Are you bloated?

Admit it, you are.  EVERYONE is bloated.  And if someone is telling you they’re not bloated, they’re lying.  Of course, my experience may be skewed by the people who come into my office, all of whom are always… you guessed it, bloated.  I’m starting to think bloating is part of the human condition, along with birth, growth, emotionality, aspiration, conflict, and mortality.

But why?  Why are so many people bloated?

The short answer is: it depends.

First, let’s get the really serious stuff out of the way.  If by “bloated” you mean your belly is distended with fluid, you might have serious problems.  There should not be enough fluid in your abdominal cavity to distend it to the point of making you feel bloated.  Get thee to a doctor, STAT.

For everyone else, bloating usually refers to a feeling of distention that most people attribute to excess gas, although often, this is a perception and is incorrect.  There are a few disorders that lead to actual overproduction or underextrusion of gas.

  1. You swallow too much air
    • you eat way too fast – slow down and smell the roses (and no pun intended)
    • you’re ingesting bubbles – put the coca cola DOWN, it’s no good for you
    • you are a gum chewer – fresh breath is important, but chances are you’re swallowing air and making yourself bloated, plus, you’re aggravating your TMJ, so spit it out, and brush your teeth instead
  2. You produce too much gas because you’re not absorbing your nutrients, and the bacteria in your gut are doing it for you, producing gas and water in the process
    • you might have lactose intolerance, or Celiac disease (gluten allergy)
    • or you have an imbalance of flora in your gut, and have small intestine bacterial overgrowth (SIBO), in which case a course of antibiotics might help
  3. You have a blockage and can’t get the gas out (get thee to a doctor, STAT again)
    • if you had a blockage, you’d be wicked sick and would need surgery, so more than likely, if you’re at the doctor’s office complaining of a lifetime of painful gas, you do NOT have a blockage

For most people, bloating, distention, and the perception of “excess gas” is subjective, and related to a functional bowel disorder.  A functional bowel disorder means, basically, we have done the tests to rule out things we can identify and fix (see above: Celiac, lactose intolerance, etc) and those have come back negative, you’re still miserable, and we don’t think it’s all in your head, but we cannot figure out why.   For these folks, believe it or not, the volume of gas contained in the GI tract as measured by fancy techniques like body plethysmography (don’t ask me to explain it) is always more or less 200ml, even when they’re feeling most distended.  Xrays checked in people who complained of gaseous distention and people who did not, for example, do not show any difference in amount of gas or gas pattern.  The actual relationship between symptoms and the amount of intestinal gas is, like all relationships, complicated.  Theories to explain it are plentiful, which usually means that we, as a medical community, have no clue.

Some of these theories are:

  • There is impaired or slow transit of intestinal contents
  • Gas trapping in the flexures (bends of the intestine) causes spasm
  • Incoordination of the abdomino-phrenic reflex (your diaphragm moves down instead of up, squeezing your intestines, and producing a feeling of distention)
  • Visceral hypersensitivity 

None of the above are all that convincing, because if they were, we wouldn’t need the other ones.  That last one might need a bigger introduction, though.  Visceral hypersensitivity refers to the concept that your viscera (internal organs) respond to stimuli at a lower threshold than most, and perceive it at a higher acuity, read: pain.  They’ve done experiments to this effect.  They took some lucky individuals and put balloons up their rectums, and blew the balloons up.  People who had these “functional” complaints detected the balloon at a much lower volume, and reported the sensation as painful, whereas people who were “normal” were able to withstand a greater volume and reported a feeling of fullness rather than pain. (Gut. 1991;32(6):665. )

Doctor, am I going to live?

In short – yes.  Bloating is not dangerous in most cases–unless you’ve got that blockage I mentioned, or unless you’ve got cirrhosis or something and are filling up with fluid, which if you are, get thee to a doctor, STAT–but is notoriously difficult to address and treat, once you’ve been ruled out for the easy fix like lactose intolerance.  Please don’t attack your GI doctor for not having the magic pill (ahem); chances are, it is your body and it is functioning funny (hence the name “functional disorder”), and has been for a while.

To help control functional bloating, the thing I recommend most is a low FODMAP diet.

FODMAP stands for fermentable oligo di- and monosaccharides and polyols.  I swear that is the name, I did not make it up.  Those are basically foods that we don’t break down well, so, as mentioned above, the bacteria in our gut do, producing gas and water as a byproduct, which results in excess gas, bloating, and in some cases, diarrhea.  If you follow the link above, you’ll see an impossible to follow chart of foods that you should and shouldn’t eat if your doctor puts you on a low FODMAP diet.  But I will make it easy for you: the magic words are “gluten” and “dairy.”  Gluten is a protein contained in wheat products, and dairy is anything that has milk.

As an aside, let me clear up something I am always shocked to hear patients ask:

  • Oh, doctor, I don’t eat wheat bread.  Only white.
    • But white bread is still made of wheat flour!
  • Oh, doctor, I’ve been avoiding dairy, and I miss eating eggs!
    • Eggs are NOT dairy.  Dairy is milk and milk comes from cows.  Eggs come from chickens.  Have an omelette!

I know I said you were tested and came out negative for allergy and intolerance of the above culprits.  However, a lot of people do better if they avoid gluten and dairy anyway.  They don’t have to be religious about it like they would if they had a true, immune-mediated gluten allergy, such as in Celiac disease, but if they restrict their intake–say, no more pizza, giant bowls of pasta, or hoagies–they feel better.  So, yeah, all those hippies at Whole Foods telling you that gluten is poison are kind of right?  Just not for the reasons they think.

Recently, there was a report that stated a gluten free diet without a diagnosis of celiac disease is actually harmful, and that could be true (BMJ 2017;357:j1892), so I would not propose going gluten free for shits (again, no pun intended) or giggles, or for weight loss purposes, as has been popular as of late.  Nor I am not proposing a strict gluten free diet for bloating; I’m just saying restrict.  I don’t know what it is about the wheat we eat these days, whether it’s the genetic modification to the point where it’s basically a mutant grain, or hormones we use, or little green aliens and crop circles or what, but these days, wheat and gluten cause issues.

If you come home from work, and you’re feeling miserable because you are bloated, my advice to you is take 2 gas-ex, lie on your left side with a little pressure to the left lower quadrant and try to fart  (not that I speak from experience or anything…)  Really!  It’s what we do after colonoscopy in what David Sedaris called “the Farting Room.”

And finally, I’d like to say that it’s not en vogue to talk about our GI issues at cocktail parties or impart knowledge on how bloated you are on your colleagues, but make no mistake about it, EVERYONE has problems, so you are not alone.  It is not just you.

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