“OH, I AM SO BLOATED!”

Susan had written, “BLOATED!” in the section of her intake form headed, “What’s the main problem?”. She went on to relate to me how she’d been suffering for years, her stomach feeling like some gremlin inside her abdomen was inflating a balloon every time she ate. When her bloating was especially severe, she looked like she was in the fifth month of a pregnancy. She was embarrassed to accept dinner invitations. “You can actually see my stomach expanding…it’s horrible!”

She’d visited a couple of gastroenterologists who quickly asserted the problem was irritable bowel syndrome (IBS), although she denied either of the two mainstays of IBS: diarrhea and/or constipation. Her gastroscopy and colonoscopy were both completely normal. She had been prescribed all the standard stuff for IBS: bulking agents (e.g., Metamucil), antidepressants (e.g., Prozac), antispasmodics (e.g., Bentyl). Since she wasn’t particularly constipated, she was never prescribed the two newer meds for IBS-Constipation Type (Linzess and Amitiza). 

One gastroenterologist gave her an honest shrug of his shoulders, “We just don’t know.”

On the plus side, despite the misery of symptoms, “bloated” has never, in the history of medicine, appeared on anyone’s death certificate. On the down side, like Susan, being bloated can really impair your quality of life, ruining your enjoyment of meals, and can be especially frustrating when you hear the mantra of medicine, “We can’t find anything wrong with you…your tests are normal.” 

Bloating itself is called a ‘subjective’ symptom, meaning something you report to your doctor as a physical sensation, but on physical exam, you look perfectly healthy and your abdominal exam is negative. When you’re with your doctor, you’ll 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 to isolate yourself somewhere and pass gas until you empty yourself like a deflating balloon. But no such luck. 

Picture (if you can) your large intestine, filled with stool and able to accommodate excess gas, which, amazing enough, you pass, silently or otherwise, 13 to 21 times a day, at approximately 7 mph. And, yes, farts are flammable. 

Your small intestine is narrower and not supposed to have any bacteria but for a variety of reasons bacteria manages to wend their way upward and then when certain foods reach the bacteria they start producing gas and you feel expansive “bloat”. Picture several feet of overinflated bicycle inner tubes in your abdomen (your small intestines) and you’ve got an idea of your SIBO (small intestine bacterial overgrowth) situation.

When bloating gets quite severe, it’s accompanied by very visible distension (“I look pregnant!). Seen at the right moment, your doctor will nod in agreement.

As Susan learned early in the game, bloating is on the list of the many 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, diarrhea, or a blend of the two, GERD (heartburn), indigestion, nausea, cramping. However, some people, and Susan is one of them, simply suffer bloating with or without distension and no other IBS symptoms.

Not surprisingly, with so many patients, a lot of research has gone into IBS and bloating. In most cases, the answers remain pretty elusive. 

The reason for the mystery surrounding both IBS and bloating is that there are so many possibilities. This explains why a treatment that works miracles for one patient will do absolutely nothing for the next. One patient eliminates, for example, gluten, and she’s cured. The next patient eliminates gluten and now she grievously misses her croissants but remains as bloated as ever. A third patient eliminates gluten, is maybe 50% better, but then she eliminates gluten and then adds acupuncture, she’s almost cured. See?Nothing is consistent.

If bloating by itself is the bane of your existence, don’t despair. Let’s see where you can start:

Three useful diagnostic tests. 

1. Food sensitivity elimination diet is the easiest place to start. 

If some particular food is an issue, you’ll usually get an answer here. For two weeks, completely eliminate all dairy, egg, corn (and corn products), gluten grains, citrus and soy (and soy products). If you are feeling better, add one food group back every three days until you locate the culprit. If you feel exactly the same after the elimination period, then food sensitivity is not an issue and move to steps 2 and 3.

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, does need professional supervision, and I’d recommend an appointment with our nutritionist, Tam Dickson-Meyer. Unlike many programs, the low FODMAP is not a lifetime diet and many high FODMAP foods can be reintroduced once symptoms are under control. Your response to a low FODMAP program is a useful diagnostic test in itself.

3. Breath Test for Bacterial Overgrowth in your Small Intestine (SIBO)

We’ll arrange to have this kit sent to you in the mail. You’ll drink a sugar-y drink to stimulate gas production, blow into a breath collection balloon, snap on vacuum tube and send back to the lab what look like four empty glass tubes to Genova Diagnostics for gas analysis.

A “positive” test will show an excessive amount of hydrogen and/or methane in your breath. See this link for a typical “positive” test.

Treatment for significant bacterial overgrowth can be natural products containing essential oils and herbs or prescription antibiotics, Xifaxan (rifamixin) with Neomycin. Here’s a study showing that the herbal program (approx. $120) is equal to the standard antibiotic program with Xifaxan (an astonishing $1,800).

Susan’s bloating solution actually 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. Preferring a natural approach, Susan started the Candibactin A/R and B/R and within a few weeks was pretty much symptom-free. However (and she’s prepared psychologically for this) bloating symptoms can return in a few months as the gas producing bacteria regenerate. It’s not uncommon to need a course of either Xifaxan/Neomycin or Candibactin A/R and B/R every year or two.

If you believe SIBO is responsible for your years of bloating miseries, schedule with any of our practitioners at any of our WholeHealth Chicago offices. We can arrange to have a breath test kit sent to you, review your results, schedule you with Tam, and prescribe either herbal or antibiotic treatment. I am not exaggerating when I say we have treated hundreds of SIBO patients.

Be well,

David Edelberg, MD