How to manage bloating in a 23-year-old patient?

Management of Bloating in a 23-Year-Old Patient

The most effective approach to managing bloating in a 23-year-old patient is to implement dietary modifications first, particularly identifying and restricting foods that may trigger symptoms, followed by targeted therapies based on the underlying mechanism. 1

Initial Assessment and Diagnosis

• Use Rome IV criteria to diagnose primary abdominal bloating and distention, distinguishing it from other disorders of gut-brain interaction 1
• Evaluate for carbohydrate enzyme deficiencies through dietary restriction trials and/or breath testing 1
• Consider celiac disease screening with serologic testing if clinically indicated 1
• Avoid routine imaging and endoscopy unless alarm features, recent worsening symptoms, or abnormal physical examination are present 1

First-Line Management: Dietary Interventions

• Begin with a detailed diet history and food-symptom diary to identify potential triggers 1
• Assess for excessive intake of indigestible carbohydrates, fruits, caffeine, or artificial sweeteners that may contribute to symptoms 1
• Consider a low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet under the supervision of a gastroenterology dietitian 1
• Evaluate for lactose intolerance, especially in patients with substantial milk intake (>280 ml/day) 1
• If dietary modifications are implemented, they should be monitored by a trained gastroenterology dietitian to avoid nutritional deficiencies 1

Second-Line Therapies Based on Specific Mechanisms

For Constipation-Associated Bloating:

• Consider medications used to treat constipation if constipation symptoms are present 1
• Evaluate for pelvic floor disorders with anorectal physiology testing if bloating is associated with constipation or difficult evacuation 1
• Implement biofeedback therapy if a pelvic floor disorder is identified 1

For Visceral Hypersensitivity:

• Central neuromodulators (e.g., antidepressants) can reduce bloating by decreasing visceral hypersensitivity and raising sensation thresholds 1
• Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors show the greatest benefit in reducing visceral sensations 1

For Abdominophrenic Dyssynergia:

• Implement diaphragmatic breathing exercises 1
• Consider central neuromodulators as adjunctive therapy 1

Psychological Approaches

• Brain-gut behavioral therapies can be effective for bloating and distention 1
• Consider relaxation therapy, which has been shown to reduce symptoms and medical consultations during long-term follow-up 1
• Hypnotherapy, cognitive behavioral therapy, and other psychological therapies may be beneficial 1

Treatments to Avoid

• Do not use probiotics for treating abdominal bloating and distention, as current evidence does not support their efficacy and they may even worsen symptoms in some cases 1, 2
• Avoid peppermint oil for bloating as recent placebo-controlled trials show no improvement in bloating symptoms 1
• Do not order gastric emptying studies routinely unless nausea and vomiting are present 1

Important Caveats

• Bloating is extremely common (10-20% of the general population) with a higher prevalence in women 1
• The placebo response in treating bloating is substantial, averaging 47% in clinical trials 1
• If an elimination diet is implemented but not beneficial, it should be discontinued 1
• Be vigilant for risk factors of eating disorders when implementing dietary restrictions 1
• Recognize that bloating may be a symptom of other conditions like IBS, functional dyspepsia, or GERD rather than a standalone issue 3, 4