We’re seeing a virtual epidemic of bloating these days. The causes range from benign yet bothersome conditions like lactose intolerance to serious diagnoses like cancer. But how do you know whether your bloating is a nuisance or a sign of something more worrisome? You’re seriously bloated when your symptoms are caused by a condition that requires immediate medical attention. It’s important to be familiar with the warning signs and symptoms that might indicate something ominous, as well as the nine diagnoses associated with serious bloating, and what to do about them. Ascites is an abnormal buildup of fluid in the abdomen or pelvis. It can cause bloating, weight gain, and a rapidly expanding waistline. Ascites is usually caused by liver disease, but cancer is the culprit about 10 percent of the time. A large amount of fluid can make you look and feel like you’re several months pregnant. The combination of bloating and jaundice, which turns the eyes and skin yellow, can be a sign of cancer that’s spread to the liver, although it can also occur with more benign forms of liver disease like hepatitis. Severe abdominal pain and bloating that occur suddenly, especially if you also have nausea and vomiting, may be a sign of a bowel obstruction from scar tissue or a tumor pressing on the bowel. Immediate medical attention is a must to avoid complications like bowel perforation that can be fatal. Obstructions are painful, because the bowel above the blocked area stretches as it fills with food and digestive juices. The pain is intense and may occur in waves as the bowels try to push their contents through the obstructed area. Blood in your stool, vaginal bleeding in between periods, or postmenopausal vaginal bleeding can all be associated with serious bloating. Fortunately, the most common causes of these symptoms (hemorrhoids, an irregular menstrual cycle, fibroids, endometrial atrophy) aren’t the most serious, but bleeding should always be evaluated because it can be a sign of cancer, particularly colon or uterine cancer. Fever that accompanies bloating is usually due to infection or inflammation. If there’s also an elevated white blood cell count, infection needs to be immediately excluded — particularly from a pelvic, urinary, or gastrointestinal source.

9 Causes of Serious Bloating You Need to Know About, and What to Do About Them

  1. Ovarian cancer isn’t the most likely, but it is one of the most lethal. Although ovarian cancer is only the fifth most common cancer in women, it causes more deaths than any other reproductive cancer — mostly in women over 50. Risk factors include never having children or having them late in life, obesity, a family history of ovarian cancer, certain genetic abnormalities, and long-term treatment with hormone replacement therapy. Persistent bloating, feeling full faster, and pelvic pain are typical symptoms. What to do if you’re concerned about ovarian cancer: A thorough pelvic exam or transvaginal ultrasound is the best way to diagnose ovarian cancer. The blood test CA-125 isn’t a reliable screening test, but it can be helpful for following the course of treatment after diagnosis.
  2. Uterine cancer. In addition to bloating, uterine cancer can cause abnormal vaginal bleeding, a watery or blood-tinged vaginal discharge, pelvic pain, or pain with intercourse or urination. But it’s important to know that sometimes bloating or a change in bowel habits (new onset of constipation) may be the only initial signs of uterine cancer. Important risk factors include taking tamoxifen; taking estrogen supplements that don’t also contain progesterone; radiation therapy; a family history of uterine cancer; or a family history of a form of inherited colon cancer called Lynch syndrome. What to do if you’re concerned about uterine cancer: Combinations of the above symptoms, especially if you have a strong family history or additional risk factors, may point to a more serious diagnosis like uterine cancer. This calls for immediate further investigation with a pelvic exam, and imaging tests like an ultrasound or CAT scan. Fortunately, even aggressive cancers, when caught early enough, can be treated and often cured.
  3. Colon cancer can block the inside of the colon, causing progressive bloating. If the cancer is located at the end of the colon in the rectum or sigmoid, there is usually bleeding and a history of worsening constipationColon canceris the second most common cause of cancer deaths in non-smokers in the United States. What to do if you’re concerned about colon cancer: Colon cancer is mostly preventable through lifestyle changes and regular colonoscopy screenings. Some studies have shown that switching to a plant-based, nutrient-rich diet can cut your risk of colon cancer in half. If you think you may be at risk or experiencing symptoms, a colonoscopy is worth pursuing. What to do if you’re concerned about pancreatic cancer: Fortunately, pancreatic cancer is not a common cause of bloating. But if you do have it, early diagnosis is the key to ensuring a good outcome. Seek immediate medical evaluation if you are experiencing the above constellation of symptoms.
  4. Stomach cancer is usually asymptomatic early on, or causes vague symptoms like bloating, indigestion, and a feeling of fullness in the upper abdomen. Like pancreatic cancer, it may have already reached an advanced stage at diagnosis, in which case there will likely be additional symptoms of weight loss, nausea, and abdominal pain. What to do if you’re concerned about stomach cancer: Infection with the bacteria Helicobacter pylori is probably the most significant risk factor for developing stomach cancer, so it’s a good idea to be tested for H. pylori if you think you may be at risk. Nitrates and nitrites in smoked and processed meats are also risk factors for stomach cancer, and in a small number of patients, stomach cancer is genetic.
  5. Liver disease is often benign. But cancer from distant organs can spread to the liver. When cancer cells get into the bloodstream, they eventually get filtered through the liver. Bloating that’s accompanied by ascites and jaundice may be a sign of cancer that’s spread to the liver or of primary liver cancer, which can develop in people with a history of hepatitis or heavy alcohol use. What to do if you’re concerned about liver disease: If you think you may have liver disease, seek medical attention for a thorough physical exam, an ultrasound of the liver and abdomen, and a blood test that evaluates liver function to confirm the diagnosis. Some liver disease can be treated through dietary changes: more green leafy vegetables, legumes, and other plants, and less animal protein and starchy, sugary foods. Some cases require prescription medication.
  6. Diverticulitis refers to infection or inflammation of small pothole-type lesions that can develop in the colon called diverticulae. Diverticulitis usually occurs in people over age 50, and is often accompanied by abdominal pain and tenderness, loss of appetite, fever, and constipation or diarrhea. What to do if you’re concerned about diverticulitis: Bouts of diverticulitis can be treated in a number of ways: bowel rest (nothing to eat or drink), a liquid diet, antibiotics (if severe pain, fever, or an elevated white blood cell count are present), and analgesia (pain management). Severe tenderness may prompt a CAT scan to exclude an abscess. Worst-case scenario includes drainage of any abscesses, or surgery to remove a severely affected area. The longer your stool sits in the diverticular orifices, the greater the risk of developing diverticulitis — so constipation is definitely to be avoided. Once the acute episode of diverticulitis is over, a high-fiber diet can help keep you regular and avoid future complications.
  7. Pelvic inflammatory disease (PID) occurs when the uterine lining, fallopian tubes, or ovaries become infected, usually from sexually transmitted diseases like chlamydia or gonorrhea.It can also occur during childbirth, abortion, or miscarriage, or with insertion of an intrauterine device. Bloating accompanied by fever, pain, and tenderness in the pelvic area, plus a vaginal discharge, is very suggestive of PID. What to do if you’re concerned about PID: A careful pelvic exam and treatment with antibiotics are essential for PID. Untreated, it can lead to infertility and ectopic pregnancies (a pregnancy that implants and grows in the fallopian tubes rather than in the uterus and can cause life-threatening tubal rupture). If you’re having bloating, vaginal bleeding or discharge, and lower back or pelvic pain and think you may be pregnant, you should seek immediate medical attention to exclude PID.
  8. Crohn’s disease is an autoimmune disorder that affects the GI tract, usually in the small intestine or colon. The lag time between initial symptoms and diagnosis can be years, and bloating is one of the early symptoms. Crohn’s can cause narrowing of the intestines and ultimately lead to a bowel obstruction, resulting in severe bloating, weight loss, and nausea and vomiting after meals. Diarrhea with blood is typical when Crohn’s occurs in the colon. There may be other symptoms present outside of the GI tract, including mouth ulcers, joint pain, skin lesions, and inflammation in the eyes. What to do if you’re concerned about Crohn’s disease: Diagnosis is often the most challenging aspect of Crohn’s disease. X-rays and even colonoscopy may not show the inflammation, which usually occurs at the end of the small intestine (the ileum), an area not within easy reach of the endoscope. More sophisticated imaging techniques such as a CAT scan, MRI, or video capsule endoscopy (a tiny ingestible micro-camera in a pill) may be required. Like its sister disease ulcerative colitis, dietary changes, supplements, and more potent prescription drugs all play a role in getting the inflammation and bloating associated with Crohn’s under control. The good news is that most people with bloating don’t have cancer, infection, or inflammation. If you’re not sure whether your bloating is serious, it’s always better to err on the side of seeking medical attention rather than ignoring it and hoping for the best. Robynne Chutkan, MD, FASGE, is the author of The Bloat Cure: 101 Solutions for Real and Lasting Relief, The Microbiome Solution, and Gutbliss. Dr. Chutkan has been on faculty at Georgetown MedStar Hospital in Washington, DC, since 1997. In 2004, she founded the Digestive Center for Women, an integrative practice that incorporates nutritional optimization, exercise physiology, biofeedback, and stress reduction as part of the therapeutic approach to digestive disorders.