Comprehensive History and Physical Examination for Chronic Bloating, Gas, and Cramps
The most appropriate history and physical examination for patients with chronic bloating, gas, and cramps should focus on identifying specific etiologies, ruling out organic disease, and guiding targeted treatment approaches.
Key History Elements
Symptom Characterization
- Determine duration of symptoms (>4 weeks suggests chronic etiology) 1
- Assess timing of symptoms in relation to meals 1
- Document frequency, severity, and impact on quality of life 1
- Differentiate between bloating (subjective sensation) and distention (objective increase in abdominal girth) 1
Alarm Features
- Weight loss, nocturnal symptoms, blood in stool, recent onset of symptoms 2
- Family history of colorectal cancer, inflammatory bowel disease, or celiac disease 1, 2
- Fever or other systemic symptoms 2
Dietary History
- Detailed food diary to identify potential triggers 1
- Intake of FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) 1
- Consumption of caffeine, alcohol, artificial sweeteners, and dairy products 1
- Eating habits (speed of eating, air swallowing) 1
Medication Review
- Current medications that may cause bloating or gastrointestinal symptoms 1
- Antihypertensives (especially ACE inhibitors)
- Non-steroidal anti-inflammatory drugs
- Antineoplastic agents
- Antibiotics
- Magnesium supplements
- Gliptins (dipeptidyl peptidase-4 inhibitors)
Past Medical History
- Previous abdominal surgeries, especially involving ileum, right colon, or gastric bypass 1, 2
- History of pancreatic disease 1
- Systemic conditions: thyroid disorders, diabetes mellitus, adrenal disease, systemic sclerosis 1
- Previous episodes of similar symptoms and their resolution 1
Bowel Habit Assessment
- Stool frequency, consistency (using Bristol Stool Chart), and volume 1
- Associated symptoms: constipation, diarrhea, alternating patterns 1
- Presence of mucus or blood in stool 1
- Differentiate true diarrhea from fecal incontinence 1
Physical Examination
Abdominal Examination
- Inspection for visible distention, asymmetry, or surgical scars 1
- Auscultation for bowel sounds (hyperactive, hypoactive, or absent) 1
- Percussion to assess for tympany or dullness 1
- Palpation for tenderness, masses, organomegaly 1
- Assessment for fluid wave or shifting dullness if ascites is suspected 1
Digital Rectal Examination
Other Relevant Physical Findings
- Vital signs (including temperature to assess for infection) 1
- Nutritional status assessment (cachexia, muscle wasting) 2
- Examination for signs of systemic disease (thyroid enlargement, skin changes) 1
Initial Diagnostic Approach
Laboratory Tests
- Complete blood count, C-reactive protein, electrolytes 2
- Liver function tests, thyroid function tests 2
- Celiac disease screening (tissue transglutaminase IgA and total IgA) 2
- Fecal calprotectin to exclude inflammatory causes 2
Imaging Considerations
- Abdominal X-ray may be useful in selected cases to assess for constipation or obstruction 1
- Consider further imaging based on clinical suspicion 1
Special Considerations
Functional vs. Organic Causes
- Rome IV criteria can help identify functional disorders but do not reliably exclude organic disease 1
- Consider both functional and organic etiologies even when symptoms appear typical for functional disorders 1
Common Pitfalls to Avoid
- Failing to distinguish between bloating (sensation) and distention (physical finding) 1
- Missing medication-induced causes of symptoms 1
- Overlooking dietary contributors to symptoms 1
- Not recognizing alarm features that warrant expedited evaluation 2