Treatment of Functional Abdominal Bloating and Distension.docx
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Treatment of Functional Abdominal Bloating and Distension.docx
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TreatmentofFunctionalAbdominalBloatingandDistension
TheTreatmentofFunctionalAbdominalBloatingandDistension
M.Schmulson,L.Chang
AlimentPharmacolTher. 2011;33(10):
1071-1086.
AbstractandIntroduction
Abstract
Background Abdominalbloatinganddistensionarecommonsymptomsinpatientswithfunctionalgastrointestinaldisorders(FGIDs),however,relativelylittleisknownabouttheirtreatment.
Aim Toreviewthetreatmenttrialsforabdominalbloatinganddistension.
Methods AliteraturereviewinMedlineforEnglish-languagepublicationsthroughFebruary2010ofrandomised,controlledtreatmenttrialsinadults.StudyqualitywasassessedaccordingtoJadad'sscore.
Results Ofthe89studiesreviewed,18%evaluatedpatientswithfunctionaldyspepsia,61%withirritablebowelsyndrome(IBS),10%withchronicconstipationand10%withotherFGIDs.Nostudieswereconductedinpatientsdiagnosedwithfunctionalabdominalbloating.Themajorityoftrialsinvestigatedtheefficacyofprokineticsorprobiotics,althoughstudiesareheterogeneouswithrespecttodiagnosticcriteriaandoutcomemeasures.Ingeneral,bloatingand/ordistensionwereevaluatedassecondaryendpointsorasindividualsymptomsaspartofacompositescoreratherthanasprimaryendpoints.AgreaterproportionofIBSpatientswithconstipationreportedimprovementinbloatingwithtegaserodvs.placebo(51%vs.40%, P <0.0001)andlubiprostone(P <0.001).AgreaterproportionofnonconstipatingIBSpatientsreportedadequatereliefofbloatingwithrifaximinvs.placebo(40%vs.30%, P <0.001).Bloatingwassignificantlyreducedwiththeprobiotics, Bifidobacteriuminfantis35624 (1×108 dosevs.placebo:
−.71vs.−.44, P <0.05)and B.animalis (livevs.heat-killed:
−.56±1.01vs.−.31±0.87, P =0.03).
Conclusions Prokinetics,lubiprostone,antibioticsandprobioticsdemonstrateefficacyforthetreatmentofbloatingand/ordistensionincertainFGIDs,butotheragentshaveeithernotbeenstudiedadequatelyorhaveshownconflictingresults.
Introduction
Bloatingisacommonsymptomthatisreportedby6%to31%ofthegeneralpopulation.[1–3] Itisusuallyconsideredthesubjectivesensationthatisassociatedwithabdominaldistension,i.e.thevisibleincreaseinabdominalgirth,[4,5] whichisconsideredmoreofanobjectivesign.Inapopulation-basedstudyinOlmstedCountyintheUnitedStates,theageandgender-adjustedoverallprevalenceforbloatingwas19%and9%forvisibleabdominaldistension.[6]
Bloatingisacommoncomplaintinpatientswithfunctionalgastrointestinaldisorders(FGIDs).InaU.S.studyofamixedpopulationrecruitedfromanacademicuniversityclinicandadvertisement,of542patientswithirritablebowelsyndrome(IBS),76%ofpatientsreportedabdominalbloating.[7] Moreover,inacross-sectionalstudyamongemployeesofaVeteransAffairsHealthCareCenterintheUnitedStates,ofwhich39%weremen,bloatingwasreportedby35%ofindividualswithnonconstipatingIBS,23%withnondiarrhoeaIBSand42%withnon-investigateddyspepsia.[8]
However,studiessuggestthatwhilebloatinganddistensionarerelated,theyaretwoseparatesymptoms.Forexample,intheabovementionedstudyinanacademicuniversityclinic,24%reportedhavingbloatingonlyand76%hadbothbloatingandvisibleabdominaldistension.[7] IBSpatientswithbloatinganddistensionhadahigherfemale-to-maleratio,constipationpredominance,symptomseverityandlessdiurnalvariationcomparedwiththosewithbloatingonly.Patientswithbloatingwithandwithoutdistensionreportedthatsymptomsprogressivelyworsenedduringthedayandwererelievedbydefecationorgaspassage.[7] Approximately50%ofthesubjectsfulfillingmodifiedRomeIIcriteriafordyspepsiareportedbloating,whilealmosthalfofthisgroupalsohadvisibleabdominaldistension.Inaddition,subjectswithdyspepsiaweretwotimesmorelikelytohavebloatingaloneordistensionalonewhencomparedwithcontrols.[6] InanotherU.S.study,distensiondefinedbythepresenceofbothbloatingandvisibleabdominaldistensionwasmoreprevalentthanbloatingaloneinIBSandfunctionaldyspepsia(FD),butbloatingalonewasmorecommonthandistensioninfunctionalconstipation.[6]
BloatinghasbeenconsideredasecondarycriterionforIBSandFDaccordingtotheRomeIclassification[9] andasupportivesymptomforIBSintheRomeIIandIIIdiagnosticcriteria.[10,11] DespitebeingacommonsymptomofseveralFGIDs,[12] theRomeclassificationincludesFunctionalBloatingasanindependententity.ThenamehaschangedfromFunctionalAbdominalBloatingbothinRomeIandII[9,10] toFunctionalBloatinginRomeIII().[11] ThisdiagnosisismadeinpatientswithsymptomsofbloatingwhodonotmeetthediagnosticcriteriaofIBS,FDorotherFGIDs.
Table1. RomeIIIDiagnosticcriteriaforfunctionalbloating11
Mustincludebothofthefollowing:
1.Recurrentfeelingofbloatingorvisibledistensionatleast3daysamonthinthelast3months
2.InsufficientcriteriaforFD,IBSorotherFGID
Criteriafulfilledforthelast3monthswithsymptomonsetatleast6monthspriortodiagnosis.
Thepathophysiologicalmechanismsassociatedwithabdominalbloatinganddistensionarepoorlyunderstood.Bloatinganddistensiontogetherwitheructation,aerophagiaandflatulence,havebeenattributedtoexcessiveintestinalgasaccumulation.[13,14] Otherproposedunderlyingmechanismsincludeimpairedsmallintestinalhandlingofgas,[15] impairedclearancefromtheproximalcolon,[16] psychologicalfactors,[17] fluidretention,[18] foodintoleranceandcarbohydratemalabsorption,[4,19] increaseinlumbarlordosis,[5,20] weaknessofabdominalwallmusculature,[21] alteredsensorimotorfunction,[22] smallintestinalbacterialovergrowthandalteredgutmicroflora.[23]
Althoughbloatinganddistensionareverycommonsymptoms,theyareconsideredchallengingtotreatinclinicalpractice.Relativelylittleisknownabouttheefficacyoftreatmentsforthesesymptoms.Therefore,wereviewedtheliteratureoftreatmentinterventionsforbloatinganddistensioninpatientswithFGIDs.
Methods
AliteraturesearchwasperformedonPubMedintheMedlinedatabaseusingthefollowingterms:
'bloatingsyndrome','functionalabdominalbloating','abdominalbloating','bloating','abdominaldistension','flatulence'and'gases'.ThesewerecombinedusingtheANDoperator,withstudiesidentifiedwiththefollowingterms:
'therapeutics','combinedmodalitytherapy','complementarytherapies','drugtherapy','therapies,investigational','psychotherapy','behaviortherapy','cognitivetherapy','surfactants','antifoamingagents','anti-bacterialagents','antibiotics','probiotics','prebiotics','dietarysupplements','pancreaticenzymes','antispasmodics'and'parasympatholytics'.Searchinglimitsincludedhumans,menandwomen,randomisedcontrolledtrials,alladultsaged18orolderandEnglishlanguage.Thesearchincludedallarticlespublishedinthepast(nostartingdaterestrictions)toapublicationcut-offdateofFebruary2010.Atotalof167articleswereretrieved.Thetitlesandabstractswerereviewedbytheauthorstoselectonlythosearticlesthatanalysedtheeffectoftreatmentonbloatingand/ordistensioninFGIDs,excludingthosethatdidnotmeeteligibility.Wealsoperformedmanualsearchesofreferencelistsfromrelevantarticlestoidentifyothermanuscriptswhichmayhavebeenmissedbythesearchstrategy.
Eighty-fivearticleswerereviewedindetail.Ofthese,fivewerenotincluded:
onewasaduplicatepublication,[24] twodidnotreportthetreatmentresponseonbloating[25,26] andtwocouldnotberetrievedinfulltext.[27,28] Thereweretworecentlypublishedarticlesthatwerenotidentifiedbythesearch,butthatanalysedtheefficacyofrenzaprideandlinaclotideonbloatingandwerethereforeadded.[29,30] Threeadditionalarticleswereidentifiedbymanualsearchofreferencesfromotherarticles.[31–33] Moreover,twomulticentre,placebo-controlledtrialsthatwererecentlypublishedinabstractformwerealsoreviewed.[34–36] Thus,atotalof87articleswereincludedinthereview. Twoofthestudieswerepublishedinfulltextwhilepreparingthisarticle,thereforetheirreferenceswereupdated.[30,36] Oftheidentifiedarticles,63%includedpatientswithIBS,16%withdyspepsia,10%withchronicconstipationand10%withsymptomsofotherFGIDs.TherewerenostudiesconductedinpatientsspecificallydiagnosedwithFunctionalAbdominalBloatingorFunctionalBloating.Wealsodidnotidentifyanypsychologicalorbehaviouraltreatmentstudiesthatmeasuredtheirefficacyonbloatingordistension.
ThequalityofreportingofeachclinicaltrialwasgradedaccordingtoJadad'sscalefrom0to5.[37] Ascoreof≥4wasconsideredtobeofhighquality.Accordingly,eacharticlewasassessedbasedonthreemethodologicalitems:
randomisation,concealmentoftreatmentandintention-to-treatanalysisandwithdrawals.Inthecaseofarticlespublishedinabstractform,wedidnotincludetheJadad'sscale,astheseformatsdonotprovideallthenecessaryinformation.
Results
DietaryInterventions
Theosmoticloadwithinthebowellumenmaycontributetoabdominaldistension[38] andcandidatesubstratesthatarehighlyfermentablearepoorlyabsorbedshortchaincarbohydratescalledFermentableOligosaccharides,Disacharides,MonosacharidesandPolyols(FODMAPs).[33] PatientswithIBSandfructosemalabsorptionwhohadreportedsymptomaticrelieftoalowFODMAPsdiet,werere-challengedwithoneoffourtestsubstances:
fructans,fructose,fructansandfructose,orglucoseinlow,mediumorhighdosesinacrossoverdesignstudy(supplementaryTableS1).Bloatingsev
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