What are the treatment options for stomach bloating?

Treatment of Stomach Bloating

Start with dietary modifications as first-line therapy, specifically a low-FODMAP diet supervised by a trained gastroenterology dietitian, which has demonstrated significant improvements in bloating and quality of life in randomized controlled trials. 1

Initial Diagnostic Approach

Before initiating treatment, identify the underlying mechanism:

• Assess for carbohydrate malabsorption through breath testing or dietary restriction trials, as fructose intolerance affects approximately 60% of patients with digestive disorders and dietary restriction improves symptoms in >80% at 1 month 1, 2
• Evaluate for constipation-related bloating through detailed bowel habit history, as this determines whether secretagogues or biofeedback therapy are appropriate 1
• Screen for celiac disease with serologic testing in appropriate patients 1
• Consider small intestinal bacterial overgrowth (SIBO) in select cases using breath testing 3, 2

First-Line Treatment: Dietary Interventions

Low-FODMAP Diet

• Implement a low-FODMAP diet under supervision of a trained gastroenterology dietitian to avoid potential negative impacts on gut microbiome and malnutrition 1
• Restrict fermentable oligosaccharides, disaccharides, monosaccharides, and polyols for 2-4 weeks initially 3, 2
• Plan for systematic reintroduction of foods after initial restriction period 1
• Discontinue the diet if no benefit is observed to prevent unnecessary nutritional restriction 1

Specific Carbohydrate Restrictions

• Trial fructose restriction if fructose intolerance is suspected, as this led to complete symptom resolution in 50% of patients at 1 year 1
• Consider fructan avoidance rather than gluten restriction in patients with suspected non-celiac gluten sensitivity 1

Critical Pitfall: Screen for eating disorders before implementing restrictive diets, as dietary restrictions can trigger or worsen avoidant/restrictive food intake disorder 1

Second-Line Treatment: Pharmacological Options

For Constipation-Associated Bloating

Secretagogues are superior to placebo for treating abdominal bloating when constipation is present: 2, 4

• Linaclotide 72-290 mcg once daily on empty stomach, 30 minutes before first meal 5
• Lubiprostone as alternative 1, 2
• Plecanatide as alternative 1, 2

For SIBO or Suspected Dysbiosis

• Rifaximin (non-absorbable antibiotic) is effective for SIBO-related bloating 3, 2, 4
• Alternative antibiotics include amoxicillin, fluoroquinolones, or metronidazole 2

For Visceral Hypersensitivity

Central neuromodulators that activate noradrenergic and serotonergic pathways reduce visceral sensations: 1, 2

• Tricyclic antidepressants (e.g., amitriptyline) 1, 2, 4
• Serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine, venlafaxine) 1, 2, 4

Antispasmodics

• Otilonium bromide or peppermint oil may provide benefit, though evidence for peppermint oil specifically for bloating is limited 1, 4

Third-Line Treatment: Behavioral and Physical Therapies

Diaphragmatic Breathing

Implement diaphragmatic breathing exercises for immediate symptom relief, particularly effective for abdominophrenic dyssynergia by reducing vagal tone and sympathetic activity 3, 2, 6

Anorectal Biofeedback Therapy

For bloating associated with constipation or pelvic floor dysfunction, biofeedback therapy achieves 54% responder rate with 50% reduction in bloating scores: 1

• Requires confirmation of dyssynergic defecation through anorectal physiology testing 1
• Particularly beneficial for patients with IBS-C and chronic constipation 1

Brain-Gut Behavioral Therapies

Cognitive behavioral therapy and gut-directed hypnotherapy show robust evidence for improving bloating symptoms: 1, 2, 6

• FDA-approved prescription-based psychological therapies now available via smartphone apps 2
• Particularly useful when psychological factors amplify bloating sensations 1, 2

What NOT to Use

Probiotics

Probiotics are NOT recommended for bloating or distention - the AGA explicitly states this based on insufficient evidence and potential adverse effects including brain fogginess, worsening bloating, and lactic acidosis 1, 6, 4

Peppermint Oil

Recent placebo-controlled trials found no improvement in bloating symptoms with peppermint oil at 6-week endpoint, though it has minimal adverse effects 1

Treatment Algorithm

1. Start with dietary modification: Low-FODMAP diet under dietitian supervision for 2-4 weeks 1, 6
2. If constipation present: Add secretagogues (linaclotide, lubiprostone, or plecanatide) 2, 5, 4
3. If SIBO suspected: Trial rifaximin after breath testing confirmation 3, 2
4. If visceral hypersensitivity suspected: Add central neuromodulators (TCAs or SNRIs) 1, 2
5. If pelvic floor dysfunction identified: Refer for anorectal biofeedback therapy 1
6. For refractory cases: Add brain-gut behavioral therapies (CBT or hypnotherapy) 1, 2, 6
7. Adjunctive therapy at any stage: Teach diaphragmatic breathing exercises 3, 2, 6

Key Pitfall: Avoid prolonged dietary restrictions without demonstrated benefit, as this leads to malnutrition and may worsen quality of life 1, 6