Bloating in Irritable Bowel Syndrome Is Associated with Symptoms Severity, Psychological Factors, and Comorbidities

  • Keren Hod
  • Yehuda RingelEmail author
  • Miranda A. L. van Tilburg
  • Tamar Ringel-Kulka
Original Article



Bloating is one of the most bothersome symptoms of irritable bowel syndrome (IBS), but its association with other symptoms is not well described.


We investigated the association between symptoms of abdominal bloating, other IBS symptoms, psychological distress, and comorbid pain conditions.


We conducted a cross-sectional study on a large cohort of IBS patients with and without symptoms of abdominal bloating and healthy controls. Subjects were assessed for IBS and its subtypes, pain severity, symptoms severity, psychological disturbances, comorbidities, and dietary restrictions of three fluid groups.


A total of 484 subjects were investigated. Compared with IBS − B, IBS + B subjects had higher rates of constipation (30% vs. 15%, p = 0.191) and lower rates of diarrhea, (70% vs. 85%, p = 0.191) although these were not statistically significant. Bloating severity correlated with IBS symptoms severity (r = 0.397, p = 0.000), pain severity (r = 0.364, p = 0.000), and both anxiety and somatization scores (r = 0.167, p = 0.015 and r = 0.219, p = 0.001, respectively). Prevalence of fibromyalgia and depression and somatization scores was significantly higher in IBS with bloating than in IBS without bloating. IBS patients with bloating reported more dietary restriction of three fluid groups to control their symptoms compared with healthy controls and IBS patients without bloating.


Abdominal bloating in IBS is associated with increased symptoms and pain severity, somatization, depression, fibromyalgia, and altered dietary fluids composition. Recognizing and addressing these factors in the diagnosis and management of patients with IBS may improve clinical outcome.


Irritable bowel syndrome Bloating Comorbidity Somatization disorder 





Healthy controls


Irritable bowel syndrome


Irritable bowel syndrome without bloating


Irritable bowel syndrome with bloating


Constipation-predominant irritable bowel syndrome


Diarrhea-predominant irritable bowel syndrome


Temporomandibular joint



This work was performed in partial fulfillment of the requirements for a PhD degree of Keren Hod, Sackler Faculty of Medicine, Tel Aviv University, Israel.


None for the design, funding, conduction, analysis, interpretation, and writing of this study. The collection of the dataset used in this study was supported by GSK.

Compliance with ethical standards

Conflict of interest

No competing interests declared.


  1. 1.
    Manning AP, Thompson WG, Heaton KW, Morris AF. Towards positive diagnosis of the irritable bowel. Br Med J. 1978;2:653–654.CrossRefGoogle Scholar
  2. 2.
    Mearin F, Lacy BE, Chang L, et al. Bowel disorders. Gastroenterology. 2016;150:1393–1407.CrossRefGoogle Scholar
  3. 3.
    Palsson OS, Whitehead WE, van Tilburg MA, et al. Rome IV diagnostic questionnaires and tables for investigators and clinicians. Gastroenterology. 2016.
  4. 4.
    Longstreth GF, Thompson WG, Chey WD, et al. Functional bowel disorders. Gastroenterology. 2006;130:1480–1491.CrossRefGoogle Scholar
  5. 5.
    Hungin AP, Whorwell PJ, Tack J, Mearin F. The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40,000 subjects. Aliment Pharmacol Ther. 2003;17:643–650.CrossRefGoogle Scholar
  6. 6.
    Ringel Y, Williams RE, Kalilani L, Cook SF. Prevalence, characteristics, and impact of bloating symptoms in patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. 2009;7:68–72. (quiz 3).CrossRefGoogle Scholar
  7. 7.
    Kanazawa M, Miwa H, Nakagawa A, Kosako M, Akiho H, Fukudo S. Abdominal bloating is the most bothersome symptom in irritable bowel syndrome with constipation (IBS-C): a large population-based Internet survey in Japan. Biopsychosoc Med. 2016;10:19.CrossRefGoogle Scholar
  8. 8.
    Houghton LA, Whorwell PJ. Towards a better understanding of abdominal bloating and distension in functional gastrointestinal disorders. Neurogastroenterol Motil. 2005;17:500–511.CrossRefGoogle Scholar
  9. 9.
    Seo AY, Kim N, Oh DH. Abdominal bloating: pathophysiology and treatment. J Neurogastroenterol Motil. 2013;19:433–453.CrossRefGoogle Scholar
  10. 10.
    Ringel-Kulka T, Palsson OS, Maier D, et al. Probiotic bacteria Lactobacillus acidophilus NCFM and Bifidobacterium lactis Bi-07 versus placebo for the symptoms of bloating in patients with functional bowel disorders: a double-blind study. J Clin Gastroenterol. 2011;45:518–525.CrossRefGoogle Scholar
  11. 11.
    Malagelada JR, Accarino A, Azpiroz F. Bloating and abdominal distension: old misconceptions and current knowledge. Am J Gastroenterol. 2017;112:1221–1231.CrossRefGoogle Scholar
  12. 12.
    Ghoshal U, Shukla R, Srivastava D, Ghoshal UC. Irritable bowel syndrome, particularly the constipation-predominant form, involves an increase in Methanobrevibacter smithii, which is associated with higher methane production. Gut Liver. 2016;10:932–938.CrossRefGoogle Scholar
  13. 13.
    Azpiroz F, Malagelada JR. Abdominal bloating. Gastroenterology. 2005;129:1060–1078.CrossRefGoogle Scholar
  14. 14.
    Lee HJ, Park KS. Bloating. Korean J Gastroenterol. 2017;70:288–295.CrossRefGoogle Scholar
  15. 15.
    Major G, Pritchard S, Murray K, et al. Colon hypersensitivity to distension, rather than excessive gas production, produces carbohydrate-related symptoms in individuals with irritable bowel syndrome. Gastroenterology. 2017;152:124–133e2.CrossRefGoogle Scholar
  16. 16.
    Niec AM, Frankum B, Talley NJ. Are adverse food reactions linked to irritable bowel syndrome? Am J Gastroenterol. 1998;93:2184–2190.CrossRefGoogle Scholar
  17. 17.
    Ragnarsson G, Bodemar G. Pain is temporally related to eating but not to defaecation in the irritable bowel syndrome (IBS). Patients’ description of diarrhea, constipation and symptom variation during a prospective 6-week study. Eur J Gastroenterol Hepatol. 1998;10:415–421.CrossRefGoogle Scholar
  18. 18.
    Simren M, Månsson A, Langkilde AM, et al. Food-related gastrointestinal symptoms in the irritable bowel syndrome. Digestion. 2001;63:108–115.CrossRefGoogle Scholar
  19. 19.
    Locke GR III, Zinsmeister AR, Talley NJ, Fett SL, Melton LJ. Risk factors for irritable bowel syndrome: role of analgesics and food sensitivities. Am J Gastroenterol. 2000;95:157–165.CrossRefGoogle Scholar
  20. 20.
    Neri L, Iovino P, Laxative Inadequate Relief Survey (LIRS) Group. Bloating is associated with worse quality of life, treatment satisfaction, and treatment responsiveness among patients with constipation-predominant irritable bowel syndrome and functional constipation. Neurogastroenterol Motil. 2016;28:581–591.CrossRefGoogle Scholar
  21. 21.
    Ryu MS, Jung HK, Ryu JI, Kim JS, Kong KA. Clinical dimensions of bloating in functional gastrointestinal disorders. J Neurogastroenterol Motil. 2016;22:509–516.CrossRefGoogle Scholar
  22. 22.
    Dorn SD, Morris CB, Hu Y, et al. Irritable bowel syndrome subtypes defined by Rome II and Rome III criteria are similar. J Clin Gastroenterol. 2009;43:214–220.CrossRefGoogle Scholar
  23. 23.
    Francis CY, Morris J, Whorwell PJ. The irritable bowel severity scoring system: a simple method of monitoring irritable bowel syndrome and its progress. Aliment Pharmacol Ther. 1997;11:395–402.CrossRefGoogle Scholar
  24. 24.
    Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64:258–266.CrossRefGoogle Scholar
  25. 25.
    Hartono JL, Mahadeva S, Goh KL. Anxiety and depression in various functional gastrointestinal disorders: do differences exist? J Dig Dis. 2012;13:252–257.CrossRefGoogle Scholar
  26. 26.
    Sandler RS, Stewart WF, Liberman JN, Ricci JA, Zorich NL. Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact. Dig Dis Sci. 2000;45:1166–1171.CrossRefGoogle Scholar
  27. 27.
    Chang L, Lee OY, Naliboff B, Schmulson M, Mayer EA. Sensation of bloating and visible abdominal distension in patients with irritable bowel syndrome. Am J Gastroenterol. 2001;96:3341–3347.CrossRefGoogle Scholar
  28. 28.
    Heaton KW, Ghosh S, Braddon FE. How bad are the symptoms and bowel dysfunction of patients with the irritable bowel syndrome? A prospective, controlled study with emphasis on stool form. Gut. 1991;32:73–79.CrossRefGoogle Scholar
  29. 29.
    Song JY, Merskey H, Sullivan S, Noh S. Anxiety and depression in patients with abdominal bloating. Can J Psychiatry. 1993;38:475–479.CrossRefGoogle Scholar
  30. 30.
    Van Oudenhove L, Törnblom H, Störsrud S, Tack J, Simrén M. Depression and somatization are associated with increased postprandial symptoms in patients with irritable bowel syndrome. Gastroenterology. 2016;150:866–874.CrossRefGoogle Scholar
  31. 31.
    Park HJ, Jarrett M, Cain K, Heitkemper M. Psychological distress and GI symptoms are related to severity of bloating in women with irritable bowel syndrome. Res Nurs Health. 2008;31:98–107.CrossRefGoogle Scholar
  32. 32.
    Sperber AD, Atzmon Y, Neumann L, et al. Fibromyalgia in the irritable bowel syndrome: studies of prevalence and clinical implications. Am J Gastroenterol. 1999;94:3541–3546.CrossRefGoogle Scholar
  33. 33.
    Bohn L, Storsrud S, Simren M. Nutrient intake in patients with irritable bowel syndrome compared with the general population. Neurogastroenterol Motil. 2013;25:23–30e1.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Keren Hod
    • 1
    • 2
  • Yehuda Ringel
    • 3
    • 4
    Email author
  • Miranda A. L. van Tilburg
    • 4
    • 5
    • 6
  • Tamar Ringel-Kulka
    • 7
  1. 1.Research Division, Epidemiology ServiceAssuta Medical CentersTel AvivIsrael
  2. 2.Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of MedicineTel Aviv UniversityRamat Aviv, Tel AvivIsrael
  3. 3.Division of Gastroenterology and Hepatology, Meir Medical CenterTel Aviv UniversityKfar SabaIsrael
  4. 4.Division of Gastroenterology and Hepatology, Department of MedicineUniversity of North Carolina at Chapel HillChapel HillUSA
  5. 5.College of Pharmacy and Health SciencesCampbell UniversityBuies CreekUSA
  6. 6.School of Social WorkUniversity of WashingtonSeattleUSA
  7. 7.Department of Maternal and Child Health, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillUSA

Personalised recommendations