2.0 Bloating and Gas (flatulence)

This is an overview of Bloating and things Gassy and gives you all of the background knowledge that you need to understand your problem. Our Diet Treatment Plans specifically are targeted to which symptoms you have whether they be Bloating alone or Diarrhoea/Constipation with or without Bloating.

The sensation of bloating is a very common problem and can be very, very distressing, either directly or through the pain/discomfort that it can cause.

Bloating is a complicated subject because there are different types and some are easier to deal with than others- some are very sensitive to diet and what we eat, others are not.

2.0.1 Some important points

Before talking about bloating (some of us describe it as “hardness” or “tightness”) and things “gassy”, four important points:

2.0.1.1 We all pass some gas and this gas is a normal by-product of how our guts digest certain foods

2.0.1.2 Looking down on our tummy, it is normal for it not to be absolutely symmetrical

2.0.1.3 Many women do have an extra pad of fat below their belly button which looks like bloating, but it isn’t!

2.0.1.4 A bloating sensation is common and normal around period time

2.1 There are different types of Bloating (very important)
We need to be very precise with the words “Bloating “or “Gassy”. Getting an exact description of the bloating is key to seeing how it can be helped. There are four situations that we commonly describe:

2.1.1 The whole tummy gradually blowing out over the day to make us look almost several months pregnant. This can be with or without excess farting.

2.1.2 The lower tummy swelling out, especially around period time

2.1.3 A sensation of being very full or bloated, even if the tummy looks more or less normal

2.1.4 The tummy blowing out like a balloon immediately on eating (even drinking water), like a reflex to eating; as quickly as if someone threw on a light-switch

2.2 Other points about bloating
Many people may also pass excessive gas (flatulence/farting), in addition to having a bloated sensation. This flatulence is a very important problem because it is caused entirely by things in the diet and so can be solved by taking extra care with what we eat.

Air that is burped up is caused by a different thing to flatulence- although it can be due to certain foods (e.g. onions, cabbage etc.), it can also be due to acid-reflux (even when there is no heartburn) and even getting into the unconscious habit of swallowing air and then bringing it back up (a condition linked to this is called "rumination" syndrome and is cured by learning how to do "diaphragmatic breathing").

A feeling of fullness in the upper tummy, immediately on eating, is not really "bloating". It is best described as being a "fullness". This may seem like splitting hairs but, it is often due to the stomach emptying slowly and so is treated with a diet avoiding oily/fatty foods (it doesn't matter whether the oil is finest virgin olive oil or a kebab!), alcohol, chocolate and caffeine.

2.2.1 Pain and Bloating
The reason that gas causes us to be uncomfortable, or to have even severe cramps, is because of how the nerve endings in the gut work.

The nerves to our skin are very sensitive and send a very precise message to the brain. If you prick your finger with a pin, you know exactly which part of which finger of which hand. But, if there were a way of opening up your tummy and sticking a pin into just your bowel, you wouldn’t feel it, not even one little bit! This is because the nerves are of a different type- a good thing because otherwise we would feel every mouthful of food going down the gut.

What the bowel does have though are nerves that sense “stretching”. Excess gas stretches the bowel, the nerve endings send a message to the brain and we feel "something". It is often difficult to explain to someone else exactly where this pain or discomfort is; again, this is because the nerves send a vague message. Everyone struggles to describe these symptoms!

2.3 Tests that I need for Bloating

It is always important to get tests done to make sure that there is nothing else, other than gas, going on. They are:

2.3.1 Bloods: Full blood count; Kidney profile; Liver blood tests; Thyroid Stimulating Hormone; Calcium level; Ferritin; CA125 (women only) and a Coeliac screen. Note: There is NO role for blood “Intolerance” tests.

2.3.2 Stools: qFIT (to look for hidden blood); Faecal Calprotectin (for bowel inflammation) and if you have been traveling or have acute diarrhoea, Stool culture/sensitivity.

2.3.3 Scan: An ultrasound of Abdomen and Pelvis

All of these tests are very standard and your GP should be able to arrange.

2.3.4 Special tests for Bloating and Flatulence
The key driver for some forms of bloating/flatulence is how the gut digests certain types of food. So, the main tests focus on this.

The tests ask the question "How good is my gut at digesting "Food A", of “Food B”, or “Food C” etc. etc.? These are tests of gut “function”- literally. So, you could say that they are "practical" tests. The main type of test is the “Breath” Test. Very uncommonly a series of blood tests, or a gut biopsy taken at endoscopy can be done.

None of these tests have anything to do with "Allergy". Apart from a blood test for coeliac disease (gluten "allergy"). Allergy tests are rarely needed for Bloating or IBS. Please read about the difference between an "Intolerance" and an "Allergy".

Breath Tests are where you drink a special, specific sugar-syrup, wait to allow the gut to digest this, and then blow into collection tubes every 15 minutes or so, to check for hydrogen or methane gas. They give information on how the gut handles dairy (lactose) or fruit / vegetable (fructose) sugars. These tests can be done in kit form at home; each one takes about 3 hours.

Such tests can be difficult to get done as they are quite specialized. Some Labs offer a postal kit service. But, don't worry about it if they are not available to you locally; they are not absolutely necessary as we can “challenge” our guts with some foods- a sort of "home-made" test e.g drinking a glass of milk (~200ml) or eating a half or full tablespoon of honey will act as a challenge for lactose and fructose respectively.

Moving away from food for the moment, another type of Breath Test (after drinking a man-made sugar called "lactulose") checks for “Small Intestinal Bacterial Overgrowth” (SIBO)- a slightly grey area of knowledge. There is another test for SIBO done after drinking some glucose rather than lactulose. Nobody knows which is better, but if you have to choose one, then lactulose is the one to go for.

With SIBO, it is thought that the relatively small amount of NORMAL bacteria in the Small Intestine begin to grow in number and so the foods that we eat meet bacteria earlier than they should. The bacteria can digest (ferment) foodstuffs and produce gas as well as laxative agents called "Free Fatty Acids".

The reason that SIBO is a "grey" area is that if you actually go looking to find these excess normal bacteria in people with “positive” breath tests, you actually only find them in a tiny number. Yet, giving antibiotics can help some people’s symptoms. Confusing??!

One theory is that, rather than identifying bacteria that are moving up the bowel, the SIBO breath test is just picking up that food is moving DOWN more rapidly (called fast transit). This fast transit is one reason why changing to a non-fermentable diet can help- don't give the bacteria what they like!

We've mentioned "sugars" a lot in this section. This has nothing to do with the "ordinary" table-sugar by the way! It is all discussed under the About Foods tab.

2.4 Treating Bloating and Gas (flatulence)

The treatment of Bloating is very much dependent on the type of Bloating. Targeting Diet can be excellent for some kinds and simple medications (simethicone, peppermint oil) can help some people. Diaphragmatic breathing, a form of Cognitive Behavioural Therapy, can help “Reflex type” Bloating. Beyond these, less common treatments include anti-histamines (fexofenadine), sodium cromoglycate which has been used in asthma and is a “Mast cell stabilizer” and the dietary supplement, Quercetin.

When we have Bloating and Constipation, strangely, treating the Constipation often does not help with the sense of Boating.

2.4.1 How good is Diet at helping Bloating?

Put simply, this is likelihood of helping:

Bloating + Gas (Very Good) > Bloating that builds up over the day but, no gas (Good) > Constant bloating with no gas (just OK) > Period related bloating (no help) > Bloating that comes on like a reflex (no help).

2.4.2 What sort of foods can trigger Bloating and Gas?

The main types of food to cause Bloating and Gas are all the ones that we are told we must eat more of! It is high fibre foods and certain vegetables (broccoli, cauliflower especially), pulses (brown, red and white beans, chickpeas), dried fruits and some fresh fruits (bananas, depending on ripeness) and then for some people, honey, agave and milk. So, breakfast with high fibre cereals and dries fruits can be a big cause.

This is just an overview and the Devil is in the detail so our Diet Treatment Plan will give tell you everything that you need to know.

2.4.3 Medications for Bloating

Medications generally are not the answer for bloating, though worth a try and do help some.

2.4.3.1 Simple medications: Charcoal and Simethicone have traditionally been used for things gassy, but don't work for many of us. Worth a try, but don’t be surprised if they don’t help! Mebeverine (“Colofac”) and Hyoscine (“Buscopan”, not available in USA) can help with the cramps that may come with it. Mint oil, however, certainly helps bloating in some people and may also help any associated cramps (though occasionally you can get acid reflux or burping whilst on it).

2.4.3.2 Antibiotics (such as metronidazole, co-amoxiclav or Rifaximin) can help bloating/flatulence due to “Small Intestinal Bacterial Overgrowth (SIBO)". If you have had a Lactulose Breath test and it has picked up hydrogen production, Rifaximin or metronidazole can be prescribed. If methane production is found, then neomycin, a non-absorbable antibiotic, is used. (The anti-cholesterol drug lovastatin can also block methane production- not available in UK)

2.4.3.3 Anti-depressants: Those of us with just a sensation of bloating, but no huge swelling, can find that low doses (anything between 10mg and 50mg, once daily in the evening) of the medication Nortriyptyline can help. It works presumably through making the nerve endings in the bowel less “sensitive”. Its sister drug, Amitriptyline, is more commonly used but is more likely to cause constipation and slight drowsiness. That having been said, bloating is not a very common use for this type of drug; they are more usually used in IBS for pain (alone or residual pain after constipation has been relieved), or especially, diarrhoea with pain.

It is important to say that although nortriptyline/amitriptyline are often used as anti-depressants, this is at a much higher dose. So, an example of one drug with two effects on the body depending on how much is used- another example is aspirin where a high dose is a pain-killer but a low dose "thins" the blood.

2.4.3.4 GC-C agonists: Linaclotide, a medication used for difficult constipation, has been shown to help bloating when it occurs with constipation (dose in USA trial was 145mcg daily; the dose available in the UK is for some reason 290mcg tablets). It doesn't have a licence for use to target bloating by itself though. Prucalopride, Lubiprostone (both available in UK) and Plecanatide (USA, not UK) can help Bloating but to a lesser degree than linaclotide. Again all are licenced for treating constipation, not Bloating alone.

2.4.3.5 Anti-histamines: medications such as fexofenadine, and also the mast cell stabilizer, Sodium Cromoglycate are used when the Bloating is not responding to Diet and all the tests have been done (Bloods and Ultrasound) and are normal. The supplement Quercetin is often added. This approach is targeting allergic type mechanisms as being a cause for Bloating.

2.4.4 Good bacteria (probiotics): These can help some people with the sensation of bloating, but they don’t work many. There is no good proof that the most commonly advertised “good bacteria” products do anything. Listen to the ads carefully- they dont actually say anything very specific! NICE (a UK government advisory organization) suggest that if you are going to try probiotics, do it for about 4 weeks- if nothing happens by then, best to stop; if they do work though, then carry on.

Some probiotics with the best clinical evidence for working are: Alflorex (Align in USA); Symprove; VSL#3 (Visbiome in USA) and Lab4 Consortium.

Probiotics probably work for about one person out of every eleven (and they're not cheap!)

One other thing in respect of the whole subject of "good bacteria" is what are called "PRE-biotics". These are dietary supplements that encourage the growth of favourable bacteria. They may not be good for those of us with bloating / gas, as they contain poorly digestible carbohydrates and may actually worsen things. Do look at the list of contents on probiotics as they can contain these substances too.

2.4.5 Alternative and Complementary medicine
Some of us find alternative therapy to be helpful; up to 50% of us with IBS do try something different. It is difficult to know what works but certainly, as with most treatments, some things work for some people and not for others.

In using alternative approaches, it is important to think about the balance between the costs (which you will have to pay), any potential side-effects (which you will have to put up with) and likely benefits.

It is important to be especially cautious in using some alternative medications, in particular Traditional Chinese herbs and Ayurvedic medicine: herbs can be contaminated with heavy metals (e.g. lead) and up to a quarter of Ayurvedic medicines available can be spiked with other drugs.

Also, do not use non-prescription drugs (even as creams) during pregnancy and avoid them if you are on other medicines as there might be interactions.

Green Tea Extract (a concentrate, not the tea we buy in ordinary shops) can be toxic for the liver. Herbal remedies should be avoided in anyone with liver disease.

Honest and un-biased information about alternative medication is available from the American website: www.ConsumerLab.com

In the UK, NICE says that treatments such as Aloe vera, Reflexology and Acupuncture are to be avoided.

That having been said though, there is some evidence that Aloe vera works for IBS (at the risk of diarrhoea) and it is possible that acupuncture could help with IBS-related pain though not helping other problems like diarrhoea/constipation, bloating etc.

So, what works? There are some “good” data from what are called Randomised (Placebo) Control Trials (the most informative type of research study done on drugs where one group takes the "drug", another a "placebo" but no one knows which group they are in) to show that these agents can work for some people:

• Atrantil; Allicin; Berberine; Quercetin