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

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.
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.

Key recommendations include:

  • Clinical history and physical examination findings and impedance pH monitoring can help to differentiate between gastric and supra-gastric belching.
  • Treatment options for supra-gastric 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.
  • Abdominal imaging and upper endoscopy should be ordered in patients with alarm features, recent worsening symptoms, or an abnormal physical examination only,
  • 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.
  • Probiotics should not be used to treat abdominal bloating and distention.
  • Central neuromodulators (e.g., antidepressants) are used to treat bloating and abdominal distention by reducing visceral hypersensitivity, raising sensation threshold, and improving psychological comorbidities.
  • Diaphragmatic breathing and central neuromodulators are used to treat abdomino-phrenic dyssynergia.