An Integrative Approach to Bloating
Before we can discuss how to treat bloating, we need to discuss what that word actually means. It is so important as a patient (and as a doctor) to relay information about our symptoms and health accurately by using the right words.
What is bloating?
Bloating is the sensation of pressure in the abdomen WITHOUT a change in girth. A change in girth (often described as a pregnant belly by patients) is abdominal distention. You can have bloating with or without abdominal distention. With abdominal distention, there is usually pain, which we call visceral hypersensitivity. Bloating is not to be confused with abdominal fat. Belly fat is not bloating.
Mechanisms of bloating
Bloating typically indicates that your GI tract has a hard time handling gas but it doesn’t necessarily mean that you are experiencing an overproduction of gas. Gas in our GI tract comes from bacterial fermentation which is a natural and healthy part of our gut environment most of the time.
Impaired GI Motility
Bloating is usually caused by impaired motility of the GI tract. Your GI tract is partly a muscular tube that contracts to flush food along the tract. If the GI tract is sluggish, this can result in a buildup of stool and gas in the large intestine that causes the sensation of pressure we describe as bloating.
How do you know if your motility is impaired? Well, if you don’t have a daily bowel movement, that tells you motility is most likely impaired. But you can still have a daily bowel movement and have issues with motility. An easy assessment is to take 4 caps of activated charcoal with breakfast and note how long it takes until your stool looks darker (can appear black). That is your transit time. Then keep track of how long it takes for your stool to return to a normal color. The total time is retention time and indicates how long food sits in your digestive tract. While there is a lot of variation in transit and retention time, if the activated charcoal hasn’t cleared in 48 hours, that may indicate an issue with motility.
What could cause impaired motility? So many things. The root cause may be an imbalance in the autonomic nervous system (the part of the nervous system that communicates with our organs) as a result of chronic stress or another health condition like diabetes. Or maybe your don’t have enough bile to stimulate intestinal motility. Maybe you have fascial adhesions from an abdominal surgery such as a gall bladder removal or C-section that impacts your intestines. Maybe your ileocecal valve (the valve between your small intestine and large intestine) is stuck shut.
Impaired Carbohydrate Absorption
If motility is normal, then bloating may be a result of impaired carbohydrate absorption. If you are not absorbing the sugars from your carbs, then bacteria can ferment them to produce gas. This may occur for a number of reasons. Digestive insufficiency is one cause. This may mean that you aren’t chewing your food enough, you don’t have enough stomach acid, you don’t have enough pancreatic enzymes, you lack enzymes on the brush border of your small intestine, or your brush border is damaged.
Altered Microbiome
The bacteria present in your large intestine can also contribute to bloating. Certain species produce gas such as hydrogen, methane, or hydrogen sulfide. For example, Methanobrevibacter smithii produces methane gas which can decrease gut transit time and lead to bloating. Bacteria in the genera Bilophila or Desulfovibrio can produce hydrogen sulfide gas, which is inflammatory. If extremely overgrown, people will complain of flatulence that smells of rotten eggs, though I have seen moderate elevations in the bacteria without that symptom. Overgrowth in Clostridium species, Escherichia species, or Enterobactericiae species can produce excessive hydrogen gas. These are common overgrowths as these are species that we all have in our gut. When they are kept in check, they are healthy, but when they overgrow, they can cause problems like bloating.
I recommend doing a 16S rRNA stool test to explore your microbiome. The good news is that you can access this type of testing without a doctor’s order. With my patients, I use Biomesight (use coupon code BIOADAPT to save ~$75). Unlike the other commercially available stool tests, they provide decent clinical information and I have been working with Biomesight to help their customers better understand their stool test results. Other commercial stool tests just use the stool test to upsell customers on supplements without providing any meaningful (or even correct) information about the customer’s microbiome.
Timing Matters
In determining the cause and mechanism of bloating, timing is a really important consideration. When do you experience bloating? Is it within an hour of a meal? Or it is 3 hours after a meal? If it happens fairly quickly after a meal, then that is a sign that the issue is in your small intestine. You should not have large populations of bacteria in your small intestine to produce gas. Bloating, especially bloating with abdominal distention occurring within an hour after a meal, is a strong sign of a small intestine bacterial overgrowth.
Treating Bloating
Obviously, successful treatment is going to depend on the root cause. Determining the root cause requires a thorough history, a good physical exam, and possibly laboratory testing. Even with all that, treatment may require some experimentation.
Some things you can try on your own that will at the very least optimize digestion include practicing good eating hygiene and using carminative herbs for symptom management.
Eating Hygiene
Good eating hygiene entails eating in a way that support proper digestive physiology. This means you sit while you are eating. You are not multitasking while you are eating. You look at your food, smell your food, taste your food, and chew it until it is mush in your mouth. Also, minimize fluids with meals to under 4 ounces so you don’t dilute your stomach acid.
Carminatives
Carminative herbs contain volatile oils that stimulate gastric emptying and motility in the GI tract to prevent the buildup of gas in the intestines. Carminative herbs include anise, caraway, cinnamon, fennel, ginger, and peppermint. Carminative herbs are best consumed as either a tea or enteric-coated volatile oil extract. You can find many different products in the Bloating section of my online supplement store. Another product that combines carminatives with herbs that block the production of methane gas is Atrantil, available for 20% off in my online supplement store in the Bloating section of my favorites. If elevated methane gas is driving the bloating, this can work great. However, it is important to note that Atrantil does not reduce the microbes that produce methane, just stops them from making methane gas.
References
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5087933/
https://www.ncbi.nlm.nih.gov/pubmed/22097886
https://www.ncbi.nlm.nih.gov/pubmed/29090023