Table 6

Investigation and management of bloating

Investigations	Potential results	Clinical management plan
Actions from history, medication and dietary assessment
History findings	Constipation	See management of constipation (p. 26).
	Dumping syndrome	See p. 20 (postprandial symptoms).
Medication findings	Opioids Metformin Statins NSAIDs	Consider stopping or alternative medications.
Dietary findings	Eating/drinking too much in one sitting Inadequate/excessive fluid or fibre intake Excessive sorbitol Excessive caffeine	Dietary advice. Referral to a dietitian with a 7-day food diary.
First line
Routine and additional blood tests	Abnormal results	Follow treatment for abnormal blood results (p. 2).
In women, also check Ca 125	Raised	Refer to gynaecology requesting an appointment within 2 weeks.
AXR	Faecal loading	See management of constipation (p. 26).
	Ileus/obstruction	This is an emergency. Discuss immediately with GI surgeon and arrange urgent CT scan.
	Bone fracture Gall stones Air in biliary tree Pleural effusion	Discuss with supervising clinician within 24 hours.
Second line
OGD and SI aspirate and SI biopsies (p. 25)	SIBO	Management of SIBO (p. 27).
	Inadequate gastric emptying	Prokinetics (p. 26).Consider formal gastric emptying studies.
	Coeliac disease	Refer to coeliac clinic/dietitians/gastroenterology.
Glucose hydrogen methane breath test	SIBO	Management of SIBO (p. 27).
Stool sample for faecal elastase	EPI	Management of EPI (p. 26).
Carbohydrate challenge	Carbohydrate intolerance/malabsorption	Management of carbohydrate malabsorption (p. 26).
CT/MRI abdomen and pelvis	Intra-abdominal pathology, eg, ascites	Discuss with supervising clinician within 24 hours.
	Malignancy/tumour recurrence	Refer to appropriate MDT requesting an appointment within 2 weeks.
Third line
US biliary tree and Doppler	Suggestive of gallstones, tumour recurrence	Discuss with supervising clinician and refer as clinically appropriate to a GI surgeon/gastroenterologist/oncology team.
	Malignancy/tumour recurrence	Refer to appropriate MDT requesting an appointment within 2 weeks.
	Ascites	Discuss with supervising clinician within 24 hours.
MRI small bowel/enteroclysis/enterogram	Small bowel disease	Discuss with supervising clinician and refer as clinically appropriate to a GI surgeon/gastroenterologist/oncology team.
Fourth line
If normal investigations		Refer to dietitian for a trial of low FODMAPs diet.
Fifth line
If no response to intervention		Referral for gastroenterology for small bowel motility studies.
		Reassure.

AXR, abdominal X-ray; CT, computerised tomography; EPI, exocrine pancreatic insufficiency; FODMAPs, fermentable oligo-di-monosaccharides and polyols; GI, gastrointestinal; MDT, multidisciplinary team; MRI, magnetic resonance imaging; NSAID, non-steroidal anti-inflammatory drug; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); SI, small intestine; SIBO, small intestinal bacterial overgrowth; US, ultrasound.