What are the treatment options for a patient with abdominal bloating?

Treatment of Abdominal Bloating

Start with a 2-week dietary elimination trial targeting FODMAPs, lactose, and fructose, as this addresses the most common causes and provides both diagnostic and therapeutic benefit in the majority of patients. 1

Initial Therapeutic Approach

Dietary Modifications (First-Line Treatment)

• Implement a low-FODMAP diet as the primary intervention, restricting fermentable oligosaccharides, disaccharides, monosaccharides, and polyols for 2 weeks initially 1
• Fructose intolerance affects approximately 60% of patients with digestive disorders, making it the most prevalent carbohydrate malabsorption, followed by lactose intolerance at 51% 1
• In patients who respond to dietary restriction (>80% improvement at 1 month), complete symptom resolution occurs in 50% at 1 year 1
• A gastroenterology dietitian must monitor treatment when dietary modifications are implemented to prevent malnutrition from prolonged restrictions 2, 1
• Do not continue strict FODMAP restriction long-term; plan for systematic reintroduction after initial restriction to avoid negative impacts on gut microbiome 1

Behavioral and Physical Interventions

• Diaphragmatic breathing provides immediate relief by reducing vagal tone and sympathetic activity, correcting paradoxical diaphragmatic contraction 2, 1
• Cognitive behavioral therapy (CBT) and gut-directed hypnotherapy have robust evidence for improving bloating symptoms and quality of life 2, 1
• Biofeedback therapy is effective when pelvic floor disorder is identified, particularly in patients with constipation and bloating 2, 1

Pharmacological Treatment Options

When Constipation Coexists

• Lubiprostone, linaclotide, or plecanatide are superior to placebo for treating abdominal bloating and distention when constipation is present 1
• These secretagogues improve both bloating symptoms and quality of life through enhanced intestinal secretion and transit 1
• Medications used to treat constipation should be considered for treating bloating if constipation symptoms are present 2

Antibiotic Therapy for SIBO

• Rifaximin 550 mg three times daily for 14 days is the most studied antibiotic for small intestinal bacterial overgrowth (SIBO) and IBS-D with bloating 1
• High-risk patients warranting empiric treatment include those with chronic watery diarrhea, malnutrition, weight loss, cystic fibrosis, or Parkinson disease 1

Central Neuromodulators

• Antidepressants treat bloating by reducing visceral hypersensitivity, raising sensation threshold, and improving psychological comorbidities 2, 1
• These agents are particularly useful when psychological comorbidities coexist with bloating symptoms 2

Simethicone (Limited Role)

• Simethicone is FDA-approved for relief of pressure and bloating commonly referred to as gas 3
• Adults may take 1-2 softgels (180 mg each) as needed after meals and at bedtime, not exceeding 2 softgels in 24 hours 3

Diagnostic Evaluation (When Indicated)

Rule Out Underlying Causes

• Screen for celiac disease with tissue transglutaminase IgA and total IgA levels, especially in patients with weight loss, iron-deficiency anemia, or direct symptom association with gluten ingestion 1
• Small bowel biopsy confirms diagnosis if serology is positive before initiating gluten-free diet 1
• Carbohydrate enzyme deficiencies may be ruled out with dietary restriction and/or breath testing 2
• In at-risk patients, small bowel aspiration and glucose- or lactulose-based hydrogen breath testing may evaluate for SIBO 2, 1

When to Order Testing

• Order abdominal imaging and upper endoscopy only in patients with alarm features (unintentional weight loss, GI bleeding, persistent vomiting, iron-deficiency anemia, family history of IBD or colorectal cancer), recent worsening symptoms, or abnormal physical examination 2
• Gastric emptying studies should not be ordered routinely for bloating and distention, but may be considered if nausea and vomiting are present 2

Pelvic Floor Evaluation

• Evaluate for dyssynergic defecation in patients with constipation and bloating, especially those reporting straining with soft stool, digital disimpaction, or splinting 1
• Digital rectal examination identifies increased/decreased sphincter tone, pelvic floor dyssynergia, rectal prolapse, anal stricture, or rectocele 1
• Anorectal physiology testing combined with balloon expulsion confirms pelvic floor disorder, particularly in women with IBS-C not responding to standard therapies 2, 1

Treatment Algorithm Based on Clinical Presentation

Bloating with Constipation

1. Start with secretagogues (linaclotide, lubiprostone, or plecanatide) 1
2. Evaluate for pelvic floor disorder with digital rectal exam 1
3. If pelvic floor disorder identified, add biofeedback therapy 2, 1

Bloating with Diarrhea

1. Implement low-FODMAP diet with dietitian supervision 1
2. Consider rifaximin if SIBO suspected or patient is high-risk 1
3. Add central neuromodulators if visceral hypersensitivity suspected 2

Bloating without Predominant Bowel Pattern

1. Start with 2-week dietary elimination trial (FODMAPs, lactose, fructose) 1
2. Teach diaphragmatic breathing techniques 2, 1
3. Consider CBT or gut-directed hypnotherapy 2, 1
4. Add central neuromodulators if symptoms persist 2

Critical Pitfalls to Avoid

• Do not use opioid analgesics for chronic abdominal pain, as they further delay gastric emptying and worsen gas symptoms 1
• Do not promote unscrupulous fad diets or herbal therapies propagated through social media, which can lead to malnutrition or toxicity 1
• PPIs have limited effectiveness for bloating unless directly associated with GERD and should not be used as first-line treatment for isolated bloating 1
• Do not use probiotics to treat abdominal bloating and distention 2
• Avoid ordering unnecessary gastric emptying studies for isolated bloating symptoms 2
• Do not overlook ovarian cancer in women ≥50 years old with new-onset bloating and abdominal fullness 4