“Abdominal bloating is a frequent and bothersome but poorly understood clinical problem”
It’s not a subject for dinner table conversation but about 15-30 percent of the population experiences it, it can be very painful, and it’s just beginning to get the respect it deserves in the research arena. It”s bloating and it has nothing to do with being fat. It usually shows up as an alarmingly distended abdomen complete with gas and cramps. It can send you to bed huddled in pain. If you haven’t experienced real bloating, let’s hope you never do.
‘Bloating’ (in various forms :)) affects many in our society. (These bellies are simply fat – not bloated).
In somewhat fractured English, the Korean authors of this overview describe bloating as having a ‘full belly’ or “heavy and uncomfortable feeling in the abdomen.” For me, I would describe it as “looking like you’re pregnant.” I’m surprised I don’t have stretch marks after some of my bigger bloating episodes.
The causes of bloating are complicated, the underlying mechanisms are unclear, no standardized treatments exist, and few clinical trials have occurred. Sound familiar? Even the definition of bloating is a bit unclear: bloating used to refer to abdominal distension, but it’s clear that bloating and discomfort can occur without a bulging abdomen.
Bloating was not described in the medical literature until 1949 when a Mayo clinic doctor described its existence in a woman with ‘psychological problems.’ (Women experience more bloating than men). If you experience bloating at least 3 days a month, you’re considered a ‘bloater.’
Gastrointestinal symptoms including bloating are greatly increased in people with fibromyalgia compared to controls. Over 75% of people with IBS experience bloating. Over 50% of people who experience bloating state that they have to reduce their activities because of it, and over 40% take medications for it (or would if they could find them). Bloating can be a serious problem.
Causes
Altered Gut Flora
Several studies have found unusual populations of gut microbiota or flora or bacteria in ‘bloaters.’ Some studies suggest that altered carbohydrate and protein metabolism due to bad gut flora causes higher levels of acids. These acids then inflame the gut lining.
Small Intestine Bacterial Overgrowth
Increased levels of gas in the small intestine has been reported to cause bloating in people with IBS, and studies indicating that antibiotics can reduce bloating and pain indirectly support the small intestine bacterial overgrowth claim. The H2 breath test has typically been used to detect increased levels of gas emanating from the small intestine, but the authors report the test has found similar H2 levels in IBS patients and controls. The lactulose breath test has not fared much better.
The authors do not believe, at this point, that small intestine bacterial overgrowth contributes to bloating. (A recent meta-analysis finding that a positive methane breath test, however, that was associated with constipation, IBS, and delayed transit (see below) in a meta-analysis suggested otherwise, however.)
Gas Accumulation in the Intestines
The vast majority of studies do not support that excessive gas induces bloating or abdominal pain. –Authors
One would think that gas accumulation would surely be a key factor in causing the belly to blow up like a balloon and cause pain, but many studies say it’s not so. There is little correlation between the amount of gas present and the degree of bloating and pain present. Increased gas may contribute to gut distention, but not necessarily cause pain. That doesn’t mean that gas doesn’t play a role: the distribution and movement of gas and ‘gut motility’ (the ability of the gut to move its contents along) do appear to play more of a role than simply the amount of gas present; i.e. if you can keep it moving, lots of gas is not necessarily a problem.
Gut Motility
‘Delayed transit’ may be more important in bloating than gas accumulation
‘Delayed transit’ or getting the food in your intestines stuck in some sort of gut traffic jam looks like it contributes to bloating.
Giving healthy people a drug designed to slow down the movement food through the gut produced bloating. Of course, (of course!) some studies find no connection at all between gut transit times and bloating, but studies finding that injected gas causes bloating and delayed transit in most IBS patients, but not in healthy controls, suggested delayed transit is a real issue for some. Why people with IBS have delayed transit is not clear but it may have to do with autonomic nervous system issues.
Other studies suggest bloaters may not necessarily have more gas but may eliminate it less well.
Strange Abdominal Wall Activity or Abdomino-phrenic Dyssynergia”
“Abdomino-phrenic dyssynergia is one of main factors for abdominal distension and bloating”
With abdominal wall activity we get into more ME/CFS and FM-like territory; i.e., a seemingly paradoxical response. Increased gut gas levels cause the abdominal walls of healthy people to tighten up and their diaphragms to relax, but the opposite occurs in many bloaters: gas causes their abdominal walls to relax and their diaphragms to tighten up. This strange reaction appears to contribute to bloating.
Food Intolerance and Malabsorption
Given the experience many bloaters have with gas-producing foods of all types, it was strange to see ‘food intolerance and malabsorption’ end up near the end of the list. Elimination diets have certainly helped many, but they were not listed and neither was gluten avoidance. (I’ve reduced bloating by giving up gluten, dairy, and eggs.)
Fiber, certain types of foods, and dairy were, however, listed. Too much fiber or too much of the wrong kind of fiber can slow down gut motility and induce bloating. Bran, for instance, appears to increase gut transit times in healthy people but can decrease them and cause bloating in some people with IBS. Studies indicate that lactose intolerance can cause bloating.
FODMAPS
A new hypothesis suggests that ‘highly fermentable’ (yum) but poorly digested (yuck) short-chain carbohydrate-rich foods (Fermentable Oligo-Di-Monosaccharides and Polyols, aka FODMAPS) can cause GI problems and bloat. (We will look more into FODMAPS later.) Diets high in these types of carbohydrates have been tied to high rates of hydrogen production, distension by fermentation and GI symptoms.
Low FODMAPS diets appear to be the best diet for irritable bowel syndrome (IBS) which often causes bloating.
FODMAPS may contribute to more than stomach pain, however. One study suggested that FODMAPS diets may be able to reduce the pain in fibromyalgia.
Constipation
Given that constipation slows (or is the result of slow) gut transit times, which is tied to bloating, it makes sense that constipation can cause bloating.
(One way to ameliorate constipation is to put your hands on the outside of your knees and then push your knees outwards against your hands when you’re going to the bathroom. This activates muscles that can help you get the poop out without the downward straining that causes hemorrhoids.)
Hypersensitivity
Increased sensitivity to gut pain is often found in ‘bloaters’
It has long been recognized that people with IBS have increased pain sensitivity in the gut. If you stick a little balloon in their gut and inflate it, they will both notice it and feel pain from it long before healthy controls would notice it. As fibromyalgia is to the muscles and joints, IBS is to the gut. Sympathetic nervous system activation can contribute to this hypersensitization, and hypervigilance can play a role as well.
Being Female
Of course, being female contributes to bloating; every symptom associated with chronic fatigue syndrome and/or fibromyalgia as well as the disorders themselves appear to be more common in women. It’s almost a given.
Treatment
Antibiotics
Short or long term courses of Rifaxamin may help
Various ways to alter the gut microflora are the top recommendations. Studies suggest that antibiotics can be effective at relieving bloating. The fact that antibiotics (or antibacterials) top the list of suggested treatments, of course, strongly implicates gut flora composition in bloating and gut pain. The authors state that Rifaximin, a non-absorbable microbial agent, poses little risk of side effects and has a low risk of producing resistant flora. They first suggest it is suitable for ‘chronic administration’, but then later suggest it be considered as a ‘short-course’ therapeutic option for bloating.
When low dose Rifaximin has been ineffective, high dose (2,400 mgs) Rifaximin has been found to be effective. It also appears to be superior to other antibiotics such as neomycin, doxycycline, amoxicillin, and ciprofloxacin.
Check out how one antibiotic dramatically improved one person’s ME/CFS.
Probiotics
Study findings on the effectiveness of probiotics in reducing bloating are decidedly mixed with some studies showing effectiveness and at least an equal number not. A meta-analysis of probiotic studies concluded there is moderate evidence that specific probiotics are useful in managing bloating. Several studies suggest that lactobacillus may increase bloating symptoms while bifidobacterium infantis may reduce them.
Antispasmodics
The evidence on antispasmodics is mixed as well. Most of the studies are small and some of the more effective antispasmodics are not available in the U.S. However, a natural alternative, peppermint oil, has been effective in several studies.
Dietary Interventions
Some of the foods in this picture are not part of a low FODMAP diet
Noting that specific foods can trigger bloating, the authors asserted that a dietary history should be done.
Many studies have shown that highly fermentable, short-chain carbohydrates (FODMAPS) can cause bloating. A low FODMAP diet was recently shown in one study to reduce bloating. (Eliminating gluten, eggs, and dairy has greatly helped reduce my bloating, but gluten is not mentioned in these studies.)
Reduce Your Bloating with Anti-foaming Agents and Charcoal
A recent multi-center trial found that a combination of activated charcoal and simethicone significantly reduced both bloating and feelings of ‘fullness.’ (Generic simethicone as well as the brands Phazyme, Flatulex, Mylicon, Gas-X, and Mylanta Gas are common OTC drugs in the US.)
Stimulating Fluid Secretion for Constipation and Bloating
Two new drugs, lubiprostone, and linaclotide, significantly improved IBS symptoms including bloating in people with constipation.
Some studies suggest peppermint oil can be effective in reducing bloating and abdominal distress
Antidepressants
SSRIs and TCAs can be effective because they have both depression and pain reducing effects. These drugs may or may not help bloating per se, but they may make it less painful.
Others
The authors’ recommendations were limited to treatments that had undergone studies and thus were limited to some extent. If you’ve reduced or conquered bloating please let us know how you did it.
This is an interesting article on a subject I wrestle with myself. I think excess gas does induce bloating at least for myself. When I am severely bloated and I do an enema a lot of air or gas is released and the bloating goes away. Of course this is not a solution because following the next meal more gas and bloating is produced again. I am curious about the statement that unusual populations of gut microbes are found in bloaters. Recently I participated in the American Gut Project, a crowd funded study that compares the populations of gut bacteria in the American population with comparisons of gender, age, BMI and diet. Interestingly my results were radically different than any of my comparable groups. 50% of my bacteria was Verrucomicrobia – ” a relatively new phylum with only a handful of described species. Although not the most abundant, they seem to be always present in soil, aquatic environments and feces.” I am wondering if this is true for others with CFS.
Very interesting Darden! It sounds like your gut has been kind of been taken over by this group of bacteria. The same was true of people with autism but it was a different type of bacteria. The CAA gut study should be published sometime. I can’t remember what they found.
I find that bloating is indeed worse when eating foods with lots of fiber i.e. whole grains, beans and nuts. A good solution is to soak these foods for at least 24 hours before cooking them. I do this with rice, oatmeal, etc. and it is a big help. For nuts I soak until they start to sprout and then dry at very low temperature.
Thanks. Have you ever tried soaking oats and then eating them raw? I seemed to do a bit better with that.
Standard store-shelf oats are glutenous. There is, however, one strain/variety that is gluten free. I must avoid wheat and all gluten, and have found Bob’s Red Mill gluten-free steel cut oats digestible without soaking.
In my case, I have eaten gluten free for the last few years and have much less bloating and upset stomach. I also take a probiotic. I do eat a little gluten here and there and when I have too much the bloating comes back quickly. It is very clear in my case that gluten is a factor and the thing I am most sensitive to. I also have problems with dairy and eggs and limit them somewhat. Over Thanksgiving this year I had a LOT more gluten than usual and I was extremely sick for a couple of days. Lesson learned!
I’m really surprised that the authors didn’t mention gluten in their overview. It was pretty cut and dry for me. First there was dairy – my bloating improved greatly…but then I had bloating with my daily eggs…..my bloating went down again and then it came back – even worse. Removing gluten, which was no difficult at all actually – has really helped. I still have bloating but it’s much less frequent than before.
Another possibility to consider is Gastroparesis. I was diagnosed last year. I didn’t have any vomiting and one of my main symptoms was having a swollen tummy, which felt particularly tight high up. Check out Richard R Burnet’s paper in 2004 which found a significant proportion of CFS people had Gastroparesis.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC544348/
Thanks. I had never heard of this.
Thank you for this interesting article. I have ME and a hiatus hernia, which was not improved by food sticking in my asophogus and causing acid, pain and eating problems. Ant acids were unsuccessful, until I was given Esomeprazol. This drug actually moves food through the stomach, but only works if I personally take it at night. I am given to understand that it can work better on a morning, for some people though.
I must avoid high fibre, carbohydrates and dairy to a certain extent. Now my digestive system is much better and find having just a small amount of these foods and avoiding them inbetween days works well for me.
I do take pro biotics and find them very helpful, especially, if I feel I am becoming unwell with an infection, when I double the dose for a while.
My 3 daughters also suffer from IBS and this information is very helpful for us all.
Thank you Cort
Thanks Hope. Glad you found something that worked and thanks for spreading the news. 🙂
This is a problem for me as my waist is usually 2 inches bigger at the end of the day than at the start.
However, I am much better than I used to be and rarely experience pain with it anymore. The solution for me has been to eat as many different (nutritious) foods as possible. Cutting out foods has often made the problem worse.
For five months now I have been food combining to get rid of the bloating and I take Aloe Vera gel 3 or 4 times a day to heal my damaged esophagus.
My bloating is now at a minimum. I have stopped my PPI medication which was my goal. Unfortunately for me I have also lost 10 lbs when I didn’t need to. I had already eliminated gluten, dairy and eggs. I find that sticking to food combining at least six days of the week has made me feel much better.
Katherine
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Food combining – do you mean things like not eating protein with starches or proteins with oils?
I do notice that some meals – perhaps because of poor combining sit on my stomach like a log – and increase my fatigue.
Yes. Meat or fish with vegetables or starch with vegetables. I try to make every meal nutritious.
I make thick vegetable soups for lunch and freeze them. They are plain with few ingredients but spicy and tasty – roasted beet, sweet potato and spinach, squash, carrot and many different combinations.
I agree that that the bloating is usually after dinner and not a problem after breakfast or lunch. My remedy is simply a half teaspoon of baking soda in a 4-6 oz glass of water when the bloating feeling begins and in 30 minutes or less it’s gone. I also take magnesium pills in the am and pm which stops the lifetime misery of constipation I’ve dealt with – no more straining. The 3rd part of the remedy is taking a probiotic in the am and again in the pm, and an occasional one if dinner was too large. I’ve taken over a dozen different brands of probiotics and not even half of them do anything for me. I now stick with one called PB-8 I get from Amazon and it is excellent at reducing the amount of gas. I also try to eat a lot of olive oil with various foods and I find this to be soothing to the feeling of stomach lining irritation that comes with the bloating, or keeps it from happening as well. I’ve noticed that plain yogurt is also a stomach soother for me.
I’m glad you stuck with probiotics until you found one that worked for you! I imagine that many people give up too early.
I have found that Heather’s Tummy Fiber Organic Acacia Senegal has been quite helpful for me. This is the only fiber that seems to work for me, and it has been a powerful help. http://www.helpforibs.com/supplements/sol_fiber1.asp
I have also used their fennel tea, but it is the fiber that has made a big difference. I do not agree with much of their diet information, for instance I think fats are essential, but they must be the right fats.
Another aspect that has been key for me is learning about the extensive ramifications of Non Celic Gluten Sensitivity and it’s accompanying dairy, soy, egg, and (for me) other related foods including beans and any grains. There is a four day webinar in progress which explains more. It started on the 30th, and goes through 2/2, but it is not too late to sign up, and it’s free: https://gg110.infusionsoft.com/app/hostedEmail/6616216/e6d94b0cf071c67b?inf_contact_key=87650aa88dd8aed54959b8f7ae5b45e13320d1be1e09980f4a1601cccfc0566b
I haven’t found a cure for this but did notice it reduced if I swam in the sea, perhas down to the magnesium present in sea water? Magnesium is great at avoiding constipation. Floradix is a good UK magnesium supplement.
There have been studies showing that many probiotics do not in fact contain many live bacteria. I found bimmuno (a pre-biotic) better. I now make my own live yoghurt. Faecal transplants re being trialled and seems very effective in changing gut flora.
Buscopan tablets work for me for milder cases, especially if the cramps and bloating is low down in the abdomen.
I didn’t see any mention of digestive enzymes. Everyone I know w/CFS/ME has some kind of digestive problem and take these. I’ve noticed a BIG difference between taking these with meals and not taking them. They make all the difference.
I have suffering from IBS for bout 3 years and having trying all sorts of medications and diets but to no avail . This time I have finally got cured in merely a span of bout 1 month…
What did you do?
I suffered from bloating for many years. I went to see a holistic practitioner and he told me I had to much yeast in my gut. I followed a yeast and sugar free diet and it worked, I am now free from bloating and pain.
CORT LA GASTROPARESIA Y DAÑO A FIBRAS AUTONÓMICAS INTESTINALES SON FRECUENTES EN FCSY FIBROMIALGIA Y MEJORAN CON VITAMINAS DEL COMPLEJO B
You trivialize the bloat complaint when you illustrate this post with an image of men whose problem is fat accumulated on their abdomens.
That is not bloat; it may or may not be gluttony; but it is definitely unappealing – especially displayed that way.
I have always had a bloating and ‘farting’ problem (too much of it) evr since I was a child and years before my ME/CFS.
However I think my problems are recently getting worse and this article may be indeed helpful. I particularly find that the bloating is more irritable at the start of my monthly cycle i.e. a day or two before I start bleeding. It has been suggested to me I go on the pill but I’m not sure that that will help the pain of the bloating or just the pain of the other stuff involved with monthly cycle.
I also find that I can eat fibre but I do get bad bloating after eating dried fruit or any drinks with artificial sweeteners and wonder if the chemicals in both these processed foods are to blame.
I shall continue to research and maybe try a strict diet if I have the discipline!!
Does any one else experience pain on their right side or their stomach blowing up so bad they look like they r pregnant from fibromyalgia like I have
If your pain is on the right side and it’s near the end of your ribs, thats your liver.
I know it’s when my liver is not happy, I feel a tenderness in that area right at the end of my ribs and a little beyond.
It’s tender to the touch as if I had a bruise but I don’t it’s my liver probably being overworked.
Not only should digestive enzymes be mentioned here but also what’s important is trying bitters or something similar to create more stomach acid for digestion.
The bitter spray I use and milk thistle to try to help my liver as well. It’s why I like the bitter spray because it’s doing both creating more stomach acid which we need for digestion most of us are low stomach not high stomach acid… and has many liver helpful herbs.
Yes I do have same problem. It’s painful and drives me crazy. All tests were good however problem won’t go away it started a month ago. Can’t stand itmuch longer.
I’m at my whits end! I have been suffering with hurendous bloating and pain for near on 3 years now with no release from trying gluten free, dairy free diets, acupuncture, scans and samples with ‘nothing to worry about’ results. I am currently trying Bimuno but this seems worse since. I feel sick sometimes and it’s having an impact on my mental health!! The doctors are too quick to say it’s IBS and push me away. I can’t cope much longer! I got from 31inch waist in the am to a 37inch waist by late afternoon. My work clothes fit in the morning but are cutting into me in the afternoon. Can anyone help please?!
Have you been tested for small intestinal bacterial syndrome (SIBO?). Have you had a gut motility test? You could have a problem with your autonomic nervous system. Another thing to look into it mast cell activation syndrome (MCAS). If you experience dizzinness fatigue etc while standing you could have POTS which can effect the gut….
After 7 years of persistent bloating and agony… I may have finally figured out the culprit… Check out this book: “The bloated belly whisperer” and ask your doctor about: Abdomino-Phrenic Dyssynergia (APD). I just realized I have it…after 7 years of trying everything under the sun.
PS: I am female
Pls i would like an opinion my stomach has looked as if i was pregnant for the past few years and docters tell me to work out and not eat to much food but i baerly eat food plus i have diabetes type 2 i dont have felling to eat
I misused laxatives for over a year and upon discovering the horrible side effects, I stopped cold turkey. Since then, my stomach is extremely distended and uncomfortable, no matter what I eat. the distention is a little less if I have a juice only diet. I had an mri, a colonoscopy and a home-kit sibo test what was administrated
and reviewed by a doctor. Everything is coming up negative. I too am at my wits end and this is starting to affect my mental health. I can’t seem to get answers. I would like an opinion as to what it could be. PLEASE HELP.
Ouch! Have you tried the FODMAPS diet? Maybe seeding your gut flora with good, raw sauerkraut and fermented foods? Really reducing the carbs? Have you checked out small bowel intestinal overgrowth (SIBO)?
My gut has been bloated ever since I lived in a mouldy house. It only seems to go away when I drink certain herbal teas and avoid foods that bind mycotoxins from my liver. I had banana for the past 3 days and now I’m very bloated. Vitamin C-enriched drinks bloat me too, I suppose because the C pulls bile out. I find eating yoghurt helps but nothing is taking away the bloat completely. I also have weird, vague pains, chills and feelings of feverishness after exercise or eating high-fibre foods. I’m sure there is something alien in my gut that is irritating it. I didn’t notice it before because I was fatter. Now my lower gut has shrunk and I can see the colon on both sides is inflamed and protruding through what should be an unbroken strip on both sides of my abdomen. I suppose it will not go away until all the toxins are gone and I rebalance my gut flora. I have been trying soil therapy with good results. This also really helps my mood, cravings and brain fog.
Have you looked into small intestinal bowel overgrowth (SIBO)?
https://www.healthrising.org/blog/2014/06/08/fibromyalgia-small-intestinal-bacterial-overgrowth-leaky-gut-connection/
https://www.healthrising.org/blog/2014/07/25/diet-drugs-herbs-sibo-one-patients-experience-pimental-approach/