GI Part III Bloating Treatment Options

As discussed previously (GI and EDS/HSD Part II ), bloating and distension occur for several reasons. No one treatment works in every patient. Fortunately, several different treatment options are currently available. These are reviewed below.

Diet. Based on your response to the questions posed at your medical visits your HCP may want to place you on a special diet. This could be a lactose-free diet if she/he believes that you are lactose intolerant. This would mean avoiding dairy products such as milk, cheese, and ice cream. Your HCP may also want you to avoid foods with high fructose corn syrup, as fructose causes bloating in many patients. Common offenders include juice, sports drinks, energy drinks and sodas. Of course, many fresh fruits contain fructose so you will need to discuss this with your provider. For example, apples, pears, mangoes, grapes, and watermelon are all high in fructose.  Other providers may wish to place you on a special diet called a low FODMAP diet. FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. As a group these foods generally produce more gas than other foods when digested. This diet, which lasts four weeks during the first phase of the diet, removes a variety of foods that commonly produce excess gas. Examples of foods that are high in FODMAPs include: dried fruits, apples, mangoes, pears, plums, honey, onions, peppers, garlic, cruciferous vegetables, and legumes (see above), artificial sweeteners and sugar-free candies, gums, and mints. Of note, wheat and dairy are also removed during the first phase of the low FODMAP diet. This diet can be somewhat complicated to explain; many providers set up an appointment to see a dietician to carefully review the diet. See here for a Q and A on Irritable bowel syndrome and lifestyle changes.

Treating constipation.  Bloating is common in patients with symptoms of constipation. Treating constipation often improves symptoms of bloating. Fortunately, there are now many treatment options available. Some are easily purchased over-the-counter (OTC) and these include magnesium products and polyethylene glycol. Fiber products are often used to treat constipation, and these can be helpful in some patients. However, these often worsen symptoms of bloating and thus should be approached cautiously. Other agents require a prescription, and these include linaclotide, lubiprostone, plecanatide, prucalopride and tegaserod. You will want to review these treatment options with your provider. Of note, lactulose is a prescription medication used to treat constipation, but this causes bloating in many patients and is thus not recommended.

Antibiotics. Antibiotics are used to treat bacterial infections. However, they can be helpful in some patients with symptoms of gas and bloating, especially those with either small intestinal bacterial overgrowth (SIBO) or those who have had a change in their colon bacteria (this change is sometimes referred to as colonic dysbiosis). Antibiotics should be used cautiously, however, as they have the potential to cause side effects. One antibiotic that has been extensively studied for this condition is rifaximin. It is generally considered quite safe as it stays within the GI tract.

Probiotics. Probiotics are living microscopic organisms (such as bacteria) that are supposed to help promote good intestinal health after being consumed. Some of the most used probiotics are Lactobacillus and Bifidobacterium. However, there are literally hundreds of different probiotics now available OTC and these come in a dizzying array of names, doses and combinations. They are advertised as providing health benefits, and are generally safe, and usually not too expensive.  However, it is important as a consumer to understand that these are not regulated like prescription medications and there is very little data to support their use to treat symptoms of gas and bloating. Most probiotics sold OTC have never even been tested in scientific studies to determine whether they will help gas or bloating. In addition, some probiotics may worsen gas and bloating. Before purchasing these agents, it is important to have a thoughtful discussion with your HCP about whether probiotics are the right choice for you.

Medications to improve gut sensation. Some people with gas and bloating sense gas in the intestinal tract more than other people. If symptoms are bothersome enough and do not respond to some of the treatments already discussed, some health care providers will use over the counter medications to help with an overly sensitive GI tract. This can be as simple as peppermint oil, which can block spasms in the GI tract, or prescription medications such as amitriptyline, desipramine, gabapentin, or duloxetine. Like all medications, there are benefits and side effects to these agents, and thus a thoughtful discussion with your HCP is needed.

Diaphragmatic breathing. Abdominal distension develops in some patients due to an abnormal reflex between the GI tract and the abdominal wall (described above). This reflex may not improve with dietary changes or medications. However, many patients note improvement with diaphragmatic breathing. This can be easily taught to you by your health care provider. In addition, there are several good apps on-line. The goal is to take slow deep breaths so that your chest does not rise and fall (as is usual) but rather your abdomen rises and falls. This takes a little bit of practice to get right, but many patients find this quite helpful. In addition, it can be a good way to relax after a stressful day.

Cognitive behavioral therapy. The goal of cognitive behavioral therapy, called CBT, is to identify behaviors or thoughts that contribute to persistent symptoms and then change those thoughts or behaviors to improve overall health. CBT is generally taught by a psychologist. It has been shown to be quite effective at improving many GI symptoms, including bloating. This can be used as stand-alone therapy, or it can be combined with the other therapies listed above.

To explore these options further, and others, information can be found here at Mayo Clinic: Irritable bowel syndrome

Author: Brian Lacy, MD, PhD