What are the treatment options for an adult with gas and bloating?

Treatment Options for Gas and Bloating in Adults

Start with a 2-week dietary elimination trial targeting the most common culprits—lactose, fructose, and FODMAPs—as this is the simplest and most cost-effective first-line approach for adults with gas and bloating. 1

First-Line Dietary Management

• Identify and eliminate common dietary triggers including carbohydrate enzyme deficiencies (lactase and sucrase), artificial sweeteners (sugar alcohols, sorbitol), and FODMAPs through a structured 2-week elimination diet. 1, 2

• Fructose intolerance affects 60% of patients with digestive disorders, making it more common than lactose intolerance (51%), so prioritize fructose restriction if symptoms persist after initial modifications. 1, 3

• Resolution of symptoms during the elimination period serves as a positive diagnostic test for food intolerance, avoiding the need for expensive testing in most cases. 1, 3

• Reserve breath testing (measuring hydrogen, methane, and CO2) only for patients who fail dietary restrictions, as it adds cost without improving outcomes in treatment-responsive patients. 1, 2

Pharmacological Options Based on Symptom Pattern

For Gas and Bloating with Constipation

• Secretagogues are superior to placebo for treating abdominal bloating when constipation is present—options include lubiprostone, linaclotide, and plecanatide, with no significant differences in efficacy between them. 1

• Prucalopride shows a number needed to treat of 8 for moderate to severe bloating improvement in constipation trials. 1

For Gas and Bloating with Visceral Hypersensitivity

• Central neuromodulators that activate noradrenergic and serotonergic pathways provide the greatest benefit—specifically tricyclic antidepressants (amitriptyline) or serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine). 1

• These medications work best when distention occurs during or after meals by reducing the bloating sensation that triggers abnormal viscerosomatic reflexes. 1

• Pregabalin has also shown improvements in bloating for patients with IBS-related symptoms. 1

For Suspected Small Intestinal Bacterial Overgrowth (SIBO)

• Rifaximin is the most studied non-absorbable antibiotic for SIBO-related bloating, though it is expensive and not FDA-approved for this indication. 1, 2

• Alternative antibiotics include amoxicillin, fluoroquinolones, and metronidazole, requiring careful patient selection given lack of FDA approval for SIBO. 1, 4

• Only pursue antibiotic therapy after confirming SIBO with hydrogen-based breath testing using glucose or lactulose, or small bowel aspirates. 3

For GERD-Related Symptoms

• Proton pump inhibitors are effective only when bloating is directly associated with GERD symptoms, not for isolated gas and bloating. 1, 2

Symptomatic Relief Options

• Simethicone is FDA-approved for relief of pressure and bloating commonly referred to as gas, providing symptomatic relief without addressing underlying causes. 5

• Mosapride citrate (Gasmotin) is a prokinetic agent used for functional dyspepsia that may help with bloating in this specific context, though it is not first-line for isolated gas and bloating. 6

Non-Pharmacological Interventions

• Diaphragmatic breathing provides immediate relief for acute bloating and cramping by reducing vagal tone and sympathetic activity, and corrects paradoxical diaphragm contraction in abdominophrenic dyssynergia. 4, 3

• Anorectal biofeedback therapy achieves a 54% responder rate (≥50% reduction in bloating scores) when pelvic floor dysfunction contributes to symptoms, particularly in patients with IBS-C or chronic constipation. 1

• Cognitive behavioral therapy and gut-directed hypnotherapy have the most robust evidence among brain-gut behavioral therapies, with FDA-approved smartphone app options now available. 1, 4

Critical Pitfalls to Avoid

• Do not use probiotics for gas and bloating—they may cause brain fogginess, worsening bloating, and lactic acidosis, with insufficient evidence supporting their use. 1, 2

• Avoid prolonged dietary restrictions without benefit, as they can lead to malnutrition—consult a gastroenterology dietitian when implementing complex elimination diets. 2

• Do not use opioid analgesics for chronic abdominal pain, as they delay gastric emptying and worsen gas symptoms. 3

• Peppermint oil showed no improvement in bloating at 6 weeks in a recent placebo-controlled trial, despite being commonly recommended. 1

When to Pursue Advanced Testing

• Evaluate for alarm features including age ≥55 years with new-onset symptoms, weight loss >10%, GI bleeding, iron-deficiency anemia, or family history of IBD or GI malignancy. 3

• Consider anorectal manometry to diagnose pelvic floor dyssynergia when constipation is present and symptoms persist despite initial management. 1, 2

• Perform high-resolution manometry with impedance only when excessive belching is the predominant symptom to differentiate supragastric from gastric belching. 1