Managing Bloating, Flatulence, and Burping
Start with a 2-week dietary elimination trial targeting poorly absorbed carbohydrates (lactose, fructose, sugar alcohols, FODMAPs), as this is the simplest, most cost-effective first-line approach that resolves symptoms in over 80% of patients with carbohydrate malabsorption. 1, 2
Initial Dietary Modifications
Eliminate these specific foods for 2 weeks:
- Foods high in lactose (milk, soft cheeses, ice cream) 1
- Fructose-rich foods (apples, pears, honey, high-fructose corn syrup) 1, 2
- Artificial sweeteners and sugar alcohols (sorbitol, xylitol, mannitol) found in sugar-free gums and processed foods 1
- High-FODMAP foods if symptoms persist (beans, cabbage, broccoli, onions, garlic) 2
The low-FODMAP diet improves bloating and quality of life in randomized trials, but must be implemented by a trained gastroenterology dietitian to avoid malnutrition and negative impacts on gut microbiome. 2 If symptoms don't improve after 2 weeks, discontinue the elimination diet. 2
Over-the-Counter Options
For immediate symptom relief:
- Alpha-galactosidase (Beano) taken with meals helps digest complex carbohydrates in beans, vegetables, and grains that cause gas 3
- Simethicone provides relief of pressure and bloating by reducing surface tension of gas bubbles 4
Important caveat: While these are widely available, evidence supporting simethicone is poor, and it's not consistently effective for gas retention. 5
What NOT to Use
Probiotics are NOT recommended for bloating or distention. 2 Despite one trial showing modest improvements, the newest American, British, and European guidelines do not endorse probiotics for these symptoms. 2 Additionally, probiotics may cause brain fogginess, worsening bloating, and lactic acidosis. 2
Peppermint oil showed no improvement in bloating symptoms at 6 weeks in recent placebo-controlled trials. 2
Addressing Burping (Belching)
Determine if your belching is gastric (involuntary) or supragastric (behavioral):
For gastric belching associated with reflux symptoms:
- Add a proton pump inhibitor (omeprazole 20 mg or lansoprazole 30 mg once daily, 30-60 minutes before breakfast) 1, 6
- Combine with diaphragmatic breathing exercises, which increase vagal tone and reduce stress response 2, 7
For supragastric belching (stops when distracted or speaking):
- Diaphragmatic breathing is immediately effective and should be your primary intervention 2, 7
- This is a learned behavior that responds to awareness and behavioral modification, not medication 2
When Symptoms Persist After 4 Weeks
If dietary changes and initial interventions fail, consider these evidence-based options:
For bloating with constipation:
- Secretagogues (lubiprostone, linaclotide, plecanatide) are superior to placebo for treating bloating when constipation is present 2, 7
For refractory symptoms suggesting visceral hypersensitivity:
- Low-dose tricyclic antidepressants (amitriptyline starting at 10 mg nightly) or SNRIs (duloxetine, venlafaxine) reduce visceral sensations along the gut-brain axis 2, 1
- These work by re-regulating brain-gut control mechanisms and improving the bloating sensation that triggers distention 2
For persistent behavioral belching:
- Cognitive behavioral therapy or gut-directed hypnotherapy have robust evidence for improving symptoms and quality of life 2, 7
Critical Pitfalls to Avoid
- Never use metoclopramide for gas symptoms—insufficient evidence and significant risk of tardive dyskinesia 1
- Avoid opioid medications, which worsen gastrointestinal symptoms and delay gastric emptying 1, 7
- Don't pursue breath testing until dietary restriction fails—symptom resolution with diet is the simplest diagnostic approach 1, 7
When to Seek Further Evaluation
Red flags requiring medical evaluation:
- Age ≥55 years with new-onset symptoms 7
- Weight loss >10% or signs of malnutrition 7
- GI bleeding or iron-deficiency anemia 7
- Severe symptoms refractory to 4 weeks of optimized therapy 1
Consider testing for: