What is the recommended workup for a patient presenting with abdominal tightness and bloating?

Recommended Workup for Abdominal Tightness and Bloating

The workup for abdominal tightness and bloating should follow a systematic diagnostic algorithm starting with Rome IV criteria to diagnose primary abdominal bloating and distention, followed by targeted testing based on associated symptoms and risk factors. 1

Initial Assessment

History and Physical Examination Focus

• Bowel habits: Assess for constipation, straining, need for digital disimpaction
• Alarm symptoms: Weight loss >10%, vomiting, GI bleeding, family history of IBD
• Food relationship: Timing of symptoms in relation to meals
• Associated symptoms: Pain, nausea, changes in bowel movements

Basic Laboratory Testing

• Complete blood count (CBC)
• Comprehensive metabolic profile (CMP)
• Serologic testing for celiac disease (tissue transglutaminase IgA and IgA levels) 1

Diagnostic Algorithm Based on Symptoms

If Constipation is Present

1. Apply Rome IV criteria for IBS-C or chronic constipation
2. Perform anorectal manometry to diagnose pelvic floor dyssynergia 1
   • Biofeedback therapy improves symptoms in >70% of patients with defecatory disorders 1

If Food Intolerance is Suspected

1. Trial dietary restriction (2 weeks) of suspected triggers
2. Consider hydrogen-based breath testing for:
   • Lactose intolerance
   • Fructose intolerance (present in 60% of patients with digestive disorders)
   • Sucrose intolerance 1

If Alarm Symptoms are Present

1. Abdominal imaging (KUB, ultrasound, CT/MRI as indicated)
2. Upper endoscopy (especially in patients >40 years with dyspeptic symptoms) 1
3. Consider motility studies if severe nausea/vomiting present to diagnose:
   • Gastroparesis
   • Chronic intestinal pseudo-obstruction
   • Other motility disorders 1

If SIBO Risk Factors are Present

• Hydrogen-based breath testing with glucose or lactulose
• Small bowel aspirates in select cases
• Risk factors include chronic diarrhea, malnutrition, weight loss, or conditions causing GI dysmotility 1

Special Considerations

For Suspected Pelvic Floor Disorders

• Digital rectal examination to assess sphincter tone and identify:
  • Pelvic floor dyssynergia
  • Rectal prolapse
  • Anal stricture
  • Rectocele 1
• Defecography (barium or MRI) if structural etiology is suspected 1

For Suspected Visceral Hypersensitivity

• Consider central neuromodulators (antidepressants) to reduce visceral hypersensitivity 1
• Brain-gut behavioral therapies may be beneficial 1

Common Pitfalls to Avoid

1. Overreliance on imaging: In the absence of alarm symptoms, the yield of clinically meaningful findings from abdominal imaging is low 1

2. Unnecessary gastric emptying studies: Should not be ordered routinely for bloating and distention, but may be considered if nausea and vomiting are present 1

3. Overlooking functional causes: Functional disorders should be considered after organic pathology has been confidently excluded 2

4. Repetitive testing: Once a diagnosis of functional pain is established, repetitive testing is not recommended 2

5. Missing adhesions: In patients with previous abdominal surgery and chronic bloating with weight loss, consider laparoscopy to identify adhesional bands 3

6. Ignoring psychological factors: Psychological support (cognitive therapy) should be considered for functional disorders 2

Treatment Considerations

• Dietary interventions should be monitored by a gastroenterology dietitian when implementing restrictive diets like low-FODMAP 1
• Probiotics should not be used to treat abdominal bloating and distention 1
• Biofeedback therapy is effective when a pelvic floor disorder is identified 1
• Central neuromodulators can treat bloating by reducing visceral hypersensitivity 1
• Medications for constipation should be considered when constipation symptoms are present 1

By following this systematic approach, clinicians can efficiently diagnose and manage patients with abdominal tightness and bloating while avoiding unnecessary testing and treatments.