Treatment Options for Bloating
The management of bloating should begin with lifestyle modifications, dietary changes, and appropriate pharmacotherapy based on symptom severity, with a multidisciplinary approach involving dietary expertise when needed. 1
First-Line Treatments
Dietary Interventions
- Low-FODMAP diet: Can provide symptom improvement in >80% of patients at 1 month and complete improvement in 50% at 1 year 1
- Should be implemented under guidance of a trained dietitian
- Include planned reintroduction phase to avoid long-term negative impacts on gut microbiome
- Reduce intake of gas-producing foods: Beans, lentils, cruciferous vegetables 1
- Avoid trigger foods: Fatty foods, spicy foods, chocolate, caffeine, alcohol 1
- Consider carbohydrate malabsorption: Evaluate for lactose, fructose, or fructan intolerance 2
- Dietary restriction led to improvement in >80% of patients with carbohydrate malabsorption 2
Pharmacologic Options
- Simethicone: FDA-approved for relief of pressure and bloating 3
- Prokinetics: May help with bloating by improving gut motility 2, 1
- Antispasmodics: Can reduce bloating by decreasing smooth muscle contractions 1, 4
- Rifaximin: Consider for documented small intestinal bacterial overgrowth (SIBO) 1
Second-Line Treatments
For Constipation-Associated Bloating
- Secretagogues: Lubiprostone, linaclotide, plecanatide 2, 1
- Prucalopride: Selective 5-HT4 receptor agonist with number needed to treat of 8 for bloating improvement 2
- Tenapanor: Sodium-hydrogen exchanger-3 agent 2
For Visceral Hypersensitivity
- Central neuromodulators: 2, 1
- Tricyclic antidepressants (e.g., amitriptyline 10-50mg)
- Serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine, venlafaxine)
- Pregabalin: Has shown improvements in bloating in IBS patients 2
Behavioral Therapies
- Brain-gut behavioral therapies (BGBT): 2, 1
- Cognitive behavioral therapy
- Gut-directed hypnotherapy
- Both have robust evidence in IBS-associated bloating
- Diaphragmatic breathing exercises: Particularly effective for abdominophrenic dyssynergia (APD) 1
- Biofeedback therapy: 54% response rate for bloating when associated with dyssynergic defecation 1
Treatment Algorithm Based on Underlying Mechanism
For gas-related bloating:
- Dietary modifications
- Simethicone
- Consider rifaximin if SIBO suspected
For constipation-associated bloating:
- Secretagogues
- Prucalopride
- Anorectal biofeedback if dyssynergic defecation present
For visceral hypersensitivity:
- Central neuromodulators
- Brain-gut behavioral therapies
For abdominophrenic dyssynergia:
- Diaphragmatic breathing exercises
- Biofeedback therapy
Common Pitfalls to Avoid
- Empiric use of probiotics is not recommended for bloating treatment 1
- Improper implementation of low-FODMAP diet can lead to nutritional deficiencies 1
- Overlooking pelvic floor dysfunction as a cause of bloating 1
- Missing psychological components (anxiety, stress) that contribute to treatment failure 1
- Prolonged use of medications without clear indication 1
Special Considerations
- Keep a two-week diary of symptoms, stresses, and dietary intake to identify aggravating factors 2
- For patients with refractory symptoms, especially with weight loss, consider evaluation for intestinal neuromyopathic disorders 2
- Evaluate for anorectal disorders in patients with concurrent constipation and bloating 2
The multifactorial nature of bloating requires a systematic approach to identify the underlying mechanisms and select appropriate treatments. Addressing both physiological and psychological factors is essential for successful management.