The Gastric Bloater

Nancy is a 28-year-old woman who has been having bloating and stomach pain after eating for 2 weeks. She recently had a viral infection with nausea, vomiting and diarrhea. Her bloating and tummy pain start about 15 minutes after she eats. She does not take nonsteroidal anti-inflammatory drugs. (aspirin, naproxen, etc), which may irritate the stomach lining and cause bleeding. An 8-week trial of proton pump inhibitor therapy (e.g  Prilosec, Prevacid, Aciphex) made no difference.

Tests

• Diabetes - HbA1c normal
• Esophagogastroduodenoscopy (EGD) - solid food stayed in the stomach, but the endoscope was able to go through the stomach to the duodenum easily, suggesting there was no obstruction or blockage.
• Gastric emptying scintigraphy study - showed delayed gastric emptying.

Causes

Stomach pain and bloating occurring soon after eating suggests gastric bloating. Potential causes include :

• Gastric outlet obstruction (GOO) - caused by cancer, chronic peptic ulcer disease, pancreatitis. GOO is often associated with vomiting of undigested or partially digested food. If suspected, EGD is done, with a normal study effectively excluding GOO.
• Abnormalities of the stomach - Gastric accommodation involves relaxation of the stomach within minutes of eating food, and the lack of this relaxation may lead to gas and bloating shortly after eating. This condition may be diagnosed by a scintigraphic study.
• Functional (nonulcer) dyspepsia - presence of chronic upper abdominal pain, bloating, or discomfort, usually present for 6 months or more, in the absence of alternative explanation or disease, with a normal EGD.
• Gastroparesis - delayed gastric emptying without a mechanical cause such as a mass causing obstruction. It is usually caused by diabetes. Another cause is infection. Nancy previously had gastroenteritis. Combined with the delayed gastric emptying on her scintigraphy study, without diabetes, it appears she has postinfectious gastroparesis.

Treatment

Therapy for patients with bloating soon after eating (gastric bloating) is tailored to the cause. 

• Gastroparesis: A gastroparesis diet (eating small meals frequently or reducing dietary fat intake). Post infectious gastroparesis is usually self- limiting and should improve with time. Gastroparesis related to a disease such as diabetes or connective tissue disease (e.g., scleroderma) should have disease treatment. A prokinetic, such as metoclopramide, may be used in gastroparesis that is not treated by diet. Liquid metoclopramide at a dose of 5 to 10 mL, 30 minutes before meals and at bedtime, may optimize the therapy.
• Abnormal gastric accommodation: A “gastroparesis diet” may help. Buspirone at a dose of 5 to 10 mg, 30 minutes before meals, has been reported to help some patients.
• Gastric Outlet Obstruction: Most likely surgery.
• Functional dyspepsia: This is a diagnosis of exclusion. A gastroparesis diet as well as avoiding triggers, identified by a diet and symptom diary may help. If symptoms persist, H pylori testing could be done (breath test, stool antigen, or biopsy at EGD) and H pylori should be treated if present. Antiacid medication may help stomach pain. Amitriptyline starting at a dose of 25mg at nighttime, increasing in 25mg increments every 2 weeks, may be considered. For fullness and bloating after eating, trying metoclopramide or buspirone may help.

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