What is the treatment plan for gas or bloating?

Treatment Plan for Gas and Bloating

The most effective treatment approach begins with a 2-week dietary elimination trial targeting FODMAPs and common carbohydrate intolerances, followed by central neuromodulators (tricyclic antidepressants or SNRIs) if dietary measures fail, as these address the underlying visceral hypersensitivity that drives bloating symptoms. 1

Initial Dietary Management

Start with identifying and restricting dietary triggers through a structured elimination approach:

• Implement a low-FODMAP diet (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) under supervision of a trained gastroenterology dietitian, as this improves bloating and quality of life in randomized trials 1
• Test for fructose intolerance first, as 65% of patients with functional bloating have carbohydrate malabsorption, with dietary restriction achieving >80% symptom improvement at 1 month 1
• Consider fructan avoidance rather than gluten exclusion, as recent evidence shows fructans (not gluten) cause symptoms in non-celiac gluten sensitivity 1
• Discontinue elimination diets if no benefit occurs within 2-4 weeks to avoid malnutrition and eating disorder development 1

Critical Dietary Pitfall

The low-FODMAP diet decreases beneficial Bifidobacterium species and risks malnutrition, so implementation must include a reintroduction phase supervised by a gastroenterology dietitian exclusively 1

Pharmacological Interventions

Central Neuromodulators (First-Line Pharmacotherapy)

Use antidepressants that activate noradrenergic and serotonergic pathways to reduce visceral hypersensitivity:

• Tricyclic antidepressants (amitriptyline) or serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine) show greatest benefit for reducing visceral sensations and improving bloating 1, 2
• These medications re-regulate brain-gut dysregulated control mechanisms and improve psychological comorbidities that amplify bloating 1
• Pregabalin has also demonstrated improvements in bloating for IBS patients 1

Secretagogues (If Constipation Present)

• Lubiprostone, linaclotide, or plecanatide show superiority over placebo for treating abdominal bloating when constipation symptoms coexist 2
• Consider these specifically when bloating occurs with IBS-C or chronic constipation 1

Simethicone (Symptomatic Relief)

• FDA-approved for relief of pressure and bloating commonly referred to as gas 3
• Limited evidence for efficacy in functional bloating, but minimal adverse effects 3

Specialized Therapies Based on Underlying Mechanisms

Anorectal Biofeedback (If Pelvic Floor Dysfunction Present)

Biofeedback therapy achieves 54% responder rate for bloating when evacuation disorders are identified:

• Use instrument-based operant conditioning to improve pelvic floor coordination via visual monitoring of anorectal push and relaxation 1
• Particularly effective for bloating associated with IBS-C and chronic constipation overlapping with dyssynergic defecation 1
• Response rates are favorable and long-lasting based on RCTs, with improvements in abdominal distention and rectal hypersensitivity 1

Diaphragmatic Breathing (For Abdominophrenic Dyssynergia)

• Implement breathing exercises to correct paradoxical diaphragm contraction that occurs when the diaphragm moves downward while abdominal wall muscles relax 2, 4
• Particularly useful for meal-triggered distention patterns with minimal intestinal gas accumulation 4

Rifaximin (If SIBO Suspected)

• Non-absorbable antibiotic effective for small intestinal bacterial overgrowth or suspected dysbiosis 2
• Alternative antibiotics include amoxicillin, fluoroquinolones, and metronidazole 2

Brain-Gut Behavioral Therapies

Psychological interventions show robust evidence for bloating improvement:

• Cognitive behavioral therapy (CBT) and gut-directed hypnotherapy address psychological components that amplify bloating sensations 1, 2
• FDA-approved prescription-based psychological therapies are now available via smartphone apps 2
• These therapies improve patient-provider relationships and reduce unnecessary healthcare utilization 1

What NOT to Use

Probiotics Are Not Recommended

Probiotics should not be used to treat abdominal bloating and distention 1:

• No studies have examined efficacy of probiotics specifically for treating bloating and distention 1
• British, European, and American guidelines for IBS and FD have not endorsed probiotics for these conditions 1
• Probiotics may cause brain fogginess, paradoxical bloating, and lactic acidosis 1

Peppermint Oil Has Insufficient Evidence

• Recent placebo-controlled RCT found no improvement in bloating symptoms at 6-week endpoint 1
• Further studies needed despite minimal adverse effects 1

PPIs Only If GERD Present

• Proton pump inhibitors have limited effectiveness for bloating unless directly associated with GERD symptoms 5
• For functional bloating without acid-related symptoms, other treatment approaches should be prioritized 5

Diagnostic Testing to Guide Treatment

Order testing selectively based on clinical presentation:

• Breath testing (hydrogen, methane, CO2) to identify carbohydrate intolerances before dietary restriction 1, 2
• Anorectal physiology testing if bloating relates to constipation or difficult evacuation to rule out pelvic floor disorder 1
• Celiac serologies if appropriate, with small bowel biopsy confirmation if positive 1
• Avoid routine gastric emptying studies, whole gut motility studies, or imaging unless alarm features present 1