What are the treatment options for bloating?

Treatment Options for Bloating

Dietary modifications, particularly a low-FODMAP diet implemented with professional guidance, are the first-line treatment for abdominal bloating, followed by central neuromodulators and psychological therapies when appropriate. 1

Dietary Interventions

• A low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet has shown significant improvements in bloating symptoms and quality of life in randomized controlled trials, particularly for patients with irritable bowel syndrome (IBS) 1, 2
• Dietary restriction should be implemented with plans for food reintroduction and monitored by a trained gastroenterology dietitian to avoid potential negative impacts on gut microbiome and malnutrition 1, 3
• Carbohydrate malabsorption is common in patients with functional bloating; dietary restriction led to symptom improvement in >80% of patients at 1 month and complete improvement in 50% at 1 year 1
• If an elimination diet is not beneficial after an adequate trial period, it should be discontinued 1

Pharmacological Treatments

• Simethicone may provide relief for gas-related bloating and can be taken after meals and at bedtime (1-2 softgels as needed, not exceeding 2 softgels in 24 hours without physician supervision) 4
• Central neuromodulators (antidepressants) are effective for treating bloating by reducing visceral hypersensitivity and improving psychological comorbidities 1
• Tricyclic antidepressants (e.g., amitriptyline) and serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine, venlafaxine) show the greatest benefit in reducing visceral sensations 1
• Medications used to treat constipation should be considered when bloating is accompanied by constipation symptoms 1

Non-Pharmacological Approaches

• Anorectal biofeedback therapy is effective for bloating when a pelvic floor disorder or dyssynergic defecation is identified, with response rates of 54% for bloating scores decreased by 50% 1
• Psychological therapies such as hypnotherapy, cognitive behavioral therapy, and other brain-gut behavioral therapies are recommended for patients with bloating and distention 1
• Diaphragmatic breathing techniques can help treat abdominophrenic dyssynergia (APD), a condition where paradoxical diaphragmatic contraction contributes to bloating 1, 3

Treatments to Avoid

• Probiotics should not be used to treat abdominal bloating and distention as there is insufficient data supporting their efficacy 1, 4
• Probiotics may even be associated with developing new onset of brain fogginess, bloating, and lactic acidosis 1
• Peppermint oil, though commonly used due to minimal adverse effects, has not shown improvement in bloating symptoms in recent placebo-controlled trials 1

Treatment Algorithm

1. First-line: Dietary modifications (low-FODMAP diet) with professional guidance 1, 2
2. For bloating with constipation: Add constipation medications and consider anorectal biofeedback if pelvic floor dysfunction is present 1
3. For refractory symptoms: Central neuromodulators (antidepressants) 1, 5
4. For visceral hypersensitivity: Psychological therapies (cognitive behavioral therapy, hypnotherapy) 1, 6
5. For abdominophrenic dyssynergia: Diaphragmatic breathing techniques 1, 3

Common Pitfalls

• Failing to distinguish between bloating (subjective sensation) and distention (objective increase in abdominal girth), which may require different management approaches 3, 6
• Overreliance on probiotics despite lack of evidence for their efficacy in treating bloating 1
• Not considering pelvic floor disorders in patients with bloating and constipation 1
• Implementing dietary restrictions without professional guidance, which can lead to nutritional deficiencies 1