Gastroenterology
Olivia C. Welter, PharmD
For many people, GI issues can cause significant disruptions to their daily lives. Belching, abdominal bloating, and distention are some of the primary symptoms that cause discomfort and can lead patients to seek care with a gastroenterologist.
With this in mind, the American Gastroenterological Association conducted a literature review and used the results to develop best practices for pathology identification and symptom management of belching, bloating, and abdominal distention. The results were published in Gastroenterology on July 13, 2023.
Best practice highlights
Moshiree and colleagues published a total of 15 best practice advice statements. Many of the statements are related to screening, diagnostic testing, and behavioral treatment options. Some statements suggest potential for pharmacist involvement in resolving their patients’ abdominal issues with medication therapy and management, which are summarized below.
As stated by authors, “a multidisciplinary approach and a patient-centered model are keys to managing treatment in patients with belching, abdominal bloating, and distention.”
Central neuromodulators
One such medication type that can be used to offer relief of certain gastric symptoms is central neuromodulators. The investigators noted that TCAs and SNRIs show the greatest relief for these symptoms.
The reasoning behind this treatment option is that central neuromodulators can help reduce psychological stress, as this type of stress can cause belching. Central neuromodulators can also raise the symptom threshold for bloating, which means the body can withstand more of the symptom before it becomes an issue for the patient. These medications can reduce visceral hypersensitivity and therefore minimize pain or discomfort felt in visceral organs like the stomach.
In patients who experience belching, central neuromodulators are most effective when combined with other therapies. Specifically, brain–gut behavioral therapies like relaxation training and gut-directed hypnotherapy can be part of the equation for improving patients’ symptom burden and, subsequently, quality of life.
Clinicians can also consider central neuromodulators for patients when bloating and distention are problematic symptoms. According to the researchers, sensations of bloating and distention may be exacerbated when patients have comorbid psychological symptoms like depression or anxiety, making antidepressants an appropriate treatment choice. Existing literature and the authors’ clinical experiences demonstrate that central neuromodulators may have the most benefit in patients with irritable bowel disease (IBS) and patients who experience distention after a meal.
Probiotics
The study authors do not recommend treating bloating or distention with probiotics. Though this option may seem appealing on the surface, guidelines established in the United States, England, and Europe for management of IBS and functional dyspepsia do not explicitly endorse using probiotics for global symptom treatment. In fact, researchers noted that the risk of adverse effects like brain fogginess and lactic acidosis could outweigh any benefit of probiotics.
Gut-related medications
Often, symptoms like belching, abdominal bloating, and distention can exist comorbidly with constipation. This is especially common for patients with IBS. Medications that treat constipation can also be effective for reducing bloating. Prescription medications including lubiprostone, linaclotide, and tepanor may be used in this situation.
Antibiotics
Sometimes, gastric issues can be caused by small intestine bacterial overgrowth. Though clinicians sometimes use empiric antibiotic therapy in patients with bloating, the authors warn that antibiotics are not approved by FDA to treat belching or bloating. For this reason, patients must be carefully selected for antibiotic therapy; providers can look for chronic watery diarrhea, signs of malnutrition and weight loss, and diseases like cystic fibrosis and Parkinson disease when deciding whether a patient would qualify for diagnostic testing or empiric antibiotic treatment.
Background
After reviewing the published literature, including clinical trials, robust observational studies, and expert opinions, the authors noted that their advice statements do not carry formal ratings regarding quality of evidence or strength of the presented considerations. Additionally, they noted a lack of existing literature investigating the pathophysiology and risk factors of belching and bloating, meaning providers don’t have much evidence to use when making treatment decisions. ■