Perspective > Ask the Experts > General Gastroenterology

Approach to the IBS Patient With

Significant Persistent Abdominal
Distension?
Yehuda Ringel, MD
DISCLOSURES
May 27, 2004
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Question

What is the recommended approach to management for patients with

irritable bowel syndrome (IBS) who present with significant persistent
abdominal distension, presumably due to excess intestinal gas?

Response from Yehuda Ringel, MD

Abdominal distension and bloating are commonly reported in patients

with IBS. In fact, Manning and colleagues[1] originally included
abdominal bloating as one of the criteria for the diagnosis of IBS, and
suggested that it be used to discriminate IBS patients from those with
organic diseases. However, later studies using factor analysis showed
only weak clustering of bloating and distension with the other
characteristic IBS symptoms (abdominal pain and alterations in bowel
functions). Therefore, the international Rome committees for functional
gastrointestinal disorders do not include bloating and distension in their
diagnostic criteria for IBS, and suggest that these symptoms may exist
independently as a separate functional gastrointestinal disorder.

Although commonly reported, either in isolation or in combination with

other disorders, abdominal bloating and distension has remained
inadequately investigated. In view of our poor understanding of the
pathophysiology that underlies these symptoms and the lack of
available clinical trials specifically designed to evaluate these
symptoms, the recommendations given to patients are based on
the presumed
pathophysiology and the physician's individual opinion.

The recommended approach to the management of patients with

abdominal bloating and distension should include identifying -- and
then treatment of -- possible contributing conditions, such as small
bowel bacterial overgrowth, malabsorptions, lactose or other
 carbohydrate intolerance, anxiety-associated aerophagia, and
comorbidity with other functional gastrointestinal disorders. As with
other functional gastrointestinal disorders, a patient's management
should include education, reassurance, active listening, and support.
Dietary and lifestyle measures might be helpful. These may include
avoidance of certain foods that may increase bloating (eg, legumes,
vegetables, fiber supplements, and high-fat foods). Weight loss for
obese patients and regular exercise may increase the overall bowel
function. Some over-the-counter products, such as simethicone,
activated charcoal, and agents that help digest complex
carbohydrates, have shown limited benefit in some patients and may
warrant a trial. Based on the presumed pathophysiology, physicians
may employ the use of prokinetic agents (eg, tegaserod, a 5-
HT4 partial agonist that has been shown to reduce bloating in female
patients with IBS with constipation) or treatments targeting visceral
hypersensitivity (eg, antidepressants and psychological therapy,
including hypnotherapy). Limited data also suggest a possible benefit
associated with the use of antibiotics and probiotics in patients with
small bowel bacterial overgrowth and IBS, respectively.
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 References
Medscape Gastroenterology. 2004;6(1) © 2004 Medscape
Cite this article: Yehuda Ringel. Approach to the IBS Patient With
Significant Persistent Abdominal Distension?
- Medscape – May 27, 2004.