The European Society of Neurogastroenterology and Motility (ESNM) and United European Gastroenterology (UEG) have jointly released the first European consensus on functional bloating and abdominal distension, offering clear, evidence-based recommendations for clinicians to boost diagnosis, evaluation, and treatment of these common yet often misunderstood gastrointestinal (GI) ailments.
Published in the "United European Gastroenterology Journal", the guidelines aim to standardize management across Europe through a structured framework developed by a multidisciplinary team of 21 leading experts using a Delphi-based consensus process.
Key Diagnostic Recommendations
The consensus underscores that diagnosis of functional bloating and abdominal distension must be primarily clinical, guided by Rome IV criteria and a thorough medical history and physical examination.
Major diagnostic points encompass:
- Use Rome IV criteria to confirm the diagnosis after excluding organic diseases.
- Perform focused physical examination and detailed medical history prior to ordering tests.
- Routine laboratory, imaging, or endoscopic tests are unnecessary unless alarm features are present.
- Validated symptom questionnaires such as the Mayo Bloating Questionnaire or other patient-reported outcome measures are encouraged to determine severity and treatment response.
- Microbiota stool tests are not advocated as they lack diagnostic value.
- Evaluate possible food triggers, carbohydrate intolerance, or malabsorption with selective testing (e.g., breath tests for lactose or fermentable oligosaccharides, disaccharides, monosaccharides, and polyols [FODMAP] intolerance).
Pathophysiology Insights for Targeted Treatment
Experts agreed that functional bloating and distension are multifactorial, involving:
- Visceral hypersensitivity as a key driver of symptoms.
- Abdomino-phrenic dyssynergia, an abnormal coordination between diaphragm and abdominal wall muscles triggering visible distension.
- Intestinal dysmotility and dysbiosis, which may contribute in select cases.
These findings redefine bloating as primarily a neuromuscular and sensory dysfunction rather than excess intestinal gas.
Evidence-Based Treatment Recommendations
The guideline introduces a tiered management algorithm integrating dietary, pharmacologic, and behavioral therapies.
1. Dietary Management
- Low FODMAP diet: Exhibits the strongest evidence for reducing bloating and distension.
- Lactose-limiting diet: Recommended only for those with self-reported symptoms or confirmed lactose intolerance.
- Gluten-free diet: Not advised unless celiac disease is diagnosed.
- Elimination diets: Short-term trials may help identify food-related triggers.
2. Pharmacologic Interventions
- Probiotics
Certain strains can improve bloating. But, benefits are strain-specific and not universal.
- Rifaximin
Beneficial for functional bloating and distension, particularly in those with gut microbiota imbalance.
- Antispasmodics:
1. Otilonium bromide and pinaverium are the preferred options.
2. Simethicone lacks sufficient supporting evidence.
- Secretagogues:
1. Linaclotide is most effective, especially in constipation-related cases.|
2. Lubiprostone and plecanatide are beneficial alternatives.
- Neuromodulators
1. Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) efficiently decrease visceral hypersensitivity.
2. Buspirone can relieve post-prandial bloating by relaxing gastric accommodation.
- Prokinetics
May be considered in select patients, though evidence remains limited (e.g., prucalopride, tegaserod).
Behavioral and Non-Pharmacologic Therapies
- Biofeedback training: Effective for correcting visible distension by retraining diaphragmatic and abdominal muscle coordination.
- Cognitive behavioral therapy: Can be offered for those with IBS-linked functional bloating refractory to standard therapy.
- Hypnotherapy: May improve bloating in irritable bowel syndrome, though not specifically validated for functional bloating/distension.
- Acupuncture and herbal remedies: Not advocated due to insufficient evidence.
Practical Algorithm for Clinicians
The consensus offers a simplified clinical pathway:
- Rule out organic disease using targeted evaluation.
- Apply Rome IV diagnostic criteria for functional bloating/distension.
- Implement first-line measures — dietary adjustments and lifestyle advice.
- Introduce pharmacologic therapy (e.g., rifaximin, probiotics, or neuromodulators) if symptoms persist.
- Add behavioral or biofeedback therapy for visible distension or refractory cases.
Clinical Impact and Future Outlook
This European consensus represents a milestone in standardizing care for patients with functional bloating and abdominal distension. By focusing on symptom-based diagnosis and stepwise management, it helps clinicians:
- Avoid unnecessary testing.
- Select evidence-based, mechanism-driven therapies.
- Integrate dietary and psychological interventions for long-term relief.
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