In a 35‑year‑old woman with four months of recurrent bloating and heartburn and no alarm features, what investigations should be performed and how should she be treated?

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

Initial Management Strategy

Begin empirical proton-pump inhibitor therapy with omeprazole 20 mg once daily, taken 30–60 minutes before breakfast, for 4–8 weeks as first-line treatment. 1 This approach is appropriate because heartburn is a hallmark symptom with high positive predictive value for gastroesophageal reflux disease (GERD), allowing clinical diagnosis without immediate objective testing in patients without alarm features. 2

Investigations Required

No Immediate Endoscopy Needed

• At age 35 without alarm symptoms, upper endoscopy is not indicated initially. 1, 3 The patient should receive empirical PPI therapy first, with endoscopy reserved for treatment failure or development of red flags. 1

Screen for Alarm Features

Before starting empirical therapy, actively exclude the following red flags that would mandate immediate endoscopy: 3, 2

• Dysphagia (difficulty swallowing—present in >50% of patients with clinically significant findings on endoscopy) 3
• Gastrointestinal bleeding (overt bleeding, melena, or hematemesis) 3
• Anemia (particularly iron-deficiency anemia suggesting chronic blood loss) 3
• Unintentional weight loss (>10% body weight raises concern for malignancy) 4, 3
• Recurrent vomiting (may indicate obstruction or severe pathology) 3

Consider H. pylori Testing

• Test for H. pylori using urea breath test or stool antigen in this young patient with dyspepsia. 4, 1 If positive, eradicate the infection as this eliminates peptic ulcer mortality risk. 1
• The "test and treat" strategy is increasingly recommended in young patients with dyspepsia without alarm symptoms presenting in primary care. 4

Evaluate for Bloating-Specific Causes

Given the prominent bloating component, consider: 4

• Assess for constipation using Rome IV criteria for IBS-C or chronic constipation 4
• Screen for celiac disease with tissue transglutaminase IgA and total IgA levels, especially if there are alarm symptoms like weight loss or iron-deficiency anemia 4
• Consider carbohydrate intolerance testing (lactose, fructose, sucrose) if bloating persists despite PPI therapy and dietary restrictions 4

Treatment Algorithm

Step 1: Initial PPI Trial (Weeks 0–8)

• Omeprazole 20 mg once daily, 30–60 minutes before breakfast, for 4–8 weeks 1
• All commercially available PPIs have similar efficacy for symptom control 1
• Advise regular aerobic exercise as an adjunctive measure 1

Step 2: If Symptoms Persist After 4–8 Weeks

• Escalate to twice-daily PPI dosing (morning and evening before meals) for an additional 4–8 weeks 1, 3
• This step-up protocol is appropriate before proceeding to endoscopy 1

Step 3: If Symptoms Persist Despite Twice-Daily PPI for 8 Weeks

• Refer for upper endoscopy to exclude structural disease, erosive esophagitis, Barrett's esophagus, or alternative diagnoses 1, 3
• Consider off-medication prolonged wireless pH monitoring if endoscopy is normal 1

Step 4: Second-Line Therapy (After PPI Failure)

• Initiate tricyclic antidepressant therapy with amitriptyline starting at 10 mg once daily, titrated slowly to a maximum of 30–50 mg daily 1
• Provide thorough counseling regarding rationale (neuromodulation of visceral hypersensitivity) and potential side effects 1

Bloating-Specific Management

Dietary Interventions

• Trial a low-FODMAP diet (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) as first-line dietary intervention for bloating 4
• If gluten-containing foods correlate with symptoms, consider elimination of fructans or gluten restriction 4

When to Consider SIBO Testing

• Reserve hydrogen-based breath testing with glucose or lactulose for patients refractory to dietary restrictions and with risk factors for small intestinal bacterial overgrowth 4
• SIBO risk factors include chronic watery diarrhea, malnutrition, weight loss, or systemic diseases causing small bowel dysmotility 4

Treatments to Avoid

Do not use the following agents for functional dyspepsia or bloating, as they lack evidence of benefit: 1

• Topical capsaicin
• Oral gabapentin
• Oral sucralfate as first-line therapy

Common Pitfalls to Avoid

• Do not continue empirical PPI therapy beyond 4–8 weeks of optimized twice-daily dosing without endoscopic assessment if symptoms persist. 3
• Do not use H₂-receptor antagonists instead of PPIs for GERD, as PPIs are superior and H₂-blockers develop tolerance within 6 weeks. 1
• Do not assume all heartburn requires long-term treatment—approximately one-third of the population experiences occasional heartburn without disease. 2
• Do not perform routine barium upper GI series to diagnose GERD, as it has high false-positive rates and is too brief to detect pathologic reflux. 2

When Age Becomes a Factor

Although this patient is only 35 years old, be aware that patients over 50 years with new-onset dyspeptic symptoms or chronic GERD should undergo prompt upper endoscopy to exclude esophageal or gastric malignancy, particularly men with multiple risk factors (obesity, nocturnal reflux, hiatal hernia, tobacco use, family history). 3, 2