How can abdominal bloating be managed?

Management of Abdominal Bloating

Abdominal bloating should be managed using a structured diagnostic approach followed by targeted dietary modifications, central neuromodulators, and psychological therapies, while avoiding probiotics and unnecessary testing in patients without alarm features. 1

Initial Diagnostic Approach

Use Rome IV criteria to diagnose primary abdominal bloating and distention as the standardized diagnostic framework. 1, 2

Clinical Assessment

• Differentiate between subjective bloating (sensation of fullness) and objective distention (measurable increase in abdominal girth), as these may occur separately or together 2, 3
• Perform digital rectal examination to identify pelvic floor disorders, which frequently present with bloating and constipation 1, 2
• Reserve abdominal imaging and upper endoscopy exclusively for patients with alarm features (unintentional weight loss, GI bleeding, persistent vomiting, iron-deficiency anemia), recent worsening symptoms, or abnormal physical examination 1, 4
• In women ≥50 years, maintain high suspicion for ovarian cancer, as bloating is often a presenting symptom 4, 2

Targeted Testing

• Rule out celiac disease with serologic testing (tissue transglutaminase IgA and total IgA); if positive, confirm with small bowel biopsy 1, 4
• Evaluate carbohydrate enzyme deficiencies first with dietary restriction trials, then breath testing if dietary trials fail 1, 4
• Do NOT order gastric emptying studies routinely for bloating alone; only consider if nausea and vomiting are prominent 1, 5
• Consider anorectal physiology testing in patients with bloating related to constipation or difficult evacuation to rule out pelvic floor disorders 1, 2

Treatment Algorithm

First-Line: Dietary Interventions

When dietary modifications are needed, involve a gastroenterology dietitian to monitor treatment, particularly for low-FODMAP diet implementation. 1, 2

• Trial dietary restriction for suspected food intolerances (lactose, fructose, fructans) as the simplest and most cost-effective first approach 1, 4
• Consider low-FODMAP diet for patients with overlapping functional GI disorders, though it has not been explicitly studied for isolated functional bloating 1
• Important caveat: Low-FODMAP diet may negatively impact gut microbiome (decreased Bifidobacterium) and cause malnutrition, so plan for reintroduction phase 1
• In patients with nonceliac gluten sensitivity, recent evidence suggests fructans rather than gluten may be the culprit 1

Second-Line: Pharmacologic Management

Central neuromodulators (antidepressants) are used to treat bloating by reducing visceral hypersensitivity, raising sensation threshold, and improving psychological comorbidities. 1, 2

• If constipation symptoms are present, medications used to treat constipation should be considered for treating bloating 1
• Rifaximin may be considered in select patients, particularly those with IBS-D and bloating, as it has shown efficacy in reducing IBS symptoms including bloating 6, 7
• Do NOT use probiotics to treat abdominal bloating and distention, as evidence does not support their efficacy 1

Third-Line: Behavioral and Physical Therapies

Psychological therapies (hypnotherapy, cognitive behavioral therapy, brain-gut behavioral therapies) may be used to treat patients with bloating and distention. 1, 8

• Biofeedback therapy may be effective for bloating when a pelvic floor disorder is identified 1
• Diaphragmatic breathing and central neuromodulators are used to treat abdominophrenic dyssynergia (paradoxical diaphragmatic contraction with abdominal wall relaxation) 1, 2
• Effective patient communication about the biopsychosocial model and brain-gut interactions improves outcomes and reduces unnecessary healthcare utilization 1

Critical Pitfalls to Avoid

• Do not over-test patients with functional bloating without alarm symptoms, as diagnostic yield is extremely low 4
• Avoid attributing all distention to gas accumulation; even small increases in intraluminal gas (~10%) can trigger significant distention in susceptible patients 2
• Do not miss ovarian cancer in women ≥50 years despite benign examination 4, 2
• Avoid opioids if gastroparesis is suspected, as they worsen gastric emptying 5
• Do not rely on shorter gastric emptying studies (<2 hours) if testing is performed, as they are inaccurate 5

Special Populations

For patients with refractory symptoms despite standard therapy, particularly women with IBS-C not responding to treatment, anorectal physiology testing is advocated to identify pelvic floor disorders 1