Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
How are belching, bloating/distention, and flatulence evaluated?
Medical history
A patient's medical history is important because it
directs the evaluation.
If the bloating/distention is continuous rather than
intermittent, then enlargement of abdominal organs, abdominal fluid, tumors, or
obesity are probable causes.
If the bloating/distention is associated with
increased flatulence, then bacteria and excessive gas production are likely
factors.
If a diet history reveals the consumption of large amounts of milk or
dairy products (lactose), sorbitol or fructose, then the maldigestion and
malabsorption of these sugars may be the cause of the distention.
When individuals complain of flatulence, it may be useful for them to count
the number of times they pass gas for several days. This count can confirm the
presence of excessive flatulence since the number of times gas is passed
correlates well with the total amount (volume) of passed gas. As you might
imagine, it is not easy to measure the amount of passed gas. It is normal to
pass gas up to 20 times a day. (The average volume of gas passed daily is
estimated to be about ¾ of a quart.)
If an individual complains of excessive gas but passes gas fewer than 20
times per day, the problem is likely to be something other than too much gas.
For example, the problem may be the foul odor of the gas (often due to
ingestion of sulfur-containing foods), the lack of ability to control (hold back) the passing
of gas, or the soiling of underwear with small amounts of stool when passing
gas. All of these problems, like excessive gas, are socially embarrassing and
may prompt individuals to consult a physician. These problems, however, are not
due to excessive gas production, and their treatment is different.
Simple abdominal X-rays
Simple X-rays of the abdomen, particularly if they
are taken during an episode of bloating or distention, can often confirm air as
the cause of the distention since large amounts of air can be seen easily within
the stomach and intestine. Moreover, the cause of the problem may be suggested
by noting where the gas has accumulated. For example, if the air is in the
stomach, emptying of the stomach is likely to be the problem.
Small intestinal X-rays
X-rays of the small intestine, in which
barium is
used to fill and outline the small intestine, are particularly useful for
determining if there is an obstruction of the small intestine.
Gastric emptying studies
These studies measure the ability of the stomach to
empty its contents. For gastric emptying studies, a test meal that is labeled
with a radioactive substance is eaten and a Geiger counter-like device is placed
over the abdomen to measure how rapidly the test meal empties from the stomach.
A delay in emptying of the radioactivity from the stomach can be caused by any
condition that reduces emptying of the stomach (for example, pyloric stenosis,
gastroparesis).
Ultrasound, CT scan, and MRI
Imaging studies, including ultrasound
examination, computerized tomography (CT), and
magnetic resonance imaging (MRI),
are particularly useful in defining the cause of distention that is due to
enlargement of the abdominal organs, abdominal fluid, and tumor.
Maldigestion and malabsorption tests
Two types of tests are used to diagnose
maldigestion and malabsorption; general tests and specific tests.
The best
general test is a 72 hour collection of stool that measures fat in the stool; if
maldigestion and/or malabsorption exist because of pancreatic insufficiency or
diseases of the lining of the small intestine for example, celiac disease), the amount
of fat in the stool will increase.
Specific tests can be done for maldigestion of individual sugars that are
commonly maldigested, including lactose (the sugar in milk) and sorbitol (a
sweetener in low calorie foods). The specific tests require ingestion of the
sugars followed by hydrogen/methane breath testing. (See below.) The sugar
fructose, a commonly used sweetener, like lactose and sorbitol, also may cause
abdominal bloating/distention and flatulence. However, the problem that can
occur with fructose is different from that with lactose or sorbitol. Thus, as
already described, lactose and sorbitol may be poorly digested by the pancreatic
enzymes
and small intestine. On the other hand, fructose may be digested normally but
may pass so rapidly through the small intestine that there is not enough time
for digestion and absorption to take place.
Hydrogen/methane breath tests
The most convenient way to test for bacterial
overgrowth of the small intestine is
hydrogen/methane breath testing. Normally,
the gas produced by the bacteria of the colon is composed of hydrogen and/or
methane. For hydrogen/methane breath testing, a non-digestible sugar, lactulose,
is consumed. At regular intervals following ingestion, samples of breath are
taken for analysis. When the lactulose reaches the colon, the bacteria form
hydrogen and/or methane. Some of the hydrogen or methane is absorbed into the
blood and eliminated in the breath where it can be measured in the samples of
breath.
In normal individuals, there is one peak of hydrogen or methane when the
lactulose enters the colon. In individuals who have bacterial overgrowth, there
are two peaks of hydrogen or methane. The first occurs when the lactulose passes
and is exposed to the bacteria in the small intestine. The second occurs when
the lactulose enters the colon and is exposed to the colonic bacteria. Hydrogen
breath testing for overgrowth also may be done utilizing lactose, glucose,
sorbitol, or fructose as the test
sugar.
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
Diarrhea is a change is the frequency and looseness of bowel movements. Cramping, abdominal pain, and the sensation of rectal urgency are all symptoms of diarrhea. Absorbents and anti-motility medications are used to treat diarrhea.
Anxiety is a feeling of apprehension and fear characterized by physical symptoms. Anxiety disorders are serious medical illnesses that affect approximately 19 million American adults.
Constipation is defined medically as fewer than three stools per week and severe constipation as less than one stool per week. Constipation usually is caused by the slow movement of stool through the colon. There are many causes of constipation including medications, poor bowel habits, low fiber diets, abuse of laxatives, hormonal disorders, and diseases primarily of other parts of the body that also affect the colon.
Diverticulitis is a condition in which diverticuli in the colon rupture. The rupture results in infection in the tissues that surround the colon. Diverticulitis symptoms include: abdominal pain, abdominal cramps, diarrhea, constipation, and bloating. Treatment methods include prescription medications, and in some cases, diverticulitis surgery.
There are many types of ovarian cancer, epithelial carcinoma is the most common. Women with a family history of ovarian cancer have an increased risk of developing the disease. Some ovarian cancer symptoms include abdominal pain, nausea, diarrhea, constipation, and abnormal vaginal bleeding, however, they usually do not present until the disease has progressed. Early diagnosis is important for successful treatment.
In lactose intolerance, the digestive system cannot digest lactose (the main sugar in milk). Symptoms of lactose intolerance include diarrhea, flatulence, abdominal pain, abdominal bloating, abdominal distention, and nausea. There are several tests to diagnose lactose intolerance. Treatment is generally made with dietary changes, supplements, and adaptation to small amounts of milk.
IBS (irritable bowel syndrome) is a common gastrointestinal disorder involving abnormal gut contractions (motility) characterized by abdominal pain,
bloating, mucous in stools, and irregular bowel habits with alternating diarrhea
and constipation, symptoms that tend to be chronic and to wax and wane over the
years. Treatment options include medication and lifestyle changes such as diet, exercise, and stress management to control symptoms. Also called spastic colitis, mucus colitis, nervous colon syndrome.
Celiac disease is a result of an immune reaction to gluten, a protein found in wheat or related grains and present in many foods that we eat. Celiac disease causes impaired absorption and digestion of nutrients through the small intestine. Signs and symptoms of celiac disease include malabsorbption (diarrhea, foul smelling gas, bloating, and increased amounts of fat in the stool) and malnutrition (weight loss, edema, anemia, bruising easily, neuropathy, and infertility). Treatment for celiac disease is a gluten free diet, and at times if necessary, medications
Gallbladder (gall bladder) pain can be caused by gallbladder disease such as gallstones or cholecystitis. Causes of gallbladder pain can be caused from biliary colic. Biliary colic is pain caused by gallstones trapped in the bile ducts. Cholecystitis is inflammation of the
gallbladder. Symptoms of gallbladder disease include nausea, vomiting, abdominal bloating and belching, sweating, and shortness of breath. Treatment of gallbladder pain depends on the cause.
Small intestinal bacterial overgrowth (SIBO) refers to a condition in which abnormally large numbers of bacteria (at least 100,000 bacteria per ml of fluid) are present in the small intestine and the types of bacteria in the small intestine resemble more the bacteria of the colon than the small intestine. There are many conditions associated with small intestinal bacterial overgrowth, to include: diabetes, scleroderma, Crohn's disease, and others. There is a striking similarity between the symptoms of irritable bowel syndrome and SIBO. It has been theorized that SIBO may be responsible for the symptoms of at least some patients with irritable bowel syndrome. Symptoms of SIBO include: excess gas, abdominal bloating, diarrhea, and abdominal pain.
Dyspepsia (indigestion) is a functional disease in which the gastrointestinal organs, primarily the stomach and first part of the small intestine, function abnormally. It is a chronic disease in which the symptoms fluctuate infrequency and intensity. Symptoms of dyspepsia include upper abdominal pain, belching, nausea, vomiting, abdominal bloating, early satiety, and abdominal distention (swelling). These symptoms are most often provoked by eating.
Colic is crying or fussing that begins suddenly, lasting for a total of three hours a day and happening more than three days a week for about three weeks. Symptoms include the baby's face turning red, the belly is distended, the feet may be cold, the hands clenched, and the legs may alternate between being flexed or extended. Treatment may involve ruling out other causes of the fussing and the doctor prescribing anti-gas bubbly medicine.
Obesity is the state of being well above one's normal weight. A person has traditionally been
considered to be obese if they are more than 20 percent over their ideal weight.
That ideal weight must take into account the person's height, age, sex, and
build.
Gastroparesis is a medical condition in which the muscle of the stomach is paralyzed by a disease of either the stomach muscle itself or the nerves controlling the muscle. As a consequence, food and secretions do not empty normally from the stomach. Gastroparesis symptoms are nausea and vomiting; abdominal bloating, and pain can result.
Patients with celiac disease are required to eat a gluten-free diet. Gluten is found in rye, barley, and wheat. Gluten damages the intestine in patients with celiac disease. Some mediations contain gluten, so careful monitoring of products consumed is imperative. Patients with celiac disease are also at risk for developing nutritional deficiencies. The information in this article contains both foods that contain gluten, and foods that do not contain gluten.
Hirschsprung's disease (Hirschsprung), is a disease of the nerve cells of of the large intestine. The primary symptom of Hirschsprung's disease is constipation. Hirschsprung's disease is diagnosed through barium enema, and treatment is surgery.
Heartburn is a burning sensation experienced from acid reflux (GERD). Symptoms of heartburn include chest pain, burning in the throat, difficulty swallowing, the feeling of food sticking in the throat, and a burning feeling in the chest. Causes of heartburn include dietary habits, lifestyle habits, and medical causes. Treatments for heartburn include lifestyle changes, OTC medication, prescription medication, and surgery.
Abdominal adhesions (scar tissue) bands of scar tissue that form between abdominal organs and tissues. Symptoms of abdominal adhesions are pelvic or abdominal pain. Abdominal adhesions on the intestines can cause bowel obstruction, which is a medical emergency. Treatment for abdominal adhesions is generally surgery to cut the adhesions away from the internal tissues and organs. There is no way to prevent abdominal adhesions.
Digestion is the complex process of turning food you eat into the energy you need to survive. The digestive process also involves creating waste to be eliminated, and is made of a series of muscles that coordinate the movement of food.
Irritable bowel syndrome (IBS) in children is a functional gastrointestinal disorder with symptoms of abdominal pain, bloating, diarrhea or constipation. The cause of IBS is unknown, however, certain foods, stress, anxiety, and depression may contribute to the symptoms of IBS. There is no cure for IBS in children; however, medications, dietary changes, and stress management may relieve symptoms.
Irritable bowel syndrome (IBS) is a functional disease that can affect the quality of those who suffer from this condition. Individuals with IBS can make lifestyle changes that may modify or control the number and severity of episodes. Certain foods, medications, and hormone levels may trigger IBS episodes. Learn how to prevent the number and severity of IBS episodes of diarrhea and constipation.
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