AGA Clinical Practice Update on Evaluation and Management of Belching, Abdominal Bloating, and Distention: Expert Review

Abstract

DescriptionBelching, bloating, and abdominal distention are all highly prevalent gastrointestinal symptoms and account for some of the most common reasons for patient visits to outpatient gastroenterology practices. These symptoms are often debilitating, affecting patients’ quality of life, and contributing to work absenteeism. Belching and bloating differ in their pathophysiology, diagnosis, and management, and there is limited evidence available for their various treatments. Therefore, the purpose of this American Gastroenterological Association (AGA) Clinical Practice Update is to provide best practice advice based on both controlled trials and observational data for clinicians covering clinical features, diagnostics, and management considerations that include dietary, gut-directed behavioral, and drug therapies.MethodsThis Expert Review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. These best practice advice statements were drawn from a review of the published literature based on clinical trials, the more robust observational studies, and from expert opinion. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations.Best Practice Advice StatementsBest Practice Advice 1Clinical history and physical examination findings and impedance pH monitoring can help to differentiate between gastric and supragastric belching.Best Practice Advice 2Treatment options for supragastric belching may include brain–gut behavioral therapies, either separately or in combination, such as cognitive behavioral therapy, diaphragmatic breathing, speech therapy, and central neuromodulators.Best Practice Advice 3Rome IV criteria should be used to diagnose primary abdominal bloating and distention.Best Practice Advice 4Carbohydrate enzyme deficiencies may be ruled out with dietary restriction and/or breath testing. In a small subset of at-risk patients, small bowel aspiration and glucose- or lactulose-based hydrogen breath testing may be used to evaluate for small intestinal bacterial overgrowth.Best Practice Advice 5Serologic testing may rule out celiac disease in patients with bloating and, if serologies are positive, a small bowel biopsy should be done to confirm the diagnosis. A gastroenterology dietitian should be part of the multidisciplinary approach to care for patients with celiac disease and nonceliac gluten sensitivity.Best Practice Advice 6Abdominal imaging and upper endoscopy should be ordered in patients with alarm features, recent worsening symptoms, or an abnormal physical examination only.Best Practice Advice 7Gastric emptying studies should not be ordered routinely for bloating and distention, but may be considered if nausea and vomiting are present. Whole gut motility and radiopaque transit studies should not be ordered unless other additional and treatment-refractory lower gastrointestinal symptoms exist to warrant testing for neuromyopathic disorders.Best Practice Advice 8In patients with abdominal bloating and distention thought to be related to constipation or difficult evacuation, anorectal physiology testing is suggested to rule out a pelvic floor disorder.Best Practice Advice 9When dietary modifications are needed (eg, low–fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet), a gastroenterology dietitian should preferably monitor treatment.Best Practice Advice 10Probiotics should not be used to treat abdominal bloating and distention.Best Practice Advice 11Biofeedback therapy may be effective for bloating and distention when a pelvic floor disorder is identified.Best Practice Advice 12Central neuromodulators (eg, antidepressants) are used to treat bloating and abdominal distention by reducing visceral hypersensitivity, raising sensation threshold, and improving psychological comorbidities.Best Practice Advice 13Medications used to treat constipation should be considered for treating bloating if constipation symptoms are present.Best Practice Advice 14Psychological therapies, such as hypnotherapy, cognitive behavioral therapy, and other brain–gut behavior therapies may be used to treat patients with bloating and distention.Best Practice 15Diaphragmatic breathing and central neuromodulators are used to treat abdominophrenic dyssynergia. Belching, bloating, and abdominal distention are all highly prevalent gastrointestinal symptoms and account for some of the most common reasons for patient visits to outpatient gastroenterology practices. These symptoms are often debilitating, affecting patients’ quality of life, and contributing to work absenteeism. Belching and bloating differ in their pathophysiology, diagnosis, and management, and there is limited evidence available for their various treatments. Therefore, the purpose of this American Gastroenterological Association (AGA) Clinical Practice Update is to provide best practice advice based on both controlled trials and observational data for clinicians covering clinical features, diagnostics, and management considerations that include dietary, gut-directed behavioral, and drug therapies. This Expert Review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. These best practice advice statements were drawn from a review of the published literature based on clinical trials, the more robust observational studies, and from expert opinion. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements Clinical history and physical examination findings and impedance pH monitoring can help to differentiate between gastric and supragastric belching. Treatment options for supragastric belching may include brain–gut behavioral therapies, either separately or in combination, such as cognitive behavioral therapy, diaphragmatic breathing, speech therapy, and central neuromodulators. Rome IV criteria should be used to diagnose primary abdominal bloating and distention. Carbohydrate enzyme deficiencies may be ruled out with dietary restriction and/or breath testing. In a small subset of at-risk patients, small bowel aspiration and glucose- or lactulose-based hydrogen breath testing may be used to evaluate for small intestinal bacterial overgrowth. Serologic testing may rule out celiac disease in patients with bloating and, if serologies are positive, a small bowel biopsy should be done to confirm the diagnosis. A gastroenterology dietitian should be part of the multidisciplinary approach to care for patients with celiac disease and nonceliac gluten sensitivity. Abdominal imaging and upper endoscopy should be ordered in patients with alarm features, recent worsening symptoms, or an abnormal physical examination only. Gastric emptying studies should not be ordered routinely for bloating and distention, but may be considered if nausea and vomiting are present. Whole gut motility and radiopaque transit studies should not be ordered unless other additional and treatment-refractory lower gastrointestinal symptoms exist to warrant testing for neuromyopathic disorders. In patients with abdominal bloating and distention thought to be related to constipation or difficult evacuation, anorectal physiology testing is suggested to rule out a pelvic floor disorder. When dietary modifications are needed (eg, low–fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet), a gastroenterology dietitian should preferably monitor treatment. Probiotics should not be used to treat abdominal bloating and distention. Biofeedback therapy may be effective for bloating and distention when a pelvic floor disorder is identified. Central neuromodulators (eg, antidepressants) are used to treat bloating and abdominal distention by reducing visceral hypersensitivity, raising sensation threshold, and improving psychological comorbidities. Medications used to treat constipation should be considered for treating bloating if constipation symptoms are present. Psychological therapies, such as hypnotherapy, cognitive behavioral therapy, and other brain–gut behavior therapies may be used to treat patients with bloating and distention. Diaphragmatic breathing and central neuromodulators are used to treat abdominophrenic dyssynergia. This American Gastroenterological Association Clinical Practice Update and best practice advice statements describe the definition, clinical features, and treatment for the 3 common symptoms of belching, abdominal bloating, and abdominal distention. 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