Bloating and Distension: Diagnosis and Treatment
Written by Brian Lacy, MD
In Part One of my posts on bloating and distension, we discussed how we define these issues, what the most common symptoms are, and the usual reasons behind them. We’ll now move forward with how patients are diagnosed and what treatment options are available.
The diagnosis of gas and bloating begins with you describing your symptoms to your health care provider (HCP). Try to answer the following questions:
- How do you describe your symptoms?
- How long have you had them?
- How frequently do they occur?
- How severe are they?
- What makes your symptoms better or worse (i.e. do they get worse after a meal)?
- Are your symptoms associated with other symptoms, such as nausea or vomiting or fevers?
- What is the relationship of gas and bloating to eating or drinking?
- Do you have symptoms of constipation?
After your HCP completes the history and physical parts of your examination, they may order simple laboratory tests, such as a CBC or complete blood count. They may also request an x-ray of your abdomen to determine how much gas is present in the gastrointestinal tract and whether there is more stool in your colon than you might think.
Some providers may want to arrange a test to determine if you have Small Intestinal Bacterial Overgrowth (SIBO). This test involves drinking a sugary sweet liquid and then blowing into a bag over the course of 90-120 minutes. If this test is positive, your provider may want to treat you with an antibiotic. In some situations, depending on patient age, symptoms of weight loss, or other clinical findings, your doctor may do additional studies like a CT scan or colonoscopy.
Based on your eating habits, your provider may want to modify your diet. This could be a lactose-free diet, if you are lactose intolerant, which would mean avoiding milk, cheese, ice cream or other dairy products. Your provider may also want you to avoid foods with high fructose corn syrup including fruits (apples, pears, mangoes, grapes, watermelon), juice, sports drinks, energy drinks, and sodas.
Other providers may wish to place you on a special diet called a low FODMAP diet. FODMAP stands for:
As a group these foods generally produce more gas than others when digested. This diet can be somewhat complicated to explain. As a result, many providers set up an appointment to have a dietician carefully review the diet with you.
Constipation affects approximately 12-14% of the US adult population – that means 1 in 7 adults. Symptoms of bloating frequently accompany symptoms of constipation. Treating constipation often improves symptoms of bloating. Fortunately, there are now many treatment options available.
Some patients note an improvement in both symptoms using over-the-counter (OTC) agents such as polyethylene glycol (e.g. Miralax, Glycolax) or magnesium products. These are generally safe to use, although magnesium products should not be used in older patients or those with chronic kidney disease. Other patients treat symptoms of constipation by using fiber supplements, however these can worsen bloating in at least 50% of patients.
Unfortunately, many patients find that symptoms of constipation persist despite using OTC agents and thus require a prescription medication. Fortunately, several prescription medications are now available to treat constipation.
Research studies involving thousands of patients have shown that these are safe, effective, and also help improve bloating. Options include linaclotide (Linzness), lubiprostone (Amitiza), plecanatide (Trulance), and prucalopride (Motegrity). Direct comparisons of one agent to another have not been performed in clinical trials, thus a conversation with your HCP is very important to help determine the best choice for you.
Antibiotics are used to treat bacterial infections. However, they can be helpful for some patients with symptoms of gas and bloating, especially those with SIBO or those who have had a change in their colon bacteria (a change sometimes referred to as Colonic Dysbiosis). Antibiotics should be used cautiously, however, as they have the potential to cause side effects.
Probiotics are living microscopic organisms (such as bacteria) that are supposed to help promote good intestinal health after being consumed. However, probiotics are not regulated like prescription medications and there is very little data to support their use to treat symptoms of gas and bloating. In fact, some probiotics may worsen gas and bloating.
Medications to Improve Gut Sensation
Some patients will 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, then over-the-counter medications or prescription medications, including neuromodulators, may prove useful.
Abdominal distension develops in some patients due to an abnormal reflex between the GI tract and the abdominal wall (as you’ll remember from Part One). Many patients note improvement with diaphragmatic breathing. This can be easily taught to you by your HCP or by practicing with an online video.
The goal is to take slow deep breaths so 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 (CBT)
The goal of 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.
The Impact of Bloating and Distension
Discomfort in the gut can deeply impact everyday life, regardless of the cause. The strength of the mind-gut connection ensures that abdominal pain will affect us emotionally and cognitively, while outside triggers or situations can result in physical symptoms. It’s a cyclical process that requires a nuanced understanding of a variety of issues in order to provide effective treatment.
As stated before, both bloating and distension are very, very common and there are many resources available to you through your HCP. You don’t have to suffer alone. The right solution for you is out there.