The Unexpected Connection Between Stress and Bloating

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We all know the feeling of an expanded stomach after a particularly indulgent meal. But beyond the occasional bloating experience, nearly a third of the U.S. population experiences chronic bloating [1]. So what’s behind this symptom when it’s more frequent?

Key Takeaways

• Stress can lead to bloating by increasing inflammation and causing gut bacteria imbalances.
• Irritable bowel syndrome (IBS) symptoms, including bloating and abdominal distention, are strongly associated with stress levels.
• Non-gut-related issues, like pelvic floor dysfunction, can cause chronic bloating.
• Bloating and other gastrointestinal (GI) symptoms can be easily treated with lifestyle and dietary changes, probiotics, and physical therapy.

If you’ve been going through a lot more stress than usual lately, you may have noticed a worsening in your symptoms. And you wouldn’t be wrong, as the research shows that increased stress can worsen bloating and stomach distention.

The link between stress and increased IBS symptoms like bloating is well-established. This is likely due to stress changing the gut microbiota, leading to dysbiosis and/or bacterial overgrowth. These gut flora changes can lead to excess gas production and inflammation inside the GI tract. Unfortunately, as inflammation levels increase, our pain sensitivity also increases, adding to the sensation of bloating.

Fortunately, dietary, lifestyle, and supplemental recommendations are effective at reducing the underlying causes of stomach bloating. This article will take you through some of the most common causes of bloating that result from stress, and will give you a step-by-step guide to alleviating this uncomfortable symptom.

Can Stress Cause Bloating?

Stress can disrupt the normal gut microbiome, creating intestinal dysbiosis and bacterial overgrowth. These changes can lead to digestive symptoms, including bloating. This may be due in part to excess gas production that may cause the sensation of bloating and physical distention, though the exact mechanism hasn’t been confirmed by research.

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Additionally, it appears that stress creates an increased perception of bloating, though the exact reason is not well understood [2]. Stress likely causes inflammation in the digestive tract that increases pain receptors, creating more distress related to bloating.

What Is Bloating?

Bloating is the subjective feeling of pressure or gas in the abdomen. It’s important to note that this is different from distention, which refers to the physical expansion of the abdomen [1]. However, these symptoms often present together, and over half of the people who experience bloating also report abdominal distention [1].

Bloating may exist as a symptom on its own, without other signs of GI disturbance. However, it often presents alongside other GI disorders, such as:

• Irritable bowel syndrome (IBS) [1]
• Inflammatory bowel disease (IBD) [3]
• Small intestine bacterial overgrowth (SIBO) [1, 2, 4, 5]
• Chronic constipation [1]
• Dyspepsia and indigestion [1]
• Exocrine pancreatic insufficiency (EPI) [1, 2, 6, 7]
• Gastroparesis [1, 2]
• Gallbladder dysfunction [8]
• Stomach ulcers [9]
• Chronic overeating [5]

Occasional bloating, flatulence, belching, and distention are all considered normal parts of digestive physiology, especially after eating. These symptoms typically aren’t considered a problem until they begin to cause pain and/or disrupt your daily life.

Let’s take a look at some cases where this can occur.

Stress and Irritable Bowel Syndrome (IBS)

IBS is a common gut disorder and is a frequent cause of bloating and abdominal distention. One study found that all patients with diagnosed IBS, regardless of the subtype, experience more sensations of bloating than healthy controls. Furthermore, nearly half of IBS patients experienced physical abdominal distention [10].

The link between stress and IBS is well-researched, and chronic stress often increases IBS-related symptoms such as:

• Gas, bloating, and abdominal distention
• Constipation
• Diarrhea
• Stomach pain
• Cramping

Those with IBS tend to struggle with mental health disorders, and research shows that they experience higher levels of depression, anxiety, and distress than the general population [11]. Additionally, people with IBS tend to have higher levels of stress and a lower quality of life [12]. Fortunately, IBS can be treated with functional medicine, offering some much-needed relief for IBS-related mood disturbances.

While we’re unsure of the exact mechanism by which stress increases symptoms of IBS, studies show that stressors alter the microbial balance and production of gut flora metabolites. This change in the microbiome then causes physiological changes in the brain via the gut-brain axis [13].

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When the brain creates a stress response, chemical messengers—like stress hormones and neurotransmitters—travel down the gut-brain axis and can cause hypersensitivity in the gut. In fact, research shows that IBS patients may not actually experience more gas production than healthy populations. It’s likely a hypersensitivity reaction in the enteric nervous system that leads to increased sensations of bloating [14].

Regardless of the exact mechanism, there appears to be a strong correlation between IBS symptoms and stress.

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Bloating in Other GI Conditions

Because of the communication between the digestive system and the brain, stress likely increases symptoms of bloating and abdominal distention in other functional GI disorders.

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For example, as stress can cause dysbiosis in the digestive tract, it’s likely a major contributing factor in the development of small intestinal bacterial overgrowth (SIBO). Additionally, exocrine pancreatic insufficiency and histamine intolerance both frequently present with bloating, and are likely aggravated by chronic stress [15, 16].

Food intolerances and allergies commonly present with bloating and are another example of how stress affects the GI tract [17, 18]. For example, sensitivities like wheat and gluten intolerance are caused by a misguided immune reaction in the gut. As stress creates inflammation and an abnormal immune response in the digestive tract, it may also lead to the development and persistence of these sensitivities.

Other Possible Causes of Bloating

Many other chronic health conditions can often present with abdominal bloating and distention. This includes disorders and other underlying factors like:

• Certain medications
• Hypothyroidism [1, 2]
• Obesity [1]
• Type-2 diabetes [2]
• Autoimmunity [2, 19, 20]
• Menstruation and ovarian cysts [21, 22, 23]

Even musculoskeletal disorders are often triggered by stress and can cause increased bloating and abdominal distention. The following are two examples of when this may occur.

Abdominal Muscle Dysfunction

Abnormal contractions in the diaphragm and belly muscles after eating can cause the nervous system to create a heightened sense of bloating. This abnormal “viscerosomatic reflex” causes poor posture and distention of the abdominal muscles, and may worsen bloating sensations [24].

Exercises that retrain the muscles to contract in a normal way after eating may reduce the perception of bloating [24].

Pelvic Floor Dysfunction

Stressful situations naturally cause our muscles to tighten and can lead to increased contractions in the muscles of the pelvic floor. These muscles control our bladder, bowel, and sexual function. When they are overly contracted (too tight) they can create a condition known as high-tone pelvic floor dysfunction [25].

Conversely, the opposite can happen when the pelvic floor muscles become overly relaxed, making it difficult to have regular bowel movements. In either case, both increased tone and over-relaxation of these muscles can lead to a wide array of symptoms, including bloating [25].

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It’s believed that people with pelvic floor dysfunction likely have disordered gut-brain connections [26]. Biofeedback is a mind-body therapy that teaches your body how to relax and can help restore the gut-brain axis. One clinical trial on women with pelvic floor dysfunction found that over half of the participants had decreased bloating after undergoing biofeedback [26].

This positive response further strengthens the evidence that our brains and digestive tracts are connected. Overall, stress appears to increase the likelihood of bloating by affecting multiple body systems, including the digestive, nervous, and musculoskeletal systems.

As little as 20 minutes of fast walking can be enough to lower inflammatory markers in the body. michaelheim/Shutterstock

Your 5-Step Guide to Reducing Stress-Induced Bloating

While much of the following research on relieving stress and GI symptoms was performed on those with IBS, we’ve found the below therapies to be helpful for people with other conditions that result in bloating and abdominal distention.

Step 1: Lifestyle Changes

Stress management: Stress-reduction techniques can reduce the “fight or flight response” that happens during times of stress and can improve your gut health. Cognitive behavioral therapy (CBT), biofeedback, and meditation all help reduce stress levels and relieve stress-induced bloating [27, 28, 29].

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One meditation technique in particular, mindfulness-based stress reduction (MBSR), shows promise in reducing bloating and overall stress levels. Additionally, results may last up to six months after undergoing MBSR therapy [30, 31, 32].

Gut-directed hypnotherapy may also significantly reduce symptoms of bloating, anxiety, and depression. These effects were seen in as few as six sessions [33, 34, 35].

Exercise: Physical activity is beneficial for improving stress, alleviating uncomfortable GI symptoms, and improving overall wellness. For the best results, aim to engage in moderate physical activity for two to three hours per week [36]. This includes activities like:

• Fast walking
• Biking on a flat surface
• Water aerobics
• Basketball, tennis, volleyball, and other sports

Yoga also appears to be an effective exercise for reducing bloating and is well-known to help reduce stress and anxiety levels [37].

Step 2: Change Your Diet

Start by following an elimination diet to help heal your gut, reduce inflammation, and determine which foods might be triggering your symptoms.

A good place to start is with a Paleo diet framework. The Paleo diet emphasizes high-protein, high-fat, and low-carbohydrate consumption. It reduces inflammation in the intestinal tract and can be effective at eliminating digestive symptoms, like bloating and distention. This is a well-rounded diet that eliminates several common triggers without being overly restrictive.

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Common triggers that are eliminated on the Paleo diet include:

• Sugar
• Processed foods
• Gluten-containing foods and other grains
• Dairy

If, after trying it for two to three weeks, the Paleo diet doesn’t work for you, try switching to a low FODMAP diet. Clinical trials show that a low FODMAP diet is highly effective at reducing abdominal pain, gas, and bloating, while improving the overall quality of life [38, 39, 40, 41, 42].

Try the low FODMAP diet for two to three weeks and see if your symptoms improve. If they do, it may not be necessary to continue to follow a strict low FODMAP protocol to maintain relief from your symptoms, as 84 percent of participants in one study still experienced relief from their digestive symptoms, even after reintroducing a few FODMAP foods [43]. In fact, long-term restriction of FODMAP foods may actually worsen symptoms, as it suppresses the growth of healthy gut flora [44].

It is important to note that everyone’s food triggers may be different and it may take some experimentation to figure out what may be causing your bloating and other GI symptoms.

Once you eliminate all of the suspected triggers from your diet, you can start adding foods back in, one at a time. Introduce a new food every two to three days, and watch to see if you experience any bloating or distention. This will allow you to identify your unique gut triggers, without being overly restrictive.

Step 3: Introduce Probiotics

Probiotics are highly effective at reducing symptoms of GI disorders, including bloating and abdominal distention [45, 46, 47, 48]. Probiotics help to dampen the dysbiosis that occurs from stress and can help restore the normal gut flora.

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In patients with IBS, probiotics can significantly reduce abdominal pain, and even help to alleviate bloating and diarrhea that accompany menstruation [48, 49, 50, 51].

It’s important to note that prebiotics, food-based supplements that promote the growth of beneficial gut bacteria, may not offer the same benefits [52].

Dietary supplements. Wikimedia Commons

Step 4: Targeted Supplement and Dietary Treatments

If your bloating and/or stomach distention isn’t solved by dietary and lifestyle changes alone, it may be time for a more targeted approach.

• Supplements: Research suggests that digestive enzymes can help reduce symptoms of bloating, abdominal pain, and flatulence [53, 54]. One enzyme in particular, ɑ-galactosidase, may be beneficial in alleviating colic in children and is considered to be safe [55].
• Intermittent Fasting: One study showed that intermittent fasting successfully reduced bloating, abdominal pain, diarrhea, nausea, and anxiety in those with IBS [56]. Intermittent fasting focuses on abstaining from eating for a certain period each day. Many people start with a 16-hour fasting window, but there are many variations, and you should always do what’s best for you.
• Elemental Diet: Don’t worry if fasting isn’t appropriate for you, as an elemental diet can effectively resolve stubborn IBS-related symptoms, like gas and bloating, in just two to three weeks [57]. The elemental diet is formulated to be easily digested, it reduces inflammation in the GI tract, and helps increase nutrient absorption. The elemental diet is easy to incorporate and can be used alone, or alongside another diet.
• Medications: Rifaxamin is a popular antibiotic that’s used to treat dysbiosis and infections in the GI tract. It’s considered safe by health care practitioners, as it’s not absorbed into the bloodstream, lessening its side effects. Rifaxamin is highly effective at reducing IBS symptoms, particularly bloating, and it may take as little as two weeks to see significant results [58]. Furthermore, rifaxamin may offer long-term relief from bloating, even after finishing the course of antibiotics [59].

Step 5: Physical Therapy

Those with bloating related to pelvic floor dysfunction may benefit from seeing a physical therapist who specializes in pelvic floor therapy. Manual physical therapy can effectively break up adhesions (scar tissue) that constrict organs and lead to abdominal distension and bloating sensations [60].

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As previously discussed, pelvic floor biofeedback may help alleviate bloating, lessen constipation, and improve overall well-being [26].

Summary: Can Stress Cause Bloating?

Research supports that stress is a likely cause of bloating in both GI disorders and non-gut-related conditions. The gut-brain axis provides a powerful pathway of communication between the brain and digestive tract, allowing stress to increase inflammation and dysbiosis in the gut.

Fortunately, there are some basic steps that you can take to improve your symptoms of bloating and abdominal distention.

Stress reduction, dietary changes, probiotics, supplements, and even physical therapy are all likely effective in improving bloating. For more guidance on discovering and treating the cause of your chronic bloating, as well as improving your digestive health, reach out to our clinic today.

Republished from DrRuscio.com.

◇ References:

1. Lacy BE, Cangemi D, Vazquez-Roque M. Management of chronic abdominal distension and bloating. Clin Gastroenterol Hepatol. 2021 Feb;19(2):219-231.e1. DOI: 10.1016/j.cgh.2020.03.056. PMID: 32246999.
2. Mari A, Abu Backer F, Mahamid M, Amara H, Carter D, Boltin D, et al. Bloating and abdominal distension: clinical approach and management. Adv Ther. 2019 May;36(5):1075–84. DOI: 10.1007/s12325-019-00924-7. PMID: 30879252. PMCID: PMC6824367.
3. Nemeth V, Pfleghaar N. Diarrhea. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021. PMID: 28846339.
4. Ghoshal UC. Antibiotic treatment for small intestinal bacterial overgrowth: Is a cocktail better than a single? United European Gastroenterol J. 2021 Jul;9(6):643–4. DOI: 10.1002/ueg2.12075. PMID: 33951351. PMCID: PMC8280792.
5. Zhang L, Sizar O, Higginbotham K. Meteorism. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021. PMID: 28613601.
6. Leeds JS, Hopper AD, Sidhu R, Simmonette A, Azadbakht N, Hoggard N, et al. Some patients with irritable bowel syndrome may have exocrine pancreatic insufficiency. Clin Gastroenterol Hepatol. 2010 May;8(5):433–8. DOI: 10.1016/j.cgh.2009.09.032. PMID: 19835990.
7. Othman MO, Harb D, Barkin JA. Introduction and practical approach to exocrine pancreatic insufficiency for the practicing clinician. Int J Clin Pract. 2018 Feb 5;72(2). DOI: 10.1111/ijcp.13066. PMID: 29405509. PMCID: PMC5873407.
8. Jones MW, Genova R, O’Rourke MC. Acute Cholecystitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021. PMID: 29083809.
9. Malik TF, Gnanapandithan K, Singh K. Peptic Ulcer Disease. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021. PMID: 30521213.
10. Houghton LA, Lea R, Agrawal A, Reilly B, Whorwell PJ. Relationship of abdominal bloating to distention in irritable bowel syndrome and effect of bowel habit. Gastroenterology. 2006 Oct;131(4):1003–10. DOI: 10.1053/j.gastro.2006.07.015. PMID: 17030170.
11. Roohafza H, Bidaki EZ, Hasanzadeh-Keshteli A, Daghaghzade H, Afshar H, Adibi P. Anxiety, depression and distress among irritable bowel syndrome and their subtypes: An epidemiological population based study. Adv Biomed Res. 2016 Nov 28;5:183. DOI: 10.4103/2277-9175.190938. PMID: 28028523. PMCID: PMC5156966.
12. Chen H-H, Hung C-H, Kao A-W, Hsieh H-F. Exploring Quality of Life, Stress, and Risk Factors Associated with Irritable Bowel Syndrome for Female University Students in Taiwan. Int J Environ Res Public Health. 2021 Apr 7;18(8). DOI: 10.3390/ijerph18083888. PMID: 33917268. PMCID: PMC8068066.
13. Foster JA, Rinaman L, Cryan JF. Stress & the gut-brain axis: Regulation by the microbiome. Neurobiol Stress. 2017 Dec;7:124–36. DOI: 10.1016/j.ynstr.2017.03.001. PMID: 29276734. PMCID: PMC5736941.
14. Major G, Pritchard S, Murray K, Alappadan JP, Hoad CL, Marciani L, et al. Colon Hypersensitivity to Distension, Rather Than Excessive Gas Production, Produces Carbohydrate-Related Symptoms in Individuals With Irritable Bowel Syndrome. Gastroenterology. 2017 Jan;152(1):124-133.e2. DOI: 10.1053/j.gastro.2016.09.062. PMID: 27746233.
15. Amieva-Balmori M, Coss-Adame E, Rao NS, Dávalos-Pantoja BM, Rao SSC. Diagnostic utility of carbohydrate breath tests for SIBO, fructose, and lactose intolerance. Dig Dis Sci. 2020 May;65(5):1405–13. DOI: 10.1007/s10620-019-05889-9. PMID: 31617133.
16. Schnedl WJ, Lackner S, Enko D, Schenk M, Holasek SJ, Mangge H. Evaluation of symptoms and symptom combinations in histamine intolerance. Intest Res. 2019 Jul;17(3):427–33. DOI: 10.5217/ir.2018.00152. PMID: 30836736. PMCID: PMC6667364.
17. Dieterich W, Zopf Y. Gluten and FODMAPS-Sense of a Restriction/When Is Restriction Necessary? Nutrients. 2019 Aug 20;11(8). DOI: 10.3390/nu11081957. PMID: 31434299. PMCID: PMC6723650.
18. Croall ID, Hoggard N, Aziz I, Hadjivassiliou M, Sanders DS. Brain fog and non-coeliac gluten sensitivity: Proof of concept brain MRI pilot study. PLoS ONE. 2020 Aug 28;15(8):e0238283. DOI: 10.1371/journal.pone.0238283. PMID: 32857796. PMCID: PMC7454984.
19. Annibale B, Esposito G, Lahner E. A current clinical overview of atrophic gastritis. Expert Rev Gastroenterol Hepatol. 2020 Feb;14(2):93–102. DOI: 10.1080/17474124.2020.1718491. PMID: 31951768.
20. Carabotti M, Lahner E, Esposito G, Sacchi MC, Severi C, Annibale B. Upper gastrointestinal symptoms in autoimmune gastritis: A cross-sectional study. Medicine (Baltimore). 2017 Jan;96(1):e5784. DOI: 10.1097/MD.0000000000005784. PMID: 28072728. PMCID: PMC5228688.
21. Meleine M, Matricon J. Gender-related differences in irritable bowel syndrome: potential mechanisms of sex hormones. World J Gastroenterol. 2014 Jun 14;20(22):6725–43. DOI: 10.3748/wjg.v20.i22.6725. PMID: 24944465. PMCID: PMC4051914.
22. Southwell BR. Treatment of childhood constipation: a synthesis of systematic reviews and meta-analyses. Expert Rev Gastroenterol Hepatol. 2020 Mar;14(3):163–74. DOI: 10.1080/17474124.2020.1733974. PMID: 32098515.
23. Ovarian cysts: Overview – InformedHealth.org – NCBI Bookshelf [Internet]. 2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539572/
24. Livovsky DM, Barber C, Barba E, Accarino A, Azpiroz F. Abdominothoracic postural tone influences the sensations induced by meal ingestion. Nutrients. 2021 Feb 18;13(2). DOI: 10.3390/nu13020658. PMID: 33670508. PMCID: PMC7922384.
25. Grimes WR, Stratton M. Pelvic Floor Dysfunction. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021. PMID: 32644672.
26. Iovino P, Neri MC, D’Alba L, Santonicola A, Chiarioni G. Pelvic floor biofeedback is an effective treatment for severe bloating in disorders of gut-brain interaction with outlet dysfunction. Neurogastroenterol Motil. 2021 Sep 16;e14264. DOI: 10.1111/nmo.14264. PMID: 34532928.
27. Ford AC, Lacy BE, Harris LA, Quigley EMM, Moayyedi P. Effect of Antidepressants and Psychological Therapies in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-Analysis. Am J Gastroenterol. 2019 Jan;114(1):21–39. DOI: 10.1038/s41395-018-0222-5. PMID: 30177784.
28. Black CJ, Thakur ER, Houghton LA, Quigley EMM, Moayyedi P, Ford AC. Efficacy of psychological therapies for irritable bowel syndrome: systematic review and network meta-analysis. Gut. 2020 Aug;69(8):1441–51. DOI: 10.1136/gutjnl-2020-321191. PMID: 32276950.
29. Lackner JM, Jaccard J, Keefer L, Brenner DM, Firth RS, Gudleski GD, et al. Improvement in gastrointestinal symptoms after cognitive behavior therapy for refractory irritable bowel syndrome. Gastroenterology. 2018 Jul;155(1):47–57. DOI: 10.1053/j.gastro.2018.03.063. PMID: 29702118. PMCID: PMC6035059.
30. Thakur ER, Shapiro J, Chan J, Lumley MA, Cully JA, Bradford A, et al. A systematic review of the effectiveness of psychological treatments for IBS in gastroenterology settings: promising but in need of further study. Dig Dis Sci. 2018 Sep;63(9):2189–201. DOI: 10.1007/s10620-018-5095-3. PMID: 29744772.
31. Zernicke KA, Campbell TS, Blustein PK, Fung TS, Johnson JA, Bacon SL, et al. Mindfulness-based stress reduction for the treatment of irritable bowel syndrome symptoms: a randomized wait-list controlled trial. Int J Behav Med. 2013 Sep;20(3):385–96. DOI: 10.1007/s12529-012-9241-6. PMID: 22618308.
32. Naliboff BD, Smith SR, Serpa JG, Laird KT, Stains J, Connolly LS, et al. Mindfulness-based stress reduction improves irritable bowel syndrome (IBS) symptoms via specific aspects of mindfulness. Neurogastroenterol Motil. 2020 Sep;32(9):e13828. DOI: 10.1111/nmo.13828. PMID: 32266762.
33. Ford AC, Quigley EMM, Lacy BE, Lembo AJ, Saito YA, Schiller LR, et al. Effect of antidepressants and psychological therapies, including hypnotherapy, in irritable bowel syndrome: systematic review and meta-analysis. Am J Gastroenterol. 2014 Sep;109(9):1350–65; quiz 1366. DOI: 10.1038/ajg.2014.148. PMID: 24935275.
34. Hasan SS, Whorwell PJ, Miller V, Morris J, Vasant DH. Six vs 12 Sessions of Gut-focused Hypnotherapy for Irritable Bowel Syndrome: A Randomized Trial. Gastroenterology. 2021 Jun;160(7):2605-2607.e3. DOI: 10.1053/j.gastro.2021.02.058. PMID: 33662389. PMCID: PMC8202328.
35. Flik CE, Laan W, Zuithoff NPA, van Rood YR, Smout AJPM, Weusten BLAM, et al. Efficacy of individual and group hypnotherapy in irritable bowel syndrome (IMAGINE): a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol. 2019 Jan;4(1):20–31. DOI: 10.1016/S2468-1253(18)30310-8. PMID: 30473202.
36. Hosseini-Asl MK, Taherifard E, Mousavi MR. The effect of a short-term physical activity after meals on gastrointestinal symptoms in individuals with functional abdominal bloating: a randomized clinical trial. Gastroenterol Hepatol Bed Bench. 2021;14(1):59–66. PMID: 33868611. PMCID: PMC8035544.
37. Schumann D, Anheyer D, Lauche R, Dobos G, Langhorst J, Cramer H. Effect of yoga in the therapy of irritable bowel syndrome: a systematic review. Clin Gastroenterol Hepatol. 2016 Dec;14(12):1720–31. DOI: 10.1016/j.cgh.2016.04.026. PMID: 27112106.
38. Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol. 2010 Feb;25(2):252–8. DOI: 10.1111/j.1440-1746.2009.06149.x. PMID: 20136989.
39. Altobelli E, Del Negro V, Angeletti PM, Latella G. Low-FODMAP Diet Improves Irritable Bowel Syndrome Symptoms: A Meta-Analysis. Nutrients. 2017 Aug 26;9(9). DOI: 10.3390/nu9090940. PMID: 28846594. PMCID: PMC5622700.
40. Varjú P, Farkas N, Hegyi P, Garami A, Szabó I, Illés A, et al. Low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet improves symptoms in adults suffering from irritable bowel syndrome (IBS) compared to standard IBS diet: A meta-analysis of clinical studies. PLoS ONE. 2017 Aug 14;12(8):e0182942. DOI: 10.1371/journal.pone.0182942. PMID: 28806407. PMCID: PMC5555627.
41. Dumitrascu DL, Baban A, Bancila I, Barboi O, Bataga S, Chira A, et al. Romanian guidelines for nonpharmacological therapy of IBS. J Gastrointestin Liver Dis. 2021 Jun 18;30(2):291–306. DOI: 10.15403/jgld-3581. PMID: 33951120.
42. Gibson PR, Shepherd SJ. Food choice as a key management strategy for functional gastrointestinal symptoms. Am J Gastroenterol. 2012 May;107(5):657–66; quiz 667. DOI: 10.1038/ajg.2012.49. PMID: 22488077.
43. Maagaard L, Ankersen DV, Végh Z, Burisch J, Jensen L, Pedersen N, et al. Follow-up of patients with functional bowel symptoms treated with a low FODMAP diet. World J Gastroenterol. 2016 Apr 21;22(15):4009–19. DOI: 10.3748/wjg.v22.i15.4009. PMID: 27099444. PMCID: PMC4823251.
44. Hills RD, Pontefract BA, Mishcon HR, Black CA, Sutton SC, Theberge CR. Gut microbiome: profound implications for diet and disease. Nutrients. 2019 Jul 16;11(7). DOI: 10.3390/nu11071613. PMID: 31315227. PMCID: PMC6682904.
45. Ford AC, Quigley EMM, Lacy BE, Lembo AJ, Saito YA, Schiller LR, et al. Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: systematic review and meta-analysis. Am J Gastroenterol. 2014 Oct;109(10):1547–61; quiz 1546, 1562. DOI: 10.1038/ajg.2014.202. PMID: 25070051.
46. Yuan F, Ni H, Asche CV, Kim M, Walayat S, Ren J. Efficacy of Bifidobacterium infantis 35624 in patients with irritable bowel syndrome: a meta-analysis. Curr Med Res Opin. 2017 Jul;33(7):1191–7. DOI: 10.1080/03007995.2017.1292230. PMID: 28166427.
47. Tiequn B, Guanqun C, Shuo Z. Therapeutic effects of Lactobacillus in treating irritable bowel syndrome: a meta-analysis. Intern Med. 2015;54(3):243–9. DOI: 10.2169/internalmedicine.54.2710. PMID: 25748731.
48. McFarland LV, Dublin S. Meta-analysis of probiotics for the treatment of irritable bowel syndrome. World J Gastroenterol. 2008 May 7;14(17):2650–61. DOI: 10.3748/wjg.14.2650. PMID: 18461650. PMCID: PMC2709042.
49. Rogha M, Esfahani MZ, Zargarzadeh AH. The efficacy of a synbiotic containing Bacillus Coagulans in treatment of irritable bowel syndrome: a randomized placebo-controlled trial. Gastroenterol Hepatol Bed Bench. 2014;7(3):156–63. PMID: 25120896. PMCID: PMC4129566.
50. Ibarra A, Latreille-Barbier M, Donazzolo Y, Pelletier X, Ouwehand AC. Effects of 28-day Bifidobacterium animalis subsp. lactis HN019 supplementation on colonic transit time and gastrointestinal symptoms in adults with functional constipation: A double-blind, randomized, placebo-controlled, and dose-ranging trial. Gut Microbes. 2018 Feb 8;9(3):236–51. DOI: 10.1080/19490976.2017.1412908. PMID: 29227175. PMCID: PMC6219592.
51. Martoni CJ, Srivastava S, Leyer GJ. Lactobacillus acidophilus DDS-1 and Bifidobacterium lactis UABla-12 Improve Abdominal Pain Severity and Symptomology in Irritable Bowel Syndrome: Randomized Controlled Trial. Nutrients. 2020 Jan 30;12(2). DOI: 10.3390/nu12020363. PMID: 32019158. PMCID: PMC7071206.
52. Wilson B, Rossi M, Dimidi E, Whelan K. Prebiotics in irritable bowel syndrome and other functional bowel disorders in adults: a systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr. 2019 Apr 1;109(4):1098–111. DOI: 10.1093/ajcn/nqy376. PMID: 30949662.
53. Spagnuolo R, Cosco C, Mancina RM, Ruggiero G, Garieri P, Cosco V, et al. Beta-glucan, inositol and digestive enzymes improve quality of life of patients with inflammatory bowel disease and irritable bowel syndrome. Eur Rev Med Pharmacol Sci. 2017 Jun;21(2 Suppl):102–7. PMID: 28724171.
54. Ciacci C, Franceschi F, Purchiaroni F, Capone P, Buccelletti F, Iacomini P, et al. Effect of beta-glucan, inositol and digestive enzymes in GI symptoms of patients with IBS. Eur Rev Med Pharmacol Sci. 2011 Jun;15(6):637–43. PMID: 21796867.
55. Di Nardo G, Oliva S, Ferrari F, Mallardo S, Barbara G, Cremon C, et al. Efficacy and tolerability of α-galactosidase in treating gas-related symptoms in children: a randomized, double-blind, placebo controlled trial. BMC Gastroenterol. 2013 Sep 24;13:142. DOI: 10.1186/1471-230X-13-142. PMID: 24063420. PMCID: PMC3849317.
56. Kanazawa M, Fukudo S. Effects of fasting therapy on irritable bowel syndrome. Int J Behav Med. 2006;13(3):214–20. DOI: 10.1207/s15327558ijbm1303_4. PMID: 17078771.
57. Pimentel M, Constantino T, Kong Y, Bajwa M, Rezaei A, Park S. A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Dig Dis Sci. 2004 Jan;49(1):73–7. DOI: 10.1023/b:ddas.0000011605.43979.e1. PMID: 14992438.
58. Pimentel M, Lembo A, Chey WD, Zakko S, Ringel Y, Yu J, et al. Rifaximin therapy for patients with irritable bowel syndrome without constipation. N Engl J Med. 2011 Jan 6;364(1):22–32. DOI: 10.1056/NEJMoa1004409. PMID: 21208106.
59. Lembo A, Zakko SF, Ferreira NL, Ringel Y., Bortey E, Courtney K, et al. T1390 Rifaximin for the Treatment of Diarrhea-Associated Irritable Bowel Syndrome: Short Term Treatment Leading to Long Term Sustained Response. Gastroenterology. 2008 Apr;134(4):A-545. DOI: 10.1016/S0016-5085(08)62544-5.
60. Rice AD, Patterson K, Reed ED, Wurn BF, Robles K, Klingenberg B, et al. Decreasing recurrent bowel obstructions, improving quality of life with physiotherapy: Controlled study. World J Gastroenterol. 2018 May 21;24(19):2108–19. DOI: 10.3748/wjg.v24.i19.2108. PMID: 29785079. PMCID: PMC5960816.