Meteorism (Tympanites)


Article Author:
Abdul Waheed


Article Editor:
Omeed Sizar


Editors In Chief:
Sebastiano Cassaro
Joseph Lee
Tanya Egodage


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Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
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Radia Jamil
Patrick Le
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Saad Nazir
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Heba Mahdy
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Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/3/2019 9:28:58 AM

Introduction

Meteorism is also known as tympanites. The primary feature of meteorism is an accumulation of gas in the gastrointestinal (GI) tract which causes a sensation of bloating and abdominal distension. One of the most common causes of flatulence is improper eating. Modification of eating habits and avoidance of certain triggers may help to alleviate symptoms.

Etiology

The causes of meteorism are usually benign, such as swallowing too much air while eating or excessive fermentation caused by bacteria of the intestinal flora. More concerning causes may include bowel obstruction, renal stones, functional disorder, overeating, bacterial overgrowth, inflammation of the bowel, blunt kidney trauma, peritonitis, and idiopathic causes. Canon of Medicine authored by Avicenna is one of the most prominent medical manuscripts which also touches on gastrointestinal disorders such as flatulence. From Avicenna's viewpoint, bloating is the result of imperfect digestion caused by 4 eating habits including: consumption of beans/peas, consumption of fruits, consumption of smoked salted foods, and overeating[1]. Certain fruits and vegetables contain large amounts of fructose and oligosaccharides that can promote excessive gas. 

Epidemiology

Meteorism is a very common symptom that occurs in people of all ages. It is equally prevalent in all races and can affect infants as well as the elderly. The majority of people present with meteorism in the third decade of life. About 15-23% of Asians and 15-30% of Americans suffer from flatulence[2].

Pathophysiology

Some common causes of meteorism

Functional: In the majority of people, the cause of meteorism is unknown. These individuals present in the third decade of life with complaints of belching, excess gas, bloated sensation, and abdominal distension. Abdominal x-rays usually reveal a nonspecific collection of gas in the intestine. Workup usually reveals no pathology. X-rays should rule out constipation[3].

Bowel obstruction from any cause can lead to accumulation of gas in the intestine. This is pathological, and the patient may present with nausea, vomiting, inability to pass gas. X-rays will show dilated bowel loops, air-fluid levels, and lack of air in the distal colon or rectum.

Ileus is essentially the disruption of normal propulsive bowel movements. It has many causes, and the failure of peristalsis leads to accumulation of air in the GI tract. Patients with ileus will present with abdominal distension, moderate abdominal discomfort, bilious vomiting, an absence of bowel movements, lignin and no appetite. Risk factors for ileus include the following:

  • Electrolyte imbalance (hypokalemia, hypercalcemia)
  • Gastrointestinal surgery
  • Diabetes mellitus
  • Hypothyroidism
  • Use of medications like opiates
  • Spinal cord injury

Ileus is managed conservatively by limiting the patient to nothing by mouth and administering fluids. A nasogastric tube may be required to decompress the intestine and stomach. Most patients start to recover within 3 to 5 days. One may use peristaltic agents like erythromycin or metoclopramide to enhance bowel movements.

Irritable bowel syndrome is a complex disorder of bowel motility that presents with abdominal pain and a changing pattern of bowel movements. Almost universally, patients complain of a bloated sensation. So far, no patient has shown any underlying damage to the bowel with IBS. The disorder presents with vague abdominal symptoms in the third decade of life. The disorder may be associated with diarrhea, constipation, or a combination of the two symptoms. 

IBS seriously affects the quality of life and results in missed work and school. These patients are not able to tolerate a wide range of foods. As soon as the offending food is ingested, the patient will complain of bloating, abdominal pain, and nausea. Many of these patients also have other existing disorders like major depression, anxiety, and fibromyalgia. 

The diagnosis of IBS is difficult as the signs and symptoms are nonspecific. Investigations are usually done to rule out other organic causes like inflammatory bowel disease, celiac disease, and food intolerance. Unfortunately, there is no cure for IBS, and there is no one treatment that works for everyone. Patients are counseled on dietary changes, use of probiotics, and eating a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP)[4]. Patients with recurrent disease may find loperamide helpful, and those with constipation may require laxatives. Antidepressants are known to help improve mood and pain in many patients.

History and Physical

The most common symptom of meteorism is a bloated sensation. It may be associated with abdominal discomfort. Some individuals may also complain of a distended stomach and excessive belching and passage of flatus. The sensation of bloating may last a few minutes or for the entire day. Sometimes the abdominal pain may feel dull or sharp and cause cramping. Often the pain of bloating can be confused with bowel obstruction, appendicitis, cholecystitis, or peptic ulcer disease. On physical exam, one may note distension of the abdomen and marked tympany on palpation. Auscultation may reveal rumblings bowel sounds or tinkling sounds. The rectal exam in these patients is unremarkable.

Evaluation

When patients present with meteorism, the onus is on the healthcare worker to first rule out an organic disorder like inflammatory bowel disease, bowel obstruction, colon cancer, strangulated hernia, or volvulus. The laboratory blood work is chiefly done to rule out other pathologies. Usually, no imaging is necessary to make a diagnosis of meteorism, but if the abdominal exam reveals marked tenderness or pain, then one should obtain plain x-rays to look for dilated bowel loops, air-fluid levels, or free air. Other tests depend on the presentation and physical exam.

Treatment / Management

Once bloating has been diagnosed, the treatment depends on the cause. For functional bloating, the treatment is supportive. The individual must keep a food diary and note all the symptoms. Any food that produces a bloating sensation must then be eliminated. One of the most common causes of flatulence is improper eating habits. 

  • Experts suggest that one should avoid overeating. Limit food intake to 4 to 7 small meals a day rather than 3 large meals. Next, avoid foods that are rich in fat and simple carbohydrates. Fats take a lot longer to digest, and since they remain in the abdomen a lot longer, the symptoms of bloating may continue for many hours. The low FODMAP diet has been shown to reduce bloating sensation in individuals.
  • Avoid eating too fast as one may swallow air. Eating slowly is the key and also suppresses the desire to eat more. Foods should be chewed thoroughly.
  • Drinking beverages while eating food or immediately after should be avoided as this will promote flatulence in some people. Beverages, vegetables, and fruits should be consumed at least 1 hour after food[5].
  • Adding ginger, cumin and some herbs such as dill, parsley, basil is beneficial to remove flatulence[5].

To decrease the gassiness, the following is recommended:

  • Do not chew gum[6]

  • Do not drink fluids through a straw

  • Avoid consuming carbonated sodas

  • Do not suck on candy

There are some individuals who tend to swallow air when they are anxious or nervous. The best way to avoid this is to relax and reduce stress. One should practice breathing exercises, yoga, or tai chi. According to a recent study, patients receiving vitamin D had improved quality of life from bloating compared with patients not receiving vitamin D[7]. Moxibustion used in conjuction with acupuncture has been shown to reduce bloating sensation[8]. Psychotherapy has also been found to improve quality of life in patients with functional dyspepsia[9].

Avoid the following foods

There are certain foods that can worsen bloating and cause gassiness. These include the following:

  • Lentils and beans contain indigestible sugars which are broken down by bacteria, resulting in the generation of gas[5]
  • Fruits and vegetables like carrots, cabbage, brussel sprouts,  prunes, and apricots also cause gassiness
  • Artificial sweeteners like sorbitol are not easy to digest and hence are broken down by bacteria to produce gas.
  • Patients with meteorism should avoid dairy products as they can worsen the bloating sensation.
  • Wheat contains a protein called gluten which may cause bloating[10]. Gluten should be included in the elimination diet to rule out gluten sensitivity.
  • Finally, people prone to meteorism should become physically active as this can also lead to increased peristalsis and emptying of gas from the intestine.

Prognosis

Temporary bloating is nothing more than a mild annoyance and can be relieved by changing diet. However, if the patient has persistent bloating and gassiness, then the healthcare provider must rule out an organic cause.

Enhancing Healthcare Team Outcomes

The diagnosis and management of meteorism is with a multidisciplinary team that includes a primary care provider, GI specialist, nurse practitioner, and dietician. The diagnosis of meteorism is not easy and there is no specific treatment. One of the most common causes of flatulence is improper eating. Modification of eating habits and avoidance of certain triggers may help to alleviate symptoms. The key is to educate the patient of proper eating. 


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Meteorism (Tympanites) - Questions

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A well-known evil dictator in the history of man gets up from the table and runs out the door leaving an unpleasant aroma in his wake. This is apparently a regular occurrence following meals. Which of the following best describes the condition?



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A 56-year-old male with no past medical history presents to your clinic for follow-up regarding abdominal bloating for the past 4 months. Patient was told to keep a food diary one week ago consistent with worsening of symptoms secondary to dairy and lentils. Which of the following is the best advice to help prevent future episodes in this patient?



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What is the best way to diagnosis meteorism?



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A female has bloating sensation and a normal physical examination and laboratories. What diet has been found to relieve bloating sensation?



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Which type of foods are unlikely to cause bloating?



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Meteorism (Tympanites) - References

References

Lacy BE,Gabbard SL,Crowell MD, Pathophysiology, evaluation, and treatment of bloating: hope, hype, or hot air? Gastroenterology     [PubMed]
Larijani B,Esfahani MM,Moghimi M,Shams Ardakani MR,Keshavarz M,Kordafshari G,Nazem E,Hasani Ranjbar S,Mohammadi Kenari H,Zargaran A, Prevention and Treatment of Flatulence From a Traditional Persian Medicine Perspective. Iranian Red Crescent medical journal. 2016 Apr;     [PubMed]
Schmulson M,Chang L, Review article: the treatment of functional abdominal bloating and distension. Alimentary pharmacology     [PubMed]
Naseri M,Babaeian M,Ghaffari F,Kamalinejad M,Feizi A,Mazaheri M,Mokaberinejad R,Adibi P, Bloating: Avicenna's Perspective and Modern Medicine. Journal of evidence-based complementary     [PubMed]
Abbasnezhad A,Amani R,Hajiani E,Alavinejad P,Cheraghian B,Ghadiri A, Effect of vitamin D on gastrointestinal symptoms and health-related quality of life in irritable bowel syndrome patients: a randomized double-blind clinical trial. Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society. 2016 Oct;     [PubMed]
Raahave D, Faecal retention: a common cause in functional bowel disorders, appendicitis and haemorrhoids--with medical and surgical therapy. Danish medical journal. 2015 Mar     [PubMed]
Shum NF,Choi HK,Mak JC,Foo DC,Li WC,Law WL, Randomized clinical trial of chewing gum after laparoscopic colorectal resection. The British journal of surgery. 2016 Oct     [PubMed]
Anastasi JK,McMahon DJ,Kim GH, Symptom management for irritable bowel syndrome: a pilot randomized controlled trial of acupuncture/moxibustion. Gastroenterology nursing : the official journal of the Society of Gastroenterology Nurses and Associates. 2009 Jul-Aug     [PubMed]
Enck P,Azpiroz F,Boeckxstaens G,Elsenbruch S,Feinle-Bisset C,Holtmann G,Lackner JM,Ronkainen J,Schemann M,Stengel A,Tack J,Zipfel S,Talley NJ, Functional dyspepsia. Nature reviews. Disease primers. 2017 Nov 3     [PubMed]
Skodje GI,Sarna VK,Minelle IH,Rolfsen KL,Muir JG,Gibson PR,Veierød MB,Henriksen C,Lundin KEA, Fructan, Rather Than Gluten, Induces Symptoms in Patients With Self-Reported Non-Celiac Gluten Sensitivity. Gastroenterology. 2018 Feb     [PubMed]
Malcolm JD, POST-OPERATIVE TYMPANITES: Its Nature and Some Points in its Treatment. British medical journal. 1917 May 12;     [PubMed]

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