Abdominal bloating: pathophysiology and treatment

Effect of Trimebutine and Rifaximin on Breath Hydrogen and Methane by Glucose Breath Test in Patients With Functional Bloating: A Randomized Double-blind Clinical Trial

Background/Aims

Drugs that stabilize intestinal motility may improve the efficacy of nonabsorbable antibiotics, such as rifaximin, against small intestinal bacterial overgrowth (SIBO). We compared the efficacy of rifaximin alone with that of its combination with trimebutine maleate against SIBO.

Methods

We performed a randomized double-blind placebo-controlled trial (https://cris.nih.go.kr, no. KCT0004836) that included patients with functional bloating, no constipation, and SIBO using the hydrogen (H2)-methane (CH4) glucose breath test (GBT). Patients were randomized into 2 groups in a 1:1 ratio, namely rifaximin (1200 mg/day) + trimebutine maleate (600 mg/day) group and rifaximin + placebo group, for 2 weeks. Patients completed a symptom questionnaire and underwent a GBT at baseline and at 1 month after treatment withdrawal. The primary outcome was SIBO eradication. The secondary outcomes included changes in the concentrations of exhaled gases, symptoms, and presence of adverse events.

Results

The complete eradication rate of SIBO was 35.9% (14/39) in the rifaximin group, and 34.1% (14/41) in the combined group with no significant differences. In both groups, no significant differences were observed in GBT profiles before and after the treatment, respectively. However total breath H2 and CH4 concentration were conspicuously decreased in the combined group after treatment. The combined group exhibited substantial relief of bloating. The adverse events were similar in the 2 groups.

Conclusion

While the combination therapy was not superior over rifaximin alone for SIBO eradication, it improves the symptom of bloating with numerically reducing the concentration of breath H2/CH4.

Prevalence and severity of abdominal bloating in patients with gastroesophageal reflux disease

Abdominal bloating (AB) is a common symptom among patients with gastroesophageal reflux disease (GERD); however, in clinical practice, its prevalence is likely underestimated due to the lack of objective tools to measure its frequency and severity. It is associated with dissatisfaction and worse quality of life, but data on its prevalence before and after mechanical control of GERD (i.e. fundoplication, magnetic sphincter augmentation, and antireflux mucosectomy) are lacking. To assess and determine the pre- and postoperative prevalence and severity of AB among patients with GERD, we conducted a structured literature search using MeSH and free-text terms in MEDLINE (via Pubmed), EMBASE, and Taylor & Francis Online between January 1977 and October 2022. Fifteen articles reporting the prevalence or severity of AB using quality-of-life questionnaires before or after antireflux surgery (ARS) were included. Overall, a high prevalence of AB before ARS was found. A decline in the prevalence and severity of AB was documented postoperatively in most cases independent of the surgical approach. Among surgical approaches, a complete fundoplication had the highest reported postoperative AB. Overall, patients reported less severe and less frequent AB after ARS than before. The traditional belief that postoperative bloating is a sequela of ARS should be reevaluated.

The Disease Spectrum and Natural History of Patients With Abdominal Bloating or Distension: A Longitudinal Study

Background/Aims

Abdominal bloating or distension (AB/D) is a common complaint in the outpatient of gastroenterology department. Since the potential contributors are numerous and complex, a longitudinal study on the disease spectrum and natural history of patients was performed to better understand the key factors of AB/D.

Methods

Consecutive patients with the chief complaint of AB/D referred to the outpatient clinic were screened. Functional gastrointestinal disorders (FGIDs) were diagnosed according to Rome IV criteria. A 3-year follow-up was performed to seek for the changes in symptoms as well as disease spectrum.

Results

A total of 261 participants were enrolled and 139 completed the follow-up. Most patients suffered from moderate to severe symptoms more than 1 day per week. Common causes of AB/D were FGIDs (51.7%) and organic diseases (17.2%). The latter group was older with lower body mass index (BMI). Functional dyspepsia was the most common type of FGIDs in AB/D. The symptoms of 18.0% of participants failed to improve at the end of the 3-year follow-up, and those diagnosed with FGIDs were most likely to continue to suffer. Abdominal pain was a positive predictive factor for good prognosis in the FGIDs group. Besides, only 22.7% of participants had a consistent diagnosis of FGIDs during follow-up.

Conclusions

FGIDs are the most common diagnosis in patients with AB/D. Symptoms were especially hard to be improved. Classification diagnoses of FGIDs in AB/D patients fluctuated significantly over time.

Efficacy and Safety of Pea Protein and Xyloglucan Versus Simethicone in Functional Abdominal Bloating and Distension

BACKGROUND

Functional Abdominal Bloating and Distension (FABD) is a multifaceted condition related in part to trapped gas, with changes in the intestinal barrier and small intestinal bacterial overgrowth (SIBO), which lead to gas production. Currently, there are no treatments targeting the etiology of FABD.

METHODS

This double-blind, multicenter, randomized study evaluated the safety and efficacy of a product containing xyloglucan and pea proteins (XG + PP) compared with simethicone, both administered orally (three times daily) for 20 consecutive days. Eighty-eight patients with FABD were randomly assigned to the two groups in a 1:1 ratio. Primary outcome was safety; secondary outcomes were (i) efficacy in alleviating the symptoms of FABD and (ii) efficacy in reducing SIBO, as assessed by hydrogen breath test (HBT).

RESULTS

No Adverse Events or Serious Unexpected Adverse Reactions were reported during the study. XG + PP showed a faster onset of action and a significant reduction in bloating and abdominal pain compared with simethicone. At Day 20, XG + PP drastically reduced abdominal girth when compared with simethicone, with an average reduction of 4.7 cm versus 1.8 cm. At Day 20, the XG + PP arm showed a significant reduction in HBT compared to baseline.

CONCLUSIONS

This study supports the evidence that FABD patients may benefit from a XG + PP-based treatment that acts on etiology and not just the symptoms.

Editorial: Faecal microbiota transplantation in IBS-Moving closer or away from success? Authors' reply

This article is linked to Yau et al papers. To view these articles, visit https://doi.org/10.1111/apt.17703 and https://doi.org/10.1111/apt.17724

Spot Hydrogen Breath Test for Predicting Response to Low Fermentable Oligo-, Di-, Mono-saccharides, and Polyols Dietary Advice in Patients With Bloating

Background/Aims

An increase in postprandial intestinal gas plays a role in bloating symptoms. We aim to study the utility of spot breath hydrogen (H2) level in predicting the response to a low fermentable oligo-, di-, mono-saccharides, and polyols (FODMAPs) diet.

Methods

Patients with functional gastrointestinal disorders diagnosed by Rome IV criteria with bothersome bloating for > 6 months were prospectively enrolled. Patients completed 7-day food diaries and collected a breath sample 2 hours after their usual lunch at baseline and 4 weeks after low FODMAPs dietary advice by a dietitian. The responder was defined as an improvement of ≥ 30% bloating scores in the fourth week.

Results

Thirty-eight patients (32 female, 52.6 ± 13.8 years; 22 irritable bowel syndrome) completed the study. Twenty-one patients (55%) were classified as responders. Baseline global gastrointestinal symptoms, bloating, abdominal pain scores, and numbers of high FODMAPs items were similar between responders and non-responders. Both groups significantly decreased high FODMAPs items intake with similar numbers at the follow-up. The area under the curve for predicting low FODMAPs responsiveness using baseline H2 levels was 0.692 (95%CI, 0.51-0.86; P < 0.05), with the best cutoff at 8 parts per million (sensitivity 66.7%, specificity 82.4%). 66% of responders had baseline H2 level > 8 parts per million vs 17% of non-responders (P < 0.05). The baseline spot hydrogen level in responders was 9.5 (3.3-17.3) vs 4.5 (3.3-6.3) in non-responders (P < 0.05).

Conclusions

A higher baseline breath hydrogen level was associated with bloating improvement after low FODMAPs dietary advice. A spot breath test after lunch, a simple point-of-care test, is possibly helpful in managing patients with bloating.

Bacillus Subtilis (BG01-4TM) Improves Self-Reported Symptoms for Constipation, Indigestion, and Dyspepsia: A Phase 1/2A Randomized Controlled Trial

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are common, difficult-to-manage conditions. Probiotics are emerging as a dietary component that influence gastrointestinal (GI) health. We conducted a double-blinded randomised controlled trial of a proprietary strain of deactivated Bacillus subtilis (BG01-4™) high in branched-chain fatty acids (BCFA) to treat self-reported FGID.

METHODS

Participants (n = 67) completed a four-week intervention of BG01-4™ (n = 34) or placebo (n = 33). The Gastrointestinal Symptom Rating Scale (GSRS) served as the outcome measure, collected prior to, at two weeks, and at four weeks after completion of the intervention.

RESULTS

At four weeks, one of three primary outcomes, constipation in the experimental group, was improved by 33% compared to placebo (15%); both other primary outcomes, Total GSRS and diarrhoea, were significantly improved in both the experimental and placebo groups (32%/26% and 20%/22%, respectively). The pre-planned secondary outcome, indigestion, was improved at four weeks (32%) but compared to the placebo (21%) was not significant (p = 0.079). Exploratory analysis, however, revealed that clusters for constipation (18% improvement, p < 0.001), indigestion (11% improvement, p = 0.04), and dyspepsia (10% improvement, p = 0.04) were significantly improved in the intervention group compared to the placebo.

CONCLUSIONS

These initial findings suggest that in people with self-reported FGID, BG01-4™ improves specific symptoms of constipation and related GI dysfunction. Longer-term confirmatory studies for this intervention are warranted.

TRIAL REGISTRATION

This study was registered prospectively (25 October 2021) at the Australian New Zealand Clinical Trials Registry (ACTRN12621001441808p).

An exopolysaccharide from Lactobacillus pentosus YY-112: structure and effect on the human intestinal microbiota

The development of novel prebiotics, which could regulate the intestinal microbiota, may help prevent and treat intestinal diseases. Here, we studied a homogeneous polysaccharide, LPE-2, produced by Lactobacillus pentosus YY-112 during fermentation. Methylation and gas chromatography-mass spectrometry analysis, combined with nuclear magnetic resonance results, suggested that the structural unit of LPE-2 comprises a branched mannan moiety and a linear glucan moiety. In vitro simulated intestinal fermentation showed that LPE-2 reduced harmful intestinal gas production and promoted short-chain fatty acid production (especially propionic acid). Moreover, it reduced the relative abundance of Escherichia-Shigella, increased that of Bifidobacterium and Lactobacillus, and had a stronger regulatory effect on intestinal flora in women than in men. The potential sex-specific prebiotic effects of LPE-2 on human intestinal health, were possibly related to its mannan branch with (1→2) and (1→3) linkages and backbones with flexible α configurations, which are sheared and degraded/utilized easier by Bifidobacterium and Lactobacillus.

Perioperative and Long-Term Outcome in Patients Treated for Jejunoileal Atresia

OBJECTIVES

Jejunoileal atresia is a common cause of neonatal intestinal obstruction. Results of long-term outcome are very limited. The aim of this study was to describe perioperative and postoperative outcome, and to evaluate long-term gastrointestinal quality of life (QoL) in patients treated for jejunoileal atresia.

METHODS

We conducted a combined retrospective and cross-sectional observational study of patients treated for jejunoileal atresia during 2001-2019. Perioperative data were registered, and complications were classified according to the Clavien-Dindo classification. To evaluate long-term clinical status and QoL, the PedsQL Gastrointestinal Symptoms Scales questionnaire and a self-designed questionnaire were used. Approval from the Data Protection Office was obtained.

RESULTS

Seventy patients were included in the retrospective part of the study. Of these, 70% got a primary anastomosis. Concomitant anomalies were registered in 46%. Median length of stay was 28 (5-140) days. Early (<28 days) complication rate was 66%. Early abdominal surgical reinterventions were performed in 11%, most frequently due to anastomotic leak. Late (>28 days) abdominal surgical reinterventions were performed in 21%, and most commonly for bowel obstruction. Overall mortality rate was 4%. Thirty-two patients with median 8 (2-19) years returned the questionnaires. Overall gastrointestinal QoL was good. However, concomitant gastrointestinal anomalies were associated with impaired outcome. Embarrassment of the scar was reported in 38%. Three (9%) patients used medication (laxatives, proton pump inhibitor) for gastrointestinal symptoms.

CONCLUSIONS

Jejunoileal atresia is associated with significant morbidity during initial treatment. Despite this, the majority of the patients have excellent long-term outcomes.

Flatus Incontinence and Fecal Incontinence: A Case-Control Study

BACKGROUND

Incontinence to gas can be a troublesome symptom impacting quality of life for patients even in the absence of fecal incontinence. Whether isolated flatus incontinence represents part of the spectrum of true fecal incontinence or a separate condition with a different pathophysiology remains unclear.

OBJECTIVE

This study aimed to evaluate the clinical features and anorectal physiology in women presenting with severe isolated flatus incontinence compared to women with fecal incontinence and healthy asymptomatic women.

DESIGN

This was a retrospective case-control study of prospectively collected data.

SETTINGS

Data from participants were obtained from a single tertiary Neurogastroenterology Unit in Sydney, Australia.

PATIENTS

Data from 34 patients with severe isolated flatus incontinence, 127 women with fecal incontinence' and 44 healthy women were analyzed.

MAIN OUTCOME MEASURES

The primary outcomes were clinical (including demographic, obstetric, and symptom variables) and physiological differences across the 3 groups.

RESULTS

Patients with flatus incontinence were significantly younger (mean 39 versus 63 years; p = 0.0001), had a shorter history of experiencing their symptoms ( p = 0.0001), and had harder stool form than patients with fecal incontinence ( p = 0.02). Those with flatus incontinence had an adverse obstetric history and impaired anorectal physiology (motor and sensory, specifically rectal hypersensitivity) but to a lesser extent than patients with fecal incontinence.

LIMITATIONS

This study was limited by its retrospective design and modest sample size.

CONCLUSIONS

Anorectal physiology was impaired in patients with flatus incontinence compared to healthy controls, but to a lesser extent than in those with fecal incontinence, raising the possibility that flatus incontinence could be a precursor to fecal incontinence. As clinical and physiological findings are different from healthy controls (including the presence of visceral hypersensitivity), isolated flatus incontinence should be considered a distinct clinical entity (like other functional GI disorders), or possibly part of an incontinence spectrum rather than purely a normal phenomenon. See Video Abstract at http://links.lww.com/DCR/B946 .

INCONTINENCIA DE FLATOS E INCONTINENCIA FECAL UN ESTUDIO DE CASOS Y CONTROLES

ANTECEDENTES:La incontinencia de gases puede ser un síntoma molesto que afecta la calidad de vida de los pacientes incluso en ausencia de incontinencia fecal. Aún no está claro si la incontinencia de flatos aislada representa parte del espectro de la incontinencia fecal verdadera o una condición separada con una fisiopatología poco clara.OBJETIVO:Evaluar las características clínicas y la fisiología anorrectal en mujeres que presentan incontinencia grave aislada de flatos, en comparación con la incontinencia fecal y mujeres sanas asintomáticas.DISEÑO:Este fue un estudio retrospectivo de casos y controles de datos recolectados prospectivamente.AJUSTE:Los datos de los participantes se obtuvieron de una sola Unidad de Neurogastroenterología terciaria en Sydney, Australia.PACIENTES:Se analizaron los datos de 34 pacientes con incontinencia grave aislada de flatos, junto con 127 mujeres con incontinencia fecal y 44 mujeres sanas.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron clínicos (incluidas las variables demográficas, obstétricas y de síntomas), así como las diferencias fisiológicas entre los tres grupos.RESULTADOS:Los pacientes con incontinencia de flatos eran significativamente más jóvenes (media de 39 años frente a 63 años, p = 0,0001), tenían un historial más corto de experimentar sus síntomas (p = 0,0001) y tenían heces más duras que los pacientes con incontinencia fecal (p = 0,02). Aquellos con incontinencia de flatos tenían antecedentes obstétricos adversos y fisiología anorrectal alterada (motora y sensorial, específicamente hipersensibilidad rectal); aunque en menor medida que las pacientes con incontinencia fecal.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo y tamaño de muestra modesto.CONCLUSIONES:La fisiología anorrectal se vio afectada en las pacientes con incontinencia de flatos en comparación con las controles sanos, pero en menor medida que en aquellas con incontinencia fecal, lo que plantea la posibilidad de que la incontinencia de flatos pueda ser un precursor de la incontinencia fecal. Dado que los hallazgos clínicos y fisiológicos son diferentes a los de los controles sanos (incluida la presencia de hipersensibilidad visceral), la incontinencia de flatos aislada debe considerarse como una entidad clínica distinta (al igual que otros trastornos gastrointestinales funcionales), o posiblemente como parte de un espectro de incontinencia en lugar de un trastorno puramente a un fenómeno normal. Consulte Video Resumen en http://links.lww.com/DCR/B946 . (Traducción-Dr Yolanda Colorado ).

A Tritordeum-Based Diet for Female Patients with Diarrhea-Predominant Irritable Bowel Syndrome: Effects on Abdominal Bloating and Psychological Symptoms

Most female patients with irritable bowel syndrome (IBS) complain of abdominal bloating rather than abdominal pain and diarrhea. The higher incidence in women could be due to the so-called dysfunctional gas handling. Since diet seems the most effective and durable strategy for managing IBS symptoms, we aimed to evaluate the effects of a 12 week diet based on a relatively new cereal, Tritordeum (TBD), on gastrointestinal (GI) symptoms, anthropometric and bioelectrical impedance parameters, and psychological profiles in 18 diarrhea-predominant IBS (IBS-D) female patients with abdominal bloating as the dominant symptom. The IBS Severity Scoring System (IBS-SSS), the Symptom Checklist-90 Revised, the Italian version of the 36-Item Short-Form Health Survey, and the IBS-Quality of Life questionnaire were administered. The TBD reduces the IBS-SSS “Intensity of abdominal bloating” with a concomitant improvement in the anthropometric profile. No correlation was found between “Intensity of abdominal bloating” and “Abdominal circumference”. Anxiety, depression, somatization, interpersonal sensitivity, and phobic and avoidance manifestations were significantly reduced after TBD. Lastly, anxiety was correlated with “Intensity of abdominal bloating”. Overall, these results suggest the possibility of lowering abdominal bloating and improving the psychological profile of female IBS-D patients using a diet based on an alternative grain such as Tritordeum.

The effects of Bacillus coagulans MTCC 5856 on functional gas and bloating in adults: A randomized, double-blind, placebo-controlled study

BACKGROUND

Gut microbiome dysbiosis is a major cause of abdominal gas, bloating, and distension. Bacillus coagulans MTCC 5856 (LactoSpore) is a spore-forming, thermostable, lactic acid-producing probiotic that has numerous health benefits. We evaluated the effect of Lacto Spore on improving the clinical symptoms of functional gas and bloating in healthy adults.

METHODS

Multicenter, randomized, double-blind, placebo-controlled study at hospitals in southern India. Seventy adults with functional gas and bloating with a gastrointestinal symptom rating scale (GSRS) indigestion score ≥ 5 were randomized to receive B coagulans MTCC 5856 (2 billion spores/day, N = 35) or placebo (N = 35) for 4 weeks. Changes in the GSRS-Indigestion subscale score for gas and bloating and global evaluation of patient's scores from screening to the final visit were the primary outcomes. The secondary outcomes were Bristol stool analysis, brain fog questionnaire, changes in other GSRS subscales, and safety.

RESULTS

Two participants from each group withdrew from the study and 66 participants (n = 33 in each group) completed the study. The GSRS indigestion scores changed significantly (P < .001) in the probiotic group (8.91-3.06; P < .001) compared to the placebo (9.42-8.43; P = .11). The median global evaluation of patient's scores was significantly better (P < .001) in the probiotic group (3.0-9.0) than in the placebo group (3.0-4.0) at the end of the study. The cumulative GSRS score, excluding the indigestion subscale, decreased from 27.82 to 4.42% (P < .001) in the probiotic group and 29.12 to 19.33% (P < .001) in the placebo group. The Bristol stool type improved to normal in both the groups. No adverse events or significant changes were observed in clinical parameters throughout the trial period.

CONCLUSIONS

Bacillus coagulans MTCC 5856 may be a potential supplement to reduce gastrointestinal symptoms in adults with abdominal gas and distension.

A Theory Planned Behaviour of Study on Improving Abdominal Bloating among the Malays Population: A Qualitative Study

Background

Abdominal bloating (AB) is a common medical complaint known to diminish patients' quality of life. However, lifestyle and behavioural changes could mitigate its expression and severity. This study sought to explore the health beliefs, intentions and health-promoting behaviours among people with AB in Kelantan, Malaysia.

Methods

The theory of planned behaviour (TPB) was employed to explore the factors that influence the management of adults with AB, namely health beliefs and intentions. An interview guide was developed by adapting the TPB and the findings of prior studies concerning the factors associated with AB management. All eligible participants took part in in-depth interviews.

Results

The mean age of the participants was 32.5 years old (standard deviation [SD] = 14.19 years old) and the majority of participants were female (58.3%). The themes and sub-themes that emerged following the application of the TPB framework represented the qualitative results of this study, which indicated that the health beliefs, intentions and health-promoting behaviours observed among people with AB were closely related.

Conclusion

The findings of this study suggest that the adoption of a healthy lifestyle could be an effective means of improving AB. Thus, it is vital to implement a health education programme that promotes health-related beliefs and intentions in order to trigger health-promoting behaviour among people with AB.

The probiotic Bacillus subtilis BS50 decreases gastrointestinal symptoms in healthy adults: a randomized, double-blind, placebo-controlled trial

ABSTRACT

Durable spore-forming probiotics are increasingly formulated into foods, beverages, and dietary supplements. To help meet this demand, the safety and efficacy of daily supplementation of Bacillus subtilis BS50 for 6 weeks was investigated in a randomized, double-blind, placebo-controlled, parallel clinical trial of 76 healthy adults. Before and during supplementation, gastrointestinal symptoms were recorded daily using a multi-symptom questionnaire. Clinical chemistry, hematology, plasma lipids, and intestinal permeability and inflammation markers were measured at baseline and end of study. Compared to placebo, 2 × 10⁹ colony-forming units (CFU) BS50 per day increased the proportion of participants showing improvement from baseline to week 6 in the composite score for bloating, burping, and flatulence (47.4% vs. 22.2%), whereby the odds of detecting an improvement were higher with BS50 (OR [95% CI]: 3.2 [1.1, 8.7], p = .024). Analyses of individual gastrointestinal symptoms indicate that BS50 increased the proportion of participants showing an improvement at week 6 compared to placebo for burping (44.7% vs. 22.2%, p = .041) and bloating (31.6% vs. 13.9%, p = .071), without affecting other symptoms. There were no clinically meaningful changes in clinical chemistry, hematology, plasma lipids and intestinal permeability and other inflammation markers. In conclusion, the results suggest that dietary supplementation of 2 × 10⁹ CFU Bacillus subtilis BS50 per day is a well-tolerated and safe strategy to alleviate gas-related gastrointestinal symptoms in healthy adults.

ABBREVIATIONS

AE adverse event; BHD bowel habits diary; BMI body mass index; BSS Bristol Stool Scale; CFU colony-forming unit; CRP C-reactive protein; FGID functional gastrointestinal disorder; GI gastrointestinal; GITQ Gastrointestinal Tolerance Questionnaire; GLP-1 glucagon-like peptide 1; GSRS Gastrointestinal Symptom Rating Scale; HDL-C high-density lipoprotein-cholesterol; IBS irritable bowel syndrome; IL-10 interleukin-10; ITT intent-to-treat; LBP lipopolysaccharide binding protein; LDL-C low-density lipoprotein-cholesterol; PP per protocol; PYY peptide YY; TG triglyceride; total-C total cholesterol.

Association Between Food Intake and Gastrointestinal Symptoms in Patients With Obesity

BACKGROUND AND AIMS

Hunger, satiation, postprandial satiety, and hedonic eating constitute key food intake parameters. We aim to study whether these symptoms are associated with gastrointestinal symptoms (GIS) in patients with obesity.

METHODS

This is a cross-sectional study of patients with obesity. Patients completed the following validated biomarkers and questionnaires: hunger was measured via visual analog scale (100 mm) following a standard meal, satiation was measured via ad libitum meal (calories to fullness; kcal), postprandial satiety was measured via gastric emptying scintigraphy (T_1/2; mins), and hedonic eating was measured via the Hospital Anxiety and Depression Scale questionnaire. Participants completed the abridged Bowel Disease Questionnaire to evaluate their GIS. We calculated the odds ratios (ORs) adjusted for sex, weight, and age between food intake parameters <25^th or >75^th percentile observed in a prior cohort of 450 participants with obesity and GIS.

RESULTS

A total of 274 participants (41 ± 10 [SD] years, 75% females, body mass index 39 ± 8 kg/m²) were included in the analysis. Increased hunger was associated with a lower prevalence of lumpy stools (OR = 0.18, P = .02). Satiation was associated with abdominal pain/discomfort (relieved by defecation [OR = 2.4, P = .02] or associated with change in stool consistency [OR = 2.92, P < .01]), loose/watery stools (OR = 2.09, P = .02), and bloating (OR = 2.49, P < .01). Abnormal postprandial satiety was associated with bloating (OR = 2.26, P < .01) and loose/watery stools (OR = 1.84, P = .04). Hedonic eating was associated with abdominal pain/discomfort with stool frequency change (OR = 2.4, P = .02), >3 bowel movements per day (OR = 1.93, P = .048), bloating (OR = 2.49, P = .01), abdominal pain after meals >1 per month (OR = 4.24, P < .01), and nausea >1 per week (OR = 4.51, P < .01).

CONCLUSION

Alterations in hunger, satiation, postprandial satiety, and hedonic eating are associated with GIS in patients with obesity.

Synthetic glycans control gut microbiome structure and mitigate colitis in mice

Relative abundances of bacterial species in the gut microbiome have been linked to many diseases. Species of gut bacteria are ecologically differentiated by their abilities to metabolize different glycans, making glycan delivery a powerful way to alter the microbiome to promote health. Here, we study the properties and therapeutic potential of chemically diverse synthetic glycans (SGs). Fermentation of SGs by gut microbiome cultures results in compound-specific shifts in taxonomic and metabolite profiles not observed with reference glycans, including prebiotics. Model enteric pathogens grow poorly on most SGs, potentially increasing their safety for at-risk populations. SGs increase survival, reduce weight loss, and improve clinical scores in mouse models of colitis. Synthetic glycans are thus a promising modality to improve health through selective changes to the gut microbiome.

The Intestinal Gas Questionnaire (IGQ): Psychometric validation of a new instrument for measuring gas-related symptoms and their impact on daily life among general population and irritable bowel syndrome

BACKGROUND

Gas-related symptoms (GRS) are common in the general population (GPop) and among patients with disorders of gut-brain interactions but there is no patient-reported outcome evaluating these symptoms and their impact on daily life. We have previously developed a 43-item intestinal gas questionnaire (IGQ). The aim of the present study is to perform a psychometric validation of this instrument.

METHODS

Participants (119 from the GPop and 186 irritable bowel syndrome (IBS) patients) were recruited from 3 countries (UK, Spain, France). IBS patients fulfilled ROME IV criteria with an IBS severity score between 150 and 300. Participants completed the IGQ, the functional Digestive Disorders Quality of Life (FDDQL), and the EQ-5D. A subgroup (n = 90) repeated the IGQ completion after 7 days on paper or electronically.

RESULTS

From the original IGQ questionnaire, 26 items were deleted because of poor performance. Confirmatory factorial analysis on the remaining 17 items (7 symptom and 10 impact items) yielded a 6-factor structure accounting for 67% of the variance for bloating (6 items), flatulence (3), belching (2), bad breath (2), stomach rumbling (2), and difficult gas evacuation (2). Global score (0-100) was worse among IBS vs GPop (40 ± 15 vs 33 ± 17; p = 0.0016). At the second visit, the intraclass correlation coefficient of IGQ scores was between 0.71 and 0.86 (n = 67) for test-retest reliability and 0.61-0.87 (n = 64) for equivalence between electronic and paper versions of IGQ.

CONCLUSION

The IGQ available in paper and electronic versions in 3 languages is a robust instrument for capturing and measuring GRS and their impact on daily life.

Aerophagia Study in Indonesia: Prevalence and Association With Family-related Stress

BACKGROUND

Aerophagia is a functional gastrointestinal disorder characterized by repeated air swallowing leading to chronic abdominal distension. Symptoms can be long lasting, lead to frustration, and distress. This study describes prevalence, related factors, and symptomatology of aerophagia, together with its relationship with emotional stress.

MATERIALS AND METHODS

Cross-sectional study. Adolescents aged 10 to 17 years from selected state schools by convenient sampling from Jakarta, Indonesia, were recruited. Rome III self-administered questionnaire was used to compile data on gastrointestinal symptoms. Data on sociodemographic characteristics, intestinal and extraintestinal symptoms, and stressful life events were collected using a separate questionnaire.

RESULTS

A total of 1796 questionnaires were included in the analysis [males 732 (40.8%), mean age 13.58 (SD 0.992) years]. There were 81 (4.5%) subjects diagnosed with aerophagia. When the criterion of belching was removed from the diagnosis of aerophagia, the prevalence drops to only 2 (0.1%). subjects. Bivariate analysis showed that sociodemographic factors have no correlation with aerophagia. In subjects with aerophagia, among the intestinal-related and extraintestinal symptoms, only loss of appetite was significantly more common in the aerophagia population (33.3%) when compared with controls (22.8%). Death of a close family member [adjusted odds ratio (OR), 2.78; 95% confidence interval (CI), 1.46-5.31; P=0.002], divorce or separation of parents (adjusted OR, 2.54; 95% CI, 1.38-4.66; P=0.003), and divorce followed by separate individual remarriage of parents (adjusted OR, 2.01; 95% CI, 1.01-3.98; P=0.046) were found to be significantly associated with aerophagia by multivariate analysis.

CONCLUSIONS

The prevalence of aerophagia was found in 4.5% of Indonesian school-aged children according to Rome III criteria, but the prevalence was found only 0.1% if the belching is removed from the criteria. Besides the main symptoms, only loss of appetite was significantly more common in aerophagia among intestinal-related and extraintestinal symptoms. Family-related stress showed a significant correlation with aerophagia.

The biological activities of postbiotics in gastrointestinal disorders

According to outcomes from clinical studies, an intricate relationship occurs between the beneficial microbiota, gut homeostasis, and the host's health status. Numerous studies have confirmed the health-promoting effects of probiotics, particularly in gastrointestinal diseases. On the other hand, the safety issues regarding the consumption of some probiotics are still a matter of debate, thus to overcome the problems related to the application of live probiotic cells in terms of clinical, technological, and economic aspects, microbial-derived biomolecules (postbiotics) were introducing as a potential alternative agent. Presently scientific literature confirms that the postbiotic components can be used as promising tools for both prevention and treatment strategies in gastrointestinal disorders with less undesirable side-effects, particularly in infants and children. Future head-to-head trials are required to distinguish appropriate strains of parent cells, optimal dosages of postbiotics, and assessment of the cost-effectiveness of postbiotics compared to alternative drugs. This review provides an overview of the concept and safety issues regarding postbiotics, with emphasis on their biological role in the treatment of some important gastrointestinal disorders.

The effect of a short-term physical activity after meals on gastrointestinal symptoms in individuals with functional abdominal bloating: a randomized clinical trial

AIM

The present study aims to compare the effect of a short duration postprandial walking and prokinetic medications on bloating reported by healthy individuals.

BACKGROUND

Abdominal bloating imposes significant clinical, social and economic burden on the healthcare systems; however, treatment of bloating is limited and not effective in all individuals with this symptom. Prokinetic agents are recommended in the treatment of bloating in individuals without underlying disorders traditionally.

METHODS

The study participants were randomized into two groups of control and intervention. In the control group, individuals were given daily domperidone plus activated dimethicone as a prokinetic medication, while the subjects in the intervention group were asked to perform a 10-15-minutewalk after each meal. The study duration was 4 weeks, the subjects were re-visited afterwards, and their symptoms was compared before and after the study.

RESULTS

This study consists of 94 individuals including 24 men and 70 women with mean age of 44.47±12.25 years with 49 participants in the control group and 45 participants in the intervention group. Both prokinetic medication use and minimal exercise after meals were associated with significant improvements in the GI tract symptoms such as belching, flatus, postprandial epigastric fullness/ bloating, gas incontinency and abdominal discomfort/pain (p-value <0.001). The changes in the score of the gastrointestinal symptoms from beginning to end of study between the two arms of study were not statistically significant except for postprandial epigastric fullness/ bloating symptoms where the intervention was superior to the use of prokinetics (p-value=0.002).

CONCLUSION

This study shows that physical activity could be effective in relieving abdominal bloating symptoms. In contrast to other means of treatment proposed for abdominal bloating and its related symptoms, it needs no materials or equipment and can be easily performed by any individual.

Comparison of a Novel Herbal Medicine and Omeprazole in the Treatment of Functional Dyspepsia: A Randomized Double-Blinded Clinical Trial

Background

The Trachyspermum ammi L. (TA), Anethum graveolens L. (AG), and Zataria multiflora Boiss (ZM) herbal oils are among the most used herbal products in traditional medicine as the antiseptic, anesthetic, carminative, and antispasmodic. However, there are no clinical studies to evaluate the efficacy of the herbs mentioned in the treatment of functional dyspepsia (FD). This study was designed to appraise the efficacy and safety of a novel herbal medicine consisting of ZM, AG, and TA essential oils compared to omeprazole in FD treatment.

Methods

The present study was a randomized double-blind clinical trial with parallel groups in Iran. Patients in control and intervention arms received omeprazole 20 mg once a day and 250 mg soft-gel capsules containing 180 mg of essential oils of ZM, AG, and TA twice a day for two weeks, respectively. The primary outcome was the sufficient response rate in the postprandial distress syndrome (PDS) and/or epigastric pain syndrome (EPS) at the end of the intervention. Secondary outcomes were the improvement rate in the PDS, EPS, Gastrointestinal Symptom Rating Scale (GSRS), and quality of life scores. Also, safety and tolerability were assessed.

Results

The within-group comparison of EPS, PDS, total GSRS, GSRS Pain, and GSRS Dyspepsia scores with that at the end of the treatment indicated a significant reduction in both control and intervention groups (p < 0.001). However, after two weeks of treatment, the herbal medication and omeprazole arms were significantly different in the sufficient response rate based on PDS (p < 0.01) and EPS (p < 0.05) scores (78.3% (18/23) and 73.7% (14/19) in the intervention group vs. 36.4% (8/22) and 40.9% (9/22) in the control group). Also, the mean reduction in EPS (p < 0.05), PDS (p < 0.01), and GSRS (p < 0.001) scores after treatment was significantly higher in the intervention group than control group.

Conclusion

Based on the study findings, this herbal medicine can be considered as an appropriate treatment of FD. However, a larger multicenter trial is needed to confirm the results of the trial.

Prebiotics and Community Composition Influence Gas Production of the Human Gut Microbiota

Prebiotics confer benefits to human health, often by promoting the growth of gut bacteria that produce metabolites valuable to the human body, such as short-chain fatty acids (SCFAs). While prebiotic selection has strongly focused on maximizing the production of SCFAs, less attention has been paid to gases, a by-product of SCFA production that also has physiological effects on the human body. Here, we investigate how the content and volume of gas production by human gut microbiota are affected by the chemical composition of the prebiotic and the community composition of the microbiota. We first constructed a linear system model based on mass and electron balance and compared the theoretical product ranges of two prebiotics, inulin and pectin. Modeling shows that pectin is more restricted in product space, with less potential for H2 but more potential for CO2 production. An ex vivo experimental system showed pectin degradation produced significantly less H2 than inulin, but CO2 production fell outside the theoretical product range, suggesting fermentation of fecal debris. Microbial community composition also impacted results: methane production was dependent on the presence of Methanobacteria, while interindividual differences in H2 production during inulin degradation were driven by a Lachnospiraceae taxon. Overall, these results suggest that both the chemistry of the prebiotic and the composition of the microbiota are relevant to gas production. Metabolic processes that are relatively prevalent in the microbiome, such as H2 production, will depend more on substrate, while rare metabolisms such as methanogenesis depend more strongly on microbiome composition.IMPORTANCE Prebiotic fermentation in the gut often leads to the coproduction of short-chain fatty acids (SCFAs) and gases. While excess gas production can be a potential problem for those with functional gut disorders, gas production is rarely considered during prebiotic design. In this study, we combined the use of theoretical models and an ex vivo experimental platform to illustrate that both the chemical composition of the prebiotic and the community composition of the human gut microbiota can affect the volume and content of gas production during prebiotic fermentation. Specifically, more prevalent metabolic processes such as hydrogen production were strongly affected by the oxidation state of the probiotic, while rare metabolisms such as methane production were less affected by the chemical nature of the substrate and entirely dependent on the presence of Methanobacteria in the microbiota.

Dysbiosis in intestinal microbiome linked to fecal blood determined by direct hybridization

The important physiological and pathophysiological roles of intestinal human microbiome (HMB) in human health have been emerging, owing to the access to molecular biology techniques. Herein we evaluated, for the first time, the intestinal HMB through direct hybridization approach using n-counter flex DX technology which bypasses the amplification procedure currently applied by other technologies to study the human microbiome. To this purpose, a clinical study was carried out on fecal samples, recruiting both healthy volunteers (N-FOB) and subjects positive for occult blood (P-FOB). A relevant custom panel of 79 16S rRNA target gene was engineered and 32 of them displayed a variation between the two clusters of subjects. Our findings revealed that bacteria belonging to Proteobacteria have higher distribution in P-FOB describing dysbiosis. Similarly, Bacteroidetes and Firmicutes phylum display high distribution in P-FOB. Of interest, the presence of Clostridium difficile that belongs to Firmicutes phylum displayed about 70% of low presence in N-FOB compared to P-FOB subjects. Only one bacterium belonging to the Actinobacteria phylum, the Bifidobacterium bifidum, was present.

Validity and Reliability of the Newly Developed Malay-Language Health Belief of Bloating (HB-Bloat) Scale

Abdominal bloating (AB), a common complaint that affects quality of life and disturbs psychological well-being, is largely a behavioral-driven disorder. We aimed to develop and validate a new health belief of bloating (HB-Bloat) scale in the Malay language. The initial item pool was developed based on the theory of planned behavior, empirical literatures, expert review and in-depth interviews. Using the population with bloating (diagnosed based on the Rome IV criteria and pictogram), exploratory and confirmatory factor analytical approaches (EFA and CFA, respectively) were utilized to explore and confirm the domains in the new scale. There were 150 and 323 respondents in the EFA and CFA, respectively. There were 45 items in the initial scale, but it was reduced to 32 items after content validity and pre-testing. In EFA, 17 items with three (3) structure factors (attitude 4 items, subjective norm 7 items, and perceived behavior control 6 items) were identified. Total variance explained by the EFA model was 40.92%. The Cronbach alpha of the three (3) factors ranged from 0.61 to 0.79. With CFA, the three factors model was further tested. Five problematic items were identified and removed. The final measurement model fit the data well (root mean square error of approximation (RMSEA (90% CI) = 0.054 (0.038, 0.070), Comparative Fit Index (CFI) = 0.941, Tucker–Lewis Fit Index (TLI) = 0.924, and standardized root mean squared residual (SRMR) = 0.044). The construct reliability of the final measurement model ranged from 0.76 to 0.84. As a conclusion, the new HB-Bloat scale is a valid and reliable tool for assessment of health beliefs in bloating.

Effects of the DASH Diet and Sodium Intake on Bloating: Results From the DASH-Sodium Trial

INTRODUCTION

Bloating is one of the most common gastrointestinal complaints. Evidence has linked fiber and sodium to bloating; however, randomized trials examining these diet components are lacking. Here, we used a randomized trial to examine the effects of the high-fiber DASH diet and dietary sodium intake on abdominal bloating. We hypothesized that both the high-fiber DASH diet and higher sodium intake would increase bloating.

METHODS

The DASH-Sodium trial (1998-1999) randomized healthy adults to a high-fiber (32 g/d) DASH or low-fiber (11 g/d) Western diet (control). On their assigned diet, participants ate 3 sodium levels (50, 100, and 150 mmol/d at 2100 kcal) in 30-day periods in random order, with 5-day breaks between each period. The participants reported the presence of bloating at baseline and after each feeding period. Statistical analyses included log-binomial models to evaluate the risk of bloating.

RESULTS

Of 412 participants (mean age 48 years; 57% women; 57% black), 36.7% reported bloating at baseline. Regardless of the diet, high sodium intake increased the risk of bloating (risk ratio = 1.27; 95% confidence interval: 1.06-1.52; P = 0.01). The high-fiber DASH diet also increased the risk of bloating over all sodium levels (risk ratio = 1.41; 95% confidence interval: 1.22-1.64; P < 0.001). The effect of high-fiber DASH on bloating was greater in men than in women (P for interaction = 0.001).

DISCUSSION

Higher dietary sodium increased bloating, as did the high-fiber DASH diet. Although healthful high-fiber diets may increase bloating, these effects may be partially mitigated by decreasing dietary sodium intake. Future research is needed to explore mechanisms by which sodium intake and diet can influence bloating.

The efficacy of a Persian herbal formulation on functional bloating: A double-blind randomized controlled trial

BACKGROUND

Bloating is a common gastrointestinal complaint which is difficult to treat.

OBJECTIVE

This study investigated the efficacy and compliance of a formulation called KAASER comprised of Trachyspermum ammi (L.) Sprague seed, Zingiber officinale Roscoe. rhizome and Piper nigrum L. berry in the treatment of functional bloating.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTION

A total of 106 patients with functional bloating, between 20 and 50 years of age, participated in this double-blind randomized controlled trial. Patients were divided into 3 parallel groups that received 500 mg of placebo, dimethicone or KAASER, three times a day for 2 weeks.

MAIN OUTCOME MEASURES

The frequency and severity of bloating were primary outcomes, while the frequencies of eructation, defecation, borborygmus and early satiation were secondary outcomes. All parameters were evaluated at the beginning (week 0), and also weeks 2, 4 and 10 of the study, through self-report checklists with a scoring system.

RESULTS

Among the 84 patients who completed the study, the frequency and severity of bloating (P < 0.001), the frequencies of eructation, defecation and borborygmus (P = 0.03) were significantly improved in the group receiving KAASER (36 patients) compared with the dimethicone (35 patients) and placebo (35 patients) groups, during the 3 phases of follow-up. These significant differences persisted through the 2 and 8 weeks of follow-ups after cessation of medication (week 4 and 10). In early satiation, no significant differences were observed among the 3 groups.

CONCLUSION

The results showed that KAASER can be effectively used to treat patients suffering from bloating. Bloating, eructation, defecation and borborygmus in the KAASER group remained significantly improved after 2 and 8 weeks of cessation of medication, making this mechanism an interesting area for further investigation.

TRIAL REGISTRATION

Registration trial IRCT2015100324327N on Iranian Registry of Clinical Trials.

Bloating in Irritable Bowel Syndrome Is Associated with Symptoms Severity, Psychological Factors, and Comorbidities

BACKGROUND

Bloating is one of the most bothersome symptoms of irritable bowel syndrome (IBS), but its association with other symptoms is not well described.

AIMS

We investigated the association between symptoms of abdominal bloating, other IBS symptoms, psychological distress, and comorbid pain conditions.

METHODS

We conducted a cross-sectional study on a large cohort of IBS patients with and without symptoms of abdominal bloating and healthy controls. Subjects were assessed for IBS and its subtypes, pain severity, symptoms severity, psychological disturbances, comorbidities, and dietary restrictions of three fluid groups.

RESULTS

A total of 484 subjects were investigated. Compared with IBS - B, IBS + B subjects had higher rates of constipation (30% vs. 15%, p = 0.191) and lower rates of diarrhea, (70% vs. 85%, p = 0.191) although these were not statistically significant. Bloating severity correlated with IBS symptoms severity (r = 0.397, p = 0.000), pain severity (r = 0.364, p = 0.000), and both anxiety and somatization scores (r = 0.167, p = 0.015 and r = 0.219, p = 0.001, respectively). Prevalence of fibromyalgia and depression and somatization scores was significantly higher in IBS with bloating than in IBS without bloating. IBS patients with bloating reported more dietary restriction of three fluid groups to control their symptoms compared with healthy controls and IBS patients without bloating.

CONCLUSIONS

Abdominal bloating in IBS is associated with increased symptoms and pain severity, somatization, depression, fibromyalgia, and altered dietary fluids composition. Recognizing and addressing these factors in the diagnosis and management of patients with IBS may improve clinical outcome.

An integrative review of dietetic and naturopathic approaches to functional bowel disorders

OBJECTIVES

Naturopathy and dietetics have evolved as two separate but parallel professions that use diet to promote optimal health and manage many illnesses and diseases. Given the increasing recognition of the influence of diet on health outcomes, there is increasing demand for the services of both professions. The aim of this research was to investigate similarities and differences between naturopathic and dietetic approaches to functional bowel disorders (FBDs).

DESIGN

For this integrative review AMED, CINAHL, the Cochrane Database of Systematic Reviews, EMBASE, Medline and PubMed databases were searched for articles that focused on dietetic or naturopathic diagnosis and treatment of food intolerance expressing as a FBD in adults. (Registration: PROSPERO 2016 CRD42016049469).

RESULTS

Of the 55 papers in the final review, 10 discussed complementary medicine approaches to FBDs. Both dietitians and naturopaths used similar holistic approaches to diagnosis and treatment, adjusted diets as a primary treatment approach, and individualised treatment for their patients. The professions differed in their use of vitamin, mineral and herbal supplements and in their willingness to recommend other treatments like osteopathy and acupuncture.

CONCLUSIONS

There is much overlap between dietetic and naturopathic approaches to assessment and treatment of FBDs. Further publications that describe naturopathic treatments for FBDs are needed to confirm these results and to provide opportunities for increased recognition and scrutiny of any distinctively naturopathic approaches. Without doing so, naturopathic practices are likely to remain marginalised and poorly understood. Moreover, the opportunity to fully contribute to the management of lifestyle-related diseases will be missed.

Mentha spicata L. essential oil, phytochemistry and its effectiveness in flatulence

Flatulence as the continuous feeling of abdominal distension is equal to "Nafkh" in Iranian Traditional Medicine. Nafkh is believed to derive from the amount of stomach temperature, humidity of food or abnormal humidity in digestive tract and their interactions. Mentha spicata as cool and spicy plant with astringent and digestive property is recommended for treatment of flatulence. The information was extracted from accessible international databases, traditional books, electronic resources, and unpublished data. M. spicata essential oil with main component of carvone has potency for treatment of flatulence related to indigestion, cesarean section and dysmenorrhea. Also, it can reduce the pain severity during the colonoscopy or dysmenorrheal conditions. No hazardous effects were reported for M. spicata essential oil, if it is used in proper dosages. M. spicata essential oil can be applied for other intestinal complaints with pain and flatulence such as Irritable Bowel Syndrome (IBS) that needs more deep clinical trials for demonstrating its potential.

Clinical Response of Rifaximin Treatment in Patients with Abdominal Bloating

BACKGROUND/AIMS

Abdominal bloating is a troublesome complaint due to insufficient understanding of the pathophysiology. The aim of this study was to evaluate the efficacy of rifaximin in reducing bloating associated with functional gastrointestinal disorders (FGIDs).

METHODS

A total of 63 patients were treated with rifaximin for FGIDs with bloating or gas-related symptoms between 2007 and 2013 at Seoul National University Bundang Hospital. Rifaximin was administered at a dose between 800 mg/day and 1,200 mg/day for 5 to 14 days. The proportion of patients who had adequate relief of global FGID symptoms and FGID-related bloating was retrospectively assessed. The response was recorded when the symptoms were reduced by at least 50% at the follow-up after treatment cessation.

RESULTS

The mean age was 56.8±14.2 years; 49.2% were females. According to Rome III criteria, 20.6% (13/63) had irritable bowel syndrome (IBS) with constipation, 9.5% (6/63) had IBS with diarrhea, 4.8% (3/63) had mixed IBS, 23.8% (15/63) had functional dyspepsia, and 12.7% (8/63) had functional bloating. Of the 51 subjects who were followed-up, 30 (58.8%) had adequate relief of global FGID symptoms and 26 (51.0%) experienced improvement of abdominal bloating after rifaximin treatment. The proportion of female was slightly higher in non-response group than in the response group (60.0% vs. 34.6%, p=0.069). Otherwise, there was no difference between the two groups.

CONCLUSIONS

Despite the limitations of this retrospective study, our data confirms that rifaximin may be beneficial for abdominal bloating. Further prospective clinical trial with a larger cohort is needed.

Efficacy and safety of APT036 versus simethicone in the treatment of functional bloating: a multicentre, randomised, double-blind, parallel group, clinical study

Background

Bloating is a common symptom reported by around 16% to 31% of the general population. Functional bloating is diagnosed in patients with recurrent symptoms of bloating who do not meet the diagnostic criteria of irritable bowel syndrome or other functional gastrointestinal disorders.

Methods

This double-blind, multicentre, randomised study compared the safety and efficacy of APT036 (xyloglucan plus tyndallized Lactobacillus reuteri and Bifidobacterium brevis; Aprotecol^®) and simethicone in treating functional bloating in adults. APT036 or simethicone were administered orally (3 times/day) for 20 consecutive days, with evaluations at baseline, and on Days 2, 10, 20 (end of treatment) and 30 (follow-up visit). The main outcome measure was safety. Efficacy was assessed at each visit by patient-reported symptom severity (Likert scale) and abdominal girth measurement. A hydrogen breath test was performed at baseline and Day 20.

Results

Both APT036 (n=54) and simethicone (n=54) were well tolerated by study subjects; no adverse effects were reported with either treatment. Compared with simethicone, APT036 significantly reduced abdominal distension (P=0.008) and flatulence (P=0.010) from baseline to Day 30. The baseline hydrogen breath test confirmed the presence of small intestinal bacterial overgrowth (SIBO) in all subjects. At Day 20, mean hydrogen gas elevation was below the threshold for a diagnosis of SIBO (<12 ppm above basal on glucose administration) in both study arms.

Conclusions

Both APT036 and simethicone had good safety profiles but APT036 was superior to simethicone in relieving symptoms of functional bloating.

The gastrointestinal symptoms present in patients with postural tachycardia syndrome: A review of the literature and overview of treatment

Orthostatic intolerance, including postural tachycardia syndrome, is often associated with gastrointestinal symptoms. In the vast majority of the cases, the gastrointestinal symptoms are not secondary to the orthostatic disorder, but rather just a comorbid condition. This concept is critical, since treatment aimed at the orthostatic condition will not improve the gastrointestinal symptoms. Only when the gastrointestinal symptoms develop in the upright position and improve or resolve in the supine position, they may be related to the orthostatic stress. The most common symptoms associated with orthostatic intolerance include nausea, dyspepsia, bloating and constipation. The majority of subjects do not have gastroparesis. The chapter discusses available treatments of these conditions.

Irritable bowel syndrome - from etiopathogenesis to therapy

Irritable bowel syndrome (IBS) is a chronic and relapsing functional gastrointestinal disorder that affects 9-23% of the population across the world. Patients with IBS are often referred to gastroenterology, undergo various investigations, take various medicines, take time off work and have a poor quality of life. The pathophysiology of IBS is not yet completely understood and seems to be multifactorial. Many pathogenetic factors, in various combinations, and not all necessarily present in each patient, can play an important role. Discomfort or abdominal pain relieived by defacation, asociated with a change in stool form, is a typical clinical manifestation of IBS. Many factors, such as emotional stress and eating, may exacerbate the symptoms. A timely diagnosis of IBS is important so that treatment which will provide adequate symptomatic relief (diarrhoea, constipation, pain and boaring) can be introduced. The diagnosis of IBS is not confirmed by a specific test or structural abnormality. It is made using criteria based on clinical symptoms such as Rome criteria, unless the symptoms are thought to be atypical. Today the Rome Criteria IV is the current gold-standard for the diagnoses of IBS. Treatment of patients with IBS requires a multidisciplinary approach. Some patients respond well to non-pharmacological treatment, while others also require pharmacological treatment. This review will provide a summary of pathophysiology, diagnostic criteria and therapies for IBS.

Bloating: Avicenna's Perspective and Modern Medicine

Bloating and abdominal distention are common complaints present in quite a number of organic and functional diseases. An important subject in traditional Persian medicine is digestive disorders, particularly bloating and its etiology. This is a literature review study conducted on The Canon in Medicine written by Avicenna and using the keywords: bloating, gas. In this article, causes for bloating, according to Avicenna, include diet causes, inappropriate lifestyle, gastrointestinal, and miscellaneous reasons. These were compared with causes suggested in modern medicine. Avicenna classifies causes based on the place of origin into upper part of the abdomen (stomach) and intestinal part of the abdomen. Also, 38 medicinal plants used as remedies were listed. Modern scientific data support all bloating causes that have been mentioned in the canon. Obviously, some causes such as uterine disorders and posterior nasal discharge need to be studied further.

Does oral α-galactosidase relieve irritable bowel symptoms?

OBJECTIVE

Abdominal bloating is reported by a majority of irritable bowel syndrome (IBS) patients. Excess colonic fermentation may cause gaseous symptoms. Several foodstuffs contain oligosaccharides with an α-galactosidic linkage that is resistant to mammalian hydrolases. Assisted hydrolysis by exogenous α-galactosidase enzyme (AG) could offer a way of controlling IBS symptoms by reducing colonic fermentation and gas production. The aim of this study was to assess the effect of AG on symptom severity and quality of life in IBS patients with abdominal bloating or flatulence.

METHODS

A total of 125 subjects with IBS received AG or placebo at meals for 12 weeks. IBS-Symptom Severity Score (IBS-SSS) and quality of life (QoL) were assessed at baseline, during the treatment and at 4-week follow-up.

RESULTS

AG showed a trend toward a more prominent decrease in IBS-SSS. The responder rate at week 16 was higher for the AG group. No difference was detected in QoL between AG and placebo groups. A total of 25 patients (18 in AG group and 7 in placebo group, p = 0.016) withdrew from the study. Abdominal pain and diarrhea were more often reported as reason for withdrawal in AG group.

CONCLUSIONS

We found no evidence to support the use of AG routinely in IBS patients. Improvement of clinical response at 4-week follow-up may suggest a long-term effect of unknown mechanism, but could also be attributed to non-responder drop out. Gastrointestinal (GI) side effects may be a coincidence in this study, but irritation of GI tract by AG administration cannot be excluded.

Small Intestinal Bacterial Overgrowth in Patients with Refractory Functional Gastrointestinal Disorders

Background/Aims

Small intestinal bacterial overgrowth (SIBO) is considered to be involved in the pathogenesis of functional gastrointestinal disorders (FGID). However, the prevalence and clinical conditions of SIBO in patients with FGID remain to be fully elucidated. Here, we examined the frequency of SIBO in patients with refractory FGID.

Methods

We prospectively enrolled patients with refractory FGID based on Rome III criteria. A glucose hydrogen breath test (GHBT) was performed using a gas analyzer after an overnight fast, with breath hydrogen concentration measured at baseline and every 15 minutes after administration of glucose for a total of 3 hours. A peak hydrogen value ≥ 10 ppm above the basal value between 60 and 120 minutes after administration of glucose was diagnosed as SIBO.

Results

A total of 38 FGID patients, including 11 with functional dyspepsia (FD), 10 with irritable bowel syndrome (IBS), and 17 with overlapping with FD and IBS, were enrolled. Of those, 2 (5.3%) were diagnosed with SIBO (one patient diagnosed with FD; the other with overlapping FD and IBS). Their symptoms were clearly improved and breath hydrogen levels decreased to normal following levofloxacin administration for 7 days.

Conclusions

Two patients initially diagnosed with FD and IBS were also diagnosed with SIBO as assessed by GHBT. Although the frequency of SIBO is low among patients with FGID, it may be important to be aware of SIBO as differential diagnosis when examining patients with refractory gastrointestinal symptoms, especially bloating, as a part of routine clinical care.

Linaclotide in Chronic Idiopathic Constipation Patients with Moderate to Severe Abdominal Bloating: A Randomized, Controlled Trial

BACKGROUND

Abdominal bloating is a common and bothersome symptom of chronic idiopathic constipation. The objective of this trial was to evaluate the efficacy and safety of linaclotide in patients with chronic idiopathic constipation and concomitant moderate-to-severe abdominal bloating.

METHODS

This Phase 3b, randomized, double-blind, placebo-controlled clinical trial randomized patients to oral linaclotide (145 or 290 μg) or placebo once daily for 12 weeks. Eligible patients met Rome II criteria for chronic constipation upon entry with an average abdominal bloating score ≥5 (self-assessment: 0 10-point numerical rating scale) during the 14-day baseline period. Patients reported abdominal symptoms (including bloating) and bowel symptoms daily; adverse events were monitored. The primary responder endpoint required patients to have ≥3 complete spontaneous bowel movements/week with an increase of ≥1 from baseline, for ≥9 of 12 weeks. The primary endpoint compared linaclotide 145 μg vs. placebo.

RESULTS

The intent-to-treat population included 483 patients (mean age=47.3 years, female=91.5%, white=67.7%). The primary endpoint was met by 15.7% of linaclotide 145 μg patients vs. 7.6% of placebo patients (P<0.05). Both linaclotide doses significantly improved abdominal bloating vs. placebo (P<0.05 for all secondary endpoints, controlling for multiplicity). Approximately one-third of linaclotide patients (each group) had ≥50% mean decrease from baseline in abdominal bloating vs. 18% of placebo patients (P<0.01). Diarrhea was reported in 6% and 17% of linaclotide 145 and 290 μg patients, respectively, and 2% of placebo patients. AEs resulted in premature discontinuation of 5% and 9% of linaclotide 145 μg and 290 μg patients, respectively, and 6% of placebo patients.

CONCLUSIONS

Once-daily linaclotide (145 and 290 μg) significantly improved bowel and abdominal symptoms in chronic idiopathic constipation patients with moderate-to-severe baseline abdominal bloating; in particular, linaclotide significantly improved abdominal bloating compared to placebo, an important finding given the lack of agents available to treat abdominal bloating in chronic idiopathic constipation patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01642914.

High-Fiber Orange Juice as a Nutrition Supplement in Women: A Randomized, Double-Blind, Placebo-Controlled Study of Tolerance and Effectiveness

BACKGROUND

The daily consumption of dietary fiber is frequently below suggested recommendations. Using a double-blind, controlled, randomized study, we assessed the efficiency and tolerance of a fiber-enriched orange juice to supplement fiber intake in women.

MATERIALS AND METHODS

After 1 week of noninterventional observation, 192 healthy adult women ingested 400 mL of orange juice for 21 days, which either was not (placebo group) or was enriched with fiber (fiber group). Orange juice ingestion was registered daily and controlled for each week during the study period. Macronutrient, fiber, and energy intake were determined using a 3-day food record, validated food chemical composition databases, and the "Pro Diet" software. Gastrointestinal symptoms were self-evaluated daily by scoring 4 grades of symptom intensity and using a visual analog scale to grade pain severity.

RESULTS

No changes were observed for macronutrient and energy ingestion. For the placebo group (n = 97), the total fiber intake record was under the daily recommended value. In contrast, the fiber group (n = 95) displayed higher comparative values of total and soluble fiber consumption (P ≤ .001), achieving the daily recommended values of fiber intake. Both groups reported an increased frequency of slight bloating and rumbles over time (P ≤ .05). The fiber group also experienced a higher frequency of slight flatulence over time (P = .002).

CONCLUSION

Consumption of fiber-enriched orange juice was efficient to achieve the daily fiber intake recommendation for women, was not accompanied by intense adverse events, and may represent a suitable method to supplement fiber intake in woman.

Primary epiploic appendagitis and fructose malabsorption

Primary epiploic appendagitis (PEA) is a rare cause of abdominal acute or subacute complaints. Diagnosis of PEA is made when computed tomography (CT) reveals a characteristic lesion. We report on contrast-enhanced CT images of a patient with PEA and regression of inflammation and the reduction in size of the inflamed appendage over the time period of 4 months. Patients with PEA usually recover without medication or surgical treatment within a few weeks. However, due to continuing bloating and irregular bowel movements we investigated carbohydrate malabsorption and diagnosed a fructose malabsorption. Bloating and irregular bowel movements in this patient with PEA were correlated to carbohydrate malabsorption and were treated successfully with a diet free of culprit carbohydrates.