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With abdominal bloating affecting up to 18% of the global population, clinicians are regularly challenged to pinpoint the cause from a broad array of possibilities that range from psychosocial disorders to ovarian cancer. But key strategies can help with diagnosis and successful treatment of the condition.

“By developing an individualized plan with a multidisciplinary team, as recommended in the Rome V criteria, we can help these patients,” said Baha Moshiree, MD, of Atrium Health, Wake Forest Medical University, in Charlotte, North Carolina, who presented on the issue at Digestive Disease Week (DDW) 2026.

In a talk aptly titled “Will I explode? Refractory bloating beyond blaming gas,” Moshiree underscored the trial-and-error process of successful diagnosis and explored treatment options for refractory bloating, given the paucity of randomized clinical trials.

Under the latest Rome V criteria, abdominal bloating is defined as involving recurrent abdominal fullness, pressure, or a visible increase in abdominal girth, with symptoms lasting at least 1 day a week and active for 3 months, with onset in the past 6 months, but without pain and alterations in bowel habits, she explained.

Clinically, patients may present with the symptoms similar to a typical case Moshiree described: The patient, a 28-year-old man, presented complaining of “a belly blowing up like a balloon by mid-afternoon,” looking “like he’s pregnant.” He feels like he needs to belch but can’t get the air out, and, while feeling better after defecation, the symptoms are having a significantly negative effect on his quality of life.

Key possibilities in a working diagnosis for such cases may range from functional bloating or irritable bowel syndrome (IBS) with constipation, to lactose intolerance, abdominophrenic dyssynergia, abelchia or a disorder of gut-brain interaction, caused, for instance, by anxiety.

Ultimately, “the potential mechanisms are multifactorial,” Moshiree said.

American Gastroenterological Association (AGA) Algorithm for Diagnosis

Under recommendations from an AGA Clinical Practice Update, on which Moshiree was the first author, the evaluation of belching, abdominal bloating and distention should begin by taking a thorough history.

“This should include making psychosocial and biopsychosocial assessments, due to the chance of [for instance,] anxiety disorders being associated with or exacerbating bloating symptoms,” said Moshiree.

Importantly, ruling out alarming symptoms, such as rectal bleeding, weight loss, anemia, and, notably, ovarian/hormonal symptoms, she said, highlight the link between bloating and ovarian cancer after menopause.

“Particularly with a woman who’s over 50 and has hyperglycemia and bloating symptoms, consider the possibility of an ovarian origin,” she noted. “Gynecologists are very cognizant of that and list bloating as a symptom of ovarian cancer.”

Initial lab tests should follow, including a complete blood count, testing for thyroid levels depending on other symptoms suggesting hypothyroidism, C-reactive protein erythrocyte sedimentation rate in patients with chronic diarrhea, celiac serology, and fecal calprotectin if inflammatory bowel disease is suspected. Not all patients need these tests, Moshiree acknowledged.

Many different breath tests are available, such as lactose/fructose breath test for carbohydrate malabsorption; however, breath testing for small intestinal bacterial overgrowth is reserved only for patients with suspected systemic disease and symptoms of chronic diarrhea and/or weight loss, she noted.

Further advanced testing may be warranted, depending on symptoms, ranging from high-resolution manometry with impedance (abelchia) to colonoscopy (if alarm symptoms are present) or a gastric emptying study if gastroparesis is suspected.

FODMAP Diet Comes With Highest Recommendation

In managing bloating, a dietary intervention is nearly always the recommended first step, with the low fermentable oligosaccharides, disaccharides, monosaccharides and polyol (FODMAP) diet representing the most evidence-supported dietary strategy.

The temporary diet involves restricting short-chain carbohydrates, FODMAPs that are poorly absorbed by the small intestine.

The FODMAP diet should be supervised by a specialized gastrointestinal-focused dietitian, who can guide patients on the three-step protocol of eliminations for 4-8 weeks, reintroduction of certain foods, and then personalization, Moshiree said.

Of note, some concerns raised with the diet include that long-term use may alter microbiota, and, due to its restrictive nature, cause malnutrition. Also, some evidence suggests that dietary fiber, if insoluble fiber, may increase or even worsen bloating in some patients, making dietician oversight and individualization especially important as soluble fiber is usually well tolerated.

Evidence supporting the low FODMAP diet in IBS trials was detailed in a meta-analysis published in The Lancet last year, which involved 26 randomized controlled trials looking at all dietary therapies for bloating and distention. The results showed that only the low FODMAP diet was superior to a habitual diet for abdominal bloating.

Medications?

For refractory constipation, which is considered the largest contributor to bloating, research further supports a variety of medications, with one studyshowing benefits of linaclotide 290 mcg, lubiprostone 8 mcg, and tenapanor 50 mg over placebo.

In addition, a pooled analysisof six phase 3 and 4 studies of more than 1800 patients with moderate-to-very severe abdominal bloating showed prucalopride to have significant benefits over placebo, with improvements starting rapidly after medication initiation.

“We can show patients that improvements in the study in abdominal bloating started at about 2 weeks,” Moshiree said, noting that the drug is not approved by the FDA for bloating and therefore must be used off-label.

While some studies have looked at probiotics for bloating, guidelines, including those of the American College of Gastroenterology, recommend against the use, she said.

Other treatment approaches have shown that treatments for bloating include biofeedback therapy, diaphragmatic breathing, with some studies showing benefits in patients with bloating who had failed on dietary treatments as well as balloon expulsion.

Neuromodulators: Treating the Central Nervous System

With knowledge that “the enteric nervous system is hardwired to the central nervous system,” as described in a blog on the issue from the Rome Foundation, some research has shown benefits of treatment of bloating with neuromodulators.

In one notable study, 77 patients (87% women) were prescribed a neuromodulator for the primary complaint of bloating, with the antidepressant duloxetine the most commonly prescribed (67.5%).

While 61% of the patients reported having any bloating response, 36.4% met the study’s definition an a priori responder of having at least a 50% improvement.

“There is a perception in this field that bloating may be a symptom just below the threshold for pain, and neuromodulators are routinely used to treat pain,” said first author of the study, Elizabeth Madva, MD, an assistant professor of psychiatry, Harvard Medical School/Massachusetts General Hospital, Boston.

“Thus, the use of neuromodulation to treat bloating represents an important gap in the literature,” she added.

Meanwhile, “distention, frequently accompanying bloating, may be a maladaptive reflex in response to visceral stretch,” she explained to Medscape Medical News. 

While the study did not assess time-to-response data, Madva noted that guidelines recommend at least 6-12 months of treatment with a neuromodulator to reduce the risk for recurrence.

The researcher noted that the findings “aligns with AGA and ESNM/UEG [European Society for Neurogastroenterology and Motility/ United European Gastroenterology] guideline recommendations that position neuromodulators as a part of a multimodal treatment strategy for bloating.”

In a separate meta-analysis of 16 studies on antidepressants compared to placebo in IBS, results included improvements in bloating, with an odds ratio (OR) of 2.4, as well as abdominal pain, with an OR, 3.27.

Antidepressants “can be beneficial to patients resistant to initial treatments and those lacking psychopathological symptoms,” the authors of the meta-analysis concluded.

Disaccharidase Deficiency?

The need to test patients with bloating symptoms for disaccharidase deficiency has gained recent focus, with these patients potentially benefitting from other, more personally tailored dietary regimens.

In one recent study, 496 patients who presented with gas and bloating but normal endoscopy and CT scans, underwent disaccharidase testing. First author Satish S.C. Rao, MD, a professor of medicine and director of the Digestive Health Clinical Research Center, Wellstar MCG Health, Augusta University, Augusta, Georgia, explained that the purpose of disaccharidase testing is to determine if the patient has a CHO enzyme deficiency; and, if so, which sugar, or if it’s more than one sugar.

The study found that as many as 28.8% of study participants had a single enzyme disaccharidase deficiency, 1.8% had a double enzyme deficiency, and 9.7% were pandeficient.

“Based on these results, we tailor their diet,” Rao told Medscape Medical News. “For example, if a patient has only lactase deficiency, which is incidentally the highest prevalent deficiency, then we will recommend a lactose free diet and not low FODMAP diet.”

“We reserve the low FODMAP diet for very few patients who have pan-disaccharidase deficiency,” he added.

Notably, those with pandeficiencies did not have worse symptoms compared with single or double enzyme deficiency, and no single symptom was more prevalent in patients with confirmed enzyme deficiency than those without.

Moshiree said that she mainly tests for disaccharidase deficiency by small bowel biopsy via upper endoscopy when patients with bloating also report chronic diarrhea and weight loss. She noted that breath testing for sucrase-isomaltase deficiency is not currently validated.

Multidisciplinary Team Approach

Ultimately, considering the range of different potential treatments, Moshiree and her colleagues underscored the importance of a multidisciplinary team in their guideline update.

“We believe a multidisciplinary approach and a patient-centered model are keys to managing treatment in patients with belching, abdominal bloating, and distention,” they wrote.

While noting that integrated care with specialists — ranging from primary care physicians, gastroenterologists, dietitians, brain-gut behavioral therapists, and motility providers — 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,” they added.

Moshiree disclosed receiving funding from the National Institutes of Health’s National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Consortium, Cystic Fibrosis Foundation, ATMO Biosciences, CinDome, and CinPhloro. Rao and Madva had no disclosures to report.