What are the best treatments for recurrent abdominal bloating and excessive flatulence?

From the Guidelines

The best treatments for recurrent abdominal bloating and excessive flatulence are dietary modifications, such as a low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet, and brain-gut behavioral therapies, including cognitive behavioral therapy and diaphragmatic breathing 1.

Key Treatment Options

• Dietary restriction: A 2-week trial of dietary restriction can help diagnose food intolerances, such as fructose or lactose intolerance, which can contribute to bloating and flatulence 1.
• Breath testing: Hydrogen, methane, and CO2 breath testing can be used to diagnose small intestinal bacterial overgrowth (SIBO) or carbohydrate malabsorption 1.
• Proton pump inhibitors (PPIs): PPIs may be used to treat bloating and flatulence related to gastroesophageal reflux disease (GERD) 1.
• Antibiotics: Rifaximin, a nonabsorbable antibiotic, may be used to treat SIBO, but careful patient selection is necessary due to its high cost and potential side effects 1.
• Central neuromodulators: Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), may be used to reduce visceral hypersensitivity and improve symptoms of bloating and distention 1.

Important Considerations

• Rome IV criteria: Should be used to diagnose primary abdominal bloating and distention 1.
• Celiac disease: Should be ruled out with serologic testing and small bowel biopsy if positive 1.
• Pelvic floor disorders: Should be evaluated with anorectal physiology testing if constipation or difficult evacuation is present 1.
• Gastroenterology dietitian: Should be involved in the management of patients with bloating and distention to provide dietary guidance and support 1.

From the Research

Therapeutic Options for Recurrent Abdominal Bloating and Excessive Flatulence

The treatment of recurrent abdominal bloating and excessive flatulence can be challenging, but several options are available. These include:

• Dietary modifications, such as avoiding highly fermentable or fructose-rich nutrients 2, 3, 4
• Treatment of constipation 2
• Prokinetics, which can help improve gut motility 2, 3, 5
• Drugs acting on visceral sensitivity, such as lubiprostone and linaclotide 3
• Probiotics, which can help modify the composition of colonic flora and reduce gas production 2, 3, 5
• Gas absorbants, although their efficacy remains to be more documented 2
• Non-pharmacological approaches, such as hypnosis, which may be discussed in some centers 2
• Antibiotics, such as rifaximin, which can help reduce gas production 3, 5
• Enzyme preparations and adsorbents, which can help reduce gas symptoms 4

Pathophysiology and Diagnosis

The pathophysiology of bloating is complex and not fully understood, but several mechanisms have been proposed, including:

• Impaired gas handling 2, 3, 4
• Gut hypersensitivity 2, 3
• Altered gut microbiota 3, 4
• Abnormal abdominal-phrenic reflexes 2, 3, 6
• Increased luminal contents (gas, stools, liquid or fat) 6 Diagnosis can be challenging due to the lack of measurable parameters to assess and grade bloating symptoms 6.