Abstract
Background:
The estimated prevalence of bloating is 15–30% in the adult US population and is even higher in patients with disorders of gut-brain interaction (DGBIs). Despite this frequency, there is little research into patients who endorse bloating as a predominant symptom. The aim of this study was to better characterize these patients.
Methods:
New patients with DGBIs were asked to identify their three most predominant symptoms over the preceding three months; those who reported bloating were classified as “bloating predominant.” Rome IV and symptom-specific questionnaires were administered to assess for frequency of DGBIs and other predominant symptoms in this patient population. Using univariable and multivariable modeling, we analyzed the associations between bloating predominance, DGBI subtype, and clinical characteristics.
Results:
Of the 586 patients surveyed, 242 (41%) reported predominant bloating. Bloating predominant patients were more likely to be female, younger, and meet criteria for IBS-mixed (IBS-M), functional constipation, and functional dyspepsia compared to non-bloating predominant patients. Bloating predominant patients were also more likely to endorse concurrently predominant constipation, incomplete evacuation, abdominal pain, belching and/or nausea. On multivariable logistic regression, constipation and abdominal pain severity were positively associated while depression was negatively associated with predominant bloating.
Conclusions:
Patients with predominant bloating are more likely to have constipation-related symptoms than diarrhea-related symptoms. They are also more likely to have more severe abdominal pain than patients without predominant bloating. These findings help characterize patients with bloating as a predominant symptom and suggest that diagnosing and treating constipation should be considered as first line treatment.
Introduction
Bloating is a very common gastrointestinal (GI) symptom, with an estimated prevalence of 15–30% in the general adult US population.1–2 The prevalence is higher in women, younger individuals, and in those with disorders of gut-brain interaction (DGBIs). It occurs in approximately 66–83% of patients with irritable bowel syndrome (IBS)3–4 and 46–57% in functional constipation.5–6 Additionally, bloating often deleteriously impacts quality of life,7 with 32% of IBS-C and 28% of functional constipation patients reporting it as being their most burdensome symptom.8 For approximately 15–20% of these patients, it is the major reason why they go on to seek medical care.1
Much of the research regarding bloating has focused on it being a symptom of DGBIs, but very little research has considered bloating as a predominant symptom. In fact, bloating as a predominant symptom is only considered in the Rome IV diagnosis of functional bloating, which has a worldwide prevalence of 3.5%.9 Despite several studies focusing on the severity of bloating and its negative impact on quality of life,8 only one study to our knowledge has specifically characterized its frequency as a predominant symptom among various DGBIs. 10 In that study, bloating-specific symptoms, such as gas and bloating sensation, were the most common (76%) and bothersome (60%) symptoms endorsed.10 However, that study, published in 1999, did not use Rome criteria to define DGBI diagnosis and, thus, updated data is necessary.
The primary aim of our study is to evaluate patients who present with bloating as a predominant symptom, what other predominant symptoms they report, and which DGBIs they have based on Rome IV criteria. In doing so, we hope to better characterize this patient population.
Materials and Methods
Patients:
The Beth Israel Deaconess Medical Center in Boston, Massachusetts provides clinical care to thousands of patients with DGBIs, many of whom are treated in the IBS and Motility Center. Patients who present to the IBS & Motility Center are asked to complete symptom-specific surveys upon initial consultation, with the option for their data to be used in research studies. If they consent to this, their questionnaire data is stored securely on Research Electronic Data Capture (REDCAP), a HIPAA compliant web-based database. Survey data was extracted from this database for those who completed all bloating specific surveys between September 2019 and March 2021.
Surveys:
Predominant Symptoms:
Patients were asked to identify their three most predominant/bothersome symptoms over the past three months, and these were then considered “predominant symptoms.” Thirteen common functional GI symptoms were listed as options in addition to an “other” section where patients could write in one of their predominant symptoms if not listed (Table 1).
Table 1:
Predominant Symptoms
| Predominant Symptom | Number | Percentage (%) |
|---|---|---|
| Bloating | 242 | 41.3 |
| Abdominal pain | 234 | 39.9 |
| Constipation | 210 | 35.8 |
| Diarrhea | 179 | 30.6 |
| Incomplete evacuation | 177 | 30.2 |
| Nausea | 125 | 21.3 |
| Heartburn | 122 | 20.8 |
| Fecal urgency | 84 | 14.3 |
| Belching | 76 | 13.0 |
| Rectal Pain | 50 | 8.5 |
| Chest pain | 46 | 7.9 |
| Vomiting | 39 | 6.7 |
| Incontinence | 33 | 5.6 |
Patient Reported Outcomes Measurement Information System (PROMIS) scales:
The PROMIS questionnaire was developed by the NIH and is a validated metric used to assess patient reported symptoms and outcomes.11 Before their initial visit, patients were administered NIH PROMIS questionnaires in regards to constipation, diarrhea, abdominal pain, anxiety (Short Form 7a), and depression (Short Form 8a). Within the NIH PROMIS constipation questionnaire, there are questions regarding frequency of straining, incomplete evacuation, and lumpy stools. Each question ranges from “not at all” or “never” (1) to “very much”, “always”, or “more than once a day” (5). 11 Composite PROMIS scores reflect U.S. population based normative data with an average t-score of 50 and standard deviation of 10.
Rome IV:
Our patients were given the Rome IV Diagnostic Questionnaire and questions pertaining to functional abdominal bloating/distension, functional constipation (FC), functional diarrhea, functional dyspepsia, and irritable bowel syndrome (IBS) were analyzed.
Statistical Analysis:
Statistical analyses were conducted using Statistical Package for the Social Sciences (SPSS). Descriptive statistics included means, standard deviations, and percentages. Using the chi-square test of independence, we compared comorbid DGBIs and symptoms between patients with and without bloating as a predominant symptom, as defined by the predominant symptoms survey. All statistical tests were deemed significant (i.e. suggesting an association) when the p-value was < 0.05. We also utilized a multivariable logistic regression model, where the dependent variable was bloating as a predominant symptom. There were both continuous and categorical independent variables, including the following: age, gender, functional dyspepsia, constipation (IBS-C or FC), diarrhea (IBS-D or functional diarrhea), PROMIS scores of abdominal pain, constipation, diarrhea, anxiety, and depression. The PROMIS variable scores were converted to t-scores for statistical analysis. These ten variables included in the logistic regression model were deemed significant (i.e. predictive) when the p-value was < 0.05.
Results
Patient Population:
Of the 772 patients who presented for initial consultation, 586 (75.9%) completed all of the aforementioned questionnaires. Of the thirteen possible GI symptoms listed on the Predominant Symptoms Survey, bloating was the most commonly endorsed predominant symptom (41.3%). This was followed by abdominal pain (39.9%), constipation (35.8%), and diarrhea (30.6%) (Table 1). Table 2 includes demographic characteristics of those with and without bloating as a predominant symptom. Compared to patients who did not report bloating as a predominant symptom, there was a higher proportion of females (80.6% vs 70.6%, p=0.01). Individuals with bloating as a predominant symptom were also slightly younger than those without predominant bloating (45.7 vs 49.5 years old, p=0.02).
Table 2:
Demographics, Clinical Characteristics, and DGBI Diagnoses of Patients with and without Bloating as a Predominant Symptom
| Demographics | Non-Bloating (N= 344) |
Bloating (N= 242) |
P-value |
|---|---|---|---|
| Female Gender (%) | 242 (70.6%) | 195 (80.6%) | 0.01 |
| Age (SD) | 49.5 (18.4) | 45.7 (16.1) | 0.02 |
| Clinical Characteristic Severity, T-Score (SD) * | |||
| Depression | 48.6 (8.8) | 48.8 (9.2) | 0.86 |
| Anxiety | 53.2 (10.1) | 55.2 (9.3) | 0.02 |
| Constipation | 50.7 (8.8) | 54.4 (8.8) | <0.001 |
| Diarrhea | 50.0 (10.2) | 51.6 (9.9) | 0.06 |
| Abdominal Pain | 53.7 (12.8) | 59.6 (9.9) | <0.001 |
| DGBI subtypes (%) ** | |||
| IBS-C | 23 (6.7%) | 20 (8.3%) | 0.47 |
| IBS-D | 31 (9.0%) | 23 (9.5%) | 0.84 |
| IBS-M | 30 (8.7%) | 34 (14.0%) | 0.04 |
| IBS-U | 5 (1.5%) | 3 (1.2%) | 0.83 |
| Functional Diarrhea | 43 (12.5%) | 36 (14.9%) | 0.41 |
| Functional Constipation | 31 (9.0%) | 42 (17.4%) | 0.003 |
| Functional Dyspepsia | 114 (33.1%) | 122 (50.4%) | <0.001 |
| PDS*** | 46 (13.4%) | 59 (24.4%) | 0.001 |
| EPS*** | 29 (8.4%) | 17 (7.0%) | 0.53 |
| Both | 39 (11.3%) | 46 (19.0%) | 0.009 |
Based on PROMIS scores
Based on Rome IV questionnaire
Postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) are subtypes of functional dyspepsia and are characterized by predominant postprandial fullness and epigastric pain, respectively.
Patients with bloating as a predominant symptom most often reported bloating 30 minutes to two hours after a meal (40.0%) followed by immediately to 30 minutes after a meal (33.3%), 2–4 hours after a meal (17.5%), and then during a meal (9.2%) (Figure 1). Similarly, they were more likely to meet criteria for IBS-M (14.0% vs 8.7%, p = 0.04), functional constipation (17.4% vs 9.0%, p = 0.003), and functional dyspepsia (50.4% vs 33.1%, p < 0.001) than those without predominant bloating (Table 2). Among patients with functional dyspepsia, those who reported predominant bloating were not more likely to have overlapping Rome diagnoses compared to those without predominant bloating (p = 0.36).
Figure 1: Timing of Bloating Symptoms.
Patients with predominant bloating experienced their symptoms most often immediately to two hours after a meal.
Concurrent Predominant GI Symptoms:
Of the predominant symptoms listed in Table 1, we examined the rates of 6 symptoms known to be associated with bloating. Compared to those who did not report bloating as one of their three most predominant symptoms, a higher proportion of patients with predominant bloating also reported nausea, belching, abdominal pain, incomplete evacuation, and/or constipation as a concurrent predominant symptom (p < 0.001 for all) (Figure 2).
Figure 2: Overlap Between Bloating and Other Predominant Symptoms.
Patients with predominant bloating were more likely to endorse co-occurring predominant nausea, belching, abdominal pain, incomplete evacuation, and constipation than patients without predominant bloating.
Constipation Symptoms:
We also identified proportions of patients with bloating as a predominant symptom who reported constipation symptoms. A larger percentage of patients with bloating as a predominant symptom endorsed lumpy stools (51.7% vs 36.4%), incomplete evacuation (68.8% vs 45.5%), and straining (57.5% vs 38.7%) occurring in >30% of bowel movements, compared to those without bloating as a predominant symptom (p < 0.001).
Multivariable Logistic Regression Model:
Using multivariable logistic regression, we found that abdominal pain and constipation severity were positively associated with bloating as a predominant symptom while depression severity was negatively associated (Table 3). For each standard deviation increase in abdominal pain and constipation severity, defined as a ten-point increase on PROMIS t-scores, there was a 28% and 33% increased risk of reporting bloating as a predominant symptom, respectively. For each standard deviation increases in depression t-score, there was a 36% decreased risk of reporting bloating as a predominant symptom. We tested for collinearity using the variance inflation factor (VIF), which measures the strength of correlation between predictor variables in a logistic regression model. Our findings indicated that there was no significant multicollinearity (VIF <5).
Table 3:
Multivariable Logistic Regression
| Odds Ratio | 95% CI [LL,UL] | P-value | |
|---|---|---|---|
| Age | 0.995 | [.984, 1.005] | 0.32 |
| Gender | 1.468 | [.958 2.248] | 0.08 |
| Abdominal Pain* | 1.028 | [1.008 1.047] | 0.005 |
| Constipation* | 1.033 | [1.009 1.058] | 0.007 |
| Diarrhea* | 0.994 | [.974 1.016] | 0.61 |
| Anxiety* | 1.026 | [.998 1.0551 | 0.07 |
| Depression* | 0.964 | [.936 .992] | 0.01 |
| Functional Dyspepsia** | 1.338 | [.913 1.961] | 0.14 |
| IBS-C or FC** | 1.251 | [.769 2.036] | 0.37 |
| IBS-D or Functional Diarrhea** | 1.332 | [.835 2.123] | 0.23 |
Based on PROMIS Score
Based on Rome IV questionnaire
Discussion
Previous studies of bloating have focused on the presence and severity of bloating as a symptom in specific DGBIs4,12 but none to our knowledge have specifically evaluated bloating as a predominant, or most bothersome, symptom. In this study, just under half of patients (41.3%) presenting to a tertiary care GI clinic endorsed bloating as one of their three most predominant symptoms. Using univariable and multivariable modeling, we found that bloating predominant patients were more likely to meet Rome IV criteria for IBS-M, functional constipation, and functional dyspepsia compared to those without predominant bloating. They were also more likely to endorse predominant nausea, belching, abdominal pain, incomplete evacuation, and constipation.
Consistent with research on bloating severity,13 there was a clear association between bloating as a predominant symptom and constipation-related symptoms in this study. On multivariable regression, diagnosis of functional constipation was associated with increased likelihood of reporting bloating as a predominant symptom. Similarly, increased severity of constipation (measured by PROMIS constipation questionnaire) was associated with higher odds of reporting bloating as a predominant symptom. In our study, IBS-C was not significantly associated with predominant bloating, potentially due to small sample in this subtype (n = 43), but IBS-M was a significant predictor of bloating. Although this subgroup has not been completely characterized, a number of previous studies have suggested that clinical characteristics of patients with IBS-M are more similar to those with IBS-C compared to IBS-D, with one study showing that the majority of patients with IBS-M identified themselves as being constipated.14
Overall, the majority of patients with predominant bloating in this study had comorbid constipation. This association may potentially be due to constipation-related delayed whole gut transit, visceral hypersensitivity, or abdomino-phrenic dyssynergia.15–18 Prior studies have shown that treatment of constipation, from biofeedback to various pharmacotherapies, not only improves the regularity of bowel movements but also the intensity of bloating symptoms and overall patient satisfaction.19–21 Together, our univariable and multivariable findings suggest that diagnosis and treatment of constipation should be considered first line, alongside bloating specific therapies, in the treatment of patients with bloating as a predominant symptom.
Approximately half of patients with predominant bloating in this cohort had functional dyspepsia. We initially hypothesized that this could be due to an overlap between functional dyspepsia and other constipation-related DGBIs. However, subgroup analysis of our functional dyspepsia cohort revealed that patients with predominant bloating had similar rates of concurrent DGBIs to those without predominant bloating. This suggests an independent relationship between functional dyspepsia and bloating as a predominant symptom. It also suggests a potentially different mechanism for bloating within this subset of patients, one that may be due to a mixture of upper gastrointestinal dysbiosis, dysmotility, and/or visceral hypersensitivity.22–25 These mechanisms can lead to the classic combination of epigastric pain and postprandial fullness, which serves as diagnostic criteria for functional dyspepsia,26 in addition to other common upper GI symptoms, such as postprandial bloating, belching, and nausea, each of which had a high rate of co-predominance with bloating (Figure 2).The latter symptoms are more prevalent in patients with postprandial distress syndrome (PDS), the most common subtype of functional dyspepsia, which again agrees with our findings.
In addition to physical symptoms, we examined the burden of psychiatric symptoms in patients with predominant bloating. Several prior studies have shown that the severity of bloating is actually positively associated with anxiety, depression, and somatization.13, 27–30 Our study showed a negative association between depression and predominant bloating but no association with anxiety. We suggest interpreting this finding with caution. Given the similar depression severity scores between patients with and without bloating as a predominant symptom (as shown in Table 2), it is possible that the significant association between depression and predominant bloating may be related to other, unmeasured, confounding factors.
Our study has a number of strengths. The first being that the population was sizable, with over 500 patients completing all associated questionnaires and just under half endorsing bloating as one of their three most predominant symptoms. This created a well-powered model that allowed us to examine bloating from a different perspective, one emphasizing symptom predominance rather than DGBI diagnosis. This is a novel approach and is important in further characterizing this previously understudied patient population. Despite it being well-powered, our study occurred at a single tertiary care center which may limit its generalizability. Additionally, we did not ask our patients to differentiate between abdominal bloating and distension. Finally, we did not assess the exact location of bloating, which may prove to be useful in further differentiating patients with predominant bloating and which specific DGBIs they are diagnosed with.
In conclusion, patients with bloating as a predominant symptom are more likely to report significant constipation and abdominal pain than patients without predominant bloating. These findings suggest that diagnosing and treating constipation in patients with predominant bloating should be considered first line. Future studies are needed to investigate long-term outcomes of patients with predominant bloating symptoms.
Patient Population Flow Chart:
Footnotes
Conflict of Interest: No conflicts of interest
References
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