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Abdominal bloating and distension in functional gastrointestinal disorders – epidemiology and possible mechanisms

SIRS, In their paper on the epidemiology and pathophysiology of abdominal bloating and distension, Agrawal and Whorwell review the putative mechanisms but reject the view that it may be because of lumbar hyperlordosis and pushing down the diaphragm – as this has been disproved by computerized tomography. This statement, however, confuses two different conditions: bloating because of disturbance of the intestinal motility and handling of gas [typical in irritable bowel syndrome (IBS)], and nongaseous bloating because of disturbance in the muscles of the abdominal wall. Nongaseous abdominal bloating (hysterical proptosis, hysterical pseudoileus, phantom abdominal tumour, pseudotympanitis nervosa, fictitious gravidity, pseudogravidity, abdomen ‘en accordeon’) was described masterfully in Alvarez’ paper and book. The distended abdomen can deflate with spectacular rapidity – like a pierced balloon – under a strong emotion or general anaesthesia, without evidence of meteorism and flatulence. I observed my first case in 1942, and in 1956 I reported on four cases. In all of them, lumbar hyperlordosis, depression of the diaphragm, protrusion of the anterior abdominal wall and absence of gas or fluid were established and documented. I gathered 10 cases which I discussed in the textbooks and included in the group of neuropathic abdominal disorders. 7 The aetiology of nongaseous abdominal bloating is evident in cases of factitious gravidity observed in royal families longing for a crown prince. Our 10 cases were exclusively middle-aged women, at around the menopause with some neurotic traits but with no apparent reason for simulating gravidity. It is tempting to speculate that a mild incomplete type of nongaseous bloating may account for sensations of abdominal tension and tightness in patients without IBS and possibly also in some with IBS – especially in those whose symptoms increase progressively during the day and disappear in the supine position and at night.