What are the treatments for stomach bloating?

Treatment of Stomach Bloating

Start with a 2-week elimination diet to identify food triggers (lactose, fructose, FODMAPs), combined with diaphragmatic breathing exercises for immediate symptom relief, then escalate to targeted pharmacotherapy based on the underlying mechanism (secretagogues for constipation-related bloating, rifaximin for suspected dysbiosis, or central neuromodulators for visceral hypersensitivity). 1, 2

Initial Dietary Interventions

Begin with a short-term (2-week) elimination diet to identify specific food intolerances before considering more restrictive approaches 1, 2:

• Target common culprits first: lactose (affecting 51% of patients with digestive disorders), fructose (affecting 60%), sorbitol, and artificial sweeteners 2, 3
• Carbohydrate malabsorption is present in 65% of patients with functional bloating, and dietary restriction improves symptoms in >80% at 1 month 1
• If the elimination diet fails after 2 weeks, discontinue it immediately to avoid malnutrition 1

The low-FODMAP diet is a second-line option, not first-line 1:

• Must be supervised by a trained gastroenterology dietitian due to risks of decreased Bifidobacterium species and malnutrition 1
• Requires planned reintroduction of foods based on tolerance 1, 2
• Screen for eating disorders before implementing any restrictive diet, as dietary restrictions can trigger or worsen avoidant/restrictive food intake disorder 1

Avoid insoluble fiber as it worsens symptoms; if using fiber, start with soluble fiber at low doses (3-4g/day) 2

Immediate Symptom Relief: Non-Pharmacological

Diaphragmatic breathing exercises provide immediate relief by reducing vagal tone and sympathetic activity 2, 4, 3:

• Particularly effective for abdominophrenic dyssynergia (APD), where the diaphragm paradoxically contracts while abdominal muscles relax 4, 3
• Can be taught quickly and used as needed for acute symptoms 1, 2

Post-meal positioning: Lie down for 30 minutes after meals to slow gastric emptying and reduce bloating 4

Fluid timing: Avoid drinking fluids until at least 30 minutes after meals to prevent gastric distension 4

Pharmacological Treatment Based on Underlying Mechanism

For Constipation-Associated Bloating

Secretagogues (linaclotide, lubiprostone, plecanatide) are superior to placebo for treating bloating in constipation 1, 3, 5:

• Linaclotide 290 mcg once daily showed statistically significant improvement in combined abdominal pain and bowel movement responder rates (12-13% vs 3-5% placebo) 5
• Polyethylene glycol is an effective and inexpensive alternative for chronic constipation 2
• Avoid anticholinergic antispasmodics as they worsen constipation 2
• Prucalopride may help both constipation and abdominal pain 2

For Suspected Small Intestinal Bacterial Overgrowth (SIBO) or Dysbiosis

Rifaximin is the first-line antibiotic for SIBO-related bloating 1, 4, 3:

• Non-absorbable antibiotic with minimal systemic effects 4, 3
• Alternative antibiotics include amoxicillin, fluoroquinolones, or metronidazole 2, 3

For Visceral Hypersensitivity

Central neuromodulators that activate noradrenergic and serotonergic pathways show the greatest benefit 1:

• Tricyclic antidepressants (amitriptyline) or serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine) reduce visceral sensations 1, 3
• These medications address the gut-brain axis dysfunction and improve psychological comorbidities that amplify bloating 1
• Pregabalin has also shown improvements in bloating for IBS patients 1

For Pelvic Floor Dysfunction

Anorectal biofeedback therapy achieves a 54% responder rate (50% reduction in bloating scores) when evacuation disorders are identified 1:

• Uses visual monitoring to teach proper defecation coordination 1
• Particularly effective for IBS-C and chronic constipation with dyssynergic defecation 1
• Home-based alternatives exist when motility specialists are unavailable 1

Brain-Gut Behavioral Therapies

Cognitive behavioral therapy (CBT) and gut-directed hypnotherapy have robust evidence for improving bloating symptoms 1, 4, 3:

• Particularly useful when psychological factors (anxiety, depression, somatization) amplify visceral sensations 1
• FDA-approved prescription-based psychological therapies are now available via smartphone apps 3
• Relaxation therapy can be self-taught via audio tapes and reduces symptoms and medical consultations 1

What NOT to Use

Probiotics are NOT recommended for bloating or distension 1:

• No studies have examined efficacy specifically for bloating 1
• May cause brain fogginess, worsening bloating, and lactic acidosis 1
• Current British, European, and American guidelines do not endorse probiotics for IBS or functional dyspepsia 1

Peppermint oil lacks evidence: A recent placebo-controlled RCT found no improvement in bloating at 6 weeks 1

Diagnostic Testing for Refractory Cases

When initial treatments fail, consider:

• Breath testing (hydrogen, methane, CO2) to identify carbohydrate intolerances or SIBO 1, 4, 3
• Anorectal physiology testing for women with IBS-C not responding to standard therapies or those with suspected pelvic floor disorders 1, 4
• Digital rectal examination to identify sphincter tone abnormalities, pelvic floor dyssynergia, rectal prolapse, or rectocele 1

Critical Pitfalls to Avoid

• Do not continue ineffective elimination diets beyond 2 weeks, as prolonged restriction without benefit leads to malnutrition 1, 2
• Do not attribute all distension to gas accumulation: Even small increases in intraluminal gas can trigger significant distention in patients with APD 4
• Screen for eating disorders before recommending any dietary restrictions, preferably with a gastroenterology psychologist 1
• Avoid anticholinergic antispasmodics in constipation-predominant patients as they worsen the underlying problem 2