What are the treatment options for persistent stomach noises?

Treatment of Persistent Stomach Noises

For persistent stomach noises (borborygmi), the most effective approach is dietary modification targeting fermentable carbohydrates, followed by prokinetic agents if symptoms persist, with the understanding that stomach noises themselves are often benign and treatment should focus on associated symptoms like bloating, pain, or altered bowel habits. 1, 2

Initial Assessment and Dietary Management

The first step is identifying whether stomach noises occur with other gastrointestinal symptoms:

• Start with a 2-week elimination diet to identify dietary triggers, particularly focusing on FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), lactose, fructose, and artificial sweeteners 1, 2
• Fructose intolerance affects approximately 60% of patients with digestive disorders, compared to 51% for lactose intolerance 1
• Restrict fat and fiber intake, as these slow gastric emptying and increase intestinal gas production 3, 4
• Eat smaller, more frequent meals rather than large meals 3, 4

Common pitfall: Patients often focus on the noise itself rather than identifying whether it's associated with pain, bloating, or bowel habit changes. The noise alone rarely requires aggressive treatment 5, 6.

When Dietary Changes Are Insufficient

If stomach noises persist with associated symptoms after dietary modification:

For Bloating-Predominant Symptoms

• Rifaximin (non-absorbable antibiotic) is effective for small intestinal bacterial overgrowth (SIBO) or suspected dysbiosis 1, 2
• Secretagogues (lubiprostone, linaclotide, plecanatide) are superior to placebo for bloating associated with constipation 1, 2
• Avoid probiotics for treating abdominal bloating and distension, as they lack evidence 2

For Motility-Related Symptoms

• Metoclopramide 10 mg three to four times daily before meals is first-line prokinetic therapy 3, 4
  • Be aware of the black box warning for tardive dyskinesia, though risk may be lower than previously estimated 3
• Erythromycin 125 mg before meals is an alternative prokinetic option 4, 5
• Activated charcoal or other prokinetic agents like tegaserod may be effective in some patients 5

For Pain or Visceral Hypersensitivity

• Low-dose tricyclic antidepressants (TCAs) are first-line central neuromodulators for abdominal pain and visceral hypersensitivity 3, 1
  • TCAs can cause constipation by prolonging gut transit, which may be beneficial in diarrhea-predominant symptoms 3
• SSRIs at therapeutic doses should be used if mood disorder is suspected alongside gastrointestinal symptoms 3
• SNRIs (serotonin-norepinephrine reuptake inhibitors) are beneficial in chronic painful disorders and may help with psychological comorbidity 3

Advanced Diagnostic Considerations

If symptoms remain refractory:

• Breath testing for hydrogen, methane, and CO2 can identify carbohydrate intolerances or SIBO 1, 2
• Gastric emptying scintigraphy (4-hour test preferred) if gastroparesis is suspected, particularly with early satiety, nausea, or vomiting 3
• Consider abdominophrenic dyssynergia (APD), where paradoxical diaphragm contraction causes distention 1
  • Diaphragmatic breathing exercises can provide relief 1

Behavioral and Non-Pharmacological Interventions

• Cognitive behavioral therapy (CBT) and gut-directed hypnotherapy have robust evidence for improving bloating and gas-related symptoms 1, 2
• Diaphragmatic breathing techniques reduce vagal tone and sympathetic activity, providing immediate relief 1
• FDA-approved prescription-based psychological therapies are now available via smartphone apps 1

Important Caveats

• Proton pump inhibitors have limited effectiveness for bloating or stomach noises unless directly associated with GERD symptoms 1, 2
• Avoid prolonged dietary restrictions without benefit, as they can lead to malnutrition 2
• Consultation with a gastroenterology dietitian is recommended when dietary modifications are needed 2
• If symptoms are well-controlled on current therapy, continue the successful regimen rather than making unnecessary changes 7

When to Refer or Escalate

Consider specialist referral if:

• Symptoms persist despite dietary modification and first-line pharmacological therapy 3
• Red flag symptoms develop: rectal bleeding, anemia, nighttime pain, unintentional weight loss 8
• Severe refractory symptoms require consideration of botulinum toxin injection into the pylorus, feeding jejunostomy, or gastric electrical stimulation 3, 4