polysaccharides in fruits and vegetables ( fiber,
reffinos) - may also be a source of excess gas
finally, poorly understood factors - eg. differences in colonic flora and motility may also
account for variations in gas production
Methane CH4 is produced by bacterial metabolism of endogenous substances in the colon
the production rate is only minimally influenced by food ingestion
some people consistently excrete large quantities of methane, others, little or none
Apparently familial, this trait appears during infancy and persists for life
Carbon dioxide (CO2) - may also be produced by bacterial metabolism,
more important source is the reaction of bicarbonate and hydrogen ions. Theoretically up to 4
L of carbon dioxide may be released into the duodenum following ingestion of a meal
The acid products released by bacterial fermentation of nonabsorbed carbohydrates in the
colon may also react with bicarbonate to produce CO2. Though bloating may occasionally
occur, the rapid absorption of CO2 into the blood prevents intolerable distention.
Gas diffuses between the lumen and the blood in a direction dependent upon the partial
pressure difference between the two.
The production of H2 , CO2 and CH4 may reduce the partial pressure of nitrogen in the lumen
to a value far below in the blood, possibly accounting for much of the nitrogen in the lumen.
Gas is eleminated - by belching, diffusion from the lumen into the blood with ultimate
excretion by the lungs, bacterial catabolism, and passage through the anus ( flatus).
Antibiotics that selectively inhibit bacterial H2 catabolism markedly increase its excretion.
Symptoms, signs and diagnosis
Excessive gas is commonly thougt to cause abdominal pain, bloating, distention, belching
, or passage of excessively voluminous or noxious flatus
been
However, excessive intestinal gas has not been clearly linked to the above complaints, it is
likely that many symptoms are incorrectly atributed to „too much gas“
In most normal persons 1 L of gas/h can be infused antegrade into the gut with a minimum of
symptoms,
while persons eg. with the irritable bowel syndrom often cannot tolerate much smaller
quanties - may be a hypersensitive intestine, also altered motility can contribute further to
symptomst
habitual aerophagia , a series of belches on command
splenic flexure syndrom - - swallowed air becomes trapped in the splenic flexure and may
cause diffuse abdominal distention
infantile colic - is a syndrome of presumed „ crampy“ abdominal pain. Hence , recent data
showed no increase in H2 production or increase in mouth-to-cecum transit times in colicky
infants. The cause of this syndrome remains unclear
flatulence - as with bowel frequency, persons who complain of flatulence often have a
misconception of what is normal
in a study of 8 normal men aged 25 to 35 yr, the average number of gas passages was 13+- 4
in one day with an upper limit of 21/day, which overlapped with many persons who
complained of excess flatus
objectively recording flatus frequency should be the first step in evaluating
Differentiation of flatus:
aromaticity is not a prominent feature
unofficially described according to its salient characteristics:
1) the „ slider“ ( crowded elevator type ; Sisyphos) which is released slowly and noiselessly,
sometimes with devastating effect
2) the open sphincter, or „ pooh „ type, which is said to be of higher temperature and more
„aromatic“
3) the staccato or drumbeat type , pleasantly passed in privacy
4) the „ bark“ type ( described in a personal communication ) is characterized by a sharp
exclamatory eruption that effectively interrupts ( and often concludes) conversation
Rarely, this usually distressing symptom has been turned to advantage, as with a Frenchman
referred to as „ Le Petomane“, who became affluent as an effluent performer who played
tunes with the gas from his rectum on the Moulin Rouge stage.
Gas explosion and flammability has rarely fatal outcome - has been reported during jejunal
and colonic surgery and even during proctosigmoidoscopic procedures, where diathermy was
used
Because „ excessive gas“ symptoms are so nonspecific and commonly overlap with the
irritable bowel syndrome as well as with organic disease, a careful history is essential to
guide the extent of medical evaluation.
Long-standing symptoms in a young person who is otherwise well and has not lost weight ary
unlikely to be caused by serious organic disease.
The older person, especially with the onset of new symptoms, merits more through
examination before „ excessive gas“, real imaginated, is treated.
Treatment - reduce aerophagia - exclude habits like excessive gum chewing or smoking,
use of carbonated beverages or antacids ( soda)
e.g. to clamp any object - pencil between the teeth to break the cycle of
aerophagia-discomfort-belch-relief
foods containing nonabsorbable carbohydrates can be avoided
milk containing products should be excluded from the diet in patients with lactose intolerance
simethicone - brakes up small gas bubbles
some persons have benefit from metoclopramide
Concluson: In general, symptoms of functional bloating, distention and flatus run an
intermittent chronic course that is only partially relieved by therapy. Reassurance that these
problems are not detrimental to health is important.
IRRITABLE BOWEL SYNDROME ( IBS)
( Spastic colon; Mucous colitis )
A motility disorder involving the entire hollow GI tract, creating a symptom complex with
both upper and lower GI symptoms. Predominant symptoms include variable degrees of
abdominal pain, constipation or diarrhea, and postprandial distention. The symptoms
nearly always occur in the waking state and are usually triggered by stress or the ingestion
of food.
This syndrom represnts about 1/2 of all GI referrals or initial GI complaints in private and
institutinal care facilities.
In a ratio 3 : 1, women are more commonly affected than men
neurodigestive asthenia
Secondary causes of abdominal distention, meteorism and flatulence
in non-gastrointestinal diseases, diseases of oher organs or systems:
urolithiasis
gynekological diseases
hypothyreoidsm
hyperparathyreoidism
abdominal tumors
ascites
gravidity
mesenterial infarct
obtuse abdominal trauma ( rupture of parenchymal organs), shock
bleeding - hemophilia, anticoagulative treatment
testicular torsion
acute myocardial infarction
basal pleuropneumonia
right side cardial insufficiency
Organic causes of abdominal distention, meteorism and flatulence
peptic ulcer
GI tumors
pancreas
cholelithiassis
liver disorders
mechanical ileus
generalizated peritonitis
invagination