What is the best course of treatment for a patient experiencing abdominal distention and flatulence?

Treatment of Abdominal Distention and Flatulence

Begin 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, 2

Initial Diagnostic Approach

Rule Out Alarm Features First

• Weight loss >10% suggests malabsorption, malignancy, or serious underlying disease requiring urgent workup 3
• Gastrointestinal bleeding (visible blood or melena) requires urgent evaluation 3
• Iron-deficiency anemia warrants celiac disease testing with tissue transglutaminase IgA and total IgA levels 1, 3
• Persistent or severe vomiting may indicate gastroparesis or obstruction 3
• Family history of inflammatory bowel disease or colorectal cancer increases risk 3

Reserve abdominal imaging and upper endoscopy exclusively for patients with alarm features, recent worsening symptoms, or abnormal physical examination findings. 1, 3

Differentiate Between Bloating and True Distention

• Bloating is a subjective sensation of trapped gas, pressure, and fullness 4
• Distention is an objective, measurable increase in abdominal girth 4
• These frequently co-exist but have different underlying mechanisms 5

First-Line Treatment: Dietary Modifications

Short-Term Elimination Diet (2 Weeks)

• Fructose intolerance affects 60% of patients with digestive disorders, making it the most prevalent carbohydrate malabsorption, followed by lactose intolerance at 51%. 1, 5, 2
• This approach is the simplest and most economically sound way to diagnose food intolerance 1
• In patients who respond (>80% improvement at 1 month), dietary restriction led to complete symptom resolution in 50% at 1 year 2

Low-FODMAP Diet Implementation

• Implement for 3-4 weeks before considering other interventions 3
• A gastroenterology dietitian should preferably monitor treatment 1
• Avoid long-term strict FODMAP restriction due to potential negative impacts on gut microbiome and risk of malnutrition; plan for systematic reintroduction after initial restriction. 2
• Recent evidence suggests fructans rather than gluten may cause symptoms in nonceliac gluten sensitivity 3, 2

Pharmacological Management

For Constipation-Associated Bloating

• Secretagogues (lubiprostone, linaclotide, or plecanatide) are superior to placebo for treating abdominal bloating and distention, particularly when constipation coexists. 5, 3, 2
• These agents improve both bloating symptoms and quality of life through enhanced intestinal secretion and transit 2

For Suspected Small Intestinal Bacterial Overgrowth (SIBO)

• Rifaximin 550 mg three times daily for 14 days is the most studied antibiotic for SIBO-related bloating 1, 5, 2
• High-risk patients warranting empiric treatment include those with chronic watery diarrhea, malnutrition, weight loss, cystic fibrosis, or Parkinson disease 2
• Although rifaximin is the most studied and is a nonabsorbable antibiotic choice, it is also the most expensive 1
• Breath testing for hydrogen, methane, and CO2 can help identify carbohydrate intolerances or SIBO in refractory cases 1, 5

For Visceral Hypersensitivity

• Central neuromodulators (tricyclic antidepressants) help manage bloating by reducing visceral hypersensitivity, raising sensation threshold, and improving psychological comorbidities 1, 5

Simethicone

• FDA-approved for relief of pressure and bloating commonly referred to as gas 6

Non-Pharmacological Interventions

Brain-Gut Behavioral Therapies

• Psychological therapies such as hypnotherapy and cognitive behavioral therapy have robust evidence for improving bloating symptoms and quality of life. 1, 3, 2
• Up to one-third of people with IBS also experience anxiety or depression 3

Diaphragmatic Breathing

• Provides immediate relief by reducing vagal tone and sympathetic activity 5, 2
• Particularly effective for abdominophrenic dyssynergia (APD), which involves inappropriate diaphragm contraction causing abdominal distention typically worse after meals 5, 3, 2

Biofeedback Therapy

• Effective for bloating and distention when a pelvic floor disorder is identified 1
• Evaluate for dyssynergic defecation in patients with constipation and bloating, especially those reporting straining with soft stool, digital disimpaction, or splinting 2
• Anorectal physiology testing is suggested to rule out pelvic floor disorder 1, 2

What NOT to Do

Probiotics should not be used to treat abdominal bloating and distention, as evidence does not support their efficacy. 1, 5, 3

Additional Pitfalls to Avoid

• Do not use opioid analgesics for chronic abdominal pain, as they further delay gastric emptying and worsen gas symptoms 2
• Avoid promoting unscrupulous fad diets or herbal therapies propagated through social media, which can lead to malnutrition or toxicity 2
• PPIs have limited effectiveness for bloating unless directly associated with GERD and should not be used as first-line treatment for isolated bloating 2
• Avoid over-testing in functional bloating, as the absence of alarm symptoms makes extensive imaging, endoscopy, and motility testing unnecessary and low-yield 3
• 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

Advanced Management for Refractory Cases

• Integrated care involving gastroenterologists, gastroenterology dietitians, and brain-gut behavioral therapists is recommended 5
• Gastric emptying studies should not be ordered routinely for bloating and distention, but may be considered if nausea and vomiting are present 1
• Whole gut motility and radiopaque transit studies should not be ordered unless other additional and treatment-refractory lower gastrointestinal symptoms exist 1