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Saturday, September 21, 2013

dyspepsia

DYSPEPSIA , BLOATING, ABDOMINAL DISTENTION AND FLATULENCE DYSPEPSIA - symptoms referred to the GI system in which a pathologic condition is not present, is poorly established or, if present, does not entirely explain the clinical state is divided according to cause: : functional, secondary and organic localisation: upper ( gastric) lower (bowel) pyrosis meteorismus (bloating) nausea, vomiting flatulence diskomfort (fullness weight, tension) fullness, tension ructus (belching) borborygms anorexia problems with stool, defecation functional: patients with such complaints are common in the primary care setting and account for 30 to 50% of referrals to gastroenterologists these ilnesses are considered difficult to understand and treat them, as they do not fit into previously learned disease categories dyspepsia with no evidence of underlying somatic disease usually calls first for reassurance and symptomatic management with observation over time Abdominal distension, meteorismus (bloating), flatulency - functional complaints GUT GAS Gas is present in the gut as a result of swallowed air, production in the lumen, or difusion from the blood into the lumen Aerophagia : occurs normally in small amounts while eating and drinking some people unconsciously swallow repeated boluses of air at other times, especially when anxious. Most of swallowed air is subsequently eructated (belched), only a small amount passes into the small bowel, the quantity apparently beeing influenced by posture e.g. when the person is supine, air trapped below the fluid in stomach tends to be propelled into the duodenum Excessive salivation may also lead to increased air swallowing( and may by associated with GI disorders - peptic ulcer, ill-fitting denttures or with nausea of any etiology chewing gum Gas production in the lumen : Gas is produced in the lumen by several mechanisms. Bacterial metabolism yields significant volumes of hydrogen, methan and CO2 Hydrogen ( H2) of ingested fermentable materials ( carbohydrates and amino acids) in the colon and therefore is negligible after a prolonged fast or after a meal that is completely absorbed in the small bowel. Hydrogen is produced in large quantities after eating certain fruits and vegetables ( eg. baked beans ) containing indigestible carbohydrates and by patients with malabsorption syndromes Patients with disaccharidase deficiencies ( most commonly lactose intolerance ) pass into the colon large amounts of disaccharides that are fermented to hydrogen. Lactase deficiency, sprue, pancreatic insuficiency Even normal persons incompletly absorb carbohydrates in certain common foods e.g. wheat, corn, potato flour. The normally indigestible polysaccharides in fruits and vegetables ( fiber, reffinos) - may also be a source of excess gas finally, poorly understood factors - eg. differences in colonic flora and motility may also account for variations in gas production Methane CH4 is produced by bacterial metabolism of endogenous substances in the colon the production rate is only minimally influenced by food ingestion some people consistently excrete large quantities of methane, others, little or none Apparently familial, this trait appears during infancy and persists for life Carbon dioxide (CO2) - may also be produced by bacterial metabolism, more important source is the reaction of bicarbonate and hydrogen ions. Theoretically up to 4 L of carbon dioxide may be released into the duodenum following ingestion of a meal The acid products released by bacterial fermentation of nonabsorbed carbohydrates in the colon may also react with bicarbonate to produce CO2. Though bloating may occasionally occur, the rapid absorption of CO2 into the blood prevents intolerable distention. Gas diffuses between the lumen and the blood in a direction dependent upon the partial pressure difference between the two. The production of H2 , CO2 and CH4 may reduce the partial pressure of nitrogen in the lumen to a value far below in the blood, possibly accounting for much of the nitrogen in the lumen. Gas is eleminated - by belching, diffusion from the lumen into the blood with ultimate excretion by the lungs, bacterial catabolism, and passage through the anus ( flatus). Antibiotics that selectively inhibit bacterial H2 catabolism markedly increase its excretion. Symptoms, signs and diagnosis Excessive gas is commonly thougt to cause abdominal pain, bloating, distention, belching , or passage of excessively voluminous or noxious flatus been However, excessive intestinal gas has not been clearly linked to the above complaints, it is likely that many symptoms are incorrectly atributed to „too much gas" In most normal persons 1 L of gas/h can be infused antegrade into the gut with a minimum of symptoms, while persons eg. with the irritable bowel syndrom often cannot tolerate much smaller quanties - may be a hypersensitive intestine, also altered motility can contribute further to symptomst habitual aerophagia , a series of belches on command splenic flexure syndrom - - swallowed air becomes trapped in the splenic flexure and may cause diffuse abdominal distention infantile colic - is a syndrome of presumed „ crampy" abdominal pain. Hence , recent data showed no increase in H2 production or increase in mouth-to-cecum transit times in colicky infants. The cause of this syndrome remains unclear flatulence - as with bowel frequency, persons who complain of flatulence often have a misconception of what is normal in a study of 8 normal men aged 25 to 35 yr, the average number of gas passages was 13+- 4 in one day with an upper limit of 21/day, which overlapped with many persons who complained of excess flatus objectively recording flatus frequency should be the first step in evaluating Differentiation of flatus: aromaticity is not a prominent feature unofficially described according to its salient characteristics: 1) the „ slider" ( crowded elevator type ; Sisyphos) which is released slowly and noiselessly, sometimes with devastating effect 2) the open sphincter, or „ pooh „ type, which is said to be of higher temperature and more „aromatic" 3) the staccato or drumbeat type , pleasantly passed in privacy 4) the „ bark" type ( described in a personal communication ) is characterized by a sharp exclamatory eruption that effectively interrupts ( and often concludes) conversation Rarely, this usually distressing symptom has been turned to advantage, as with a Frenchman referred to as „ Le Petomane", who became affluent as an effluent performer who played tunes with the gas from his rectum on the Moulin Rouge stage. Gas explosion and flammability has rarely fatal outcome - has been reported during jejunal and colonic surgery and even during proctosigmoidoscopic procedures, where diathermy was used Because „ excessive gas" symptoms are so nonspecific and commonly overlap with the irritable bowel syndrome as well as with organic disease, a careful history is essential to guide the extent of medical evaluation. Long-standing symptoms in a young person who is otherwise well and has not lost weight ary unlikely to be caused by serious organic disease. The older person, especially with the onset of new symptoms, merits more through examination before „ excessive gas", real imaginated, is treated. Treatment - reduce aerophagia - exclude habits like excessive gum chewing or smoking, use of carbonated beverages or antacids ( soda) e.g. to clamp any object - pencil between the teeth to break the cycle of aerophagia-discomfort-belch-relief foods containing nonabsorbable carbohydrates can be avoided milk containing products should be excluded from the diet in patients with lactose intolerance simethicone - brakes up small gas bubbles some persons have benefit from metoclopramide Concluson: In general, symptoms of functional bloating, distention and flatus run an intermittent chronic course that is only partially relieved by therapy. Reassurance that these problems are not detrimental to health is important. IRRITABLE BOWEL SYNDROME ( IBS) ( Spastic colon; Mucous colitis ) A motility disorder involving the entire hollow GI tract, creating a symptom complex with both upper and lower GI symptoms. Predominant symptoms include variable degrees of abdominal pain, constipation or diarrhea, and postprandial distention. The symptoms nearly always occur in the waking state and are usually triggered by stress or the ingestion of food. This syndrom represnts about 1/2 of all GI referrals or initial GI complaints in private and institutinal care facilities. In a ratio 3 : 1, women are more commonly affected than men neurodigestive asthenia Secondary causes of abdominal distention, meteorism and flatulence in non-gastrointestinal diseases, diseases of oher organs or systems: urolithiasis gynekological diseases hypothyreoidsm hyperparathyreoidism abdominal tumors ascites gravidity mesenterial infarct obtuse abdominal trauma ( rupture of parenchymal organs), shock bleeding - hemophilia,

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