Constipation with bloating: a clinical approach

 

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Ann Med. 2026 Jun 19;58(1):2684172. doi: 10.1080/07853890.2026.2684172

Constipation with bloating: a clinical approach to evaluation and management

David J Cangemi a,✉, Adam P Laitman b, Orit Faiman b, Bianca W Chang च

Key Messages

Patients presenting with constipation, with bloating as a predominant symptom, should be evaluated for underlying conditions, including irritable bowel syndrome with constipation (IBS-C), chronic idiopathic constipation (CIC), pelvic floor dysfunction, and microbial overgrowth (e.g. intestinal methanogen overgrowth), among other causes

If food intolerances are suspected, a trial of dietary restriction, such as a low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet, can be suggested

Improvement in bloating has been demonstrated in large, randomized trials of several gastrointestinal-targeted pharmacologic therapies (e.g. secretagogues) in patients with IBS-C or CIC

Pelvic floor physical therapy with biofeedback should be considered for patients with dyssynergic defecation

Introduction

Constipation and bloating are common bothersome gastrointestinal (GI) symptoms [1,2]. The estimated 

prevalence of constipation has ranged from 6% to 9% in Asian countries 

to 15% to 17% in Europe and North America [3].

 The estimated prevalence of bloating has ranged from approximately 11% in East Asian countries to approximately 20% in European, Latin American, Middle Eastern, and North American countries [4]. 

Sociocultural factors likely contribute to differences in patient perception of symptoms and reported prevalence rates [3,5].

Constipation and bloating frequently present concurrently [6,7]. 

In a global survey of 51,425 people with nonorganic causes of GI symptoms, approximately one-third of individuals reporting constipation with ≥30% of their bowel movements also reported bloating at least once per week [4].

 Rates of bloating were higher among individuals with irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC), with 71% and 36% of these populations, respectively, reporting bloating at least once weekly [4].

 In another global survey (N = 20,099), among 10,425 (51.9%) individuals who reported having कॉन्स्टीपशन

 in the previous 6 months, 65% reported also having bloating/distention [7]. Of note, a study in Italy of patients with IBS-C (n = 369) or CIC (n = 1834) identified substantially higher bloating prevalence rates of 96% and 91%, respectively, based on a 2-week recall period [1]. 

Although patients may often experience bloating and abdominal distention concurrently, these are distinct phenomena. 

Distension refers to an objective measurable increase in abdominal girth, whereas bloating refers to a subjective sensation of gassiness or fullness/pressure within the abdomen and does not include visible distension [2].

 The underlying pathophysiology of bloating is complex and diverse, as will be discussed latter in the manuscript, whereas abdominal distension may result from an increased volume of gas or stool within the intestines. Abdominophrenic dyssynergia, in which the diaphragm inappropriately contracts and the anterior wall muscles inappropriately relax in response to intestinal gas load, leading to distension, remains an underrecognized cause of abdominal distension, particularly in disorders of gut-brain interaction [8].

 Data have shown that both constipation and bloating impair patient health-related quality of life (QoL) [1,9]. 

Constipation is associated with pronounced detriments to general health, social functioning, 

and mental health, leading to impairments इन

 health-related QoL that are comparable to those associated with chronic diseases, such as diabetes and osteoarthritis [10]. Chronic constipation has been associated with poor QoL and impaired general well-being [11–13],

 with a strong negative correlation between symptom severity and QoL [12]. 

Individuals with CIC experience markedly impaired QoL compared with individuals without constipation [10,14]; likewise, individuals with IBS-C report greater impairments in health-related QoL, work productivity, and activity compared with those without IBS-C [15].

 Notably, patients with bloating have impaired QoL, independent of CIC or IBS-C [1]. In a US survey of patients with IBS-C (n = 328) or CIC (n = 552), bloating was 

reported as a ‘very/extremely bothersome’ symptom in 56% of patients with IBS-C and 46% of patients with CIC (p < 0.03 between the 2 groups) [16]. 

Additionally, the frequency of bloating was higher in patients with IBS-C vs CIC (2.8 vs 1.4 mean days/week, p < 0.0001). A systematic literature review of studies of CIC that used validated or disease-specific QoL measures, including the Patient Assessment of Constipation Quality of Life questionnaire, concluded that increased intensity of symptoms of constipation, including bloating, correlated with impaired QoL [17].

Given that constipation and bloating are common symptoms that can occur with a range of medical conditions,

 it is crucial to recognize the underlying condition(s) and tailor therapeutic interventions appropriately. The objective of this narrative review is to highlight key considerations in the evaluation and management of adults with constipation who also have the subjective sensation of bloating as a clinically predominant (i.e. bothersome) symptom.