🤰 Bloating — Assessment & Management

The ovarian cancer bloating connection is one of the most important cancer safety-net rules in primary care — the classic symptoms of ovarian cancer are frustratingly non-specific and frequently attributed to IBS or functional bowel disorders, causing diagnostic delays. The NICE NG12 (updated April 2026) guidance specifies: in women presenting with any of — abdominal or pelvic pain, increased abdominal size/bloating, early satiety/appetite loss, urinary urgency or frequency — that are persistent, unexplained, or new, CA125 should be measured. A CA125 at or above the NG12 age-specific threshold (updated April 2026: ≥35 IU/mL at 40–49, ≥31 at 50–59, ≥24 at 60–69, ≥25 at 70–79, ≥31 at 80+) should prompt urgent USS pelvis; under 40, CA125 should not be used on its own. The concept of 'persistent' bloating is the key qualifier — functional bloating varies day to day and relates to meals and bowel activity. The bloating of ovarian cancer is progressive, persistent (daily, not intermittent), and does not respond to the usual dietary or laxative measures. GPs who see women — particularly 50 and over — with new persistent or frequent bloating or early satiety should follow the NG12 CA125/USS pathway before attributing symptoms to IBS; if non-suggestive, investigate other causes and safety-net.

The FODMAP mechanism explains the majority of dietary-related bloating — FODMAPs are short-chain fermentable carbohydrates that are osmotically active (drawing water into the intestinal lumen) and rapidly fermented by colonic bacteria (producing hydrogen and methane gas). The key clinical insight: the symptoms are reproducible and food-dependent (bloating develops 1–4 hours after consuming high-FODMAP foods), distinguishing dietary bloating from functional bloating (which is less predictably related to specific foods). The low-FODMAP diet (developed at Monash University, Australia) is an evidence-based option for IBS when general dietary measures have not helped. However, it requires dietitian supervision (it is a complex elimination diet with a reintroduction phase), and long-term strict adherence may reduce prebiotic fibre intake and gut microbiome diversity. GPs should arrange dietitian referral (not just give a FODMAP leaflet) for patients with bloating who are suitable for this intervention. Small intestinal bacterial overgrowth (SIBO) is a frequently over-diagnosed condition — breath testing is poorly standardised and has high false-positive rates. The clinical picture of SIBO: bloating + diarrhoea predominantly after fermentable foods + risk factors (prior GI surgery, gastroparesis, small bowel dysmotility, PPI use, immunodeficiency). Breath testing is not needed for typical IBS (NICE CG61, BSG); testing and treatment are a gastroenterology decision — no empirical rifaximin in primary care.

The faecal calprotectin test is the most important investigation distinguishing IBS from IBD in primary care — calprotectin is a protein released by neutrophils into the gut lumen during intestinal inflammation. Cut-offs vary by assay and local pathway: a low result makes IBD less likely, an intermediate result is usually repeated after reviewing NSAIDs and infection, and a high result prompts gastroenterology referral; a normal result does not exclude all IBD (isolated small-bowel disease, proctitis). NICE HTG320 (formerly DG11, 2013) recommends faecal calprotectin as the first-line investigation for distinguishing IBD from IBS in adults with lower GI symptoms before proceeding to colonoscopy — avoiding unnecessary colonoscopy in the majority of patients who have IBS. Important caveats: calprotectin can be elevated by: NSAIDs (causes gut mucosal inflammation), PPI use (modest elevation), bowel preparation, recent GI infection, and colorectal cancer (sometimes). Ensure the patient has not taken NSAIDs for 2 weeks before the test for accurate interpretation. Use the local laboratory pathway for borderline results.

The positive IBS diagnosis principle (NICE CG61) is one of the most important quality improvements in primary care gastroenterology — NICE CG61 specifically recommends that IBS should be diagnosed positively based on characteristic symptoms, rather than as a diagnosis of exclusion after exhaustive investigation. The clinical rationale: over-investigating patients with typical IBS symptoms (particularly with invasive investigations like colonoscopy) increases anxiety, medicalises a functional condition, and has not been shown to improve outcomes or patient satisfaction compared to positive clinical diagnosis with appropriate safety-netting. The key is that the positive diagnosis must be accompanied by: appropriate red-flag exclusion (age, alarm symptoms, investigations if indicated), clear explanation of the diagnosis (not 'nothing is wrong with you' — which is unhelpful and inaccurate), and management planning. The IBS explanation that improves patient outcomes: 'Your bowel is structurally normal, but it is more sensitive to certain stimuli — food, stress, infection. This is a real, common condition, and there are effective treatments. It will not progress to cancer or IBD.'

The dietitian referral for low-FODMAP is a NICE CG61 recommendation — NICE CG61 specifies that exclusion diets such as low-FODMAP for IBS should be given only by a healthcare professional with expertise in dietary management (in practice, a dietitian), not self-implemented from a handout. The reason is important: the low-FODMAP diet has three phases (elimination, reintroduction, and personalisation), and incorrect implementation commonly leads to: (1) permanent restriction of many nutritious foods that do not actually trigger symptoms in that individual (the reintroduction phase is designed to identify which specific FODMAPs are problematic for each patient — most patients can tolerate at least some categories); (2) significant reduction in prebiotic fibre intake, potentially adversely affecting the gut microbiome; and (3) patient frustration and abandonment after initial elimination phase without personalisation. A properly trained dietitian conducts the elimination phase (typically 6 weeks), supervises systematic reintroduction of individual FODMAP categories, and helps the patient develop a personalised diet that excludes only their specific triggers. This approach achieves equivalent symptom reduction to full FODMAP restriction while maintaining better nutritional quality and gut microbiome diversity.

Gut-directed hypnotherapy (GDH) is one of the most evidence-based yet underutilised treatments for IBS — NICE CG61 advises considering referral for psychological interventions (including hypnotherapy) when IBS has not improved after 12 months of drug treatment and symptoms continue. The Gut-Focused Hypnotherapy protocol (Manchester protocol, developed by Whorwell) uses a course of sessions (number varies by service) focusing specifically on gut symptoms and visceral perception rather than general relaxation. Trials show meaningful benefit for many patients with refractory symptoms. The mechanism is thought to involve: modification of visceral hypersensitivity (changing central pain processing), reduction in rectal urgency and colonic motility, and improvement in psychological distress that drives the gut-brain axis dysregulation. Access in the NHS: some clinical psychology services offer GDH; some gastroenterology departments have clinical psychologists who provide it; private practitioners are also available. The Gutsy app and other digital health tools are emerging as accessible GDH delivery platforms with early positive evidence.

Spontaneous bacterial peritonitis (SBP) is a life-threatening complication of cirrhotic ascites that GPs must recognise — it occurs in approximately 10–30% of hospitalised patients with cirrhotic ascites and has a mortality of approximately 20% even with treatment (higher without). SBP is caused by translocation of gut bacteria (predominantly E. coli, Klebsiella, Streptococcus) through the bowel wall into the peritoneal fluid, where the immune response is impaired by low complement and protein levels in the ascites. Clinical presentation: fever, abdominal pain, confusion (hepatic encephalopathy triggered by infection), and deterioration in hepatic function. Importantly, SBP can present without classical peritonitis features — up to 30% are essentially asymptomatic, presenting only with hepatic encephalopathy or unexplained deterioration. Any patient with cirrhotic ascites presenting with unexplained deterioration, new confusion, or fever should be referred to hospital for diagnostic paracentesis. GPs managing cirrhotic patients should advise: any new confusion, fever, or abdominal pain in a cirrhotic patient = hospital assessment same day.

The gut-brain axis explanation is the single most therapeutic communication in managing IBS — patients who understand the mechanism (bidirectional communication between the enteric nervous system and the central nervous system, mediated by the vagus nerve, the hypothalamic-pituitary axis, and the gut microbiome) are better equipped to understand why stress worsens their symptoms, why psychological treatments are effective, and why there is nothing 'in their head' about their symptoms. The most useful analogy: 'Just as your heart races when you're nervous, your gut responds to stress too — it's connected to your brain through a major nerve called the vagus nerve. The gut is sometimes called the second brain because it has 100 million nerve cells of its own. When you're anxious or stressed, your gut receives the same stress signals and becomes more sensitive and reactive.' This explanation reduces the stigma of functional diagnosis and increases engagement with psychological interventions that have the strongest evidence base.

The CA125 monitoring principle for post-menopausal women with bloating is a NICE NG12 (updated April 2026) recommendation that is frequently not implemented — NICE NG12 (updated April 2026) sets the primary-care CA125 testing and referral criteria for persistent bloating; NICE CG122's primary-care detection section was removed in April 2026 and now points to NICE NG12 (updated April 2026). The word 'persistent' means occurring more than 12 times per month — daily or near-daily bloating is the threshold, not occasional bloating. The most common error: attributing persistent bloating in a post-menopausal woman to IBS, GORD, or 'just ageing' without measuring CA125 or USS pelvis. The Ovarian Cancer Action charity estimates that in the UK, approximately 4,000 women per year receive a diagnosis of ovarian cancer only after the cancer has reached stage III or IV — when 5-year survival is approximately 30%, compared to approximately 90% at stage I. Most of these delayed diagnoses involve GI symptoms (bloating, early satiety, change in bowel habit) that were attributed to functional disorders. Follow the NG12 pathway at the first presentation of persistent unexplained bloating — CA125 then USS at 40+, USS alone considered at 39 or under — and safety-net if results are non-suggestive.