From the Guidelines
The initial workup for a patient presenting with bloating should begin with a thorough history and physical examination to identify potential causes, as recommended by the most recent guidelines 1.
Initial Evaluation
The evaluation should include:
- A detailed history of the pattern and timing of bloating, relationship to meals, and associated symptoms like pain or altered bowel habits
- Inquiry about dietary factors, including lactose, gluten, or FODMAPs
- A focused physical exam to assess for abdominal distension, tenderness, and masses
Laboratory Tests
Basic laboratory tests should include:
- Complete blood count
- Comprehensive metabolic panel
- Thyroid function tests
- Celiac disease antibodies
- Stool studies for ova and parasites, fecal calprotectin, and fecal occult blood may be appropriate
Further Testing
Depending on clinical suspicion, further testing may include:
- Hydrogen breath testing to evaluate for small intestinal bacterial overgrowth or carbohydrate malabsorption
- Abdominal imaging with ultrasound or CT scan if structural abnormalities are suspected
- Endoscopic procedures like upper endoscopy or colonoscopy for patients with alarm features such as weight loss, anemia, or family history of gastrointestinal malignancy, as recommended by the AGA clinical practice update 1
Diagnosis and Management
The diagnosis and management of bloating should follow a systematic approach, using the Rome IV criteria to diagnose primary abdominal bloating and distention, and considering carbohydrate enzyme deficiencies, small intestinal bacterial overgrowth, and other potential causes, as outlined in the AGA clinical practice update 1. A thorough history and physical examination, combined with targeted laboratory tests and imaging studies, can help distinguish between functional disorders like irritable bowel syndrome and organic diseases such as celiac disease, inflammatory bowel disease, or malignancy, allowing for appropriate management strategies 1.
From the Research
Initial Workup for Bloating
The initial workup for a patient presenting with bloating involves a comprehensive approach to identify the underlying cause of the symptoms.
- A thorough history and physical examination are essential in evaluating the patient, as presented in 2.
- The evaluation may involve assessing for symptoms such as gas, bloating, diarrhea, abdominal pain, and negative endoscopy and radiology tests, as discussed in 3.
Diagnostic Tests
Diagnostic tests such as breath tests can be useful in identifying conditions like small intestinal bacterial overgrowth (SIBO), fructose or lactose intolerance, as mentioned in 3.
- These tests can help determine the prevalence of SIBO, fructose intolerance, and lactose intolerance, which can be around 33%, 34%, and 44%, respectively, as found in 3.
- Breath tests can also identify hypersensitivity, which can be present in 16% of patients during fructose breath tests and 9% during lactose breath tests, as reported in 3.
Classification of Bloating Disorders
Patients with bloating can be classified into different categories, including gastric bloating, small bowel bloating, bloating with constipation, or belching disorders, as described in 4.
- The most common causes of these disorders are functional dyspepsia, irritable bowel syndrome, and chronic idiopathic constipation, as mentioned in 4.
Empiric Therapy
Empiric therapy can be a reasonable initial approach to functional gastrointestinal disorders, including acid suppression with proton pump inhibitors for functional dyspepsia, antispasmodics for irritable bowel syndrome, and osmotic laxatives and increased fiber for chronic idiopathic constipation, as discussed in 4.
- Dietary changes, such as a low-fructose diet, can also be beneficial in improving symptoms of irritable bowel syndrome, as suggested in 5.