Abdominal DistensionCHAPTER 1

Abdominal distension^* may be defined as an increase in the girth of the abdomen. It is noticed by the patient because of the increase in belt or clothing size, recent weight gain, or ankle edema. Its onset may be sudden or gradual, persistent or intermittent. It may be entirely asymptomatic. More often the patient may describe distension as bloating,^1,2 fullness, hardness, tightness or pressure. These symptoms are usually exacerbated by meals, fluctuate in intensity, and are worse in the day and settle overnight. Other symptoms such as belching, postprandial discomfort, nausea, vomiting, shortness of breath, localized pain, and constipation, if present, may provide clues for the etiology of abdominal distension. As a mnemonic device the causes can be remembered as five ‘fs’: fat (obesity), fluid (ascites), flatus (gastrointestinal), fetus (pregnancy), and feces (constipation). However, abdominal distension/bloating may be contributed to by several simultaneous conditions, and the diagnosis may be particularly challenging, especially in a subset of patients with functional GI disorders (FGIDs).^3–6 A careful history and physical examination are necessary to develop an ade-quate differential and investigations, including psychosocial evaluation, that will help in the cost-effective approach to the diagnosis and care of these patients, who are otherwise susceptible to receiving unnecessary, costly, and sometimes risky studies and treatments.⁷

FGIDs is defined as a variable combination of chronic or recurrent GI symptoms not explained by structural or biochemical abnormalities. It cannot be diagnosed through endoscopic, radiologic, or laboratory studies. Furthermore, even though these disorders share certain physiologic characteristics (such as abnormal 5motility and visceral hypersensitivity) that are associated with symptom generation, the findings are not specific for diagnosis, and the clinician has limited ability to evaluate them in practice. In the absence of any objective marker, the identification and classification of FGIDs are based on symptoms, and consist of a wide spectrum of syndromes which cross over and in some cases overlap various anatomic areas of the luminal gut. Although IBS has traditionally been the most studied and written about, FGIDs constitute a number of unique disorders, including functional esophageal disorders (noncardiac chest pain, functional dysphagia, and globus sensation); functional dyspepsia (pain, discomfort, nausea, and other symptoms above the navel in persons who do not meet the diagnostic criteria for IBS); functional abdominal pain syndrome; functional abdominal bloating; functional diarrhea; functional disorders of the biliary tract, including Oddi sphincter; functional disorders of the anorectal area, such as pelvic floor dyssynergia; and proctalgia fugax. The diagnosis of FGIDs relies heavily on the clinical history, a limited diagnostic evaluation and early symptomatic treatment that include symptom monitoring and reassessment. There is increasing evidence that psychopharmacologic and psycho-therapeutic management of FGIDs are highly effective and, in many instances, surpass the efficacy of standard medical treatment.

Meigs syndrome is defined as the triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor. The ovarian tumor in Meigs syndrome is a fibroma. Pseudo-Meigs syndrome consists of pleural effusion, ascites, and benign tumors of the ovary other than fibromas. Pseudo-pseudo Meigs syndrome includes patients with systemic lupus erythematosus and enlarged ovaries.

Proctalgia fugax is a diagnosis of exclusion, and defined as sudden, severe pain in the anorectal region lasting several seconds or minutes, and then disappearing completely. It is common but largely underreported. The etiology is not well-defined. Attacks are infrequent, left-sided, and short-lived. Patients are asymptomatic between episodes. The discomfort is usually triggered by stressful event; can occur during the day or night; although it is not typically associated with bowel movements, it may be relieved by heat, anal dilatation, or relaxation techniques.

Rumination means repeated regurgitation (backflow of food from the stomach into the mouth) and rechewing of food, i.e. voluntary or involuntary regurgitation and rechewing of partially digested food that is either re swallowed or expelled. This regurgitation appears effortless, may be preceded by a belching sensation, and typically does not involve retching or nausea. In rumination, the regurgitant does not taste sour or bitter. The behavior must exist for at least 1 month, with evidence of normal functioning prior to onset. Rumination occurs within a few minutes postprandial and may last 1-2 hours. Though frequency may vary, rumination typically occurs daily and may persist for many months or years. Although the etiology of rumination is unknown, multiple theories have been advanced to explain the disorder. These theories range from psychosocial factors to organic origins. Cultural, socioeconomic, organic, and psychodynamic factors have been implicated.6

SBP is a bacterial infection of ascitic fluid in patients with decompensated cirrhosis. The term ‘spontaneous’ distinguishes this from surgical peritonitis. Enteric organisms are isolated from more than 90% of infected ascites fluid in SBP, suggesting that the GI tract is the source of bacterial contamination. Symptoms of infection occur in most patients with SBP, including fever, abdominal pain, mental status changes, and ileus. A high index of suspicion should exist for SBP in patients with cirrhosis and ascites, especially in those who do not improve following administration of diuretic medication.