What is the treatment for bloating, diarrhea, and gassiness?

Treatment for Bloating, Diarrhea, and Gas

Start with first-line dietary modifications—eliminate lactose, fructose, and artificial sweeteners for 2 weeks while using loperamide for diarrhea control, then advance to a supervised low-FODMAP diet if symptoms persist. 1, 2

First-Line Dietary Interventions

Begin with a 2-week elimination trial targeting the most common triggers before implementing more restrictive diets 2, 3:

• Eliminate lactose-containing foods if consuming >280 ml milk daily, as 51% of patients with digestive disorders have lactose intolerance 1, 2
• Remove fructose and sorbitol (artificial sweeteners in sugar-free products), as 60% of patients with digestive disorders have fructose intolerance 2, 3
• Avoid carbonated beverages, chewing gum, and excessive liquid intake to reduce gas swallowing 4, 5
• Limit fermentable carbohydrates (beans, cabbage, lentils, brussels sprouts) that increase flatus production 4

Add soluble fiber (ispaghula) starting at 3-4 g/day and increase gradually, but avoid insoluble fiber (wheat bran) as it worsens bloating 1, 3

Pharmacologic Management for Diarrhea

Loperamide is the first-line antidiarrheal agent for IBS-related diarrhea, though it commonly causes abdominal pain, bloating, nausea, and constipation—titrate the dose carefully to minimize these effects 1, 6:

• Avoid doses exceeding recommendations due to risk of cardiac arrhythmias and QT prolongation 6
• Contraindicated in children under 2 years due to respiratory depression and cardiac risks 6
• Monitor for dehydration and provide appropriate fluid/electrolyte replacement 6

Second-Line Low-FODMAP Diet Protocol

If symptoms persist after 2 weeks of simple elimination, implement a supervised low-FODMAP diet with three distinct phases 1, 2, 3:

• Restriction phase (4-6 weeks maximum) under guidance of a trained gastroenterology dietitian to avoid nutritional deficiencies 1, 2, 3
• Reintroduction phase to identify specific trigger foods according to individual tolerance 1, 2
• Personalization phase to create a sustainable long-term diet 3
• Consider daily multivitamin supplementation during restriction to prevent deficiencies 3

The low-FODMAP diet improves global symptoms and abdominal pain in IBS, though evidence quality is very low 1

Antispasmodic Therapy for Acute Symptoms

Certain antispasmodics effectively treat global symptoms and abdominal pain (RR 0.65; 95% CI 0.56-0.76), though dry mouth, visual disturbance, and dizziness are common 1, 2:

• Avoid anticholinergic antispasmodics if constipation is present, as they worsen this symptom 2
• Titrate doses carefully to minimize side effects 1

Antibiotic Therapy for Suspected SIBO

Rifaximin is effective for IBS with diarrhea when small intestinal bacterial overgrowth is suspected, though its effect on abdominal pain is limited 1, 7:

• FDA-approved for IBS-D in adults and can be used for travelers' diarrhea caused by noninvasive E. coli 7
• Alternative antibiotics include amoxicillin, fluoroquinolones, or metronidazole if rifaximin is unavailable 2
• Consider breath testing (hydrogen, methane, CO2) to confirm SIBO before treatment 1, 3

Neuromodulators for Refractory Cases

Tricyclic antidepressants (TCAs) are effective second-line therapy for global symptoms and abdominal pain when first-line treatments fail 1, 3:

• Start amitriptyline 10 mg once daily and titrate slowly to maximum 30-50 mg once daily 1
• Provide careful explanation about using these as gut-brain neuromodulators, not antidepressants 1
• TCAs work by reducing visceral sensation and re-regulating brain-gut control mechanisms 3

SSRIs are an alternative neuromodulator with weaker evidence but may be effective for global symptoms 1

Behavioral Interventions

Diaphragmatic breathing provides immediate symptom relief by increasing vagal tone, reducing stress response, and improving abdominophrenic coordination 1, 2, 3:

• Teach this technique first as it can be implemented immediately without cost 2, 3
• Cognitive behavioral therapy and gut-directed hypnotherapy have strong evidence for improving bloating symptoms 1, 3

Anorectal biofeedback therapy achieves 54% responder rate when evacuation disorder contributes to bloating 1, 3

Critical Pitfalls to Avoid

Do NOT use probiotics—current AGA guidelines explicitly recommend against probiotics for bloating and distension due to insufficient evidence, and they may paradoxically worsen symptoms or cause lactic acidosis 2, 3

Do NOT recommend gluten-free diets unless celiac disease is confirmed, as evidence is very low quality 1

Do NOT use food elimination diets based on IgG antibodies, as these are ineffective 1

Screen for eating disorders before implementing restrictive diets to prevent malnutrition 3

Discontinue elimination diets if no benefit after trial period to avoid unnecessary nutritional deficiencies 2, 3

When to Escalate Treatment

If symptoms remain refractory after dietary modifications, antispasmodics, and loperamide:

• Consider 5-HT3 receptor antagonists (ondansetron 4-8 mg, titrated up to three times daily)—this is likely the most efficacious drug class for IBS-D, though constipation is common 1
• Consider secretagogues (linaclotide, polyethylene glycol) if constipation predominates, as these are superior to placebo for bloating and constipation 2, 3
• Evaluate for celiac disease with tissue transglutaminase IgA and total IgA levels if symptoms persist 1