How to treat Advanced Bloating

Transcript of How to Treat Advanced Bloating
Martin Carr, MD

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Hello, everyone, and welcome to my podcasts about helping treat different aspects of irritable bowel syndrome and other functional gut disorders. Today I am dealing with the topic of bloating. So this is how to treat advanced bloating. We are not talking about a problem of occasional feeling of distention or having intestinal gas-we are talking about a frequent, even daily problem. Bloating can be defined as the sense that there is pressure in the abdomen that cannot be easily relieved by belching or by having a bowel movement. It can either be created by the actual increase in the amount of gas in the intestines or it can be increased due to the actual contraction of the intestines around gas. This is a very common symptom and is one of the most bothersome that I help people with. First a couple of concepts. We are going to be talking here about bloating that is not because there is a tumor in the abdomen. For women, especially women over 40, it is important to exclude ovarian cancer. So women should have a pelvic ultrasound as part of assessment of a recent onset of a constant bloating problem. In both men and women there should be some consideration of a need for colonoscopy to determine if there is a tumor in the colon or some other major problem with the colon. People with a surgical history may need to be assessed for the possibility of some scar tissue causing narrowing in an area of the intestines. There can also be disease of what is called the mesentery, which is the trunk that the small intestine and colon are suspended on. The only really good way to get a look at that mesentery is with a CT scan of the abdomen and pelvis. So for the purpose of this discussion, we are assuming that a physician has listened to the symptoms to determine if there is a need for pelvic ultrasound in a woman or abdominal CT scan or colonoscopy.

What are the causes of bloating and how do we treat it? When we eat things we are going to have digestion and absorption take place, but not everything that we put into our stomachs is completely digested in the first couple of feet of the upper intestine. There are bacteria in the small intestine and bacteria in the colon that are going to be happy to digest things that we cannot digest. So the first step we will be dealing with in somebody who has this uncomfortable pressure or bloating is to eliminate food intolerance of different types. In a few moments we are going to be talking about something called FODMAPs, that is F as in fermentable, O as in oligosaccharides, D is disaccharides, M is monosaccharides and P for polyols. But before we get to the work that Monash University staff in Australia taught us all over 10 years ago, first there are some other steps that we typically ask our patients to follow. Again I am giving credit to Susan Watkins, registered dietitian with whom I work, who has put together this particular sequence that has been very helpful for patients to follow. The first thing is to remove what our dietitians refer to as the Common Irritants.

Here are the common irritants that you should eliminate to figure out if these are contributing to your bloating:

 Coffee including decaf the oils and coffee can be a source of bloating for some people so you would have to completely get rid of coffee including decaf.

 Fatty greasy foods–things like pizza, doughnuts, pastries, fatty ground meat, French fries, hamburgers, cheeseburgers. Get rid of those things.

 Foods made with a lot of butter and oils, even the so-called good oils like olive oil or canola oil. Some people are sensitive to too much fat in one meal and that will be a trigger for bloating.

 Hard to digest foods such as raw fruit and raw vegetables, especially those that have a lot of seeds or tough skin.

 This next category might surprise you because a lot of people have been told to eat a lot of this if they have GI problems– whole-wheat and high-fiber breads. All those breads in the store that have 5 grams of fiber per slice and look like they have pieces of nuts and seeds in them –get rid of those high-fiber breads because that may be an irritant. Brown rice is another thing to eliminate.

 During this initial phase you also need to eliminate nuts, seeds like sunflower seeds, granola and popcorn.

 You have to get rid of gas-producing foods such as broccoli, cauliflower, cabbage, beans, peanut butter

As far as dairy goes, it may be a problem for some. Many people already know whether or not they are lactose intolerant, that is, whether they get bloating or gas or diarrhea from lactose. Four ounces of milk or less will not have enough lactose to cause symptoms in most people with lactose intolerance. Either completely get rid of dairy that contains lactose or have a very small amount.

So after you have removed those irritants from your diet you also need to look carefully at the labels of different foods you eat to make sure that you eliminate the following things:

 Inulin which is a fiber component and chicory root. This is an inexpensive fiber additive that is used to increase fiber content or as a filler in many foods. For example soy meats and other meat alternatives have a lot of inulin or chicory root, as do granola, protein bars and fiber bars– Fiber One Bars, for example, have chicory root as the first ingredient.

Artificial sugars or sugar alcohols. Let me go through the names of these so that you be able to identify them on labels.

 ACESULFAME potassium which is an ingredient in foods, also sold as packets under the brand name Sunnett or Sweet One.

 ASPARTAME either added to foods or as packets or in containers labeled NutraSweet or Equal.

 SACCHARINE which is labeled Sweet and Low

 SUCRALOSE which is Splenda and is also in a lot of artificially-sweetened sodas.

All of these artificial sugars are things that we cannot digest and absorb. Splenda is added to a lot of cereals and also to yogurts. All of these artificial sugars do not give calories because we cannot digest or absorb them, but the bacteria in our intestines are happy to do that and they produce carbon dioxide, hydrogen, and methane and that will create bloating. You have to get rid of all of those artificial sugars.

You also have to get rid of the sugar alcohols. These have names such as:

 XYLITOL –this is natural, made from beech wood but if you have a large quantity of it it still can be a cause of diarrhea. A lot of artificially sweetened gums contain xylitol.

 SORBITOL, MANNITOL, MALTITOL and ERYTHRITOL are other sugar alcohols. They are made from corn and they do not give us calories to absorb, so they are sugar-free or calorie-free. But they can cause diarrhea or gas or bloating in sufficient quantities. They are used in different foods and also in artificially-sweetened gums.

What about Stevia? Stevia is actually a natural sweetener, 100 times sweeter than cane sugar, from a plant that originated in South America but is now grown around the world. Stevia rebaudiana extract typically will not cause diarrhea but if you have enough, it can cause bloating. Truvia is actually a Stevia extract combined with some erythritol and other flavors. It also in large enough quantity can cause bloating.

Once you have figured out if your bloating has improved after removing that list of common irritants, after getting rid of inulin or chicory root, and the artificial sugars or sugar alcohols, what if you are still having bloating? Sometimes a fiber supplement will help by improving the speed of transit. When you take something like Benefiber, which is a plain soluble fiber, or acacia fiber such as the Heather’s Tummy Care brand of fiber, sold at Mother’s Markets and is sold on Amazon or on the website of the Heather’s Tummy Care company, it can improve transit through the colon and make bowel movements occur more easily, along with a large amount of water. Sometimes just having more regular bowel movements will cut down a lot on bloating and increased intestinal gas. If you have tried all this, and you are eating smaller more frequent meals instead of really large meals, if you start to get more exercise and you are still having a problem, then you need to go to the next step. That is to examine in more detail whether you are sensitive to some high FODMAP foods. I give a lot of credit to the staff at MoNash University in Australia. Over 10 years ago they began doing the work that led to the creation of this term FODMAP which again are the first letters of

 Fermentable which means can be digested and fermented by bacteria to produce gases,
 Oligosaccharides such as fructans or galacto- oligosaccharides such as wheat, onions, beans, lentils
 Disaccharides, a good example would be lactose
 Monosaccharides such as fructose in honey, apples, high fructose corn syrup
 And
 Polyols–we just talked about some of those such as erythritol, sorbitol, mannitol. Sugar alcohols can be natural in some fruit and vegetables but also in a synthetic form uses artificial sweetener.

So how do you figure out if a FODMAP is your problem? Jump right to the issue of the grains. Some of you may have already been told to get rid of gluten from your diet. You may know somebody who had bloating or gas abdominal pain who says, “I felt a lot better when I am when I went on a gluten-free diet.” You may have asked, “Do you have celiac disease?” Celiac disease is the abnormal immunological reaction in the small intestine to components of the protein gluten that is in wheat, rye and barley and is used throughout the food industry as an additive. Now about these people who answer your question, “No, I do not have celiac disease, I had those antibody tests and I have had a biopsy of my small intestine. I do not have celiac disease but I feel better when I do not eat gluten” –it turns out that for most of those people it is not really the gluten itself that was causing their symptoms. Instead the cause is the oligosaccharides that are found in the wheat, rye and barley. It turns out that wheat, rye and barley are the high FODMAP grains. Other starches such as corn, oats, potato, quinoa, tapioca, rice are low FODMAP foods. Breads or noodles that are made from a gluten-free type of flour such as a mixture of corn, sorghum and buckwheat and oatmeal will not cause the symptoms that a FODMAP-sensitive person will get from eating wheat, rye and barley.

If you have gotten this far in your quest to find out the source of your bloating and none of the other things I talked about have worked, you have got to start on a schedule that has low FODMAP intake. This doesn’t mean that for the rest of your life you can never eat any high FODMAP foods. You have to do a 2-4 week experiment. How can you guide yourself to do this?

There is a fantastic smart phone app available for the iPhone and available for Android phones from Monash University. You can buy it in the App Store or in the Google Play Store. Look under Monash low FODMAP and you will see the green icon for it. Currently it costs $9–it is well worth it. It is an outstanding app. You will have it with you all the time, you can sit down and use it to make a list to go to the store so that

 you buy some dairy alternatives, if you know you are lactose intolerant,
 you can get some non-wheat- barley-rye (gluten-free) bread or other types of pasta products,
 you can get some fruit that are low FODMAP like bananas and blueberries,
 you can get some low FODMAP vegetables and do an experiment for couple of weeks.

You can use the App to help you plan all of this. I had a patient whom I saw for about 6 months with ongoing symptoms. The patient and his wife read about the low FODMAP diet experiment from Monash University and he tried it. They realized that it was his love of blackberries, which are high a FODMAP fruit, that was causing all of his symptoms. So that is your next step–to get the App from Monash University or buy 1 of the books from Monash University about the low FODMAP diet experiment and carry that out. Once you have improved, and by this time your symptoms probably will improve, then you can gradually test yourself on the high FODMAP foods that you like in small quantities and figure out what you can tolerate. A little quarter of the plate of pasta may not give symptoms to a person who did get symptoms when he was eating a half a plate of wheat pasta.

So that is how you would figure out what you could eat later on. Most people, if they get to the point of having to do a low FODMAP 2-4 weeks experiment and then reintroduce things, most people will have figured out what to do at this point. Is there something else to do, though? Yes, there is, and that potentially is to do a lactulose breath test. This concept was developed over 40 years ago. A lot of the research about the use of breath testing was done at Cedars-Sinai Medical Center in the GI motility department under the direction of the staff there. I have practiced about 30 miles from there and have sent patients to have breath testing at Cedars-Sinai, more recently at UC Irvine Medical Center, and the medical center where I work is now finally getting the equipment to be able to do breath testing. Some people have what is called small intestinal bacterial overgrowth or SIBO. If you have small intestinal bacterial overgrowth caused by your irritable bowel syndrome, or caused by your tendency to be an adult-onset diabetic, you may have to get this diagnosed and treated before your bloating really can be under control. It may get somewhat better on a low FODMAP diet and trying all the other things we talked about, but some people have to have a breath test make the diagnosis of either hydrogen overproduction or methane overproduction and get appropriate treatment for that.

For people who are found to have a rapid hydrogen spike, meaning that they are bringing out hydrogen in excess within 90 minutes of starting the test, they will have to be treated either with a special combination of herbs that was first written about in a paper from Johns Hopkins about 4 years ago, or they will have to take an antibiotic called Xifaxan. Xifaxan is a special antibiotic that does not wipe out all the good bacteria in your colon. It does not get into the bloodstream, it does not lead to yeast infections elsewhere in the body, and so far it has not been a cause of dangerous antibiotic resistance. Xifaxan seems to be a safe thing for people with small intestinal bacterial overgrowth to be treated with. People who have a methane spike instead of a hydrogen spike will need to be treated with Xifaxan plus either an antibiotic called neomycin or an antibiotic called metronidazole.

So you have gone through this whole protocol and you have figured out the bloating but sometimes you are out and about and you have eaten something. Perhaps it was the only thing available, and you knew it was going to give you some bloating and you are stuck with it now. What can you take that will help to relieve the bloating? There are some things that are helpful. There is a chemical called simethicone that basically helps air bubbles to dissolve into the water that the air bubbles are over. Simethicone is sold under the name brand of Phazyme. This is an over-the-counter item, it is not by prescription. Phazyme is a good brand of simethicone and so is Gas-X, and there are store brands of that. It is quite safe. You can take a couple of those pills 4 times a day in complete safety, and that can help to alleviate the bloating. Some people find a lot of benefit from using either ginger in the form of the ginger tea drink or ginger chews that you can buy at Trader Joe’s and at GNC and at some other stores. Some people use ginger capsules. I have some patients who get actual ginger root and shave pieces off it and boil that in water and drink it. Ginger can help to reduce bloating. So can peppermint for some people. I also have some patients who have gotten some benefit from either chamomile tea or fennel tea.

There also can be some benefit from some prescription medications. An example of that is dicyclomine which is an anticholinergic drug. This is by prescription from a physician. It will relax the intestines and can alleviate some of the discomfort of bloating at least for a period of time.

Another thing to know about is changing position. If you are walking around and feeling uncomfortable in your mid and upper abdomen because you have been standing or sitting or walking at work–if you could lie down for a few minutes, the gas that is trapped in your intestines will now redistribute. Just imagine taking a two thirds full bottle of soda and turning it on its side. The air will move to the the side of the bottle that is pointing up, moving with gravity. There is also something called the knee-chest position which you can do at home. You can get on top of the bed on your knees. Put your elbows and forearms on the bed, turn your head to one side, put your head down on your hands and this can allow air and gas to move up your intestines, up to the rectum and out. I have had patients describe passing gas in that position and having tremendous relief from the bloating. So lying down, turning from one side to the other, using the knee-chest position to allow some trapped gas to leave the body–all these things can be helpful as well. Taking a walk–I many patients who tell me that when they will feel bloated they will take a walk in the parking lot at work, feel some gas leave through the rectum during that walk, and they feel a lot better. Sometimes you do have to actually do one of these maneuvers to move the gas around so that you are not so uncomfortable.

As with anything that is related to irritable bowel syndrome or functional gut syndromes, stress makes symptoms worse. Stress causes the intestines to stop contracting normally, to tighten up, to make the bloating worse. Mindfulness-based stress reduction, using meditation, learning yoga or other stretching exercises, learning to calm yourself down and breathe more slowly when you are under stress, learning to relieve that stress in the muscles in your neck and shoulders–these are all important techniques. You may need a psychologist or a counselor, such as someone with training as a licensed marriage and family therapist who is a stress-reduction therapist to help you to learn those techniques.

We have covered a lot of ground in these 24-25 minutes. I hope this is been helpful to some of you. There will also be a transcribed written version of this on my website,