In a 35‑year‑old woman with recurrent bloating and heartburn, what investigations are indicated and what is the appropriate management?

Management of Recurrent Bloating and Heartburn in a 35-Year-Old Woman

Begin with baseline investigations including full blood count, H. pylori testing (breath or stool antigen test), and coeliac serology if bloating suggests IBS overlap, then initiate empirical proton pump inhibitor therapy while awaiting results. 1

Initial Diagnostic Approach

Baseline Investigations Required

• Full blood count to screen for anemia that may indicate underlying organic disease 1
• H. pylori testing using either 13C-urea breath test or stool antigen test (not serology, as these have higher specificity) 1, 2
• Coeliac serology given the presence of bloating, which suggests potential IBS-type symptom overlap 1

Assessment for Alarm Features

At age 35 without alarm features, urgent endoscopy is not indicated unless specific red flags are present 1:

• Unexplained weight loss (≥10% body weight)
• Family history of gastro-oesophageal malignancy
• Progressive dysphagia
• Persistent vomiting

Non-urgent endoscopy should be considered only if symptoms prove treatment-resistant after empirical therapy trials 1

Distinguishing GERD from Functional Dyspepsia

The combination of heartburn and bloating suggests potential overlap between gastro-oesophageal reflux disease and functional dyspepsia, which coexist in approximately one-third of patients 1. A burning sensation starting in the epigastrium that radiates to the chest favors GERD, while epigastric pain unrelated to chest radiation suggests dyspepsia 1.

However, dominant heartburn has limited diagnostic value—even when heartburn is the primary complaint, the likelihood of confirmed GERD on pH testing is only slightly over 50% 3.

Treatment Algorithm

First-Line Management

1. H. pylori "Test and Treat" Strategy

• If H. pylori is positive: Provide eradication therapy immediately, as this cures underlying peptic ulcer disease and prevents future complications 1, 2
• If H. pylori is negative or symptoms persist after eradication: Proceed to empirical acid suppression 1, 2

2. Empirical Proton Pump Inhibitor Therapy

• Initiate full-dose PPI (e.g., omeprazole 40 mg once daily, taken 30-60 minutes before meals) for 4-8 weeks 1, 4, 2
• PPIs are superior to H2-receptor antagonists and are particularly effective for epigastric pain and heartburn 1, 2
• Do not perform repeat H. pylori testing after eradication in primary care, as most patients will not achieve complete symptom resolution from eradication alone 2

Second-Line Management (If Symptoms Persist)

For persistent bloating after PPI trial:

• Consider switching to a prokinetic agent, as bloating and fullness may represent dysmotility-predominant symptoms that respond better to prokinetics than acid suppression 1, 2
• Avoid cisapride due to cardiac toxicity; alternative prokinetic agents may be considered 1, 2

For persistent heartburn/epigastric pain after PPI trial:

• Consider low-dose tricyclic antidepressant (e.g., amitriptyline 10 mg at bedtime, titrated to 30-50 mg daily) as the most effective second-line therapy for refractory epigastric pain syndrome 2

Lifestyle and Dietary Modifications

• Avoid specific foods that trigger symptoms while being cautious not to adopt overly restrictive diets that could lead to malnutrition 2
• Head-of-bed elevation and avoidance of meals within 3 hours of bedtime for heartburn symptoms 4
• Regular aerobic exercise is recommended for all patients with functional dyspepsia 2

Key Clinical Pitfalls to Avoid

• Do not delay investigation if alarm features develop, even if there is symptomatic response to PPI therapy 4
• Avoid prescribing opioids for functional dyspepsia, as they cause iatrogenic harm without benefit 2
• Do not recommend overly restrictive diets (including low FODMAP diets, for which there is insufficient evidence in functional dyspepsia) that may lead to malnutrition or disordered eating 2
• Recognize symptom overlap: Gastro-oesophageal reflux symptoms coexist in approximately one-third of patients with functional dyspepsia, and functional heartburn shares more characteristics with functional dyspepsia than with true GERD 1, 5, 6

When to Refer to Gastroenterology

Referral is appropriate when 2:

• Diagnostic doubt exists
• Symptoms are severe or refractory to first-line treatments (H. pylori eradication and PPI therapy)
• Treatment-resistant dyspepsia in patients ≥25 years warrants non-urgent endoscopy 1

Patient Education

Establish an empathic relationship and explain that if investigations are normal, this represents a disorder of gut-brain interaction (functional dyspepsia with overlapping GERD), not a psychological condition, and that symptoms are impacted by diet, stress, and behavioral responses 1, 2. This approach may reduce healthcare utilization and improve quality of life 1.