How are the causes of belching, bloating/distention, and flatulence evaluated?
Medical history
A patient’s medical history is important because it directs the evaluation.
- If the bloating or distention is continuous rather than intermittent, then enlargement of abdominal organs, abdominal fluid, tumors, or obesity causes to be considered.
- If the bloating or distention is associated with increased flatulence, then bacteria and excessive gas production are likely factors.
- If a diet history reveals the consumption of large amounts of milk or dairy products (lactose), sorbitol, or fructose, then the maldigestion and malabsorption of these sugars may be the cause of the distention.
- When individuals complain of flatulence, it may be useful for them to count the number of times they pass gas for several days. This count can confirm the presence of excessive flatulence since the number of times gas is passed correlates with the total amount (volume) of passed gas. As you might imagine, it is not easy to measure the amount of passed gas. It is normal to pass gas up to 20 times a day. (The average volume of gas passed daily is estimated to be about ¾ of a quart.)
- If an individual complains of excessive gas but passes gas fewer than 20 times per day, the problem is likely to be something other than too much gas. For example, the problem may be the foul odor of the gas (often due to ingestion of sulfur-containing foods), the lack of ability to control (hold back) the passing of gas, or the soiling of underwear with small amounts of stool when passing gas. All of these problems, like excessive gas, are socially embarrassing and may prompt individuals to consult a doctor. These problems, however, are not due to excessive gas production, and their treatment is different.
Simple abdominal X-rays
Simple X-rays of the abdomen, particularly if they are taken during an episode of bloating or distention, often can confirm air as the cause of the distention, since large amounts of air can be seen easily within the stomach and intestine. Moreover, the cause of the problem may be suggested by noting where the gas has accumulated. For example, if the air is in the stomach, emptying of the stomach is likely to be the problem.
Small intestinal X-rays
X-rays of the small intestine, in which barium is used to fill and outline the small intestine, are particularly useful for determining whether there is an obstruction of the small intestine.
Gastric emptying studies
These studies measure the ability of the stomach to empty its contents. For gastric emptying studies, a test meal that is labeled with a radioactive substance is eaten and a Geiger counter-like device is placed over the abdomen to measure how rapidly the test meal empties from the stomach. A delay in emptying of the radioactivity from the stomach can be caused by any condition that reduces emptying of the stomach (for example, pyloric stenosis, gastroparesis).
Ultrasound, CT scan, and MRI
Imaging studies, including ultrasound examination, computerized tomography (CT), and magnetic resonance imaging (MRI), are particularly useful in defining the cause of distention that is due to enlargement of the abdominal organs, abdominal fluid, and tumor.
Maldigestion and malabsorption tests
Two types of tests are used to diagnose maldigestion and malabsorption: general tests and specific tests.
The best general test is a 72-hour collection of stool in which the fat is measured; if maldigestion and/or malabsorption exist because of pancreatic insufficiency or diseases of the lining of the small intestine (for example, celiac disease), the amount of fat will increase before proteins and starches in the stool.
Specific tests can be done for maldigestion of individual sugars that are commonly maldigested, including lactose (the sugar in milk) and sorbitol (a sweetener in low-calorie foods). The specific tests require ingestion of the sugars followed by hydrogen/methane breath testing. (See below.) Sugar fructose, a commonly used sweetener, like lactose and sorbitol, also may cause abdominal bloating/distention and flatulence. However, the problem that can occur with fructose is different from that with lactose or sorbitol. Thus, as already described, lactose and sorbitol may be poorly digested by the pancreatic enzymes and small intestine. Fructose, on the other hand, maybe digested normally but may pass so rapidly through the small intestine that there is not enough time for digestion and absorption to take place.
Hydrogen/methane breath tests
The most convenient way to test for bacterial overgrowth of the small intestine is hydrogen/methane breath testing. Normally, the gas produced by the bacteria of the colon is composed of hydrogen and/or methane. For hydrogen/methane breath testing, a non-digestible sugar, lactulose, is consumed. At regular intervals following ingestion, samples of breath are taken for analysis. When the lactulose reaches the colon, the bacteria form hydrogen and/or methane. Some of the hydrogen or methane is absorbed into the blood and eliminated in the breath where it can be measured in the breath samples.
In normal individuals, there is one peak of hydrogen or methane when the lactulose enters the colon. In individuals who have bacterial overgrowth, there are two peaks of hydrogen or methane. The first occurs when the lactulose passes and is exposed to the bacteria in the small intestine. The second occurs when the lactulose enters the colon and is exposed to the colonic bacteria. Hydrogen breath testing for overgrowth also may be done utilizing lactose, glucose, sorbitol, or fructose as the test sugar.