Abstract

This is an update of the WHO SSI guideline published in 2018, focussing on areas pertinent for gastrointestinal (GI) surgery and hepatobiliary and pancreatic (HBP) surgical procedures. Based on new information and appraisal of current evidence, the following recommendations can be suggested: During skin preparation, we suggest using alcohol-based chlorhexidine for clean, clean-contaminated, and contaminated GI and HBP surgical field preparation in the absence of a mucous membrane (e.g., stoma, genitalia, anus). Preoperatively, we suggest that corticosteroids and anti-TNF medication be discontinued. No recommendations could be made on the following comparisons, given the paucity of high-quality evidence and panel discussion not favouring one intervention over the other based on clinical experience: 2%-3% chlorhexidine gluconate versus aqueous povidone-iodine for surgical field preparation. 4%-5% chlorhexidine gluconate versus aqueous povidone-iodine for surgical field preparation. Aqueous chlorhexidine gluconate versus aqueous povidone-iodine for surgical field preparation Pre-operative dexamethasone in single-dose versus no pre-operative dexamethasone for patients undergoing GI surgery. Discontinuing Vedolizumab preoperatively versus continuing Vedolizumab preoperatively for patients undergoing GI surgery. Discontinuing Ustekinumab preoperatively versus continuing Ustekinumab preoperatively for patients undergoing GI surgery.

ABSTRACT

Introduction

Abdominal distension is an objective visible sign of increased abdominal girth. Bloating is a feeling of abdominal fullness and discomfort. Bloating may be associated or not with abdominal distension. Bloating and abdominal distension are among the most commonly reported gastrointestinal symptoms and may be associated with both organic and functional disorders. Nevertheless, specific consensus and recommendations on diagnosis, underlying mechanisms, assessment and management of functional bloating and abdominal distension are still lacking. The aim of this European consensus, then, is to provide expert opinions and recommendations on the epidemiology, diagnosis, pathophysiology and treatment of functional bloating and abdominal distension.

Methods

A multidisciplinary team of experts in the field, including European specialists and national societies, participated in the development of this consensus. Relevant questions were formulated and addressed through a literature review and statements were developed and voted using a Delphi process.

Results

Functional bloating and abdominal distension are common and frequently overlap with other disorders of gut-brain interaction. Diagnosis is made according to the Rome IV criteria after the exclusion of organic disease, based on the physical examination and assessment of the patient's medical history and alarming signs. In the absence of alarming signs or any relevant finding, clinical laboratory, imaging or endoscopic tests are unnecessary. The pathophysiology of functional bloating and abdominal distension is multifactorial and involves visceral hypersensitivity, abdomino-phrenic dyssynergia, intestinal dysmotility and dysbiosis. Treatment may include dietary modifications (e.g. lactose-limiting diet and low FODMAP diet), probiotics, antispasmodics (e.g., otilonium bromide, peppermint oil), rifaximin, secretagogues (e.g., linaclotide), neuromodulators (e.g., serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, buspirone), and plethysmography-based biofeedback. Moreover, cognitive behaviour therapy and hypnotherapy can be used in case of functional bloating associated with irritable bowel syndrome.

Conclusion

This consensus provides an evidence-based framework for the evaluation and treatment of patients with functional bloating and abdominal distension.