Abdominal Bloating and Visible Distension: Could It Be Abdominophrenic Dyssynergia (APD)?

Why your abdomen can become visibly larger and what may help

Medically reviewed by Dr Douglas Samuel, Gastroenterologist · September 2026

Side view of a man with visible abdominal distension and forward protrusion of the abdomen.

Abdominal bloating and visible distension: could it be APD?

If your abdomen looks and feels larger, the first useful step is working out what kind of change it is, because that points to different causes and different treatment.

Bloating is what you feel: fullness, pressure or tightness. Visible distension is when your abdomen actually looks larger than usual.

An abdomen that is simply prominent most of the time, and much the same on waking as after meals, may not be what doctors mean by “distension” at all.

This page helps you tell these apart and explains one mechanism, abdominophrenic dyssynergia (APD), that can drive genuine, visible, come-and-go abdominal distension.

If you wake up relatively flat, drink a glass of water and suddenly look nine months pregnant, help may be on its way.

What is Abdominophrenic Dyssynergia (APD)?

Abdominophrenic dyssynergia (APD) is a proposed mechanism that can cause episodes of visible abdominal distension. It describes abnormal coordination between the diaphragm and abdominal wall, rather than a disease of the bowel itself.

Many people with long-standing bloating have more than one contributing mechanism. APD may explain the visible change in abdominal shape, while constipation, irritable bowel syndrome, functional dyspepsia, food fermentation and visceral hypersensitivity may contribute to fullness, pressure, pain or gas.

In APD, the diaphragm moves downward while the front abdominal wall relaxes and moves outward. This can make the abdomen visibly larger without a large increase in intestinal gas. The change is often noticed after meals or as the day progresses, although the timing varies from person to person.

Diagram comparing normal abdominal accommodation with abdominophrenic dyssynergia (APD), showing the diaphragm rising normally but descending in APD as the abdominal wall relaxes and the abdomen protrudes.

APD is most likely to be relevant when the abdomen changes visibly from its usual baseline during episodes. People may notice:

the abdomen becoming noticeably larger during or after meals, or later in the day;
clothing becoming tighter during these episodes;
pressure, fullness or discomfort accompanying the visible change;
the abdomen becoming smaller again between episodes, sometimes overnight or by morning; and
a repeatable pattern of visible distension that seems out of proportion to the amount eaten.

APD describes a proposed physical pattern involving gut–brain signalling and the muscles that shape the abdomen. It is not imagined, and it does not mean symptoms are simply caused by anxiety.

APD is only one possible mechanism. Bloating and visible distension can also occur with constipation, IBS, functional dyspepsia, food fermentation and visceral hypersensitivity. A persistently prominent abdomen that changes little from its baseline may instead reflect the abdominal wall, posture or body shape, although these patterns can coexist.

What’s the difference between bloating, distension and structural abdominal prominence?

felt, not always seen

what you feel

Bloating

Fullness, pressure or tightness. Can occur with little or no visible change in size.

on waking

↔

later in day

episodic visible change

Visible distension

A small change in gas, but a large change in shape. Often larger after meals or later in the day, and smaller by morning. This is the pattern APD can drive.

on waking

later in day

much the same all the time

Persistent (structural) prominence

Prominent on waking and after meals alike. More often reflects the abdominal wall, posture or body shape than the gut.

each dot represents gut gas

These are different things, but they often overlap. More than one can be present at the same time.

Bloating is the sensation of fullness, pressure, tightness or swelling. Distension is a visible increase in the size of the abdomen compared with its usual baseline. They often occur together, but they are not the same symptom: you can feel markedly bloated with little visible change, or look visibly larger with relatively little discomfort.

Some visible change after meals, or when standing rather than lying, is ordinary and normal. The body accommodates food and gas with some change in shape, and how noticeable this is varies from person to person. A mild change that does not trouble you does not need treatment.

The more useful question is not how large the abdomen looks, but whether it is changing from your own baseline. An abdomen that is already prominent on waking and changes little after meals or through the day is better thought of as persistent abdominal prominence, rather than distension alone. That distinction matters because persistent prominence can have different causes and may need a different approach. It can also coexist with genuine episodes of distension.

APD is one possible mechanism for visible change: the diaphragm moves downward while the front abdominal wall relaxes and moves outward, altering the shape of the abdomen without a large increase in intestinal gas.

Other contributors to bloating or distension include constipation, IBS, functional dyspepsia, food-related fermentation or intolerance, and visceral hypersensitivity. A persistently prominent abdomen, by contrast, may reflect the abdominal wall, posture or body shape rather than the gut. Stress and anxiety can amplify gut sensations and how intrusive they feel, but they do not mean the symptoms are imagined.

Bloating, abdominal distension and persistent abdominal prominence can overlap. APD is one possible cause of visible distension, and treatment should target the main troublesome driver.

How Is APD Assessed?

There is currently no routine test or accepted set of clinical criteria that confirms APD.

APD is a proposed mechanism that may be considered when there are reproducible episodes of visible abdominal distension, particularly when the abdomen becomes larger after meals or later in the day and no other important cause is apparent after appropriate assessment.

Assessment may include:

the pattern and timing of visible distension;
whether the abdomen returns towards its usual baseline;
associated bloating, fullness, pain or bowel symptoms;
examination of the abdomen and abdominal wall;
checking for warning symptoms; and
targeted investigation when another condition needs to be excluded.

If the history and examination are reassuring and there are no warning features, extensive blood tests, scans or endoscopy are usually not needed simply because bloating or distension is present. Tests are targeted when another condition needs to be excluded.

Research studies have measured APD using muscle recordings, thoracoabdominal movement sensors and imaging during episodes of distension. These methods are not routinely available as diagnostic tests.

Improvement with APD retraining does not prove that APD was the cause.

When APD May Be Contributing

APD is most relevant when there are episodes of visible abdominal distension rather than simply a persistently prominent abdomen.

Clues may include:

the abdomen becoming visibly larger after meals or later in the day;
a reproducible change from the person’s usual abdominal shape;
improvement overnight or on waking;
distension that seems disproportionate to the amount eaten; and
no other explanation found after appropriate assessment.

APD can coexist with constipation, IBS, functional dyspepsia, food-related fermentation or visceral hypersensitivity.

A persistently prominent abdomen that changes little through the day is less typical of the pattern studied in APD biofeedback trials.

↑ Back to top

Why does APD happen to me?

We do not yet know exactly why this develops.

APD appears to be an abnormal, potentially learned coordination pattern between the diaphragm, abdominal wall and rib cage. Gut sensations such as fullness, bloating or distension can trigger the wrong muscular response. Instead of the diaphragm relaxing and the abdominal wall supporting the abdomen, the diaphragm contracts and moves down, the rib cage and intercostal muscles become more active, and the abdominal wall relaxes.

Why this pattern develops in the first place is uncertain. Abdominal surgery, Caesarean section, pregnancy and childbirth, posture and habitual breathing patterns have all been proposed as possible contributors, but none has been proven to cause APD.

The encouraging part is that APD is not a damaged or weak diaphragm. It is a coordination problem that can be retrained.

What your body has learned, it can unlearn and then learn to do differently.

Could it be something else?

APD is only one possible contributor to bloating or visible distension. Other common possibilities include:

constipation or incomplete emptying;
IBS, functional dyspepsia or other disorders of gut–brain interaction (DGBIs);
food-related fermentation or intolerance;
visceral hypersensitivity;
pelvic-floor dysfunction; and
abdominal-wall or structural problems (see below).

The pattern of symptoms usually gives more useful clues than trying to test for every possibility.

Treating APD and common overlapping conditions

There is no single treatment for everyone with bloating or visible distension.

Bloating and distension are not always completely curable. For some people, they can affect clothing, eating, work, exercise and social life, and embarrassment about abdominal appearance can become severe enough that they avoid going out.

The aim is to identify the main drivers, reduce how often and how severely symptoms occur, and help you get back to everyday life. Even when symptoms do not disappear completely, worthwhile improvement is often possible.

Treatment works best when it targets the main driver or drivers of the symptoms.

For some people, APD movement retraining is the main treatment. For others, constipation, pelvic-floor dysfunction, food-related fermentation, functional dyspepsia, visceral hypersensitivity or another contributor may need more attention.

Several mechanisms can occur together, so treatment is often best introduced step by step.

APD movement retraining

APD retraining aims to change the coordination between the lower chest, diaphragm and abdominal wall.

The key movement is:

Lower chest gently up, abdomen gently in.

I use the term Pendulum Breathing to describe this full movement.

As the lower chest moves gently up, the abdomen moves gently in. On the return movement, the chest moves gently down while the abdominal wall relaxes and the belly is allowed to soften and fall naturally with gravity rather than being pushed out.

Breathing should remain comfortable throughout.

Start the 4-Week APD Movement Program

Pendulum Breathing is not the same as conventional diaphragmatic or “belly” breathing. Diaphragmatic breathing can be useful for other reasons, but APD retraining teaches a different pattern of chest and abdominal movement.

The best evidence comes from supervised biofeedback studies in people with recurrent visible abdominal distension. Sensors allowed patients to see in real time how their chest and abdominal muscles were moving and learn to reverse the abnormal pattern.

The movement can also be taught by an experienced doctor or therapist. Some people can produce a visible reduction in their distension during a supervised session, although learning to reproduce the movement naturally and consistently usually takes practice.

The home program on this website adapts this movement pattern for self-guided practice. It has not been shown to be equivalent to sensor-guided biofeedback, and improvement with the exercises does not by itself confirm a diagnosis of APD.

Choosing where to start

You do not need to treat everything at once. A practical approach is:

Visible episodes of distension that change from your usual baseline and come and go: consider APD movement retraining.
Constipation or incomplete emptying: improve bowel function and consider pelvic-floor assessment when appropriate.
Clear food-related symptoms: consider structured dietary assessment rather than broad or prolonged food restriction.
Early fullness, nausea or upper abdominal discomfort: consider functional dyspepsia and other upper-gut mechanisms.
Pain, pressure or heightened awareness of digestion: consider treatments directed at visceral hypersensitivity and gut–brain signalling.
A focal bulge, or an abdomen that remains prominent rather than changing through the day: consider an abdominal-wall or structural cause.
Several overlapping patterns: introduce treatments gradually so you can tell what is helping.

The goal is not to make every abdomen flat, achieve any particular body shape, eliminate every normal digestive sensation or prevent normal changes in abdominal shape after eating.

Ideas about what an abdomen should look like vary between people and cultures. The clinical question is whether there are troublesome symptoms or a meaningful change from your own baseline.

The goal is to reduce troublesome symptoms and help you eat, move and get on with daily life more comfortably.

The APD Movement Training Program

The strongest treatment evidence for APD comes from supervised biofeedback studies in people with recurrent episodes of visible abdominal distension.

During these studies, sensors showed participants how their lower chest and abdominal wall were moving. They learned to change this movement pattern and then practised it at home.

The four-week program on this website is a practical self-guided adaptation of that movement.

It is not the same as the sensor-guided treatment used in the clinical trials, and the self-guided version has not been shown to produce the same results.

It is most relevant if your abdomen becomes visibly larger during episodes. The research has not established that APD retraining changes a persistently prominent resting abdominal shape.

Start the 4-Week APD Movement Program

What If APD Movement Training Does Not Help?

Not everyone with bloating or visible distension has APD as the main mechanism, and not everyone with APD will respond to self-guided movement training.

If you are confident that you are performing the movement correctly but there is little improvement after repeated practice, simply practising harder is unlikely to be the answer. Another mechanism may be contributing and may need more attention.

If the technique itself remains uncertain, a clinician or physiotherapist familiar with APD may help check the movement. Where available, sensor-guided biofeedback is the approach closest to that used in the clinical trials.

Improvement should be judged over repeated episodes and over time, rather than by whether you can make the abdomen flatten immediately during a single episode.

Other Things That May Help

APD movement retraining is only one part of managing bloating and distension. The sections below cover other common contributors and practical treatment options.

Which are most relevant depends on your symptoms. You do not need to try everything.

Constipation and incomplete emptying

Constipation can contribute substantially to bloating and visible distension, even when bowel motions occur regularly. The important question is not simply how often you go, but how effectively the bowel empties.

Possible clues

hard or infrequent bowel motions;
straining;
a persistent feeling of incomplete emptying;
abdominal discomfort or bloating that improves after a bowel motion; or
difficulty passing gas.

Treatment may include

gradually introducing soluble fibre, particularly psyllium;
an osmotic laxative such as polyethylene glycol;
prescription constipation medication when needed;
regular physical activity; and
assessment for a pelvic-floor evacuation disorder when emptying is difficult.

Treating constipation can improve bloating when constipation is contributing. Fibre does not help everyone. Wheat bran and rapid increases in fibre can make bloating worse. Soluble fibre is generally better tolerated and should be introduced gradually.

When pelvic-floor dysfunction may be contributing

Sometimes the problem is not getting stool into the rectum but getting it out. The pelvic-floor and anal muscles may fail to relax normally, or may tighten during attempted evacuation. One form of this is called dyssynergic defecation.

Clues include:

prolonged or repeated attempts to empty the bowel;
difficulty passing a soft bowel motion;
a sensation that stool is blocked at the outlet;
needing to use a finger to help remove stool;
pressing around the vagina or perineum to assist emptying; or
needing unusual positions or “toilet acrobatics” to empty effectively.

When difficult evacuation is prominent, anorectal physiology testing, usually including anorectal manometry and a balloon-expulsion test, can help identify a pelvic-floor disorder. If dyssynergic defecation is confirmed, targeted pelvic-floor physiotherapy and biofeedback are generally more useful than simply increasing fibre or laxatives.

Abdominal wall, posture and body shape

Not every prominent abdomen comes from the bowel, and not every prominent abdomen is “distension.” Shape also depends on the abdominal wall, posture and body build.

A wall or postural contribution is more likely when the prominence is present on waking, changes little after meals, and varies more with standing, lying, coughing or straining than through the day. These are clues, not proof, because DGBI-related distension can also vary with posture.

Possible contributors include

abdominal-wall laxity or reduced support, sometimes associated with age, major weight change, pregnancy or surgery;
normal body shape and fat distribution, including central adiposity;
posture and spinal alignment, such as increased lumbar lordosis;
rectus diastasis: widening between the two rectus muscles rather than a true hole;
hernia: an actual fascial defect, such as an umbilical, epigastric or incisional hernia;
eventration: thinning or weakness of the wall causing it to bulge while remaining continuous;
mesh bulge after hernia repair: outward bowing of the mesh or repaired wall without necessarily having a recurrent defect; and
pseudohernia: bulging from muscle weakness or paralysis despite intact fascia, usually from nerve injury or denervation, for example after abdominal or flank surgery.

A simple self-check

Lie on your back and lift your head and shoulders slightly, as though beginning a sit-up.

A smooth midline ridge or dome can suggest rectus diastasis. A distinct lump that becomes more obvious with coughing, straining or sitting up, especially if it reduces when you lie down or with gentle pressure, raises the possibility of a hernia.

These are clues, not a diagnosis. A focal or troublesome bulge is worth showing your doctor.

Examination and imaging

Examination is usually the first step, ideally both standing and lying down and while coughing, straining or tensing the abdominal muscles.

Examination may be uncertain with obesity, small defects, coexisting diastasis and hernia, previous mesh repair or a postoperative bulge. Imaging is most useful when the diagnosis remains unclear or surgery is being considered.

Ultrasound can assess the wall dynamically during coughing or straining and, in some centres, while standing. It is particularly useful for small or intermittent hernias.

CT defines the wall and fascial defects well but is usually performed lying flat, where some bulges become less obvious. In selected cases, CT during straining or a Valsalva manoeuvre can make a hernia more apparent. MRI is occasionally useful in complex cases.

These tests look for structural abdominal-wall problems. They do not test for APD or DGBI-related bloating and distension, and more than one mechanism can coexist.

Treatment follows the cause

If the abdominal wall is contributing, treatment should target the wall rather than simply escalating bowel treatment.

Rectus diastasis or general wall weakness: targeted physiotherapy and progressive core retraining may improve strength, control and function. Exercise may narrow the separation slightly, but evidence is limited and there is no single proven programme. The goal is better function and support, not a completely flat abdomen.

Rectus diastasis usually does not need surgery. Repair is reserved for selected people with persistent troublesome symptoms, impaired wall function or an associated midline hernia.

A true hernia is different because there is an actual fascial defect. A symptomatic, enlarging or troublesome hernia may warrant surgical assessment; the decision depends on its type, size, symptoms, risks and likely benefit of repair.

A postoperative bulge may instead reflect denervation, muscle atrophy, eventration or mesh bulge. This matters because fascial repair will not necessarily correct muscle-driven bulging, and a bulge after mesh repair does not necessarily mean recurrence.

If the diagnosis remains uncertain, an abdominal-wall specialist can distinguish a true or recurrent hernia from rectus diastasis, eventration, mesh bulge, muscle atrophy or denervation-related pseudohernia, using dynamic examination and, when needed, targeted ultrasound or CT.

The outcome may be reassurance, physiotherapy or rehabilitation, monitoring, or, in a smaller group with a correctable structural problem causing significant symptoms, surgical repair or reconstruction.

If the prominence reflects normal body shape, fat distribution or posture, with no structural abnormality or troublesome functional problem, medical treatment may not be needed.

Food-related fermentation and intolerance

Some carbohydrates are incompletely absorbed or rapidly fermented by gut bacteria. This can increase gas and water in the bowel and contribute to bloating, particularly when the gut is sensitive.

Fermentation itself is normal. The aim is not to eliminate fermentable foods, but to identify whether particular foods reliably trigger troublesome symptoms.

Common triggers include lactose, excess fructose, fructans (in wheat, onion and garlic), polyols such as sorbitol and mannitol, and galacto-oligosaccharides (GOS) in legumes.

If symptoms are clearly food-related

Useful approaches include:

testing suspected triggers one at a time, rather than avoiding many foods at once;
a short low-FODMAP(opens in new tab) trial, usually 2–6 weeks, followed by structured reintroduction; and
working with a dietitian if symptoms are substantial or the diet is becoming restricted.

A low-FODMAP diet is not meant to be permanent. Reintroduction is an important part of the process: it helps identify which FODMAP groups actually matter to you and how much you can comfortably tolerate, so the diet stays as broad, nutritionally adequate and enjoyable as possible.

Targeted enzyme options

These can help with specific triggers but do not replace identifying the food itself:

Lactase, taken with lactose-containing food, when lactose intolerance is likely.
Alpha-galactosidase, taken with GOS-rich foods such as beans and other legumes, may reduce gas-related symptoms in some people.
Xylose isomerase for fructose and combination products marketed for mixed FODMAPs are available, but the evidence is more limited. They are best regarded as targeted trials rather than a substitute for identifying the trigger.

Simethicone is sometimes tried for gas-related discomfort and is generally well tolerated, although evidence for persistent functional bloating is limited.

Meal size and eating pattern

Large meals can worsen fullness and distension, partly because more food enters the stomach and bowel at once, and partly because of the way a sensitive gut responds to a meal.

If meals reliably trigger symptoms, it may help to:

avoid very large meals;
spread food more evenly through the day;
eat more slowly and chew food well;
reduce carbonated drinks, including beer, if they clearly worsen symptoms; and
remain gently active after meals.

People with early fullness or upper abdominal discomfort may tolerate smaller meals better, particularly when functional dyspepsia is also present.

The goal is not to eat progressively less. Significant food restriction, weight loss or fear of eating should prompt further assessment.

Irritable bowel syndrome

IBS commonly overlaps with bloating and visible distension.

People with IBS may have abdominal pain together with constipation, diarrhoea or a mixture of both. Bloating may reflect several mechanisms at once, including bowel contents, fermentation, visceral hypersensitivity and altered gut–brain signalling.

Treatment should therefore be guided by the dominant symptoms. This may include:

treating constipation or diarrhoea;
dietary strategies when appropriate;
regular physical activity;
gut-directed hypnotherapy or gastrointestinal CBT; and
selected medications for pain or visceral hypersensitivity.

Having IBS does not exclude APD. A person may have IBS contributing to pain and bowel symptoms while APD contributes to episodes of visible distension.

Functional dyspepsia and early fullness

Functional dyspepsia is a common cause of upper abdominal fullness, discomfort and bloating.

Symptoms can include:

feeling full sooner than expected during a meal;
uncomfortable fullness after eating;
upper abdominal pressure, burning or pain;
nausea; and
bloating that is most noticeable after meals.

Several mechanisms may contribute. These include impaired relaxation of the stomach after a meal, visceral hypersensitivity, altered gut–brain signalling and abnormalities of stomach or intestinal motility.

Some patients have delayed gastric emptying. Others have very similar symptoms despite a normal gastric-emptying study. A normal gastric-emptying test therefore does not mean that the symptoms are not genuine or that gastric function is entirely normal.

Treatment may include:

testing for Helicobacter pylori and eradicating it when present;
a proton-pump inhibitor, particularly when pain, burning or reflux-type symptoms are prominent;
avoiding very large meals and using smaller meals when early fullness is troublesome;
treating constipation when it contributes;
a prokinetic medicine in selected patients with prominent early fullness, post-meal fullness, nausea or suspected impaired motility;
selected neuromodulator medicines; and
gastrointestinal CBT or gut-directed hypnotherapy when gut–brain mechanisms are important.

Persistent vomiting, progressive difficulty swallowing, gastrointestinal bleeding, unexplained weight loss or other warning features need medical assessment rather than being assumed to be functional dyspepsia.

Visceral hypersensitivity and gut–brain signalling

Some people experience normal digestive events — stretching, movement, gas or bowel contractions — as unusually intense pressure, fullness or pain. This is called visceral hypersensitivity.

It does not mean that the symptoms are imagined. The digestive tract and nervous system are communicating differently, so sensations that would barely be noticed by another person may become intrusive or painful.

Treatment can include:

gastrointestinal CBT;
gut-directed hypnotherapy;
relaxation and other strategies that reduce symptom-related threat and vigilance;
regular physical activity and sleep optimisation; and
selected neuromodulator medicines when appropriate.

Neuromodulators are medicines that can alter pain and gut–brain signalling. When used for digestive symptoms, the medicine and dose are chosen for their effects on gut sensitivity and signalling rather than for mood. The choice depends on symptoms, bowel habit, other medical conditions and potential side effects.

These treatments can be useful alongside APD retraining rather than instead of it when both mechanisms appear to be contributing.

Small intestinal bacterial overgrowth and dysbiosis

Small intestinal bacterial overgrowth, or SIBO, can cause bloating in selected patients, but it is not the explanation for most chronic bloating.

Breath tests have important limitations and can produce misleading results, particularly when intestinal transit is rapid. A positive test therefore needs to be interpreted alongside the clinical picture rather than treated as proof that SIBO is causing the symptoms.

Repeated courses of antibiotics for unexplained bloating are generally best avoided without a convincing reason to suspect SIBO.

Factors that may increase the likelihood of SIBO include certain anatomical abnormalities, previous intestinal surgery and disorders that significantly impair intestinal movement.

The term dysbiosis describes changes in the intestinal microbial community, but routine commercial microbiome testing currently has little established role in diagnosing or directing treatment for chronic bloating.

Probiotics are not routinely recommended as a general treatment for bloating. Some individual products may help particular symptoms, but effects vary substantially between products and between people.

Physical activity

Regular physical activity can help bowel function, general wellbeing and some symptoms of bloating.

A gentle walk after meals may be useful for some people, particularly when constipation or sluggish bowel transit contributes to symptoms.

Exercise is not a specific treatment for APD, and there is no particular walking or exercise prescription proven to correct APD.

Choose activity that is comfortable and sustainable rather than exercising specifically to try to flatten the abdomen.

When to Seek Medical Advice

Bloating and distension are usually not caused by serious disease, but new, persistent or progressive symptoms should not automatically be assumed to be APD or another functional disorder.

Seek medical assessment if symptoms are associated with:

unexplained weight loss;
persistent or recurrent vomiting;
gastrointestinal bleeding or black stools;
iron-deficiency anaemia;
progressive difficulty swallowing;
persistent severe or localised abdominal pain;
fever;
a new or progressively enlarging abdominal mass;
new or progressively increasing persistent abdominal swelling; or
a substantial unexplained change in bowel habit.

Severe cramping abdominal pain with persistent vomiting and inability to pass stool or gas may indicate bowel obstruction and needs urgent medical assessment.

The need for investigation depends on age, medical history, examination findings and the pattern of symptoms.

If worry about your abdomen is affecting how you eat, exercise or feel day to day, that is also worth discussing with your doctor.

Frequently Asked Questions

Does bloating mean I have too much gas?

Not necessarily. Bloating is a sensation, and visible distension can occur without a large increase in intestinal gas. Gut sensitivity, bowel contents, muscle responses and abdominal-wall mechanics can all contribute.

Is APD caused by anxiety?

No. APD describes a proposed physical pattern of thoracoabdominal movement. Stress and anxiety can influence gut–brain signalling and symptom severity, but that does not make the symptoms imagined.

Does a normal CT, gastroscopy or colonoscopy rule out APD?

No. These investigations are designed mainly to look for structural disease. APD describes a proposed thoracoabdominal movement pattern, and there is currently no routine diagnostic test that confirms it.

If my abdomen is always prominent, is that APD?

Not necessarily. APD research has mainly studied people with episodes in which the abdomen becomes visibly larger than its usual baseline. A persistent resting abdominal shape may instead reflect body shape, abdominal fat distribution, posture, abdominal-wall mechanics or other causes.

Should the exercises flatten my abdomen straight away?

No. Immediate visible flattening has not been established as a test of successful APD treatment. The more useful question is whether troublesome episodes become less frequent, less severe or easier to manage over time.

Can APD occur with IBS, constipation or functional dyspepsia?

Yes. APD can coexist with IBS, constipation, functional dyspepsia and other causes of bloating. Different mechanisms may contribute different parts of the symptom pattern.

Why can APD make you feel short of breath?

When distension is severe, breathing can feel tight, laboured or as though you cannot take a satisfying deep breath.

The diaphragm contracts and moves down while the muscles between the ribs contract and lift the chest. This can leave the chest relatively hyperinflated and make breathing feel more effortful.

Researchers have described this pattern as resembling severe asthma because the chest becomes hyperinflated and breathing can feel inefficient and difficult. The important difference is that in APD the airways are not narrowed. The problem is abnormal coordination of the diaphragm, abdominal wall and rib cage, not obstruction to airflow.

Because breathlessness has many causes, new, severe or unexplained breathing symptoms should be assessed in their own right by your doctor and not assumed to be APD.

Evidence and Further Reading

The evidence base for APD includes physiologic studies, imaging and electromyography studies, expert review, and randomized trials of biofeedback-based retraining.

Moshiree B, Drossman D, Shaukat A.
AGA Clinical Practice Update on Evaluation and Management of Belching, Abdominal Bloating, and Distention: Expert Review(opens in new tab).
Gastroenterology. 2023;165(3):791-800.e3.
doi:10.1053/j.gastro.2023.04.039.
Damianos JA, Tomar SK, Azpiroz F, Barba E.
Abdominophrenic Dyssynergia: A Narrative Review(opens in new tab).
Am J Gastroenterol. 2023;118(1):41-45.
doi:10.14309/ajg.0000000000002044.
Villoria A, Azpiroz F, Burri E, Cisternas D, Soldevilla A, Malagelada JR.
Abdomino-phrenic dyssynergia in patients with abdominal bloating and distension(opens in new tab).
Am J Gastroenterol. 2011;106(5):815-819.
doi:10.1038/ajg.2010.408.
Burri E, Cisternas D, Villoria A, Accarino A, Soldevilla A, Malagelada JR, Azpiroz F.
Accommodation of the abdomen to its content: integrated abdomino-thoracic response(opens in new tab).
Neurogastroenterol Motil. 2012;24(4):312-e162.
doi:10.1111/j.1365-2982.2011.01846.x.
Barba E, Burri E, Accarino A, et al.
Abdominothoracic mechanisms of functional abdominal distension and correction by biofeedback(opens in new tab).
Gastroenterology. 2015;148(4):732-739.
doi:10.1053/j.gastro.2014.12.006.
Barba E, Accarino A, Azpiroz F.
Correction of Abdominal Distention by Biofeedback-Guided Control of Abdominothoracic Muscular Activity in a Randomized, Placebo-Controlled Trial(opens in new tab).
Clin Gastroenterol Hepatol. 2017;15(12):1922-1929.
doi:10.1016/j.cgh.2017.06.052.
Barba E, Burri E, Quiroga S, Accarino A, Azpiroz F.
Visible abdominal distension in functional gut disorders: Objective evaluation(opens in new tab).
Neurogastroenterol Motil. 2023;35(2):e14466.
doi:10.1111/nmo.14466.
Barba E, Livovsky DM, Accarino A, Azpiroz F.
Thoracoabdominal Wall Motion-Guided Biofeedback Treatment of Abdominal Distention: A Randomized Placebo-Controlled Trial(opens in new tab).
Gastroenterology. 2024;167(3):538-546.e1.
doi:10.1053/j.gastro.2024.03.005.