“I Am So Bloated!”

Susan had written “BLOATED!” in the section marked “What’s the main problem?” She told me she’d been suffering for years, her stomach feeling like some gremlin was inflating a balloon every time she ate. When the bloating was especially severe, Susan said she looked like she was in her fifth month of pregnancy. She was even embarrassed to accept dinner invitations. “You can actually see my stomach expanding. I have to wear elastic waistbands…it’s horrible!”

Susan had visited a couple of gastroenterologists, who quickly asserted the problem was irritable bowel syndrome (IBS), though she had neither of the two IBS mainstays, diarrhea and/or constipation. Her colonoscopy was completely normal. She’d been prescribed all the standard stuff for IBS: bulking agents (e.g., Metamucil), antidepressants (e.g., Prozac), and antispasmodics (e.g., Bentyl). Since she wasn’t particularly constipated, she was never prescribed the two newer meds for constipation-related IBS (LINZESS and AMITIZA).

One gastroenterologist gave her an honest shrug of his shoulders, telling her “We just don’t know.” On the plus side, despite the misery of her symptoms, “bloated” has never, in the history of medicine, appeared on anyone’s death certificate. On the downside, being bloated can truly impair your quality of life, ruining day-to-day enjoyment of meals and activities. It’s especially frustrating when you hear over and over again the mantra of modern medicine, “We can’t find anything wrong with you…all your tests are normal.”

Bloating itself is a subjective symptom

Subjective symptoms are those you report to your doctor as physical sensations. A physical examination, including an abdominal exam, may show you’re perfectly healthy. When you’re with your doctor, you might say something like, “I just feel so full and gassy every time I eat. I want to belch but nothing happens.” What you really feel like doing is isolating yourself and passing gas until you empty out like a deflating balloon. But no such luck.

When bloating becomes severe, it’s accompanied by very visible distension, or expansion, of your abdomen. Seen at the right moment, your doctor will nod in agreement.

As Susan learned early on, bloating is on the list of the numerous symptoms associated with irritable bowel syndrome (IBS), a condition that in one way or another affects about 25% of the population. Symptoms of IBS are just what you’d expect: constipation or diarrhea (or a blend of the two), GERD (gastroesophageal reflux disease, or heartburn), indigestion, nausea, pain, and cramping. However, some IBS sufferers experience bloating with or without belly distension and no other IBS symptoms.

Not surprisingly, a lot of research has gone into IBS and bloating. In most cases, the answer is still elusive. The reason for the mystery is that there are so many possibilities, which explains why a treatment that works miracles for one patient will do absolutely nothing for the next. Patient A, for example, might eliminate gluten from her diet and find she’s cured. Patient B eliminates gluten and now she grievously misses her croissants but remains as bloated as ever. A third patient eliminates gluten and feels maybe 50% better, but when she adds acupuncture to the mix she’s almost cured.

If bloating is the bane of your existence, don’t despair

Let’s see where you can start. First, nutritional approaches and useful diagnostic tests:

1–Food sensitivity elimination diet. If a particular food is an issue, you’ll usually get a clear answer. For two weeks, completely eliminate all dairy, egg, corn (and corn products), gluten grains, citrus, and soy (and soy products). If you’re feeling better, add one food group back every three days until feeling crummy again indicates you’ve located the culprit. If you feel exactly the same after the elimination/reintroduction period, then food sensitivity is not an issue. Move to steps 2, 3, and 4.

2–Reduce your FODMAPs. A lot of recent research has shown that reducing foods containing FODMAPs can help IBS and bloating. The letters stand for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, which are gas-producing, short-chain carbohydrates. The FODMAP diet, though not difficult, is best undertaken with professional supervision. I’d recommend an appointment with one of our nutritionists. Unlike many programs, the low-FODMAP eating plan is not a lifetime diet. Many high-FODMAP foods can be reintroduced once your symptoms are under control.

3–Comprehensive Stool Digestive Analysis with test for parasites and candida. You’ll get a kit to take home, where you’ll collect some poop and FedEx it to the lab for a detailed testing of your digestive processes, bacterial balances, and the presence (or absence) of parasites. Most insurers cover the lion’s share of this test, though there’s usually some out-of-pocket expense. When test results are positive, they’re usually caused by:

• Bacterial imbalances, which you can treat with probiotics.
• Missing digestive enzymes, treated with enzymes and/or betaine (stomach acid).
• Candida (yeast) or parasites, treated with natural or prescription meds.

4–Breath Test for Bacterial Overgrowth in your Small Intestine (SIBO). This kit contains a harmless sugary liquid to drink and a very clever system to collect samples of your breath. You’ll FedEx your breath to the lab for analysis (anyone else chuckling at that sentence?). Again, insurers cover much of the cost. A positive test result will show an excessive amount of hydrogen and methane in your breath. Check this link for a typical positive test result. Treatment for significant bacterial overgrowth can include natural products containing essential oils and herbs or a prescription antibiotic called Xifaxan.

Next steps

If those approaches to your bloating yield absolutely nothing of use, try any of these well recognized treatments. At least one of them should give you some relief, and if you do get relief, add a second to see if you’ll do even better.

• Probiotics such as Probiophage DF or Thera-Biotic Factor 4, both of which contain Bifidobacterium and a prebiotic to stimulate probiotic growth.
• Carminative herbs. These are herbs that historically reduce gas and bloating. The word “carminative” is from the Latin “card for wool” and the herbs are to untangle “knots” (i.e., gas) from your intestines. Excellent carminatives include peppermint capsules or peppermint tea, ginger tea, or a few drops of bitters before a meal.
• Acupuncture with Chinese herbs. You can schedule an acupuncture appointment with Cindy Kudelka, Mari Stecker, or Helen Streitelmeier. One study showed that moxibustion, the burning of herbs at the end of the acupuncture needle, was especially effective for bloating symptoms.
• Homeopathy. Schedule with Sujatha Mannal.

The solution  to Susan’s bloating turned out to be fairly straightforward. Her SIBO Breath Test was very positive for significant bacterial overgrowth, and even before the results were back from the lab she was improving with a low-FODMAP eating plan. We went right to the prescription intestinal antibiotic and she’s now pretty much symptom-free.

However (and she’s prepared psychologically for this), bloating symptoms can return in a few months as gas-producing bacteria regenerate. It’s not uncommon to need a course of antibiotics each year or two, but we’ll make every effort to keep her symptoms at bay with periodic use of the natural antibiotics.

Be well,
David Edelberg, MD