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

Treatment of Abdominal Bloating and Gas

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 Dietary Management

• Implement a low FODMAP diet as first-line therapy, with 76% of adherent patients reporting satisfaction and significant improvements in abdominal pain, bloating, flatulence, and diarrhea. 2

• 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), dietary restriction led to complete symptom resolution in 50% at 1 year. 1

• Consult a gastroenterology dietitian when implementing dietary modifications to avoid malnutrition from prolonged restrictions. 2

• Do not continue strict FODMAP restriction long-term due to potential negative impacts on gut microbiome and risk of malnutrition; plan for systematic reintroduction after initial restriction. 1

Pharmacological Treatment Options

When Constipation Coexists

• Prescribe lubiprostone, linaclotide, or plecanatide as these agents are superior to placebo for treating abdominal bloating and distention, particularly when constipation coexists. 1, 2

• These secretagogues improve both bloating symptoms and quality of life through enhanced intestinal secretion and transit. 1

For Suspected Small Intestinal Bacterial Overgrowth (SIBO)

• Use rifaximin 550 mg three times daily for 14 days for SIBO and IBS-D with bloating, as this is the most studied antibiotic for these conditions. 1, 3

• High-risk patients warranting empiric treatment include those with chronic watery diarrhea, malnutrition, weight loss, cystic fibrosis, or Parkinson disease. 1

• Rifaximin is FDA-approved for IBS-D, with clinical trials showing adequate relief of IBS symptoms in 41% of patients versus 31-32% with placebo. 3

Central Neuromodulators

• Consider central neuromodulators (antidepressants) to reduce visceral hypersensitivity, raise sensation threshold, and improve psychological comorbidities, particularly when bloating is meal-related and triggers abdominophrenic dyssynergia. 4, 2

• These agents work best when bloating occurs during or immediately after meals, as they reduce the bloating sensation that triggers the abnormal viscerosomatic reflex. 4

• Central neuromodulators are less effective when bloating is constant or unrelated to meals. 4

Brain-Gut Behavioral Therapies

• Implement brain-gut behavioral therapy (BGBT) including cognitive behavioral therapy (CBT) and gut-directed hypnotherapy as these therapies improve global symptoms including bloating in IBS and functional dyspepsia, are safe, relatively inexpensive, and now FDA-approved for use on smart apps. 4

• CBT reduces supragastric belching episodes, esophageal acid exposure, and improves quality of life. 2

• These psychological therapies reduce psychological distress and improve quality of life, which is particularly important since up to one-third of IBS patients have anxiety or depression. 2

Diaphragmatic Breathing for Abdominophrenic Dyssynergia

• Teach diaphragmatic breathing techniques to patients with visible abdominal distention, as this provides immediate relief by reducing vagal tone and sympathetic activity, correcting the paradoxical diaphragmatic contraction seen in abdominophrenic dyssynergia (APD). 4, 1, 2

• APD describes a paradoxical viscerosomatic reflex where the diaphragm contracts downward and anterior abdominal wall muscles relax, leading to marked abdominal distention with even minimal gaseous distention (approximately 10% increase in intraluminal gas). 4

• This method is inexpensive, safe, and supported by expert consensus from brain-gut behavioral therapists and neurogastroenterologists. 4

• Slow deep breathing intervention leads to improvements in autonomic response assessed by exercise heart rate recovery and heart rate variability in IBS patients. 4

Evaluation for Underlying Structural Causes

• Evaluate for dyssynergic defecation in patients with constipation and bloating, especially those reporting straining with soft stool, digital disimpaction, or splinting. 1

• Perform digital rectal examination to identify increased/decreased sphincter tone, pelvic floor dyssynergia, rectal prolapse, anal stricture, or rectocele. 1

• Confirm pelvic floor dyssynergia with anorectal physiology testing combined with balloon expulsion, particularly in women with IBS-C not responding to standard therapies. 1

• Implement biofeedback therapy when pelvic floor disorder is identified, as this is effective for bloating and distention. 2

Screening for Celiac Disease

• Screen with tissue transglutaminase IgA and total IgA levels in patients with bloating, especially with weight loss, iron-deficiency anemia, or direct symptom association with gluten ingestion. 1, 2, 5

• Small bowel biopsy confirms diagnosis if serology is positive before initiating gluten-free diet. 1

• Recent evidence suggests fructans rather than gluten may cause symptoms in nonceliac gluten sensitivity; consider fructan elimination only. 1

Multidisciplinary Approach

• Adopt a patient-centered model involving gastroenterologists, gastroenterology dietitians, brain-gut behavioral therapists, and motility providers as this integrated care approach is key to managing treatment in patients with belching, abdominal bloating, and distention. 4

• The pathophysiology converges on dysregulation of the brain-gut axis, requiring treatment that addresses diet, motility, visceral sensitivity, and psychosocial parameters. 4

Critical Pitfalls to Avoid

• Do not use opioid analgesics for chronic abdominal pain, as they further delay gastric emptying and worsen gas symptoms. 1

• Avoid promoting unscrupulous fad diets or herbal therapies propagated through social media, which can lead to malnutrition or toxicity. 1

• Do not use PPIs as first-line treatment for isolated bloating unless directly associated with GERD, as they have limited effectiveness for bloating. 1, 2

• Do not order gastric emptying studies routinely for bloating and distention alone; reserve these for patients with prominent nausea and vomiting. 2, 5

• Do not attribute all distention to gas accumulation, as even small increases in intraluminal gas can trigger significant distention in patients with APD through viscerosomatic reflex. 2

• In women ≥50 years old with new-onset bloating and abdominal fullness, maintain high suspicion for ovarian cancer despite benign examination. 2, 5