The agony of the bloated belly

Treatment for bloated stomachUnexplained bloating is one of the most common complaints of my patients.

Such a seemingly innocent condition can cause so much distress. The most important consideration for effective and lasting relief is to track down and remove the cause.

When someone feels bloated they describe it as a discomfort in the belly region, usually accompanied by feeling full and distended. This swelling may be quite visible and causing distress due to its appearance and how it interferes with movement. Pain or cramping can be associated with many types of bloating, as well as constipation, nausea and feeling generally unwell. 

It is more mysterious when all the common causes of bloating have been eliminated, such as eating too many gas-forming cruciferous vegetables (cabbage, cauliflower, broccoli, Brussels sprouts); onions, leeks and garlic; beans, lentils, legumes and nuts also cause flatulence.

If you have tried drinking mint tea or taking charcoal tablets to relieve your bloating and it is not improving, it is time to look further into the problem with the assistance of your healthcare practitioner to make a correct diagnosis so that the problem can be effectively addressed. 

In our affluent society I see that overeating and rushing meals is the most common scenario that contributes to belly bloating. 

Malabsorbed food passes into the lower intestine (where it should never reach) due to lack of processing by digestive juices upstream. The residual ferments in the intestine by unwelcome, well-fed microbes, causing a variety of gases to be produced which distend the abdomen, some odorous and some innocuous. Amazingly fermentation of overloaded carbohydrates in the gut can even produce measurable amounts of alcohol which appear in the bloodstream, so beware the breathaliser after a carb binge!

Poor elimination from a sluggish, constipated colon will also lead to bloating. Loss of appetite and abdominal distension are often the signs of constipation, even though a daily bowel action may reassure you that your bowels are working. Incomplete daily elimination can lead to a backing-up of stools that distend the colon and even cause the transverse portion (which sits below the stomach) to prolapse to produce upper abdominal distension. A swollen sigmoid colon can given lower abdominal distension and quite intense pain.

So who is best equipped to help you make the correct diagnosis for your bloating?

Doctors may put you through a raft of tests and tell you everything looks OK, which is not the answer you were hoping to hear.

This is because the diagnostic tools doctors use are to eliminate serious diseases like inflammatory bowel disease and cancer. This is an important process, but it does not always provide the information that can resolve the problem. So you don't have cancer, but where does that leave you, still trying to manage your bloated belly?

It is my experience that minor digestive problems should not be referred to a gastroenterologist as a first step, since they rarely discuss diet management and are unlikely to run functional stool testing to check what is happening with your digestion. Many of my patients complain that they were given "a top and tail" (endoscopy and colonoscopy) as a first measure by a gastroenterologist, which is mildly invasive and expensive and does not always illuminate the issue, which may be microscopic on the musical surface of the intestines.

If you have more serious symptoms, such as bleeding from the bowel, vomiting or diarrhoea which are prolonged, or severe constipation, see your GP first for immediate advice, who will then decide whether you need specialist referral.

What could be causing it? Here is a list of the most common causes of bloating.

Your natural health practitioner or integrative GP would be the best person to consult to identify the condition and its underlying contributing factors. Complementary therapies are be better equipped to offer you appropriate interventions for the conditions listed below as they have a spectrum of solutions to offer you from their natural toolbox.

Indigestion (Dyspepsia, Upset Stomach)

The commonest cause of bloating - indigestion - usually results from eating excessive amounts of food at meals. The digestive juices which contain acids, alkalis and enzymes are unable to cope with the quantity of food, so that it travels partially digested to the small intestine where it begins to ferment and cause distention. Also very common is a stressed digestion, where mental stress has reduced gut blood flow and therefore shut down the production of digestive enzymes, stomach acid and bile, leading to bloating and distension in the same way. Symptoms of dyspepsia can also include upper abdominal pain, belching, nausea, vomiting, abdominal, early satiety (feeling full quickly), and flatulence.

Indigestion can be helped by taking herbal bitters to improve digestive capacity by increasing the output of digestive enzymes from the pancreas. Gall bladder tonic (cholagogue) herbs increase bile flow to help fat digestion and digestive enzymes (animal or vegan) can be taken to supplement what is not being naturally produced. There are also some lovely stomach tonic herbs for dyspepsia, such as meadowsweet, licorice and marshmallow root, which soothe inflammation and assist processing.

Paying attention to your dental hygiene is also critical for ensuring that your digestion works well. Having pain and inflammation in gums and teeth will affect chewing and mechanical processing of meals and over a period of time indigestion will result. Also jaw alignment problems will affect digestion in the same way and need to be correctly diagnosed and treated. Make sure you have an appointment with your dentist to discuss these matters in relation to your digestion. 

Irritable Bowel Syndrome (IBS) 

Characterised by alternating constipation and diarrhoea, this condition is often accompanied by a sense of urgency to empty the bowels, involving strong, painful gut contractions. There may also be inflammatory mucus in stools, but this is more typical of colitis or other types of inflammatory bowel disease. Typical triggers for IBS are stress, food allergen, drinking coffee and often a positive family history for this condition as well as other allergic states.

Emotional stress is always a component, if not the main component, of IBS and needs to be addressed always when managing the condition. Natural therapies are the choice par excellence for successful treatment of IBS, focussing on reducing gut stressors and soothing the intestines with herbs such as marshmallow root, chamomile, fennel and passiflora. Warming the gut is also helpful with herbs like cinnamon and ginger. Supplement this treatment with aromatherapy massage, meditation and light rhythmic exercise, such as walking, swimming and vinyasa flow yoga, to balance the tone of the nervous system.

For classic IBS an excellent over the counter herbal remedy is Iberogast (Flordis). Bioceuticals Ultrabiotic IBS is the best suited probiotic for this condition.

Removing harmful micro-organisms from the gut flora is essential for fast-tracking recovery and the only way to create lasting relief from IBS is by replacing them with probiotics (the beneficial bacteria). Restroration of the health gut flora,  and therefore the microbiome, we know now is essential to our mental health and wellbeing, as much as our metabolism and immune systems. To help these good bugs to cultivate it is also necessary to supply them with probiotics, such as pectin (apples) and resistant starch (bananas, oats, cooled cooked potatoes and rice).

Small Intestinal Bacterial Overgrowth (SIBO)

This is a very common cause of bloating in my experience, due to chronic stress and the widespread use of antacids or proton pump inhibitor (PPI) drugs. These drugs are used by doctors to treat heartburn and reflux by suppressing the natural production of digestive stomach acid. The hydrochloric acid our stomachs produce also provides a bacterial barrier to sterilise our food and to prevent the harmful over-colonisation of the intestinal tract with the wrong organisms. 

If stomach acid levels are reduced, as occurs with ongoing stress, antacids and the menopause, SIBO occurs. The result is poor digestion of proteins in the stomach and fermentation of carbohydrates in the small intestine, which leads to excess gas, abdominal bloating and intestinal candidiasis (see below). Diarrhea may also occur with SIBO, leading to malabsorption then nutritional deficiencies of such nutrients as vitamin B12 and magnesium, creating serious complications such as loss of skeletal muscle bulk and low bone density (osteoporosis). 

If protein malabsorption continues over a longer period it will also lead to hormonal deficiencies, poor skin tone, reduced capacity for wound healing and impaired cognitive function. The brain in particular depends critically upon optimal nutrient intake, especially protein. Normalising the gut milieu with pre- and probiotics is the goal for treatment of SIBO, followed by an appropriate diet and nutritional supplementation regime to recover from the period of malabsorption.

Intestinal Candidiasis ("Candida")

A syndrome long denied by the medical profession and identified enthusiastically by naturopaths, is intestinal candidiasis (“candida”). After thirty years’ experience practising complementary medicine, I firmly believe this is a true clinical entity and should be treated seriously, since it is the cause of significant suffering in our community. Equally, effective treatment of intestinal candidiasis may be life changing for the patient. I believe the intestinal candidiasis that we are seeing today in our clinics is the legacy of a generation of antibiotic use. An era of over-enthusiastic antibiotic prescribing, coupled with the often unnecessary surgical removal of the appendix, has left a generation struggling to correct their gut flora and regain their digestive health. 

DID YOU KNOW? ... The humble and much maligned appendix has been shown in recent research to be a reservoir of probiotics? “Long denigrated as vestigial or useless, the appendix now appears to have a reason to be – as a “safe house” for the beneficial bacteria living in the human gut” (Science Daily, Oct. 8, 2007). After a bout of diarrhoea which can eradicate the intestinal flora, the appendix assists in repopulating the gut with probiotics. It therefore makes sense not to remove the appendix unnecessarily, as has been surgical vogue in the past.

The symptoms which may be associated with intestinal candidiasis are primarily bloating, abdominal distension,cramping and flatulence. Further complications which may result are fatigue, brain fog, sugar cravings, perianal itching, sluggish liver metabolism, skin rashes such as tinea, and particularly vaginal thrush in women. Naturopaths have an even more extended list of associated conditions, they usually having a great deal of experience with treating this syndrome.

Food sensitivities occur when “leaky gut” (increased intestinal permeability) results from low-grade injury to the gut wall by the toxins released from candida and other harmful micro-organisms as they over-colonise the gut. Larger than normal food particles then travel through these gaps in the intestinal lining and stimulate allergic responses in the blood of susceptible individuals, leading to food and chemical allergies. It is also possible to be allergic to the candida itself, which further complicated the clinical picture.

I also associate “leaky gut” with “leaky brain”, meaning candidiasis sufferers also complain of feeling mentally vague, foggy and unfocussed. 

Overgrowth of yeasts, particularly Candida albicans, in the intestinal environment, is part of the syndrome of dysbiosis, meaning a digestive state with “the wrong mix of organisms”. Maldigestion in the upper digestive tract can create an environment in the lower gut conducive to the cultivation of yeasts and ferments and the consequent reduction in numbers of beneficial bacteriae. Regular and excessive intake of fermented drinks, such as wine, beer and especially champagne, creates an ideal growth medium for yeasts in the intestine (unfortunately!) Yeasted foods like breads and yeast extract spreads add to the problem, along with foods in the mould and ferment categories (see your natural health practitioner for a complete list of these foods). Feed them with plenty of sugary foods and drinks and you have a Candida time bomb ticking in the intestines! 

There are some excellent treatment regimes for intestinal candidiasis, using antimicrobial herbs, dietary correction and replacement of essential probiotics (commercial yoghurt drinks are not very effective as probiotic replacement and often contain sugar). The goal is to achieve longstanding recovery and to prevent relapses, which can occur quite easily and be quite distressing when they do. An experienced natural health practitioner is your best ally for this program to be successful.

Dysbiosis is a common complication of antibiotic therapy. Taking even one course of antibiotics may cause our enteric flora such devastation that, without appropriate treatment, it may take ten years to restore the ideal, delicate balance of your microbiome. There is usually around 1.5 - 2.0 kilograms of beneficial bacteria in an adult intestine - that is a whole other organ! Their role is to create a healthy stool for elimination by processing dietary fibre, as well as producing antibodies for the intestinal mucosa (lining) to assist in local immune defence. They also assist in hormone detoxification and regulation, by aiding processing of oestrogens for excretion. Very hard-working micro-organisms!

The best way to assess your intestinal flora and digestive function to assist in creating your recovery from bloating program is to have a Comprehensive Digestive Stool Analysis performed through Bioscreen or Healthscope Laboratories and interpreted by your natural health practitioner.

Coeliac Disease 

Signs and symptoms of coeliac disease along with bloating include flatulence, diarrhoea, foul smelling gas, and increased amounts of undigested food visible in the stool, greasiness (fat). These are signs of malabsorption, due to the damage caused by dietary gluten to the intestinal lining in individuals who have an inherited intolerance to this protein. Genetic testing on blood can confirm whether or not you have true coeliac disease and an endoscopy may be required to confirm the diagnosis.

With our Celtic heritage in Australia, where it is thought the gene originated in Ireland, we are seeing a significant number of individuals being diagnosed as coeliac. It may also result from intestinal wall damage from an infection, but this type of gluten-sensitive enteropathy has the potential to fully reverse with correct treatment. 

It is very important to have a clear diagnosis of either genetically-linked coeliac disease, gluten-sensitive enteropathy, wheat allergy or intolerance to faciltate best treatment results. Your nutritionally-trained medical practitioner is your best ally in this case. 

Lactose Intolerance

Similar to gluten intolerance, lactose intolerance is a condition where the individual may have a genetic deficiency of lactase, the enzyme required to process lactose, the sugar in animal milks. Lactase deficiency is commonly seen in Asian populations, perhaps since it is uncommon to consume dairy products in many of these cultures.It is also possible that lactose intolerance may result from an episode of enteric infection, such as food poisoning, making it hard to process lactose for at least one week after the infection. Consuming milk after a bout of infectious diarrhoea may prolong the lactose intolerance so that it becomes a chronic condition.

Symptoms of lactose intolerance include abdominal bloating and distention, diarrhoea, flatulence, abdominal pain and less commonly nausea. Symptoms completely resolve with the removal of animal milk products from the diet of the affected individual, or by supplementing lactase to the meals at which dairy is eaten. Butter is usually easily tolerated in lactose intolerant individuals since it is mainly animal fat and not so much sugar.

Premenstrual Syndrome (PMS)

Many women who experience the cyclic distress of PMS complain of abdominal bloating during the days or weeks that they experience oestrogen dominance in the last week or so of their cycle. Mood swings, fatigue, irritability, headache, fluid retention, weight gain and sore breasts are all symptoms which can occur when excessive amounts of oestrogen circulate in the second phase of a woman’s menstrual cycle, leading to salt and water retention. This type of bloating is relieved by assisting the liver with herbs and nutrients to process these excess oestrogens and eliminate them via the kidneys, along with the salt and water.

Intestinal Parasites 

Bloating is also a symptom associated with infestation by intestinal parasites - a far more common presenting problem in Australia today than one would imagine. A classic presentation for someone who has intestinal parasites is lower abdominal bloating, cramping and urgency to empty the bowels, usually early in the morning, often disturbing sleep. Evacuating the colon usually brings temporary relief until the organisms cultivate again and the cycle resumes. Parasite infestation also leads to malabsorption, particularly of iron, leading to anaemia and fatigue.

Blastocystis hominis, Giardia lamblia, Dientamoeba fragilis and cryptosporidium are commonly found in the faeces of Australians, contrary to popular medical belief. One gastroenterologist indignantly told my patient “We are not a Third World country!” when she asked if her abdominal discomfort and diarrhoea could be due to having parasites. That may be true of our economy, however our intestinal parasites are global, now that Aussies are such dedicated travellers throughout developing nations, as well as being owners of millions of pets!

If you suspect you may have a parasite or other dysbiosis, arrange to have the Comprehensive Digestive Stool Analysis performed through Bioscreen or Healthscope Laboratories and have it interpreted by your natural health practitioner. There are herbal therapies available for treating parasites, which are very effective.

Creating a healthy digestive environment

Eating food should always be a relaxing and pleasurable experience to effectively nourish to your body. Eating on the run, swallowing food in chunks or whole and consuming unhealthy, devitalised, processed food leads to maldigestion and undernutrition. It’s also a waste of time and money!

  • Food should be eaten consciously, without any distractions such as watching TV or doing emails, when you are in a calm state of mind. Sending the blood to the brain, as occurs with a business lunch, makes sure the gut does not receive the circulation to help process the food just eaten. Each bite needs to be chewed thoroughly, and if this is not the case a live blood analysis can evaluate this problem by assessing the appearance of protein indigestion after a client has eaten a meal. This testing is available through the experts, Australian Biologics Testing Laboratories, in Sydney.
  • The digestion process actually begins when food becomes mixed with saliva. A common mistake is to drink water with meals. This dilutes and inhibits our digestive juices from acting fully upon the food. It is best to avoid drinking anything for 30 minutes prior to a meal, during and for one hour afterwards. Avoid carbonated beverages completely, as they neutralise the digestive secretions.
  • Keeping food choices and cooking processes simple will simplify digestion and avoid bloating. Using beneficial digestive herbs, such as dill, fennel, and mint will reduce flatulence and warming spices such as cinnamon, black pepper and ginger improve the blood flow to the gut during meals to make digestion more efficient. Fresh fruits and vegetables provide us with many plant enzymes that aid in digestion and help us assimilate nutrients better. Raw fruits and vegetables are best, particularly when freshly juiced and consumed immediately. 
  • Avoid over-consumption of food, which outstrips digestive capacity and leads to fermentation in the lower bowel. Chewing your food slowly will also fill you up faster and you will want less to eat, also aiding in weight loss. Even grazing is not good for digestion, as it does not stimulate digestive function effectively and this food may then lead to increased fermentation and poorer nutrient absorption.
  • Managing constipation will improve bloating,so one of the first steps to correcting digestion and other health issues is to treat constipation. There are excellent foods and herbs to assist elimination, such as aloe vera juice, chia seeds and slippery elm powder.Having the optimal bacterial profile for your microbiome is the way to create the healthiest stool which eliminates without any effort or distress, so appropriate probiotic supplementation is a "must" for treating constipation. Colon cleansing at a colon hydrotherapy clinic is the best treatment for chronic and more serious constipation states.
  • Digestive tonics, acids and enzymes can be used to assist your digestion. Generally most of us have low levels of hydrochloric acid in our stomachs, which leads to food only being partially digested. Taking betaine hydrochoride may assist this problem, along with a herbal tonic for calming the mind to improve stomach acid production naturally. A lovely digestive bitter formula is Gallexier (Floradix).
  • See your herbalist for a tailor-made formula to suit your problem. A good quality digestive enzyme taken 20 to 30 minutes prior to eating is very beneficial for stressed digestion, but should not be taken long term to prevent suppression of endogenous production of our own digestive enzymes. Try to limit its usage to two months maximum.

Take good care of your digestion and everything else about your health and wellbeing will fall into place. Good digestion is truly the essential foundation for good health.

© Copyright Giselle Cooke

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