Clinical practice update focuses on belching, bloating, distention

The American Gastroenterological Association recently offered best practice advice on belching, bloating, and abdominal distention, which it described as highly prevalent GI symptoms that can be debilitating and affect patients' quality of life.

The 15 best practice advice statements were published as a clinical practice update by Gastroenterology on July 13 and were drawn from a review of the literature and expert opinion.

Clinical history, physical examination findings, and impedance pH monitoring can help differentiate between gastric and supragastric belching, the update said. Treatment options for supragastric belching may include brain-gut behavioral therapies, such as cognitive behavioral therapy, diaphragmatic breathing, speech therapy, and central neuromodulators, such as antidepressants, it advised.

To diagnose primary abdominal bloating and distention, clinicians should use the Rome IV criteria, according to the update. To rule out carbohydrate enzyme deficiencies, they can use dietary restriction and breath tests, while small bowel aspiration and glucose- or lactulose-based hydrogen breath testing may be used to evaluate for small intestinal bacterial overgrowth in a small subset of at-risk patients, it said. Clinicians may use serologic testing to rule out celiac disease in patients with bloating, and patients with positive results should undergo a small bowel biopsy to confirm the diagnosis, the update said.

Regarding imaging, clinicians should order abdominal imaging and upper endoscopy in patients with alarm features, recent worsening symptoms, or an abnormal physical examination only, the update said. Meanwhile, they should not order gastric emptying studies routinely for bloating and distention but can consider them if symptoms include nausea and vomiting. Clinicians should not order whole gut motility and radiopaque transit studies unless there are other GI symptoms that indicate testing for neuromyopathic disorders, according to the update.

Clinicians should not use probiotics to treat abdominal bloating and distention, the update said. If these symptoms are related to constipation or difficult evacuation, the update suggested anorectal physiology testing to rule out a pelvic floor disorder, for which biofeedback therapy may be effective. Central neuromodulators, such as antidepressants, can be used to reduce visceral hypersensitivity, raise sensation threshold, and improve psychological comorbidities, the update said. Medications for constipation should be considered in patients with bloating if constipation is a symptom, and psychological therapies, such as hypnotherapy, cognitive behavioral therapy, and other brain-gut behavior therapies, may be used to treat bloating or distention, according to the update. Finally, the update noted that diaphragmatic breathing and central neuromodulators are used to treat abdominophrenic dyssynergia.

The statement said that a multidisciplinary approach, patient-centered model, and integrated care are key to managing treatment in patients with belching, abdominal bloating, and distention but acknowledged that integrated care may not be available in all settings.

“Careful attention to the patients' primary symptoms, physical examination, and limited diagnostic studies can help to navigate patients toward the proper diagnostic evaluation,” the statement concluded. “Furthermore, education and effective communication skills using a patient-centered care model will optimize treatment with improved outcomes and increased patient and provider satisfaction and reduce unneeded diagnostic testing and health care costs.”