I have intermittent epigastric pain, bloating, flatulence, and frequent trips to the bathroom with scant stool output but no vomiting, fever, or diarrhea; what is the likely diagnosis and recommended management?

Likely Diagnosis: Irritable Bowel Syndrome (IBS)

Your symptoms of intermittent epigastric pain, bloating, flatulence, and frequent bathroom trips with minimal stool output strongly suggest Irritable Bowel Syndrome (IBS), specifically IBS with mixed bowel habits (IBS-M) or IBS with constipation (IBS-C). 1, 2

Understanding Your Symptoms

Your symptom pattern is classic for IBS:

• Abdominal pain with bloating and gas are hallmark features of functional gastrointestinal disorders 1
• Frequent urge to defecate with scant stool output reflects altered bowel motility and visceral hypersensitivity, where your gut nerves are overly sensitive to normal amounts of gas and stool 3, 4
• Bloating that worsens throughout the day is typical—the abdomen feels flat in the morning and gradually becomes more bloated, peaking by late afternoon or evening 5
• Absence of fever, vomiting, or true diarrhea makes serious organic disease unlikely 2, 6

Critical Red Flags to Rule Out First

Before accepting an IBS diagnosis, you must exclude alarm features that require urgent evaluation:

• Age over 50 with new symptoms requires colonoscopy 2, 7
• Rectal bleeding or blood in stool needs immediate investigation 2, 6
• Unintentional weight loss >10% is concerning for malignancy or inflammatory bowel disease 6, 7
• Symptoms that wake you from sleep suggest organic disease rather than IBS 2
• Fever or signs of infection require immediate medical attention 2

Essential Initial Testing

The 2023 American Gastroenterological Association guidelines recommend baseline laboratory screening even without alarm symptoms 6, 7:

• Complete blood count (CBC) to check for anemia 7
• C-reactive protein (CRP) or ESR to detect inflammation 7, 5
• Celiac disease screening (tissue transglutaminase IgA with total IgA) because celiac commonly presents with bloating and altered bowel habits 6, 7
• Fecal calprotectin to rule out inflammatory bowel disease—if <100 μg/g, this supports IBS diagnosis 7, 5

Dietary Triggers to Assess

Food intolerances frequently cause your exact symptoms:

• Lactose intolerance if you consume >280 ml (0.5 pint) of milk daily 6
• Fructose and sorbitol from fruits, juices, or artificial sweeteners cause bloating and gas 6, 5
• High FODMAP foods (fermentable carbohydrates) worsen symptoms in many IBS patients 8, 5, 9

Try eliminating dairy and high-FODMAP foods for 2 weeks—this is the simplest and most cost-effective diagnostic approach 1, 5

First-Line Management Strategy

Immediate Dietary Modifications

• Increase water-soluble fiber (ispaghula/psyllium) gradually, as it is better tolerated than wheat bran 1
• Avoid wheat bran specifically, as many IBS patients are intolerant to it 1
• Trial a low-FODMAP diet for 2-4 weeks to identify trigger foods 8, 5, 9

Medication Options Based on Your Symptoms

Since you have constipation-like symptoms (frequent urges but minimal output):

• Osmotic laxatives (polyethylene glycol 3350) as first-line therapy 2, 10
• Linaclotide or lubiprostone if osmotic laxatives fail—these also reduce abdominal pain directly 2, 8

For bloating and gas:

• Antispasmodics (hyoscine, dicyclomine) or peppermint oil are first-line for pain and bloating 8, 9

If Symptoms Persist After 4-6 Weeks

• Tricyclic antidepressants (low-dose amitriptyline 10-25mg at bedtime) are proven to reduce abdominal pain in IBS 8, 9
• Cognitive behavioral therapy (CBT) or hypnotherapy have excellent evidence for symptom relief 1, 8
• Rifaximin (non-absorbable antibiotic) if bloating is severe and refractory 1, 8

Common Pitfalls to Avoid

• Do not undergo extensive imaging or colonoscopy if you're under 50 without alarm features—the yield is extremely low and may lead to unnecessary procedures 6
• Avoid unnecessary surgery (cholecystectomy, hysterectomy) as functional symptoms are often misattributed to other organs, and surgery may worsen IBS 1
• Do not use laxatives long-term without medical supervision as this can cause electrolyte imbalance and dependence 10
• Recognize that stress significantly impacts symptoms—chronic life stress prevents recovery in IBS patients 2

When to Seek Immediate Care

Return immediately if you develop:

• Severe, unrelenting abdominal pain 2
• Persistent vomiting 2
• Fever or signs of infection 2
• Visible blood in stool 2, 6

Expected Course

IBS follows a pattern of flares and remissions lasting 2-4 days each 2. Symptoms may change over time, with some patients alternating between constipation and diarrhea patterns 2. Prognosis is better with shorter symptom duration and absence of chronic life stress 2.