Gas, Bloating, and Belching: Approach to Evaluation and Management

 

Am Fam Physician. 2019 Mar 1;99(5):301-309.

  Patient information: See related handout on gas, bloating, and belching, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Gas, bloating, and belching are associated with a variety of conditions but are most commonly caused by functional gastrointestinal disorders. These disorders are characterized by disordered motility and visceral hypersensitivity that are often worsened by psychological distress. An organized approach to the evaluation of symptoms fosters trusting therapeutic relationships. Patients can be reliably diagnosed without exhaustive testing and can be classified as having gastric bloating, small bowel bloating, bloating with constipation, or belching disorders. Functional dyspepsia, irritable bowel syndrome, and chronic idiopathic constipation are the most common causes of these disorders. For presumed functional dyspepsia, noninvasive testing for Helicobacter pylori and eradication of confirmed infection (i.e., test and treat) are more cost-effective than endoscopy. Patients with symptoms of irritable bowel syndrome should be tested for celiac disease. Patients with chronic constipation should have a rectal examination to evaluate for dyssynergic defecation. Empiric therapy is a reasonable initial approach to functional gastrointestinal disorders, including acid suppression with proton pump inhibitors for functional dyspepsia, antispasmodics for irritable bowel syndrome, and osmotic laxatives and increased fiber for chronic idiopathic constipation. Nonceliac sensitivities to gluten and other food components are increasingly recognized, but highly restrictive exclusion diets have insufficient evidence to support their routine use except in confirmed celiac disease.

Patients with symptoms of gas, bloating, and belching often consult family physicians, particularly when milder chronic symptoms of abdominal pain or altered bowel habits acutely flare up and become less tolerable. Most often, these symptoms are attributable to one or more of the functional gastrointestinal disorders (FGIDs), including functional dyspepsia, irritable bowel syndrome (IBS), and chronic idiopathic constipation.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Functional dyspepsia, IBS, and chronic idiopathic constipation can be diagnosed using symptom-based clinical criteria.

C

2, 3, 79, 16

Excluding organic disease through exhaustive investigation is not necessary; usually only limited testing is needed.

Noninvasive testing for Helicobacter pylori, and eradication therapy if positive (test-and-treat strategy), should be used for the initial evaluation of dyspepsia without alarm symptoms in younger patients.

C

7, 8, 19

See Table 1 for a list of alarm symptoms; urea breath testing is preferred (Table 4); endoscopy is recommended as the initial test in patients older than 55 years (Table 4).

Part of the initial evaluation of patients with diarrhea-predominant or mixed-presentation IBS symptoms should include testing for celiac disease.

C

9, 20, 21

If the incidence of celiac disease is known to be less than 1%, testing can be deferred.

Empiric proton pump inhibitor therapy is moderately effective for treating functional dyspepsia in patients who are H. pylori negative or who remain symptomatic after H. pylori eradication.

C

8

Patients with functional dyspepsia may have increased acid sensitivity.

Highly restrictive gluten-free diets and diets restricted in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols have insufficient evidence to be routinely recommended for IBS management.

C

16, 32, 35

Questions remain about safety, effectiveness, cost, and practicality of long-term implementation.


IBS = irritable bowel syndrome.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Functional dyspepsia, IBS, and chronic idiopathic constipation can be diagnosed using symptom-based clinical criteria.

C

2, 3, 79, 16

Excluding organic disease through exhaustive investigation is not necessary; usually only limited testing is needed.

Noninvasive testing for Helicobacter pylori, and eradication therapy if positive (test-and-treat strategy), should be used for the initial evaluation of dyspepsia without alarm symptoms in younger patients.

C

7, 8, 19

See Table 1 for a list of alarm symptoms; urea breath testing is preferred (Table 4); endoscopy is recommended as the initial test in patients older than 55 years (Table 4).

Part of the initial evaluation of patients with diarrhea-predominant or mixed-presentation IBS symptoms should include testing for celiac disease.

C

9, 20, 21

If the incidence of celiac disease is known to be less than 1%, testing can be deferred.

Empiric proton pump

The Authors

show all author info

JOHN M. WILKINSON, MD, is a consultant in the Department of Family Medicine and an associate professor in the Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn....

ELIZABETH W. COZINE, MD, is a consultant in the Department of Family Medicine and an assistant professor in the Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science, Rochester.

CONOR G. LOFTUS, MD, is a consultant in the Division of Gastroenterology and Hepatology and an associate professor in the Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science, Rochester.

Address correspondence to John M. Wilkinson, MD, Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science, 200 1st St. SW, Rochester, MN 55905 (e-mail: wilkinson.john@mayo.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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