Approach to bloating

Thanks Miles for presenting an excellent case on a middle age male coming in with acute-subacute progressive constipation and bloating, new ascites with a diagnosis of peritoneal carcinomatosis of unknown primary.

peritoneal carcinomatosis

Learning points:

  • 1) When a patient comes in with bloating, ask whether alarm symptoms are present eg. anemia, unintential wt loss, progressive, new onset in elderly
  • 2) The differential diagnosis for bloating can be broken down into anatomic, malabsorption, drugs, functional, infection, and neurologic
  • 3) Biomarkers and genetic testing are helpful for diagnosis of carcinoma of unknown primary because it may identify the primary in some cases and can guide treatment. You can set up a free account to access the NCCN guidelines to learn more.

Want more info?

Differential diagnosis for bloating

  • When a patient comes in with bloating, ask about distention, gassiness, and stool quality as well as red flag sx
  • 1) anatomic
    • a) obstruction/ partial obstruction
    • b) gastroparesis
    • c) malignancy - classically ovarian carcinoma
    • d) constipation
  • 2) malabsorption - lactose intolerance, celiac, gluten sensitivity
  • 3) drugs - Ca supplements, consumption of large amts of fiber, any constipating drugs (eg opiates, antihypertensives, anticholinergics, vitD, heavy metals, etc)
  • 4) functional
    • a) functional bloating/ dyspepsia
    • b) aerophagia
    • c) IBS
    • d) dyssinergic defecation -> constipation
  • 5) infection
    • a) giardia, cyclospora
    • b) SIBO
  • 6) neurologic
    • a) dysmotility - connective tissue dz
    • b) Hirschsprung's

Ddx of radiographic "peritoneal carcinomatosis"

  • Malignancy: metastatic dz from bladder, colon, gastric, breast, pancreatic, lung, lymphoma vs
  • Non-malignancy: TB, sarcoidosis, crohn's, endometriosis
  • This NEJM has a nice table of other tumors of the peritoneum that could be considered