This article provides a detailed narration on the causes of stomach bloating and distention and the best ways of managing it.

What is bloating and distention?

1. These two difficulties are often observed, with a frequency of between 16% and 31% in the general population. It may vary between 66% and 90% in people with irritable bowel syndrome (IBS). Additionally, they are more prevalent in people with constipation and in women.
2. Around 75% of people with bloating describe their symptoms as moderate to severe, and 50% state that it impairs their ability to do everyday tasks of normal function.
3. Patients who arrive with these symptoms often express that they feel pregnant or as if they have a balloon in their belly and are unable to bear it. Distention of the abdomen and abdominal bloating are not usually synonymous. Only roughly 50% – 60% of people with bloating report experiencing distention.

Why does bloating and distention happen?

People think their symptoms are caused by their bodies making too much gas when it comes to the root cause. This is true in a small percentage of cases. It is not so much a result of an increase in gas as it is a result of an increase in feeling.

1. Small intestine bacterial overgrowth and carbohydrate intolerance, the latter of which is exacerbated by lactose and fructose intolerance, are the primary pathophysiologic factors of these diseases.
2. Lactose deficiency does not always result in malabsorption, and not everyone who is lactase deficient becomes symptomatic when lactose is consumed. Rather than that, some people may need additional elements such as genetic predisposition or visceral hypersensitivity to generate symptoms.
3. Pathogenesis may also be impacted by a dysbiotic microbiome, which is a phenomenon seen across almost all disease states. The involvement of the gut microbiota in creating changes in gastrointestinal (GI) motility, sensation, or permeability has a dramatic influence on producing these symptoms of abdominal bloating and distention.
4. Abnormal gastrointestinal motility- Bloating of the abdomen is frequent in people with abnormal gastrointestinal motility. This is especially noticeable in individuals with gastroparesis, where the incidence might reach 50% or more.
5. Pelvic floor dysfunction- It is comparable in people who suffer from pelvic floor dysfunction. Patients with established anorectal motor dysfunction may have difficulties removing flatus and faeces. Obstruction of the pelvic exit might also result in increased colonic transit time.
6. Abdominal-phrenic dyssynergia- Another possible related condition that you may have overlooked is abdominal-phrenic dyssynergia. This is a paradoxical reaction in which the diaphragm tightens and the abdominal wall relaxes as something is pushed down. The abdominal muscles should contract and the diaphragm should relax in order to preserve the integrity of the craniocaudal capacity and prevent distention. Reversing this might result in abdominal distention and bloating.
7. Visceral hypersensitivity- Additionally, there is a definite causal relationship between visceral hypersensitivity. This effect may be amplified by complicated brain-gut neuronal connections as well as by anxiety, sadness, somatization, and hypervigilance.
8. Lack of sleep- Many of these disorders are also influenced by sleep, which is being mentioned more often in recent years. Sensory thresholds are decreased across the board in the context of sleep fragmentation, which exacerbates visceral hypersensitivity.

Diagnosis 

1. Breath tests are a simple diagnostic method for determining the presence of bacterial overgrowth. We offer lactose and fructose breath tests in addition to the more frequently used glucose and lactulose breath tests. These tests are readily accessible commercially.
2. Additionally, considering the frequency of celiac disease, we must consider it. When this condition is suspected, serologic testing is recommended.
3. When a patient exhibits alarming characteristics, upper endoscopy and abdominal imaging are indicated. Additionally, alterations in gastrointestinal motility and gastroparesis disorders should be evaluated.
4. Anorectal motility testing, maybe in conjunction with defecography, is the best alternative for individuals with suspected pelvic floor dysfunction.

How to manage?

1. Diet - When considering therapy, can be begun with dietary modifications. Obtaining an accurate eating history in order to rule out bloating and distention is crucial.
2. Artificial sweeteners are a frequent cause of these symptoms. These sweeteners include carbs that are not fermentable. These carbohydrates are fermented in the stomach, resulting in an increase in gas production.
3. Fructans and FOFMAPs- Additionally, we should examine the effect of fructans and FODMAPs (fermentable oligo-, di-, and monosaccharides), which may dramatically increase the osmotic load. 
4. Eliminating gluten- Numerous patients express concern regarding the function of gluten. Around 70% of individuals with non-celiac gluten intolerance report experiencing bloating. However, it is not gluten per se that causes this, but rather gluten derivatives, notably wheat and barley, fructans, and FODMAPs. Eliminating such from patients' meals may be a highly effective method to alleviate their bloating and distention symptoms. While it is straightforward for physicians to consider FODMAPs, it is a very challenging idea for patients to grasp. It is best to involve a dietitian to ensure that the therapeutic benefit is realised.
5. Carbs- Additionally, we should keep in mind that carbs may sneak into diets through the usage of high-fructose corn syrup.
6. Probiotics have not been found to have a significant impact on symptom relief.
7. Antibiotics have been demonstrated to be useful in relieving bloating, notably rifaximin at a dose of 550 mg three times a day for 14 days, but obtaining permission to pay for this remains problematic unless the patient has IBS and diarrhoea.
8. Antispasmodics, maybe in combination with simethicone, are a fair alternative.
9. Secretagogues are another choice if you're treating a constipated patient, since they may help with stool transit.
10. Peppermint oil- Additionally, a range of alternative therapy is available. Peppermint oil is worth experimenting with since there are a few drawbacks.
11. Biofeedback therapy may be highly beneficial for patients with abdominal diaphragmatic distention.
12. Diaphragmatic breathing- The diaphragmatic breathing is beneficial for some individuals.
13. Hypnotherapy - Additionally, there is some evidence that hypnotherapy may result in some improvement.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.