Bloating, belching and general gassiness are associated with a variety of conditions, and are a common reason to visit a primary care office. These symptoms are often caused by functional gastrointestinal disorders (FGIDs).
FGIDs are characterized as disorders of gut-brain interaction. This can involve disorders of gastrointestinal motility and visceral hypersensitivity, which are often worsened by stressors.
The most common of these disorders are functional dyspepsia, irritable bowel syndrome, and chronic idiopathic constipation. Sometimes the symptoms occur secondary to overgrowth of certain bacteria which are prone to cause stomach ulcers (i.e. Helicobacter pylori/ SIBO). Furthermore, symptoms can also be caused by food sensitivities and malabsorption syndromes such as celiac disease or lactase deficiency. Finally, symptoms may be attributed to issues with defecation, where constipation is a predominant concern.
Your primary care doctor can limit the usage of extensive, invasive testing and help resolve your symptoms by lab testing, and avoidance of causative agents. If a bacterial overgrowth is of concern, antibiotics may be used to help improve symptoms.
What is bloating?
Bloating is a sense of gassiness or of being distended, at times, although not necessarily, associated with visible increase in abdominal girth. It is thought that these symptoms are a sensory phenomenon within the small intestines. Not all patients with symptoms of bloating produce excessive gas. Symptoms may be correlated with a decreased pain threshold and increased sensitivity.
Belching can be an associated symptom of FGID, but the process is often unrelated to bloating. Belching is the release of excess gas from the stomach, and is thought to occur secondary to excess air swallowed during eating or chewing.
Flatulence is the release of colonic gas and is usually related to dietary intake. excessive flatulence is also not directly correlated with bloating, but may indicate that the gut flora is having a tough time digesting the foods consumed.
When researched, these symptoms coexist with anxiety and depression and during an acute flare up, symptoms of FGID can be exacerbated. I want to point out that mental health issues are not the cause of functional gastrointestinal disorders.
When to seek medical attention?
Your primary care physician is always by your side. If your symptoms are bothersome, your family doctor can help you evaluate the root cause of your concerns. The framework of diagnosis can take numerous visits, but establishing a trusting relationship is key to help control your symptoms.
Patients often believe their symptoms are not appreciated, so continuity of care is important to provide a thorough evaluation and simultaneously accept the limitations of therapy. Patients are encouraged to engage in effective self-management with the guidance of their physician.
Alarming symptoms
Gas, bloating and belching is quite common, but it is important to know when to dig deeper and consult a specialist for further invasive testing.
If patients are concerned with unexplained weight loss, difficulty swallowing, gastrointestinal bleeding, unusually severe symptoms such as extreme diarrhea, or new-onset symptoms in older adults with previous history of cancers or abdominal surgery, then more urgent evaluation is warranted.
How are your symptoms evaluated?
The patient-physician relationship is important, and it is important to categorize symptoms to help prevent confusion in making a diagnosis.
Patients are encouraged to keep a food journal to help provide a detailed dietary history. It is important to distinguish timing and patterns of eating, along with the food content consumed.
The physician can utilize this information along with a thorough history to determine patterns associated with symptoms of functional gastrointestinal disorders.
A rule of thumb when evaluating FGIDs are asking two simple questions:
Can you eat a full plate of food?
Do you regularly have a good bowel movement?
This allows the physician to categorize your symptoms to distinguish between gastric issues vs small bowel issues. Furthermore, if symptoms are associated with constipation, you may need further evaluation via a physical examination or more invasive testing to evaluate an issue with defecation.
If symptoms are isolated to purely belching and not associated with gassiness, bloating or bowel movement irregularities, then often no further testing is necessary and recommendations may be to adjust eating patterns and perhaps a trial of empiric acid suppressive medications can help. Consult with your primary care physician or gastrointestinal specialist for further recommendations.
What is the initial therapy for Functional Gastrointestinal Disorders?
Patient's can play a major role in self- management by optimizing their eating patterns and lifestyle. If symptoms have still not improved, then medications can be prescribed or recommended to help alleviate the concerns.
Diet:
- Eat in moderation
- Consume adequate fiber intake
- Decrease consumption of fatty and spicy foods
- Avoid caffeine
- Avoid soft drinks and carbonated beverages
- Avoid artificial sweeteners
For patients with concerns of food sensitivities or malabsorption syndromes such as celiac disease or lactase deficiency, avoid causative agents. This can include gluten, and lactose, as consumption of these products can exacerbate symptoms of irritable bowel syndrome.
FODMAPs
Foods containing a variety of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) may worsen symptoms in certain individuals. Some patients find relief of symptoms when avoiding or restricting these foods. It should be known that the routine use of highly restrictive exclusion diets has not been well studied and is generally not recommended. Once again, consult with your physician to prevent malnourishment.
Foods containing FODMAPs:
Oligosaccharides (Fructans) - Large amounts of wheat and rye, onions, leeks, zucchini
Disaccharides (Lactose) - Diary products, cheese, yogurt, milk
Monosaccharides (Fructose) - Honey, apples, pears, peaches, mangoes, fruit juice, dried fruit. This is bothersome in some individuals when consumed in excess.
Polyols (Sorbitol) - Artificial sweeteners, sugar-free gums, apricots, peaches
Galactose (Raffinose) - Lentils, cabbage, brussels sprouts, asparagus, green beans, legumes.
Probiotics:
Probiotics in general help balance a healthy gut flora, especially Bifidobacterium infantis, which can help improve gas and bloating in IBS. This may also help chronic idiopathic constipation.
Exercise:
Regular daily exercise decreases symptoms of FGIDs. When we optimize our lifestyle, it is important to maintain an exercise regimen. Start at your own pace, but daily activity has been shown to benefit most diseases in general.
Fiber:
Soluble fiber (psyllium) provides a small benefit for some patients with IBS, but in others it can also worsen bloating.
Insoluble fiber (bran, methylcellulose, calcium polycarbophil) is somewhat more effective for chronic idiopathic constipation. This can also worsen bloating and flatulence in some people.
When adding fiber to your diet, it is important to increase fiber intake gradually to minimize symptoms of bloating, distention, flatulence and cramping.
Worsening of gas and bloating may be secondary to underlying issues with defecation and should be evaluated further.
This is once again a reason to keep a food journal to truly understand what improves symptoms.
Osmotic Laxatives:
Polyethylene glycol is the osmotic laxative best studied and is considered most effective in chronic idiopathic constipation. Other laxatives include lactulose, sorbitol, and mannitol.
If you are requiring additional assistance to maintain a regular bowel movement regimen, this should be done under doctor supervision.
Medications:
If one were to optimize their eating patterns and avoid foods that may worsen symptoms, then FGIDs are often tolerable and controlled. If one has continued to have bothersome symptoms, your physician may prescribe medications.
Medications are available that help with diarrhea dominant IBS, or abdominal cramping associated with FGIDs. At times, especially with co-existing mental health concerns, then ask your physician about medications that work on both conditions to limit the need of excessive medications.
Bottom Line:
Symptoms of bloating, belching, gas, or increase flatulence can be managed often on your own by optimizing your lifestyle. If they become bothersome, build a trusting relationship with your primary care physician and understand that these issues can take some time to improve.
There is no magic pill, and these symptoms often don't occur overnight. They also don't improve overnight.
The best strategy is to keep a food journal, optimize your eating patterns and lifestyle, and try to understand what can be the driving force behind your functional gastrointestinal disorder.
We at Florida Advanced Medicine are here to help with your digestive concerns. The goal for a visit at our office is to establish care. We take that very seriously. Family physicians aim to manage health over a lifetime, and with every visit, we keep our goals in mind to help tomorrow be better than today.
Primary care medicine focuses on prevention. We are leaders in general health, and emphasize screening modalities to ensure our patients receive optimal health care. We are trained to take care of all age groups and genders.
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