Bloating and functional gastro-intestinal disorders: Where are we and where are we going?

Bloating is one of the most common and bothersome symptoms complained by a large proportion of patients. This symptom has been described with various definitions, such as sensation of a distended abdomen or an abdominal tension or even excessive gas in the abdomen, although bloating should probably be defined as the feeling(e.g. a subjective sensation) of increased pressure within the abdomen. It is usually associated with functional gastrointestinal disorders, like irritable bowel syndrome, but when bloating is not part of another functional bowel or gastrointestinal disorder it is included as an independent entity in Rome Ⅲ criteria named functional bloating. In terms of diagnosis, major difficulties are due to the lack of measurable parameters to assess and grade this symptom. In addition, it is still unclear to what extent the individual patient complaint of subjective bloating correlates with the objective evidence of abdominal distension. In fact, despite its clinical, social and economic relevance, bloating lacks a clear pathophysiology explanation, and an effective management endorsement, turning this common symptom into a true challenge for both patients and clinicians. Different theories on bloating etiology call into questions an increased luminal contents(gas, stools, liquid or fat) and/or an impaired abdominal empting and/or an altered intra-abdominal volume displacement(abdomino-phrenic theory) and/or an increased perception of intestinal stimuli with a subsequent use of empirical treatments(diet modifications, antibiotics and/or probiotics, prokinetic drugs, antispasmodics, gas reducing agents and tricyclic antidepressants). In this review, our aim was to review the latest knowledge on bloating physiopathology and therapeutic options trying to shed lights on those processes where a clinician could intervene to modify disease course.

Preparation and Bloating Mechanism of Porous Ultra-lightweight Ceramsite by Dehydrated Sewage Sludge and Yellow River Sediments

To solve the disposal problems of solid wastes, dehydrated sewage sludge and Yellow River sediments were tested as components for production of ultra-lightweight ceramsite. The effects of Yellow River sediments addition on the characteristics of ceramsite were investigated. Ceramsite with different Yellow River sediments additions was characterized using thermal analysis, X-ray diffraction, morphological structures analyses, pore size distributions and porosity analyses. Chemical components, especially ratios of Si O2 ＋ Al2O3/Flux, were used to explain the glassy shell formation, physical properties and pores distribution of ultralightweight ceramsite; physical forces for instance expansion force and frictional resistance which combined with Si O2 ＋ Al2O3/Flux ratios were used to explain the bloating mechanism. Results showed that the maximum addition of Yellow River sediments for making ultra-lightweight ceramsite was 35%. Macropores（between 0.226 μm and 0.554 μm） of ultra-lightweight ceramsite were dominant in the pore structures of ultra-lightweight ceramsite and its porosity was up to 67.7%. Physical force of expansion force was constant with the variation of Yellow River sediments content and physical force of frictional resistance was decreased with the increase of Yellow River sediments addition. The relationship between expansion and frictional resistance could determine the expansion rate of ceramsite. Larger pores inside the ceramsite bodies could be obtained as Yellow River sediments additions ranged from 10% to 30%. Ceramsite with higher Yellow River sediments additions of 40%（Si O2 ＋ Al2O3/Flux ratios 4.25） became denser and have lower porosity. Crystal components analysis proved that the sintering process made some components of raw materials transfer into other crystals having better thermostability.

X-ray diagnosis with a bloating agent for foreign object ingestion

The location of an ingested foreign object is often difficult to determine by X-ray if gastric air bubbles are not clear in the image.Methods that provide negative contrast can facilitate precise object localization,which is important for object retrieval and treatment of the patient.This case report describes a male child,2 years and 2 mo of age,who accidentally swallowed a lithium battery while playing at home.A plain X-ray showed that the battery was in the abdomen,but it was unclear whether the object was still inside the stomach.A second X-ray examination performed after oral administration of a bloating agent to produce expansion of the stomach and provide negative contrast confirmed that the ingested battery was still in the stomach.The battery was then carefully removed using magnetic and balloon catheters under fluoroscopic guidance.This case report describes the successful use of an orally administered bloating agent without pain to the child in orderto determine the precise location of a foreign object in the abdomen.

Effect of Daikenchuto (TJ-100) on abdominal bloating in hepatectomized patients

AIM: To evaluate the clinical usefulness of Daikenchuto (DKT) in hepatecomized patients. METHODS: Twenty patients were enrolled with informed consent. Two patients were excluded because of cancelled operations. The remaining 18 patients were randomly chosen for treatment with DKT alone or combination therapy of DKT and lactulose (n = 9, each group). Data were prospectively collected. Primary end points were Visual Analogue Scale (VAS) score for abdominal bloating, total Gastrointestinal Symptoms Rating Scale (GSRS) score for abdominal symptoms, and GSRS score for abdominal bloating. RESULTS: The VAS score for abdominal bloating and total GSRS score for abdominal symptoms recovered to levels that were not significantly different to preoperative levels by 10 d postoperation. Combination therapy of DKT and lactulose was associated with a significantly poorer outcome in terms of VAS and GSRS scores for abdominal bloating, total GSRS score, and total daily calorie intake, when compared with DKT alone therapy. CONCLUSION: DKT is a potentially effective drug for postoperative management of hepatectomized patients, not only to ameliorate abdominal bloating, but also to promote nutritional support by increasing postoperative dietary intake.

Caecal pH is a biomarker of excessive colonic fermentation

AIM:To ascertain whether caecal pH is different in patients with irritable bowel syndrome(IBS),whose primary symptoms are bloating and distension,to healthy controls.METHODS:Motility and pH data were reviewed from16 patients with RomeⅢdefined IBS and 16 healthy controls,who had undergone a wireless motility capsule(WMC)study using a standardized protocol.Motility measures were anchored around known anatomical landmarks as identified by compartmental pH changes.Sixty-minute epochs were used to quantify antral,duodenal,ileal,caecal and distal colonic contractility.The maximum and minimum pH was measured either side of the ileo-caecal junction.RESULTS:No differences were seen in motility parameters,compartmental transit times or maximal ileal pH between the two groups.Caecal pH was significantly lower in patients compared to controls(5.12±0.05vs 6.16±0.15,P<0.0001).The ileal:caecalΔchange was greater in patients than controls(-2.63±0.08 vs-1.42±0.11,P<0.0001).There was a significant correlation between caecal pH and right colonic contractility(r=0.54,P=0.002).CONCLUSION:Patients with bloating and distension have a lower caecal pH compared to controls.The measurement of caecal pH using the WMC provides a quantifiable biomarker of fermentation potentially identifying those patients that may preferentially benefit from antibiotic or dietary interventions.

Routine clinical administration of 4-week alverine citrate and simeticone combination relief global IBS symptoms

Introduction: The primary treatment aim for irritable bowel syndrome (IBS) is to relieve overall symptoms which can significantly impair the patient’s quality of life (QOL);however, it generally requires a high pill burden that may be improved by administration of combinatorial formulations. Thus, the effectiveness of alverine citrate and simeticone combination (ACS) for global symptom relief for IBS was investigated in this non-interventional study. Patients and Methods: ROME III IBS patients (n = 640;52.3% male: mean age: 43.6 ± 12.5 years) with abdominal pain and discomfort ≥60 of 0-100 visual analogue scale (VAS) were included in a prospective, multicenter, non-interventional study at 26 Chinese sites from December 2010 to January 2012. Patients received alverine citrate (60 mg) with simeticone (300 mg) (ACS) 3× daily for 4 weeks. Pain/discomfort and bloating/distension were assessed by VAS. Global symptoms and QOL were assessed by 7-point and 5-point Likert scales, respectively. Post-treatment bowel function was assessed by Bristol Stool Form Scale (BSFS) and treatment-related adverse events (AEs) were recorded. Results: Of 640 patients, 540 (84.4%) completed the study, and 100 (15.6%) withdrew. In total, 87.5% reported bloating at baseline. After 4-week ACS treatment, 89.1% reported global symptom improvement. Furthermore, 4-week ACS treatment reduced pain and bloated VAS scores significantly from 78.4 ± 9.9 to 32.1 ± 21.0 and from 63.2 ± 27.2 to 22.6 ± 20.9, respectively (both p < 0.001), decreased diarrhea or constipation occurrence from 67.2% to 10.2% (p < 0.001), and reduced IBS impact on QOL with only 2 treatment-related AEs. Conclusion: Routine clinical administration of ACS for IBS over a 4-week period provides effective relief of IBS symptoms and improves QOL in IBS patients.

Response of irritable bowel syndrome with constipation patients administered a combined quebracho/conker tree/M. balsamea Willd extract

The aim of this case series was to retrospectively examine the symptom response of irritable bowel syndrome with constipation(IBS-C) patients administered an herbal extract in a real-world setting. Twenty-four IBS-C patients in a community office practice were provided a combination over-the-counter dietary supplement composed of quebracho(150 mg), conker tree(470 mg) and M. balsamea Willd(0.2 mL) extracts(Atrantil?) and chose to take the formulation for a minimum of 2 wk in an attempt to manage their symptoms. Patient responses to the supplement were assessed by visual analogue scale(VAS) for abdominal pain, constipation and bloating at baseline and at 2 wk as part of standard-of-care. Patient scores from VAS assessments recorded in medical chart data were retrospectively compiled and assessed for the effects of the combined extract on symptoms. Sign tests were used to compare changes from baseline to 2 wk of taking the extract. Significance was defined as P < 0.05. Twenty-one of 24 patients(88%) responded to the dietary supplement as measured by individual improvements in VAS scores for abdominal pain, bloating and constipation symptoms comparing scores prior to administration of the extract against those reported after 2 wk. There were also significant improvements in individual as well as mean VAS scores after 2 wk of administration of the combinedextract compared to baseline for abdominal pain [8.0(6.5, 9.0) vs 2.0(1.0, 3.0), P < 0.001], bloating [8.0(7.0, 9.0) vs 1.0(1.0, 2.0), P < 0.001] and constipation [6.0(3.0, 8.0) vs 2.0(1.0, 3.0), P < 0.001], respectively. In addition, 21 of 24 patients expressed improved quality of life while taking the formulation. There were no reported side effects to administration of the dietary supplement in this practice population suggesting excellent tolerance of the formulation. This pilot retrospective analysis of symptom scores from patients before and after consuming a quebracho/conker tree/M. balsamea Wil d extract may support the formulation's use in IBS-C.

Case Series of 10 Drug-Refractory IBS Patients Who Respond to Oral Serum-Derived Bovine Immunoglobulin/Protein Isolate (SBI)

Aim: The responses of 10 patients with long-standing, symptomatic, intractable drug-refractory histories of irritable bowel syndrome with diarrhea (IBS-D) and with abdominal pain, gas/bloating and distention, termed IBS undefined (IBS-U), were evaluated when administering a medical food product containing serum-derived bovine immunoglobulin/protein isolate (SBI). Methods: Patients in this case series were chosen based on their lack of satisfactory response to a variety of drugs, including antidiarrheal and antispasmodic medications, serotonin 5-HT3 receptor antagonists, selective serotonin re-uptake inhibitors (SSRIs), proton pump inhibitors (PPIs), antibiotics, and antidepressive drugs. Patients met Rome III criteria and were administered 5 g/day of SBI as standard-of-care nutritional support. A scale of 0% - 25%, 25% - 50%, 50% - 75%, 75% - 100% response to SBI was used for patient-reported improvement in overall IBS symptoms following administration for one month. Exact methods for calculating confidence intervals and p-values were used to assess complete management of symptoms and response to therapy. Adverse events were also monitored for this nutritional product. Results: The onset of gastrointestinal (GI) symptom reduction utilizing nutritional management with SBI occurred within an average time of 2-4 weeks with improved or near complete management in all 10 patients who were refractory to previous drug therapies by 4 weeks. When prompted, patients reported significant IBS symptom improvement which averaged between 50% - 100% (p = 0.002) with an average for complete management in all patients of 69%. No side effects were reported after SBI administration even when taken for up to 28 weeks. Conclusion: Based on the safety profile and reported outcomes in this case report, SBI should be considered as a nutritional option for management in IBS-D and IBS-U.