Issue 1; August 2017 Dr. Rajiv Sharma attended medical school at Daya- nand Medical College, Punjab, India. He received his Undernourished, intelligence Internal Medicine training from Loma Linda Univer- sity, Loma Linda, California and received his Gastro- becomes like the bloated belly enterology Fellowship training from University of Rochester, Rochester, New York. Dr. Sharma trained of a starving child: swollen, under the mentorship of Dr. Richard G. Farmer, who is world renowned for his work on Inflammatory Bowel Disease. filled with nothing the body Rajiv Sharma, MD Dr. Sharma’s special interests include GERD, NERD, can use.” Inflammatory Bowel Disease (Crohn’s & Ulcerative Colitis), IBS, Acute and Chronic Pancreatitis, Gastro- intestinal Malignancies and Familial Cancer Syn- - Andrea Dworkin dromes. In an effort to share his extensive knowledge with the public, Dr. Sharma re- leased his first book, Pursuit of Gut Happiness: A Guide for Using Probiotics to Inside this issue Achieve Optimal Health, in 2014. In Dr. Sharma’s free time, he enjoys medical writing, watching movies, exercis- Differential Diagnosis 2 ing and spending time with his family. He believes in “whole person care” and the effect of mind, body and spirit on “wellness”. He has a special interest in nu- trition, exercise and healthy eating. He prides himself on being a “fact doctor” as Signs of a More Serious 2 he backs his opinions and works with solid scientific research while aiming to deliver a simple and clear message. Problem Lab Workup 2 Non-Pathological Bloating 2 Today’s Topic: Bloating Bloating may seem an odd topic to choose for our first newsletter. It’s a What are FODMAPs? 3 common condition, often overlooked by physicians and patients alike, but it can also be an extremely useful diagnostic clue. Many serious conditions may present with bloating as an initial symptom. The treatment of bloat- The Low FODMAP Diet 3 ing can also be very complicated; the underlying causes of bloating are varied and the treatment is often a change in diet or lifestyle rather than a drug. Food Intolerances 4 Bloating is defined as an uncomfortable sensation of tightness or fullness Infantile Colic 4 in the abdomen. It may or may not be accompanied by distension (an in- crease in abdominal diameter), flatus, belching, or abdominal pain. Irritable Bowel Syndrome 5 Because everyone has experienced bloating at some time in their lives it can be tempting to dismiss it as a simple, straightforward symptom, the etiology is actually quite complex however. While the sensation of bloat- Phone: (812) 814-3417 E-mail: [email protected] Website: www.dhagastro.com Disturbances in colonic microflora Differential Diagnosis Eating disorders (anorexia, bulimia) Evacuation disorders of the pelvic floor The following conditions may present with bloating: Functional diseases (IBS, functional bloating, functional dyspepsia, etc.) Acute infectious enteritis Gastroparesis Acute or subacute bowel ischemia (eg, left sided Irritable bowel disease (crohn’s or ulcerative coli- heart failure) tis) Aerophagia Medication side effect Ascites Parasitic disease (eg, giardia) Celiac disease Small bowel diverticulosis Chronic constipation Small intestinal bacterial overgrowth Diet Abnormal small intestinal motility (eg, blockage, Lactose intolerance scleroderma, diabetic neuropathy) Fructose intolerance Gluten sensitivity High intake of nonabsorbable sugars (eg, sorbitol) High intake of FODMAPs ing is often blamed on excess air in the excess solids/liquids or increased sen- beverages, drinking through straws, intestinal tract, this is actually a false sitivity of the bowels. Location also smoking, chewing gum, sucking on assumption in many cases (1). Excess matters: air in the small intestines is candy, and eating too fast. Patents intestinal air is only one cause of feel- much more likely to be experienced as with ill-fitting dentures are also more ing bloated; it can also be caused by bloating than air in the colon. likely to swallow excess air. Signs of a More This issue of the Digestive Health Unlike ingested air, gas produced by Newsletter will explore bloating as a gut bacteria is much more likely to Serious Problem complex and informative symptom produce bloating. that can enrich your knowledge of A patient that presents with the topics ranging from colic to irritable Lab Workup following alarm signs, in addi- bowel disease (IBS). tion to bloating, should be given Suspected food intolerance a further workup to rule out seri- The Causes of Ex- Breath test (for lactose or fruc- ous conditions: cess Intestinal Gas tose intolerance) Food diary Diarrhea Elimination diet While bloating is not always caused by excess intestinal gas, it is often at Weight loss Suspected small intestinal bacteri- least a contributing factor. There are al overgrowth (SIBO) Abdominal pain only two sources of intestinal gas: in- Breath test gested air and gas produced by gut Anemia Small bowel culture microbiota. Blood in the stool Imaging to look for predispos- Ingested air rarely leads to bloating ing factors such as diverticula Lack of appetite because it is quickly expelled either by Empiric antibiotics There are many ways to go about test- Fever belching or absorption. However, pa- tients with functional abdominal ing for SIBO. The gold standard, a Vomiting symptoms such as IBS are much more culture of the small bowel, is also cost- likely to have an impaired ability to ly and invasive so many practitioners Bloating that has a sudden expel or absorb excess swallowed air choose to use a breath test instead. onset (1). If your patient is experiencing ex- cess belching in addition to bloating it Signs of malabsorption (eg, Unilateral bloating may be beneficial to recommend that weight loss, anemia, steatorrhea) they avoid the following: carbonated CBC Celiac blood test abdominal adipose tissue can aggra- ile, the colon is populated by a large Upper endoscopy with duo- vate the sensation of bloating via me- and diverse population of microbes. denal biopsies chanical pressure on the gut as well as Undigested carbohydrates that make increasing gut inflammation which it to the colon are metabolized by Coexisting nausea and vomiting may increase bowel sensitivity to some bacteria into gas. Small bowel imaging pressure. In addition to beans, other high FOD- Gastric-emptying scan In addition to lifestyle modifications MAP foods include: there are also OTC products that may Coexisting diarrhea be helpful: Onions and garlic Stool studies Colonoscopy Beano breaks down the complex Asparagus, cabbage, and Brussel Imaging studies may be used to rule carbs found in beans and other sprouts out obstruction or conditions that may raffinose-containing vegetables. predispose to SIBO. Apples, pears, plums, and peach- Activated charcoal taken with es Non-pathological meals may help to absorb excess bloating gas. Wheat and rye Pepto-Bismol may not reduce the Cashews and pistachios Occasionally, a patient may present volume of gas, but it can reduce with complaints of minor bloating the odor. episodes that are primarily due to large meals and high FODMAP foods rather than pathology. What are FODMAPs? Beans are famous for their tendency to induce gas and bloating. This charac- teristic is due to their high concentra- “Foods high in tion of galacto-oligosaccharides and FODMAPs tend to fructans. These carbohydrates are ex- amples of FODMAPs (an acronym produce gas and referring to “fermentable oligosaccha- rides, disaccharides, monosaccharides bloating because and polyols”). Foods high in FOD- they feed the co- MAPs tend to produce gas and bloat- ing because they feed the colonic mi- lonic microbiome.” crobiome. While the small bowel is usually ster- Examples of low and high FODMAP foods. Table supplied by the Monash University website. http://www.med.monash.edu/cecs/gastro/fodmap/low-high.html These patients may be counseled to eat smaller meals and chew well in order to reduce the amount of undi- gested carbohydrate that reaches the colon. Foods high in FODMAPs, starches, and insoluble fiber are more likely to aggravate symptoms. You may counsel your patients to replace their starchy food of choice with white rice which does not produce gas. Additional lifestyle modifications such as weight loss, probiotic foods (eg. Yogurt 2-3 times per day), and exercise may also be beneficial. Excess The Low FODMAP Diet The low FODMAP diet can be a useful tool for the management of symptoms in IBS, IBD, small intestinal bacterial overgrowth, and even fibromyalgia. The presence of either unbalanced gut flora or increased gut sensitivity means that the patient will likely see an improvement in their symptoms when they limit or eliminate their in- take of FODMAPs. Rather than being a long-term solu- tion, the low FODMAP diet is meant to be used as a short-term elimination diet to help the patient identify which foods exacerbate their symptoms. It can also be helpful as a way to control symptoms while testing for bacterial overgrowth which should ultimately There are several types of anti-colic bottles on the market. All are be treated with antibiotics or antibacte- designed to limit the amount of air ingested by the infant. The rial supplements. The long term effects most effective anti-colic bottles are those that vent the air either of a strict low FODMAP diet have not been tested and it is best to address the through a straw (pictured above) or through a valve on the bot- underlying problem when possible. tom of the bottle. Patients interested in trying a low FODMAP diet to control their symp- proteins through the breast milk that 2) Allergenic foods (milk, eggs, pea- toms should be referred to a dietician the infant is intolerant to. nuts, tree nuts, wheat, soy, and . familiar with the diet. Alternatively, fish) (6) the book IBS: Free at Last by Patsy To reduce air swallowing, an infant Catsos M.S. R.D. L.D.