Treatment of Chronic Bloating
Begin with dietary modifications supervised by a gastroenterology dietitian, specifically a low-FODMAP diet, followed by central neuromodulators (low-dose antidepressants) if dietary changes fail, while avoiding probiotics entirely. 1
Initial Clinical Assessment
Rule out alarm features first: Unintentional weight loss, gastrointestinal bleeding, persistent vomiting, anemia, or family history of GI malignancy mandate immediate investigation before treating symptomatically. 2
Perform digital rectal examination to detect abnormal sphincter tone, pelvic-floor dyssynergia, rectal prolapse, anal stricture, or rectocele—findings that would redirect treatment toward biofeedback therapy. 2
Assess bowel habits carefully: Straining with soft stool, need for digital disimpaction, splinting, or fecal incontinence indicate pelvic-floor dysfunction requiring anorectal physiology testing rather than empiric bloating treatment. 2
Screen for celiac disease with tissue transglutaminase IgA and total IgA levels; if positive, confirm with small bowel biopsy before initiating a strict gluten-free diet. 1
Diagnostic Testing Strategy
Avoid routine testing in uncomplicated bloating. Reserve abdominal imaging and upper endoscopy exclusively for patients with alarm features, recent symptom worsening, or abnormal physical examination. 1, 2
Do NOT order gastric emptying studies for bloating alone—approximately 40% of gastroparesis patients report bloating, yet bloating severity does not correlate with gastric emptying delay. 2
Consider hydrogen/methane breath testing for lactose, fructose, or sucrose intolerance only after a failed 2-week empiric dietary restriction trial. 2
Evaluate for pelvic-floor disorders with anorectal physiology testing (including balloon expulsion) when bloating appears related to constipation or difficult evacuation, particularly in women with constipation-predominant IBS unresponsive to standard therapy. 2
First-Line Treatment: Dietary Modifications
Implement a low-FODMAP diet under supervision of a gastroenterology dietitian to prevent malnutrition—this is the cornerstone of initial management. 1, 3
For suspected non-celiac gluten sensitivity, prioritize fructan avoidance rather than gluten restriction, as fructans are the likely culprit. 2
Use dietary restriction as the simplest and most cost-effective first approach before escalating to breath testing or medications. 2
Second-Line Treatment: Pharmacologic Management
Central neuromodulators (low-dose tricyclic antidepressants or SNRIs) reduce visceral hypersensitivity, raise sensory thresholds, and improve psychological comorbidities when dietary modifications fail. 1, 3
Antispasmodics (otilonium bromide, peppermint oil) can be considered for symptom relief, particularly when bloating coexists with abdominal pain. 3
Rifaximin may be beneficial in select cases, particularly when small intestinal bacterial overgrowth is suspected. 3
Secretagogues (linaclotide) can be used when bloating coexists with constipation-predominant symptoms. 3
Medications for constipation should be considered when constipation symptoms are present alongside bloating. 1
Behavioral and Physical Therapies
Biofeedback therapy is effective when a pelvic-floor disorder has been identified through anorectal physiology testing. 1
Diaphragmatic breathing exercises are recommended for abdominophrenic dyssynergia—a condition where abnormal abdominal wall muscle contraction causes visible distension. 1
Psychological therapies (hypnotherapy, cognitive behavioral therapy, brain-gut behavioral therapies) may be used, particularly when bloating coexists with irritable bowel syndrome. 1, 3
Critical Pitfalls to Avoid
Do NOT use probiotics—they are explicitly not recommended for treating abdominal bloating and distention. 1
Avoid over-testing functional bloating without alarm symptoms, as the diagnostic yield is extremely low and delays appropriate symptomatic treatment. 2
Do not order whole-gut motility studies or antroduodenal manometry unless refractory upper-GI symptoms with severe bloating, distention, and weight loss suggest an intestinal neuromyopathic disorder. 2
Recognize that over 30% of patients with severe gastroparesis exhibit delayed small-bowel or colonic transit—severe constipation co-existing with upper-GI symptoms may warrant combined motility assessment. 2
When to Escalate Care
Escalate to comprehensive testing if any alarm feature emerges, symptoms progress despite conservative measures (dietary modification plus central neuromodulators), or the physical examination becomes abnormal. 2
Refer to gastroenterology if quality of life is significantly impaired despite first-line and second-line therapies, or if diagnostic uncertainty persists. 4