Gastroenterology Book



Aka: Flatulence, Abdominal Wind, Flatus, Fart, Farting, Eructation, Belching, Burping, Gaseous Regurgitation, Borborygmus, Abdominal Bloating, Abdominal Distention, Abdominal Swelling, Functional Gastrointestinal Disorders, Excessive Gas
  1. See Also
    1. Functional Dyspepsia
    2. Irritable Bowel Syndrome
    3. Functional Constipation
  2. Definitions
    1. Functional Gastrointestinal Disorders (FGID)
      1. Includes Functional Dyspepsia, Irritable Bowel Syndrome, Functional Constipation
    2. Bloating
      1. Sensation of gasseousness or distention (with or without abdominal girth changes)
    3. Belching (Eructation, Burping)
      1. Excessive Gas expulsion from the Stomach
      2. Belching is a normal clearance of Stomach gas, typically occurring 25-30 times per day (often unconsciously)
    4. Flatulence (Farting, Abdominal Wind)
      1. Excessive colonic gas expulsion from the anus
  3. Pathophysiology
    1. Belching: Gas in Stomach from air Swallowing (Aerophagia)
      1. Hurried Eating or Drinking
      2. Smoking or Chewing gum
      3. Wearing badly fitted dentures
      4. Postnasal drainage
      5. Dry Mouth from anxiety or Anticholinergics
    2. Bloating and Abdominal Distention
      1. Altered intestinal motility and transit typically of the Small Intestine
      2. CNS processing (lower pain threshold)
      3. Visceral Hypersensitivity
      4. Other factors such as gut microflora and immune function may play a role
      5. Typically not related to increased gas production
        1. Not typically related to Flatulence (gas in colon does not cause bloating Sensation in most cases)
        2. Not typically related to Belching (due to swallowed air, not gas generated in Small Intestine)
    3. Flatulence: Gas from Large Intestine
      1. Typically diet related
      2. Bacterial degradation of Large Intestine contents
        1. Indigestible Carbohydrates
        2. Malabsorption (e.g. Lactose Intolerance)
  4. Symptoms
    1. Eructation
    2. Bloating
    3. Borborygmus
    4. Flatulence
  5. History
    1. General
      1. Symptoms and their timing
      2. Palliative and provocative measures
      3. Recent illness
      4. Emotional stress
      5. Abdominal surgeries
      6. Gastrointestinal and genitourinary disorders
    2. Localizing symptoms
      1. Able to eat a full plate of food?
      2. Regular, normal Bowel Movements?
    3. Dietary history
      1. Meal patterns (e.g. large meals, rapid eating)
      2. Caffeine
      3. Carbonated drinks
      4. FODMAPs (Fementable Oligosaccharides, Disaccharides, Monosaccharides and Polyols)
        1. See FODMAP
        2. Fructose (e.g. apples, pears, peaches, mangoes, dried fruit, honey, fruit juice, high fructose corn syrup)
        3. Fructans (fructo-Oligosaccharides, inulins, levans - e.g. high fiber bars, onions, leeks, zucchini)
        4. Disaccharides (Lactose): Dairy, cheese, milk
        5. Polyols: Apricots, peaches
          1. Sugar Alcohols (esp. common in sugar-free gum): Sorbitol, xylitol, Mannitol, malitol)
        6. Galactooligosaccharides or Raffinose (brussel sprouts, cabbage, green beans, lentils, legumes, chick peas)
  6. Exam
    1. General examination
    2. Focused abdominal exam
    3. Rectal exam
  7. Findings: Red Flag Symptoms and signs
    1. Unintentional Weight Loss
    2. Fever
    3. Vomiting
    4. Gastrointestinal Bleeding
    5. Abdominal mass
    6. Dysphagia
    7. Jaundice
    8. Lymphadenopathy
    9. Severe symptoms
    10. Severe Diarrhea
    11. Tenesmus
    12. New onset in over age 55 years
    13. Cancer history
  8. Associated Conditions
    1. Emotion and Stress exacerbate symptoms (but are not typically the underlying cause)
      1. Anxiety
      2. Depressed mood
      3. Emotional stress
      4. Comorbid illness
  9. Differential Diagnosis
    1. Bloating or Abdominal Distention in general
      1. Abdominal Mass
      2. Pregnancy
      3. Abdominal Wall Hernia (e.g. Umbilical Hernia, Ventral Hernia)
      4. Ovarian Cancer
      5. Ascites
    2. Eructation (Belching, Burping)
      1. Typically aerophagia (see pathophysiology above)
      2. Gastric Belching
        1. Hurried Eating or Drinking
        2. Smoking or Chewing gum
        3. Wearing badly fitted dentures
        4. Postnasal drainage
        5. Xerostomia
        6. Gastroesophageal Reflux Disease
        7. Functional Dyspepsia
      3. Supragastric Belching
        1. Patient ingests air into esophagus and immediately belches without it reaching the Stomach
        2. Learned repetitive Belching (up to 20/min) in response to stress, anxiety, GERD
        3. Better when distracted, sleeping, and with biofeedback and management of anxiety
    3. Gastric Bloating (symptoms begin <30 minutes after eating)
      1. See Dyspepsia Causes
      2. Functional Dyspepsia
        1. Post-prandial fullness, early satiety and bloating
        2. Epigastric Pain not related to eating may also occur
      3. Gastroesophageal Reflux Disease
      4. Helicobacter Pylori infection
      5. Gastroparesis (post-Viral Gastroenteritis, Diabetes Mellitus, Bariatric Surgery)
      6. Impaired gastric accommodation
      7. Gastric outlet obstruction (esp. chronic Peptic Ulcer Disease with scarring)
      8. Delayed Gastric Emptying
    4. Small Bowel Bloating (symptoms begin >30 minutes after eating)
      1. Pain-Dominant Irritable Bowel Syndrome
      2. Celiac Sprue (Gluten Sensitive Enteropathy)
      3. Dietary intake (see FODMAPs listed above)
      4. Bacterial overgrowth within Small Intestine
    5. Constipation with Bloating
      1. See Constipation Causes
      2. Chronic Constipation (Functional Constipation)
      3. Constipation-Dominant Irritable Bowel Syndrome
      4. Slow transit Constipation
      5. Dyssynergic Defecation (Pelvic Floor Dysfunction)
        1. Lack of coordination between abdominal wall, pelvic floor and anal sphincter on attempted Defecation
        2. Treated with pelvic floor retraining
  10. Evaluation: Testing to consider
    1. Eructation (Belching, Burping)
      1. No testing is typically needed, as this is nearly always aerophagia
    2. Gastric Bloating (symptoms begin <30 minutes after eating)
      1. Upper endoscopy
      2. Hemoglobin A1C
      3. Gastric Emptying Study
    3. Small Bowel Bloating (symptoms begin >30 minutes after eating)
      1. Celiac Sprue: IgA Tissue Transglutaminase (TTG) and Total IgA (if low, obtain IgG Gliadin instead of TTG)
      2. Hydrogen Breath Test
    4. Bloating with Constipation
      1. Rectal Exam (impaction, Pelvic Floor Dysfunction)
      2. Thyroid Stimulating Hormone (TSH)
      3. Serum Calcium
      4. Colonoscopy
      5. Colon transit study
      6. Anorectal manometry
  11. Management
    1. General
      1. Avoid discounting patient concerns (as with other functional disorders)
      2. Offer reassurance when findings are consistent with functional gastrointestinal disorder
      3. Manage underlying emotional stress and Mood Disorders (Major Depression, Anxiety Disorder)
      4. Consider Exercise (esp. Irritable Bowel Syndrome, Chronic Constipation)
    2. Exclude secondary causes
      1. Perform testing as indicated based on history including red flag symptoms
    3. Eliminate causative factors
      1. Manage aerophagia in Eructation
      2. Reduce FODMAPs in bloating
    4. Follow specific management strategies for Functional Gastrointestinal Disorders
      1. See Functional Dyspepsia
      2. See Irritable Bowel Syndrome
      3. See Functional Constipation
    5. Consider empiric management for common conditions
      1. Consider Proton Pump Inhibitor for Functional Dyspepsia
      2. Consider antispasmodics (e.g. Hyoscyamine, Dicyclomine, Peppermint Oil) for Irritable Bowel Syndrome
      3. Consider fiber supplementation in Irritable Bowel Syndrome, Chronic Constipation (after initial disimpaction regimen)
    6. Avoid measures without evidence
      1. Simethicone
        1. No evidence that Simethicone is better than Placebo
  12. References
    1. Wilkinson (2019) Am Fam Physician 99(5): 301-9 [PubMed]

Abdomen distended (C0000731)

Definition (NCI) Swelling of the abdomen resulting from excessive food intake, malnutrition, liver disease, primary abdominal tumors, and tumors metastatic to the abdominal cavity.
Definition (NCI_CTCAE) A disorder characterized by swelling of the abdomen.
Concepts Finding (T033)
SnomedCT 207238007, 41931001, 226284003, 158434004, 60728008, 84454003
English ABDOMEN DISTENTION, ABDOMINAL DISTENSION, SWOLLEN ABDOMEN, [D]Abdominal swelling, Abdomen Distention, [D]Abdominal swelling (context-dependent category), distended abdomen, abdominal swelling, abdominal swelling (symptom), abdominal distention (physical finding), abdominal distention, Swelling abd, Distended abdomen, Swelling abdomen, Abdominal Distention, Distension;abdomen, Swollen;abdomen, abdominal swellings, swelling of abdomen, abdomen distended, Abdominal swelling (disorder), [D]Abdominal swelling (situation), Abdominal Bloating, Abdominal distention, Abdominal distension, Abdominal swelling, Swollen abdomen, Swelling of abdomen, Abdominal distension (finding), Swollen abdomen (finding), abdomen; swelling, intra-abdominal; swelling, swelling; abdomen, swelling; intra-abdominal, Abdominal swelling, NOS, Abdomen distended, swollen abdomen, abdominal distension
Italian Distensione dell'addome, Rigonfiamento addominale, Rigonfiamento addom., Addome disteso, Addome rigonfio
Dutch uitgezette buik, gezwollen abdomen, gezwollen buik, Opgezette buik, abdomen; zwelling, intra-abdominaal; zwelling, zwelling; abdomen, zwelling; intra-abdominaal, abdominale distensie
French Abdomen distendu, Gonflement de l'abdomen, Abdomen gonflé, Abd gonflé, BALLONNEMENT ABDOMINAL, DISTENSION ABDOMINALE, Distension abdominale
German geschwollener Abdomen, Schwellung Abdomen, Schwellung abd., aufgetriebener Bauch, BAUCHUMFANG VERGROESSERT, Bauch aufgetrieben
Portuguese Tumefacção do abdómen, Abdómen tumefacto, Abdómen distendido, DISTENCAO ABDOMINAL, DISTENSAO ABDOMINAL, Distensão abdominal
Spanish Abdomen distendido, Hinchazón de abdomen, Hinchazón abdominal, Abdomen hinchado, [D]tumefacción abdominal (categoría dependiente del contexto), ABDOMEN INFLAMADO, hinchazón abdominal, [D]tumefacción abdominal, hinchazón abdominal (trastorno), [D]tumefacción abdominal (situación), abdomen distendido (hallazgo), abdomen distendido, distensión abdominal (hallazgo), distensión abdominal, Distensión abdominal
Japanese 腹部膨隆, 腹部膨満, フクブボウマン, フクブボウリュウ
Czech Zduřené břicho, Břišní distenze, Vzedmuté břicho
Hungarian Abdominalis distensio, Duzzadt has, Duzzanat has, Hasi distensio, Abdominalis duzzanat
Derived from the NIH UMLS (Unified Medical Language System)

Eructation (C0014724)

Definition (MSHCZE) Odchod plynů ze žaludku dutinou ústní. (cit. Velký lékařský slovník online, 2012 )
Definition (NCI) To belch, the casting of upwind from the stomach.
Definition (NCI_FDA) To belch, the casting of upwind from the stomach.
Definition (MSH) The ejection of gas or air through the mouth from the stomach.
Concepts Sign or Symptom (T184)
MSH D004884
ICD10 R14.2
SnomedCT 207126009, 68711006, 158433005, 139349006, 162074007, 271834000, 275299008
English Belching, Belchings, Eructations, BELCHING, ERUCTATION, GAS RAISING, GASEOUS REGURGITATION, [D]Eructation, Belching, Burping, [D]Eructation (context-dependent category), Eructation, function, belching, belching (symptom), eructation, burping, Gas raising, Gaseous regurgitation, Eructation [Disease/Finding], belching symptom, burps, belching symptoms, eructations, belch, burp, ructus, Burp, Belch, [D]Eructation (situation), Eructation symptom, ERUCTATE, Ructus, Burping, Belching symptom, Burping (finding), Eructation, function (observable entity), Eructation (function), Eructation, Belching symptom (context-dependent category), Belching symptom (finding)
French ERUCTATION, Augmentation des gaz, Régurgitation de gaz, Eructations, REGURGITATION GAZEUSE, RENVOIS, Eructation, Éructation
Portuguese ERUCTACAO, Regurgitação gasosa, Produção de gases, ARROTAR, AUMENTO DA PRODUCAO GASOSA, REGURGITACAO GASOSA, Arroto, Eructação
Spanish ERUCTACION, síntoma de eructo (hallazgo), Producción de gases, Regurgitación gaseosa, Recto, síntoma de eructo (categoría dependiente del contexto), [D]eructos (categoría dependiente del contexto), ERUCTOS, GAS, ASCENSO DE, REGURGITACION GASEOSA, eructo (hallazgo), eructo(hallazgo), [D]eructos, [D]eructos (situación), eructación, eructo (entidad observable), eructo (función), eructo, regüeldo, síntoma de eructo, Eructos, Eructación, Eructo
Dutch ructus, boeren, boertje doen, gasregurgitatie, oprisping, Boeren
German Ruelpsen, Aufsteigen von Gas, Regurgitation von Gas, Ructus, AUFSTOSSEN DARMLUFT, AUFSTOSSEN GASIG, AUFSTOSSEN SAUER, RUELPSEN, Aufstossen, Aufstoßen, Rülpsen
Italian Aumento di gas, Rigurgito di gas, Ruttazione, Eruttazione
Japanese ゲップ, オクビ, ゲップ, おくび, あい気, げっぷ
Swedish Rapning
Czech říhání, Říhání, eructatio, eruktace, ructus, krkání
Finnish Röyhtäily
Polish Odbijanie się
Hungarian Ructus, Büfögés, Gáz feljövés (böfögés), Böfögés, Eructatio, Gázos regurgitatio
Norwegian Eructatio, Raping, Eruktasjon
Derived from the NIH UMLS (Unified Medical Language System)

Flatulence (C0016204)

Definition (ICF) Functions involved in the expulsion of excessive amounts of air or gases from the intestines.
Definition (ICF-CY) Functions involved in the expulsion of excessive amounts of air or gases from the intestines.
Definition (FMA) Excretion in gaseous state processed in the stomach and small intestine.
Definition (MSHCZE) Zvýšený odchod střevních plynů konečníkem. (cit. Velký lékařský slovník online, 2012 )
Definition (UWDA) Excretion in gaseous state processed the stomach and small intestine.
Definition (UWDA) Excretion in gaseous state processed the large intestin
Definition (SCTSPA) Eliminación de gases por el ano
Definition (SNOMEDCT_US) Passage of gas by anus
Definition (NCI) Gas or air in the gastrointestinal tract.
Definition (NCI_FDA) Gas or air in the gastrointestinal tract.
Definition (NCI) A state of excessive gas in the alimentary canal.
Definition (NCI_CTCAE) A disorder characterized by a state of excessive gas in the alimentary canal.
Definition (MSH) Production or presence of gas in the gastrointestinal tract which may be expelled through the anus.
Concepts Sign or Symptom (T184)
MSH D005414
ICD10 R14.3
SnomedCT 267052005, 308698004, 207125008, 309475008, 40015002, 158432000, 162074007, 139349006, 139355001, 162079002, 207131006, 275298000, 249505007, 158438001, 6352008, 162076009, 249504006
English Flatulence, Flatus, Wind, FLATULENCE, [D]Flatulence, [D]Wind, Farting, Wind symptom, [D]Flatulence (context-dependent category), [D]Flatulence NOS (context-dependent category), Wind NOS, [D]Flatulence NOS, Flatulence NOS, Flatus, function, excessive farting, excessive passing of gas, flatus (symptom), flatus, Abdominal wind, Gaseousness, Flatulence [Disease/Finding], winding, gas passing, farts, wind, passing wind, fart, pass wind, [D]Flatulence NOS (situation), [D]Flatulence (situation), Wind NOS (finding), Wind symptom (finding), Farting (finding), Flatulence (finding), FLATUS, Intestinal gas excretion, Passage of gas by anus, Wind - flatus, Flatulence/wind, Full of wind, Passing flatus, Flatulence symptom, Flatulence/wind (finding), Flatus, function (observable entity), Passing flatus (finding), flatulence, Flatus (function), Flatulence symptom (context-dependent category), Wind symptom (context-dependent category), Flatulence symptom (finding)
Portuguese FLATULENCIA, Formação de gases, Gases abdominais, FLATUS, Gases Intestinais, Flato, Flatulência
Spanish FLATULENCIA, FLATO, síntoma de flatulencia (hallazgo), Gases, Gases abdominales, síntoma aéreo (categoría dependiente del contexto), síntoma de flatulencia (categoría dependiente del contexto), [D]flatulencia (categoría dependiente del contexto), [D]flatulencia, SAI (categoría dependiente del contexto), ventear, SAI (hallazgo), [D]flatulencia, SAI (situación), ventear, SAI, flatulencia (hallazgo), [D]flatulencia (situación), síntoma aéreo (hallazgo), Eliminación de ventosidades, [D]flatulencia, Wind NOS, [D]flatulencia, SAI, síntoma aéreo, Eliminación de ventosidades (hallazgo), Gases Intestinales, eliminación de gases (hallazgo), eliminación de gases, excreción intestinal de gas, flato (entidad observable), flato (función), flato, flatulencia/gas (hallazgo), flatulencia/gas, flatulencia, pasaje de gas por el ano, síntoma de flatulencia, Flatulencia, Flato
German FLATULENZ, Bauchwind, Wind im Darm, Wind, Flatus, FLATUS, Flatulenz, Blähung
Dutch flatus, buikwind, wind, gasvorming, flatulentie, Flatulentie, Flatus, Meteorisme
French Flatuosité, Gaz abdominaux, Gaz, Flatulences, FLATULENCE, Météorisme, Flatulence, Ballonnement
Italian Flato, Peto, Flatulenza
Japanese ガス発生, ガスハッセイ, 鼓腸, ホウヒ, 放屁, 鼓脹, 鼓脹症
Swedish Gasbildning
Czech meteorismus, flatulence, flatus, Plynatost, Břišní nadýmání, Flatulence, Nadýmání, plynatost, meteorizmus
Finnish Ilmavaivat
Polish Wzdęcia, Bębnica
Hungarian Flatus, Gázosság, Flatulentia, Abdominalis szél, Szél
Norwegian Vindplager, Flatulens, Flatus, Luftavgang
Derived from the NIH UMLS (Unified Medical Language System)

Bowel sounds (C0232693)

Concepts Finding (T033)
SnomedCT 87042004, 413681009
English BORBORYGMUS, borborygmus, Borborygmus, bowel sounds, bowel sounds (physical finding), bowel sound, borborygmi, BS - Bowel sounds, Bowel sounds (observable entity), Bowel sounds, NOS, Peristaltic sounds, Bowel sounds, Borborygmi, Borborygmi (finding)
Spanish Borborigmos, Borborigmo, BORBORIGMO, borborigmo, ruidos intestinales (entidad observable), ruidos intestinales, ruidos peristálticos, borborigmos, borborigmos (hallazgo)
French Borborygmes, BORBORYGMES
Dutch borborygmus, borborygmi
Portuguese Borborigmo, Borborigmos, BORBORIGMO
German Borborygmus, Borborygmi, BAUCHKOLLERN
Italian Borborigmi, Borborigmo
Japanese グルオン, グル音, 腹鳴, フクメイ
Czech Borborygmus
Hungarian Haskorgás, Borborygmusok
Derived from the NIH UMLS (Unified Medical Language System)

Functional Gastrointestinal Disorders (C0559031)

Definition (MSH) Chronic or recurrent gastrointestinal disorders without an identifiable structural or biochemical explanation by the routine diagnostic tests. Functional gastrointestinal disorders are classified according to the presumed site of the disorder, such as IRRITABLE BOWEL SYNDROME, non-ulcer DYSPEPSIA, and non-cardiac CHEST PAIN.
Concepts Disease or Syndrome (T047)
MSH D005767
SnomedCT 155789001, 155784006, 266526001, 266528000
English Functional GIT disorder NOS, Functional gastrointestinal disorder, Functional GIT disorder NOS (disorder), Functional gastrointestinal tract disorder NOS, Functional gastrointestinal tract disorder NOS (disorder), Disorder, Functional Gastrointestinal, Disorders, Functional Gastrointestinal, Functional Gastrointestinal Disorder, Gastrointestinal Disorders, Functional, Gastrointestinal Disorder, Functional, Functional Gastrointestinal Disorders, Functional gastrointestinal disturbance
French Troubles gastro-intestinaux fonctionnels, Trouble gastro-intestinal fonctionnel, Troubles gastrointestinaux fonctionnels
German Funktionelle gastrointestinale Störungen, Funktionsstoerung des Gastrointestinaltrakts, Funktionelle Magen-Darm-Beschwerden, Funktionelle Magen-Darm-Störungen, Gastrointestinale Störungen, funktionelle, Magen-Darm-Beschwerden, funktionelle, Magen-Darm-Störungen, funktionelle
Italian Disturbi gastrointestinali funzionali, Disturbo gastrointestinale funzionale
Spanish Trastornos gastrointestinales funcionales, Functional GIT disorder NOS, trastorno funcional del tracto gastrointestinal, SAI, trastorno funcional del tracto gastrointestinal, SAI (trastorno)
Portuguese Afecção gastrointestinal funcional
Dutch functionele gastro-intestinale aandoening
Hungarian Funkcionális gastrointestinalis betegség
Czech Funkční gastrointestinální porucha, funkční gastrointestinální poruchy, funkční gastrointestinální obtíže, gastrointestinální nemoci funkční
Japanese キノウセイイチョウショウガイ, 機能性胃腸障害
Norwegian Funksjonell gastrointestinal forstyrrelse, Funksjonell mage- og tarmforstyrrelse
Derived from the NIH UMLS (Unified Medical Language System)

Bloated feeling (C0857257)

Definition (ICF) Sensation of distension of the stomach or abdomen.
Definition (ICF-CY) Sensation of distension of the stomach or abdomen.
Definition (NCI) A question about whether an individual feels or felt bloated.
Concepts Sign or Symptom (T184)
Dutch opgeblazen gevoel
French Sensation de ballonnement
German Gefuehl der Blaehung
Italian Sensazione di gonfiore
Portuguese Sensação de enfartamento
Spanish Sensación de estar hinchado
Japanese 腹部膨満感, フクブボウマンカン
Czech Pocit nadmutí
English Bloated feeling, Feeling bloated, bloating feeling, bloated feeling, bloating feelings, feeling bloated, I feel bloated, Feel Bloated
Hungarian Felfújódásérzés
Derived from the NIH UMLS (Unified Medical Language System)

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