What is the initial evaluation and management approach for a patient presenting with bloating?

From the Guidelines

The initial evaluation of a patient with bloating should begin with a thorough history and physical examination to identify potential causes, as recommended by the most recent guidelines 1. The evaluation process should assess for alarm symptoms such as weight loss, rectal bleeding, or family history of colorectal cancer that may warrant urgent investigation.

• Basic laboratory tests including complete blood count, comprehensive metabolic panel, thyroid function tests, and celiac disease serology are appropriate.
• The Rome IV criteria should be used to diagnose primary abdominal bloating and distention 1.
• Carbohydrate enzyme deficiencies may be ruled out with dietary restriction and/or breath testing, and small bowel aspiration and glucose- or lactulose-based hydrogen breath testing may be used to evaluate for small intestinal bacterial overgrowth in a small subset of at-risk patients 1.
• Serologic testing may rule out celiac disease in patients with bloating, and if serologies are positive, a small bowel biopsy should be done to confirm the diagnosis 1.
• Abdominal imaging and upper endoscopy should be ordered in patients with alarm features, recent worsening symptoms, or an abnormal physical examination only 1. Management starts with dietary modifications, including:
• Elimination of gas-producing foods
• Reducing lactose, fructose, and FODMAPs
• Avoiding carbonated beverages
• A low-FODMAP diet may be beneficial, but its implementation should be done in the hands of a trained gastroenterology dietitian or a trained gastroenterology provider exclusively 1. Central neuromodulators, such as antidepressants, may be effective in reducing visceral hypersensitivity and improving psychological comorbidities, and should be considered in the treatment of bloating 1. Other treatment options may include:
• Brain–gut behavioral therapies, such as hypnotherapy, cognitive behavioral therapy, and other modalities
• Anorectal biofeedback therapy for patients with bloating and distention thought to be related to constipation or difficult evacuation
• Medications used to treat constipation, such as secretagogues, 5-hydroxytryptamine 4 receptor agonists, and sodium-hydrogen exchanger-3 agents, may help bloating symptoms 1.

From the FDA Drug Label

Symptoms that Cumulatively Support the Diagnosis of Irritable Bowel Syndrome: – Abnormal stool frequency (for research purposes “abnormal” may be defined as greater than 3 bowel movements per day and less than 3 bowel movements per week); Abnormal stool form (lumpy/hard or loose/watery stool); Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation); Passage of mucus; Bloating or feeling of abdominal distension.

The initial evaluation and management approach for a patient presenting with bloating may involve assessing for symptoms that cumulatively support the diagnosis of Irritable Bowel Syndrome (IBS), such as abnormal stool frequency, form, or passage, and passage of mucus. Bloating is one of the symptoms that can be associated with IBS.

• Key considerations include:
  • Assessing for abdominal distension and other IBS symptoms
  • Evaluating for abnormal stool patterns
  • Considering the use of rifaximin for patients with IBS-D, as it has been shown to provide adequate relief of IBS symptoms in some patients 2

From the Research

Initial Evaluation

• The evaluation of a patient with bloating can be complex and challenging 3
• A simplified approach to history and physical examination is recommended, suitable for application in the primary care setting 3
• An organized approach to the evaluation of symptoms fosters trusting therapeutic relationships 4

Management Approach

• Patients can be reliably diagnosed without exhaustive testing and can be classified as having gastric bloating, small bowel bloating, bloating with constipation, or belching disorders 4
• Functional dyspepsia, irritable bowel syndrome, and chronic idiopathic constipation are the most common causes of these disorders 4
• Empiric therapy is a reasonable initial approach to functional gastrointestinal disorders, including:
  • Acid suppression with proton pump inhibitors for functional dyspepsia 4
  • Antispasmodics for irritable bowel syndrome 4
  • Osmotic laxatives and increased fiber for chronic idiopathic constipation 4

Diagnostic Considerations

• For presumed functional dyspepsia, noninvasive testing for Helicobacter pylori and eradication of confirmed infection (i.e., test and treat) are more cost-effective than endoscopy 4
• Patients with symptoms of irritable bowel syndrome should be tested for celiac disease 4
• Patients with chronic constipation should have a rectal examination to evaluate for dyssynergic defecation 4