Unraveling the Mystery of Persistent Positional Borborygmi

ABSTRACT

We present a case report of young thin-built woman with persistent positional abnormal abdominal sounds audible only while sitting or standing and relieved in supine position. Sounds become more prominent on heavy meals and deep inhalation and improved with breath-holding or self-applying local pressure. Routine investigations, including esophagogastroduodenoscopy, colonoscopy, and contrast-enhance computed tomography of whole abdomen, all were normal. Interestingly, a barium study in standing position revealed an hourglass-shaped stomach, but while in lying down position showed normal anatomy, which might be due to compression of stomach with rib cage. The patient was managed conservatively with medical management, and no definitive medical therapy is available to date.

INTRODUCTION

Borborygmi refers to the characteristic growling or rumbling sounds made by the stomach and intestines as food, fluids, and gas pass through them during digestion.¹ Borborygmi, also known as bowel sounds, can be physiological or pathological, caused by a variety of medical conditions, including intestinal obstruction, celiac disease, food intolerance, stress, anxiety, irritable bowel syndrome, and inflammatory bowel disease. In most cases, these sounds are heard in both lying down and standing positions. However, we present a rare case in which intractable abnormal abdominal sounds are only audible when the patient in a sitting or standing position and are relieved on lying down.

CASE REPORT

An 18-year-old, thin-built woman presented to the gastroenterology department with a primary complaint of abnormal abdominal sounds (borborygmi) for the past 8 months. These sounds were only audible when the patient was sitting or standing and disappeared when lying down, causing no discomfort during nighttime or sleep. The sounds become more prominent after heavy meals and deep inhalation but improve with breath-holding or self-applying pressure to the left upper quadrant of the abdomen. The borborygmi were loudly audible to others when standing next to the patient, causing her significant discomfort during public gatherings and educational activities. In addition, she reported nausea, occasional vomiting, and mild abdominal pain. The patient had history of initial 5 kg intentional weight loss, followed by further loss due to reduced intake of food from fear of abdominal sounds and pain, with a body mass index (BMI) of 16.1 kg/m² at the time of presentation. She had no similar complaints in past and no history of such issues in family. Five years ago, she underwent a right-sided open nephrolithotomy for renal stones. In the past few months, she underwent numerous investigations and consulted multiple physicians, but the cause of her borborygmi remained undiagnosed. At our department, we conducted several initial investigations, including blood tests, abdominal ultrasound, chest and abdominal radiographs, esophagogastroduodenoscopy, colonoscopy, contrast-enhanced CT of whole abdomen, 2D-echocardiogram, and Doppler study, all of which yielded negative results. The esophagogastroduodenoscopy did not reveal any subtle signs of mucosal irritation, gastric outlet obstruction, abnormal peristalsis, or hiatal hernia. These tests were performed while the patient was lying down. Given the persistent symptoms, we decided to conduct barium studies in the standing position, which revealed an unusual finding: The patient's stomach assumed an hourglass shape when standing, a configuration not observed when lying down (Figure 1). The stomach extended down to the pelvis in a standing position, and the hourglass-shaped stomach might be due to gastric compression (Figure 2). This hourglass-shaped stomach could explain the intractable borborygmi the patient had been experiencing. We managed the patient conservatively with diet modification, antiemetics, prokinetics, and nutritional supplements.

Figure 1.

Barium study in lying down position with normal shape of stomach (arrow).

Figure 2.

Barium study on standing position showing hourglass stomach (arrow), extending to pelvis (arrow head).

DISCUSSION

This case report presents a young woman with intractable positional borborygmi, which were audible only in a sitting or standing position. All investigations performed while in a lying-down position were normal, but only the barium study performed in a standing position revealed an hourglass-shaped stomach. This uncommon anatomical variation may account for the abnormal sounds, though the exact cause remains uncertain. A few alternative etiologies may contribute to positional borborygmi and should be considered in the differential diagnosis (Table 1).^2,3

Table 1.

Alternative causes of positional borborygmi

Gastric outlet obstruction

Gastroparesis

Small intestinal bacterial overgrowth (SIBO)

Abdominophrenic dyssynergia

The stomach is a muscular structure with smooth muscles organized into circular, longitudinal, and oblique muscle layers. Slow waves or pace-setter potentials are gastric myoelectrical activities, that regulate, control, and pace gastric smooth muscle contractions.^4,5 A normal human stomach has slow waves occur at approximately 3 cycles per minute or between 2.5 and 3.7 cycles per minute.^6,7 Normally, the stomach has a J-shape; however, its shape can vary and these variations may be congenital or acquired. Pyloric muscle hypertrophy is common in infants; a few cases in adults have also been reported. Hypertrophy of the muscular layers in the proximal antrum can cause an annular constriction, giving the stomach an hourglass appearance.⁸

The most common cause of an hourglass stomach is scarring in the midstomach, typically due to chronic peptic ulcer disease, causing fibrosis and thickening of the stomach walls.⁹ With the growing popularity of bariatric surgery and antireflux surgery, the incidence of complications such as midstomach strictures may increase, potentially leading to an hourglass-shaped stomach.^10,11 Less common causes include caustic ingestion, gastric syphilis, tuberculosis.^12–14 In addition, unlike positional changes that can shift with movement, these deformities are usually fixed and not reversible without surgical intervention.

An hourglass stomach can cause borborygmi due to its constricted shape, which interferes with normal gastric motility. First, the narrowed stomach causes delayed gastric emptying, leading to abnormal contractions causing rumbling sounds. Second, trapped gas, liquids, and food in the narrowed areas may shift or be released, also producing audible sounds. Third, the hourglass shape becomes more pronounced with postural changes which can aggravate the borborygmi.

In this case, an intriguing hypothesis is that the lower anterior rib or cartilage may compress the stomach when the patient is standing, causing the hourglass-shaped stomach and causing persistent symptoms. The patient's low BMI and thin build could contribute to this compression, making it more noticeable. This hourglass stomach is likely visible in the patient's standing radiograph (Figure 3).

Figure 3.

Normal abdominal radiograph of the patient in standing position showing hourglass shape of stomach may be caused by compression by ribcage (arrow).

A similar case was published in the United Kingdom in 2010, involving a 48-year-old woman with a 2-year history of prominent borborygmi, which were particularly noticeable when the patient remained standing. This case also included a history of weight loss and a low BMI, similar to our own. All investigations were normal, except for a barium meal, which showed that her stomach adopted an hourglass shape when sitting or standing due to compression from the left anterior ribs. Compression from the diaphragm during inspiration caused the audible borborygmi.¹⁵

Currently, there is no definitive treatment available for this condition, and treatment options are limited based on our knowledge. One potential approach could be weight gain, as increased abdominal and visceral fat may reduce compression of the stomach by the ribcage, alleviating the problem. Since the sounds were reduced by applying pressure to the left hypochondrium, a tight-fitting corset can be advised to the patient. Other potential treatments, such as rib resection, percutaneous gastrostomy, subtotal gastrectomy, partial gastrectomy, or gastrojejunostomy, could also be explored. The patient can also undergo diagnostic laparoscopy to assess for stomach scarring, and, if needed, adhesiolysis can be planned. However, in this case, the patient is being managed conservatively due to their refusal of any endoscopic or surgical intervention. The patient has been under follow-up for over 6 months, experiencing a weight gain of approximately 3.5 kg, along with slight improvement in pain in abdomen and borborygmi, though these symptoms have not completely resolved.

This is a rare case of persistent positional borborygmi, with only one other instance reported in the literature to our knowledge. The patient's stomach assumes an hourglass shape while standing, diagnosed on barium study, leading to borborygmi that cause significant distress and disruption to her daily life. As no definitive hypothesis or established treatment exists for this condition, further cases and follow-up are necessary to improve patient care and management.

DISCLOSURES

Author contributions: N. Gupta, GK Gupta, and S. Nijhawan has substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; and M. Jain, H. Bhardwaj, M. Mohsin, and N. Bishoni had draft the work or reviewed it critically for important intellectual content; and GK Gupta has given final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. GK Gupta is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.