bloating

Bloating: Can We Talk About Gas?

Bloating (Intestinal gas) is a very common problem in the general population and is a frequent reason why people seek medical attention. Passage of intestinal gas is viewed differently depending your age and gender.

Kids make lots of jokes and take pride in telling someone to “pull my finger.” Boys grow up to be men who believe passing flatus is not rude or embarrassing and like to use phrases like “whoever smelt it dealt it” or “whoever denied it supplied it.”

Females would like to deny that intestinal gas exists and will try to hold it to avoid any embarrassment. This practice can certainly lead to increased intestinal symptoms of bloating, distention, and discomfort.

One of the most common symptoms leading individuals to seek gastrointestinal evaluation is “gas.” They are convinced that excess gas is the cause of their abdominal bloating and distention. In addition, they believe that the need to belch and expel flatus is also due to an excess production of gas.

There have been many studies evaluating the above mentioned symptoms and results are rather surprising.

BELCHING

Belching is due to swallowing excess air. It is not due to increased intestinal or gastric production.

We all swallow some air when we eat or drink especially carbonated beverages. But people who complain of needing to belch frequently usually have developed an air-swallowing habit. This usually occurs for one of two reasons:

  • Sometimes people swallow excess air to ease symptoms due to heartburn or ulcers. Easing these symptoms with acid suppressive medications may lessen the desire to swallow air.
  • The other reason for chronic belching is due to an unconscious way of dealing with stress or anxiety. For these individuals, making them aware of their excess air swallowing can sometimes be helpful.

BLOATING AND DISTENTION

When people experience the discomfort of abdominal bloating and distention, they believe it is due to excess gas production in the intestines.

Studies have determined that people who have symptoms of bloating have no more intestinal gas than normal people1. The cause of the symptoms has been attributed to “visceral hypersensitivity.”

Visceral hypersensitivity is a term used to describe the heightened level of intestinal discomfort that individuals experience due to normal intestinal activity.

Research studies have found that when air is instilled into the intestines of individuals with visceral hypersensitivity, they experience symptoms of bloating and distention while the normal group notices no discomfort.2

Visceral hypersensitivity has been thought to be part of the syndrome of Irritable Bowel Syndrome(IBS). Historically, this syndrome has been attributed to psychological disorders. However, recent observations have noted that up to 30% of individuals who experience an episode of infectious diarrhea develop post infectious IBS symptoms3. One of the most prominent symptoms of IBS is bloating.

The current thinking is that an intestinal infection disrupts the healthy intestinal bacterial flora resulting in an immune response that leads to chronic low-grade inflammation. The inflammation then causes visceral hypersensitivity.

Recent studies using probiotics to re-establish the normal intestinal bacterial flora have been successful in down regulating the inflammation and easing the symptoms of bloating.4,5

FLATULENCE

Here are some interesting facts you can share with your friends, about flatulence:

  • Passage of gas or flatus is normal. Generally, healthy people pass 8-25 ounces daily. Frequency is 10-20 passages/day.

 

  • Gas is produced by intestinal bacteria primarily located in the colon.

 

  • The amount gas produced is determined by three factors:
  1. The amount and type of carbohydrates consumed
  2. The amount and types of intestinal bacteria present
  3. The ability of the small intestines to digest and absorb the carbohydrates

 

  • Two common causes of excess flatulence are:
  1. poor digestion of the sugar lactose in dairy products;
  2. limited absorption of fructose which is a sugar found in soft drinks and certain fruits like apples and bananas.

 

  • Some vegetables have starches that are only partially absorbed. The nonabsorbed starches pass into the colon and contribute to excess flatus production. Beans, brussel sprouts, carrots, onions and celery are the major offenders.

 

  • The carbohydrates in bread and pasta can be a problem for some people. Recently, there has been a lot written about “gluten sensitivity.” Avoiding the grains of wheat, barley, and rye can help some people lessen the production of excess flatus.

 

  • Colonic bacteria normally generate intestinal gas through fermentation of the carbohydrates that escaped absorption in the small intestines. An imbalance in the gut bacterial flora may result in excessive gas formation. Some bacterial groups are more prone to gas production than others. Hence, improving the bacterial balance with a probiotic may improve gas-related symptoms.8

Take Home Message

If you are experiencing symptoms of bloating, distention, or increased flatus, consider taking a high quality probiotic like EndoMune.

In addition, you may want to modify your diet by avoiding foods that contribute to flatulence. It is always wise to check with your doctor if your symptoms persist.

Eat healthy, exercise and live well!!!

Best Wishes,

Dr. Hoberman

Foods that may cause gas include:*

  • Beans
  • Vegetables, such as broccoli, cabbage, brussels sprouts, onions, artichokes, and asparagus
  • Fruits, such as pears, apples, bananas and peaches
  • Whole grains, such as whole wheat and bran
  • Soft drinks and fruit drinks
  • Milk and milk products, such as cheese and ice cream, and packaged foods prepared with lactose, such as bread, cereal, and salad dressing
  • Foods containing sorbitol, such as dietetic foods and sugar-free candies and gums

References

*National Digestive Diseases Information Clearinghouse
Gas in the Digestive Tract

http://digestive.niddk.nih.gov/ddiseases/pubs/gas/

1) An understanding of excessive intestinal gas.
Suarez FL, Levitt MD.Curr Gastroenterol Rep. 2000 Oct;2(5):413-9. Review.

2) J Gastroenterol Hepatol. 2011 Apr;26 Suppl 3:119-21. doi: 10.1111/j.1440-1746.2011.06640.x.Visceral hypersensitivity in irritable bowel syndrome.
Kanazawa M, Hongo M, Fukudo S

3) Incidence of post-infectious irritable bowel syndrome and functional intestinal disorders following a water-borne viral gastroenteritis outbreak.Zanini B, Ricci C, Bandera F, Caselani F, Magni A, Laronga AM, Lanzini A; San Felice del Benaco Study Investigators.Am J Gastroenterol. 2012 Jun;107(6):891-9. doi: 10.1038/ajg.2012.102. Epub 2012 Apr 24.

4) The putative role of the intestinal microbiota in the irritable bowel syndrome.
Collins SM, Denou E, Verdu EF, Bercik P.Dig Liver Dis. 2009 Dec;41(12):850-3

5) Probiotic bacteria Lactobacillus acidophilus NCFM and Bifidobacterium lactis Bi-07 versus placebo for the symptoms of bloating in patients with functional bowel disorders: a double-blind study.
Ringel-Kulka T, Palsson OS, Maier D, Carroll I, Galanko JA, Leyer G, Ringel Y.
J Clin Gastroenterol. 2011 Jul;45(6):518-25.

6) Non-Celiac Wheat Sensitivity Diagnosed by Double-Blind Placebo-Controlled Challenge: Exploring a New Clinical Entity.Carroccio A, Mansueto P, Iacono G, Soresi M, D’Alcamo A, Cavataio F, Brusca I, Florena AM, Ambrosiano G, Seidita A, Pirrone G, Rini GB.Am J Gastroenterol. 2012 Jul 24. doi: 10.1038/ajg.2012.236.

7) Review article: the treatment of functional abdominal bloating and distension.Schmulson M, Chang L.Aliment Pharmacol Ther. 2011 May;33(10):1071-86. doi: 10.1111/j.1365-2036.2011.04637.x. Epub 2011 Mar 29. Review.

How Probiotics Can Aid IBS Sufferers

I have spent a lot of time talking with physicians, pharmacists, and patients about the benefits of probiotics. The one topic that comes up most frequently is how probiotics can aid individuals who suffer with Irritable Bowel Syndrome (IBS).

IBS affects up to one in five Americans. Second only to the common cold as a leading cause of workplace absenteeism in the U.S., IBS costs the U.S. healthcare system up to an estimated $30 billion annually in direct and indirect costs.

Medical Presciptions for IBS

When I first went into gastroenterology, the understanding of IBS was very limited. It was generally thought that the symptoms of bloating, gas, diarrhea, and constipation were most likely related to stress. If the intestinal symptoms were manifestation of the stress, then controlling the stress would alleviate the problem. Commonly prescribed therapies included tranquilizers like Librium and phenobarbitol, and antidepressants like Elavil and Aventyl, which were then combined with other drugs – antispasmotics – that affected the nerves that go to the GI tract.  The typical drug armament included such medications as Librax, Bentyl, Levsin and Donnatal. They were relatively safe, but did have side effects of dry mouth and sedation.

Other longtime therapies have included fiber type products that increase stool bulk, like Metamucil and Fibercon.

More recently, drugs that interact with serotonin receptors in the GI tract have been developed. Serotonin is a neurotransmitter that is primarily found in the gastrointestinal tract and in the brain. Serotonin increases intestinal motility, probably by stimulation of 5-HT4 and 5-HT3 receptors. Two prescription medications that interact with the serotonin receptors were developed and approved by the FDA.

Zelnorm, approved by the FDA in 2002, eases constipation by stimulating the 5HT4 serotonin receptor.  It was withdrawn from the market in 2007 due to serious adverse effects on the blood supply to the intestines.

Lotronex was approved by the FDA in 2000 for women with severe diarrhea-predominant irritable bowel syndrome. Lotronex blocks the 5HT3 serotonin receptor. It is called a 5HT3 antagonist. Clinical studies showed only a 15-20% improvement in diarrhea symptoms in patients taking Lotronex versus placebo.  There have been serious adverse effects associated with this medication. Overall, Lotronex has very limited use in treating IBS patients.

A major concern with prescribing prescription medications is adverse drug interactions. Most medications are metabolized and eliminated by the liver. In the liver there are enzymes that can modify and eliminate drugs. The blood level of a specific medication can be increased or decreased by a second drug’s effect on the liver enzymes. The second medication can induce or inhibit the enzyme system resulting in elevated or reduced blood levels of the first drug. Changing the blood level of a medication can cause significant adverse drug reactions.

What About Probiotics for IBS Sufferers?

Here is the good news with regard to probiotics:

  1. Probiotics are safe and not associated with any severe adverse effects in healthy individuals.
  2. There are no drug interactions with other medications.
  3. Studies have shown that probiotics can alleviate symptoms of IBS.

Two recent reports(1, 2) reviewed the available studies using probiotics to treat symptoms of IBS. Both reports concluded that probiotics appear to be efficacious in IBS but the magnitude of the benefit and the most effective species and strains are uncertain. This means that probiotics show statistical significance in reducing IBS symptoms compared to patients taking a placebo. The problem is determining what types of probiotic bacteria and what dosage of probiotics work best.

There are a number of studies that indicate that the dosage of a multispecies/strain probiotic should be at least 5-10 billon organisms per day.

The mechanisms by which probiotics lessen IBS symptoms are being actively investigated(3).  For example, studies have shown that the bacterial flora in patients with IBS is different than in individuals without IBS symptoms. The bacteria in IBS patients can produce increased gases like methane which causes constipation and bloating(4). By altering the bacteria population with probiotics, it is possible to lessen methane production and ease symptoms of constipation.

I can go on about how probiotics improve intestinal function, but I am afraid I will start to bore you.

The point I am trying to make is that probiotics can help people with IBS symptoms, and they are very safe. If you have symptoms, then consider a trial of a probiotic. Obviously, if you have new onset symptoms, it is best to consult your physician first.

The problem is trying to choose the right probiotic product. It’s important to consider:

  1. Dosage per serving size – how many billon organisms/serving?
  2. Number and type of different probiotic bacteria – how many Lactobacillus, Bifidobacteria strains in each serving?
  3. What is the shelf life at room temperature?
  4. Does the product also contain fructooligosaccharides (FOS) – prebiotics*?
  5. Is the packaging in dark, glass bottles, helping to lessen exposure to oxygen and sun light?

Take Home Message

If you have symptoms of IBS, consider taking an excellent probiotic like EndoMune Advanced. Each capsule contains 10 different bacteria strains.  A serving size of two capsules contains 16 billon organisms and 50mg of FOS.

For children, consider EndoMune Junior. Each serving size of ¼ Tsp contains four bacterial strains, a total of 10 billon organisms, and 50mg of FOS.

Eat healthy and live well!
Lawrence J Hoberman MD

*FOS are prebiotics. Prebiotics are starches in foods like those found in the fiber of fruits, beans and the bran in whole grain breads and cereals. They are called resistant starches because our intestines can’t break them down. These starches enter the colon and are used as nourishment by the good bacteria, Lactobacillus and Bifidobacteria. These bacteria ferment these starches and produce short chain fatty acids that nourish the colon cells and enhance its healthy function.

(1) The efficacy of probiotics in the therapy of irritable bowel syndrome: a systematic review.Moayyedi P, Ford AC, Talley NJ, Cremonini F, Foxx-Orenstein A, Brandt L, Quigley E.Gut. 2008 Dec 17.

(2) Meta-analysis of probiotics for the treatment of irritable bowel syndrome. McFarland LV, Dublin S.World J Gastroenterol. 2008 May 7;14(17):2650-61.

(3) The role of probiotics in management of irritable bowel syndrome. Borowiec AM, Fedorak RN.Curr Gastroenterol Rep. 2007 Oct;9(5):393-400.

(4) Methane and the Gastrointestinal Tract.Sahakian AB, Jee SR, Pimentel M. Dig Dis Sci. 2009 Oct 15.

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