What can be given to a patient with a feeling of fullness or bloating?

Management of Abdominal Fullness and Bloating

For patients with a feeling of fullness or bloating, start with dietary modifications (low-FODMAP diet, lactose restriction) for 3-4 weeks, followed by prokinetic agents (metoclopramide 10-20 mg every 6-8 hours) if symptoms persist, particularly when early satiety or postprandial fullness dominates the clinical picture. 1

Initial Clinical Approach

Before initiating treatment, exclude alarm features that mandate urgent investigation:

• Weight loss >10% suggests malabsorption, malignancy, or serious underlying disease requiring immediate workup 1, 2
• Gastrointestinal bleeding (visible blood or melena) requires urgent evaluation 1
• Iron-deficiency anemia warrants celiac disease testing with tissue transglutaminase IgA and total IgA levels 3, 1
• Women ≥50 years old with new-onset bloating and fullness require consideration of ovarian cancer 3, 2

In the absence of alarm symptoms, extensive imaging, endoscopy, and motility testing are unnecessary and low-yield. 1 The 2023 AGA guidelines emphasize that abdominal imaging and upper endoscopy should be reserved exclusively for patients with alarm features, recent worsening symptoms, or abnormal physical examination findings. 1

First-Line Treatment: Dietary Modifications

The most recent 2023 AGA guidelines prioritize dietary interventions as first-line therapy:

• Implement dietary modifications for 3-4 weeks before considering pharmacological interventions 1
• Small evening meals with longer intervals between eating and lying down help mitigate symptoms of nausea, vomiting, and abdominal pain from delayed gastric emptying 1
• Low-FODMAP diet is effective for suspected carbohydrate intolerance, as lactose intolerance affects 51% and fructose intolerance affects 60% of patients with bloating 1, 2
• Gluten and fructan restriction may benefit patients with self-reported gluten sensitivity, as fructans rather than gluten often cause symptoms 3, 1

A 2006 pilot study demonstrated that 72% of patients with functional abdominal bloating had sugar malabsorption, and 67% maintained clinical improvement at 12 months on malabsorbed sugar-free diets. 4

Pharmacological Management

For Fullness and Early Satiety (Dysmotility-Like Symptoms)

Prokinetic agents are first-line pharmacological therapy for gastroparesis-related symptoms and postprandial fullness:

• Metoclopramide 10-20 mg every 6-8 hours is the primary prokinetic option 1
• The 2022 BSG guidelines note that prokinetic agents are appropriate when fullness, bloating, or satiety dominate the clinical picture 3

For Bloating with Constipation

• Secretagogues (linaclotide, lubiprostone) are effective for abdominal bloating when constipation is present 1, 5
• These agents work by increasing intestinal secretion and decreasing visceral sensitivity 6

For Suspected Small Intestinal Bacterial Overgrowth (SIBO)

• Rifaximin may be effective for SIBO-related bloating, particularly in high-risk patients with chronic watery diarrhea, malnutrition, or systemic diseases causing dysmotility 1, 2

For Epigastric Pain/Ulcer-Like Symptoms

If epigastric pain is the predominant symptom rather than fullness:

• Full-dose PPI therapy (omeprazole 20 mg once daily) should be first-choice therapy, as this confirms the acid-related nature of symptoms 3
• The 2002 Gut guidelines note this is consistent with treating ulcer-like dyspepsia 3

Adjunctive Therapies

• Antispasmodics (otilonium bromide, peppermint oil) can reduce bloating symptoms 5
• Simethicone is FDA-approved for relief of pressure and bloating commonly referred to as gas 7
• Neuromodulators (SNRIs, tricyclic antidepressants, buspirone) may be considered for refractory cases 5, 6

Brain-Gut Behavioral Therapies

For patients with persistent symptoms or psychological comorbidity:

• Cognitive behavioral therapy and hypnotherapy are effective, as up to one-third of IBS patients experience anxiety or depression 1, 5
• Diaphragmatic breathing and biofeedback treat abdominophrenic dyssynergia, which involves inappropriate diaphragm contraction causing abdominal distention typically worse after meals 1, 5

Treatment Algorithm

1. Exclude alarm features (weight loss, bleeding, anemia, age >50 in women) 1, 2
2. Test for H. pylori in all patients with dyspepsia and treat if positive 3
3. Implement dietary modifications (low-FODMAP, lactose restriction) for 3-4 weeks 1
4. If fullness/early satiety predominates: Start metoclopramide 10-20 mg every 6-8 hours 1
5. If bloating with constipation: Use secretagogues (linaclotide, lubiprostone) 1, 5
6. If symptoms persist: Consider rifaximin for SIBO, antispasmodics, or neuromodulators 1, 5
7. For refractory cases: Add brain-gut behavioral therapies (CBT, biofeedback) 1, 5

Critical Pitfalls to Avoid

• Do not assume gastroparesis based on symptoms alone, as bloating, nausea, and fullness do not correlate with the degree of gastric emptying delay on scintigraphy 3, 1, 2
• Do not over-test in functional bloating, as extensive imaging and motility testing are unnecessary without alarm symptoms 1
• Do not use probiotics as primary therapy for abdominal bloating and distention, as they are not recommended for this purpose 1
• Do not ignore pelvic floor dysfunction, as straining with soft stool or need for manual assistance suggests dyssynergia requiring different management 3, 1, 2
• Do not miss ovarian cancer in older women, as bloating and fullness are often presenting symptoms in women ≥50 years 3, 2