“I Am So Bloated!”

Susan wrote this on our WholeHealth Chicago form in the section marked “What’s the main problem?” She went on to tell 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, she said she looked like she was in her fifth month of pregnancy.

Susan was so embarrassed she’d stopped accepting dinner invitations. “You can actually see my stomach expanding…it’s horrible!”

She had visited a couple of gastroenterologists who quickly diagnosed the problem as irritable bowel syndrome (IBS), though she had neither of the two IBS mainstays, diarrhea and/or constipation. Her colonoscopy was completely normal.

Susan had tried all the standard IBS approaches: 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 IBS with constipation (Linzess and Amitiza).

One gastroenterologist gave her an honest shrug of her shoulders and said, “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. But as Susan knew, being bloated can definitely impair quality of life, ruining not only the enjoyment of meals but also the time spent with people sharing them.

It can be especially frustrating when you hear one of the mantras of Western medicine: “We can’t find anything wrong with you. All your tests are normal.”

A subjective symptom

Bloating itself is called a subjective symptom, meaning it’s something you report to your doctor as a physical sensation you’re experiencing. A physical exam often reveals nothing—your belly looks perfectly healthy to your doctor’s eye unless the bloating is severe and accompanied by visible distension/expansion of your abdomen.

As Susan learned early in the game, bloating is one of the many symptoms linked to irritable bowel syndrome (IBS), a condition that in one way or another affects about 25% of the population. Symptoms of IBS include constipation, diarrhea (or a blend of the two), heartburn, indigestion, nausea, pain, and cramping.

However, some people–and Susan is one of them–experience bloating only, with or without distension of the stomach.

Not surprisingly, a lot of research has gone into IBS and bloating, but an answer is still elusive, mainly because there are so many underlying possibilities for why bloating occurs. This explains why a treatment that works miracles for one patient will do absolutely nothing for the next.

One patient, for example, eliminates gluten from her diet and she’s cured. The next eliminates gluten, but remains as bloated as ever only now she grievously misses her croissants. A third eliminates gluten, is maybe 50% better, but then adds acupuncture and is almost cured.

If bloating is bothersome, try these steps

Start with these four useful diagnostic approaches, two DIY and two we can help you with.

1-Food sensitivity elimination diet. If a particular food is an issue, you’ll usually get an answer by following an elimination diet. 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 at the end of the two weeks, add one food group back, wait three days, and see how you feel. If OK, add the next, and so on. The way you feel will help you identify the culprit. If you’re feeling exactly the same after the elimination period, then food sensitivity is not an issue and you can move to the next steps.

2-Reduce 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 all gas-producing, short-chain carbohydrates that can cause bloating, constipation, diarrhea, and other symptoms in susceptible people. Your response to a low-FODMAP meal plan is a useful diagnostic test in itself.

Here’s an overview on eliminating and re-introducing FODMAP foods. If you’d like the guidance of a nutritionist, click here. Unlike many programs, the low-FODMAP approach is not a lifetime commitment. Many suspect foods can be reintroduced once your symptoms are under control.

3-Comprehensive stool digestive analysis with test for parasites and candida.
For this test you’ll take home a kit, collect some poop, and FedEx it to the lab for a detailed evaluation of your digestive processes, bacterial balance, and the presence (or absence) of parasites. Most insurers cover the lion’s share of this test, though there are some out-of-pocket costs. A positive test result usually indicates one or more of the following:

• A bacterial imbalance, treated with probiotics.

• Missing digestive enzymes, treated by replacing digestive enzymes and/or taking betaine (which bolsters stomach acid).

• Candida (yeast) or any of several intestinal parasites, treated with herbs or prescription meds. Blastocystis is the most commonly overlooked parasite.

4-A breath test for bacterial overgrowth in your small intestine. This is commonly called SIBO, which stands for small intestinal bacterial overgrowth. You’ll get a kit with a harmless sugary liquid to drink and a very neat system to collect samples of your breath, which you’ll FedEx to the lab for analysis. Insurers cover much of the cost of this test. A positive result indicates an excessive amount of hydrogen and/or methane in your gut and thus in your breath.

Treatment for significant SIBO can be with one of these products containing essential oils and herbs or with a prescription antibiotic called Xifaxan (rifamixin). Here’s a study showing that the herbal program (which costs approximately $120) is equal to the standard antibiotic program with Xifaxan (an astonishing $1,800).

Susan’s results

The solution to Susan’s bloating turned out to be fairly straightforward. Her SIBO breath test was positive for significant bacterial overgrowth. Even before the results were back from the lab she was improving with a low-FODMAP eating plan.

Preferring a non-pharmaceutical approach, Susan started taking Candibactin A/R and B/R and within a few weeks was pretty much symptom-free. We advised her that bloating can return after a few months as the gas-producing bacteria regenerate. It’s not uncommon to need a course of either the Candibactin A/R and B/R or Xifaxan every year or two.

She’s prepared psychologically for the possibility and, until the pandemic hit, was happily re-joining friends for bloat-free meals.

Be well,
David Edelberg, MD