European Consensus on Functional Bloating and Abdominal Distension-An ESNM/UEG Recommendations for Clinical Management

Abstract

Introduction: Abdominal distension is an objective visible sign of increased abdominal girth. Bloating is a feeling of abdominal fullness and discomfort. Bloating may be associated or not with abdominal distension. Bloating and abdominal distension are among the most commonly reported gastrointestinal symptoms and may be associated with both organic and functional disorders. Nevertheless, specific consensus and recommendations on diagnosis, underlying mechanisms, assessment and management of functional bloating and abdominal distension are still lacking. The aim of this European consensus, then, is to provide expert opinions and recommendations on the epidemiology, diagnosis, pathophysiology and treatment of functional bloating and abdominal distension.

Methods: A multidisciplinary team of experts in the field, including European specialists and national societies, participated in the development of this consensus. Relevant questions were formulated and addressed through a literature review and statements were developed and voted using a Delphi process.

Results: Functional bloating and abdominal distension are common and frequently overlap with other disorders of gut-brain interaction. Diagnosis is made according to the Rome IV criteria after the exclusion of organic disease, based on the physical examination and assessment of the patient's medical history and alarming signs. In the absence of alarming signs or any relevant finding, clinical laboratory, imaging or endoscopic tests are unnecessary. The pathophysiology of functional bloating and abdominal distension is multifactorial and involves visceral hypersensitivity, abdomino-phrenic dyssynergia, intestinal dysmotility and dysbiosis. Treatment may include dietary modifications (e.g. lactose-limiting diet and low FODMAP diet), probiotics, antispasmodics (e.g., otilonium bromide, peppermint oil), rifaximin, secretagogues (e.g., linaclotide), neuromodulators (e.g., serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, buspirone), and plethysmography-based biofeedback. Moreover, cognitive behaviour therapy and hypnotherapy can be used in case of functional bloating associated with irritable bowel syndrome.

Conclusion: This consensus provides an evidence-based framework for the evaluation and treatment of patients with functional bloating and abdominal distension.

Keywords: Delphi; ESNM; European guidelines; Rome criteria; UEG; abdominal distension; consensus; disorders of gut‐brain interaction; functional bloating; microbiota.

FIGURE 1

Algorithm of recommendations for the optimal management of functional bloating and abdominal distension. CBC, Cell Blood Count; CBT, cognitive behaviour treatment; CRP, C‐Reactive Protein; CT, Computed Tomography; DGBI, disorders of gut‐brain interaction; EMG, Electromyography; FEL, Faecal Elastase; FODMAP, Fermentable; GI, Gastrointestinal; HbA1C, Haemoglobin A1C; IBS, Irritable bowel syndrome; Oligosaccharides; Disaccharides; Monosaccharides and Polyols; IBS, irritable bowel syndrome; GI, gastrointestinal; TCA, tricyclic antidepressant; TSH, Thyroid Stimulating Hormone; TTG, Tissue Transglutaminase Antibody; SNRI, Serotonin‐norepinephrine reuptake inhibitors. #: biofeedback has been shown to be effective especially in patients exhibiting visible abdominal distention.