June 06, 2026
Mayo Clinic Gastroenterology and Hepatology specialists take a novel approach to treating abdominophrenic dyssynergia (APD). Diaphragmatic exercises with biofeedback can significantly improve the severe bloating and distension experienced by people with this underrecognized gut-brain interaction disorder.
"This symptom often shows up as 'bloating.' But for many patients, APD is bad enough that they say they can't function," says Xiao Jing (Iris) Wang, M.D., a gastroenterologist at Mayo Clinic in Rochester, Minnesota.
People with APD experience not just bloating but also distension of the lower belly that causes pants to be uncomfortable or gives the appearance of pregnancy. The distension is caused by reduced tone and protrusion of the anterior abdominal wall and increased tone and descent of the diaphragm, triggered by small amounts of gas or food in the intestines.
At Mayo Clinic, patients can learn breathing exercises to relax the diaphragm through combined contraction of the abdominal wall and elevation of the costal wall. The equipment-free technique — developed by a research team led by Mayo Clinic-trained physician Fernando Azpiroz, M.D., Ph.D. — has been validated by research using electromyography.
"We can teach patients to reset their diaphragms in a way that is durable and anchored in decades of research. It's a technique that you can teach a patient, using just hands," Dr. Wang says. "Physicians who see patients with this type of abdominal distension can validate that symptom as a musculoskeletal problem that's fixable."
Targeting underlying miscoordination
Dr. Wang notes that patients typically wake up with a flat belly. "Then throughout the day, as they eat or even drink small amounts of water, their bellies start getting fuller to the point that they look pregnant," she says. "They're miserable. They can't eat well. And then they go to sleep, wake up feeling fine and it all happens again."
Although the bloating is driven by production of gas, research has shown that the amount of gas produced is generally too low to cause severe distension. In people with APD, even a normal amount of gas triggers the dyssynergic muscle reflex affecting the anterior abdominal wall and diaphragm.
The movement of the diaphragm also can strain intercostal muscles. "People tell us, 'I can't breathe,' and it's partially because the muscles contract like they're having an asthma attack," Dr. Wang says.
The guidelines for treating bloating include options such as antibiotics and a low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet. "The problem with both of these is that they aim to minimize gas. But in 85% of patients, excess gas is not the problem," Dr. Wang says. "The amount of gas in patients with this muscle disorder is only about 50 cubic centimeters."
The breathing technique used at Mayo Clinic targets the underlying neuromuscular dysfunction. Physical therapists teach patients how to move the abdominal wall and the chest, to control the diaphragm's activity and thereby correct abdominal distension. Collaboration between gastroenterologists and physical therapists exemplifies Mayo Clinic's multidisciplinary approach to care.
Hypnosis is another option for some patients with bloating. "Hypnotherapy has been shown in the literature to be as good as an antidepressant for irritable bowel syndrome (IBS). And the downside is minimal," Dr. Wang says. She and her collaborators have developed and tested a new protocol that targets both bloating sensation and distension, through combined hypnotherapy and diaphragmatic breathing.
"About 69% of our patients who had this combined therapy had improvement in their bloating, and up to 75% of them had improvement in their overall IBS symptoms," Dr. Wang says. "Complementary interventions have big potential if we carefully select patients who might benefit."
Personalized treatment is a cornerstone of care. "We take the time to sit and listen to a patient," Dr. Wang says. "We dive more deeply into symptoms and try to understand the patient's physiology so we can target therapies. That's what we do here at Mayo Clinic."
For more information
Refer a patient to Mayo Clinic.