By Chirag Patel, MDBloating & Food Choices

Bloating & Food Choices

By Chirag Patel, MD

Belching, bloating and flatulence are some of the most common reasons why patients seek medical advice and dietary guidance. In many cases, this may be completely normal, but with increasing frequency and severity, symptoms can be rather distressing.

Belching is a normal process that comes from accumulated air in the stomach related to swallowing. This can either come back up as belching, or moved forward into the remainder of the gastrointestinal tract, eventually passed as flatus. Flatulence results from a combination of this swallowed air and gas produced by colonic microbiota. Bloating is a sensation of fullness or distension, mostly at the upper abdomen. Food or gas in the stomach, especially in abnormal amounts, can contribute to this sensation. The gutbrain axis can play as a large factor with this sensation as well. It is important to note that symptoms like melena, hematochezia or weight loss should raise suspicion for more aggressive or life-threatening etiologies. In such cases, there should be a very low threshold to refer to a gastroenterologist for further evaluation. Otherwise, there can be a large amount of overlap between these symptoms. Similar lifestyle and dietary interventions can lead to clinical improvement.

Everyone swallows air as a part of eating and drinking. Excess air can be swallowed with carbonated beverages like beer or soda and even with something as simple as chewing gum. In large amounts, this can lead to belching, bloating or flatulence. Eating large meals or eating rapidly can result in these symptoms as well. Avoidance can be helpful to mitigate some of these symptoms. Some carbohydrates, like cauliflower, broccoli, beans or cabbage can go undigested in the small intestine and eventually the colonic bacteria can metabolize them to gases leading to excess flatulence. Other foods that can increase flatulence include onions, celery, carrots, raisins, bananas, apricots, prunes, Brussels sprouts, alcohol and caffeine. When similar symptoms occur consistently with ingestion of dairy, lactose intolerance should be suspected early, especially given its high prevalence. The key to all of these is to identify the triggers and to use trial avoidance to seek symptom relief. Multi-day, food diary logging timing of types of foods ingested, along with timing and types of symptoms experienced, can be very helpful to identify potential dietary triggers.

Constipation can sometimes contribute to these symptoms and can usually be detected upon further symptom review. Treatment can many times lead to resultant improvement in bloating or flatulence symptoms as well.

Beyond these avoidances and constipation management when necessary, ongoing symptoms may indicate the need for a gastroenterology consultation. Imaging, laboratory testing, breath testing for small intestinal bacterial overgrowth and endoscopic evaluation can all play a further diagnostic role. The role of food allergy testing is unclear, and currently testing is not recommended for these symptoms in particular. As you can imagine, expansive workup can be quite costly and many may choose to seek further dietary modifications via specialized diets like Low FODMAP (low in fermentable oligo-, di-, and monosaccharides and polyols), elimination diets or a low residue diet. These specific diets are best executed by a consultation with a registered dietitian and with supportive data to suggest superior clinical outcomes versus physician consultation alone. Of these, a Low FODMAP diet is one of the most popular recommended diets from a gastroenterologist, especially when a case of Irritable Bowel Syndrome (IBS) is suspected. Patients with IBS have shown to be sensitive to even the slightest increase in intestinal gas and sometimes even a normal amount of gas. They may

have additional symptoms of abdominal cramping, constipation and/or diarrhea. The Low FODMAP diet has shown to be an excellent cost-effective option as an initial “best step” in management and evaluation. This is especially true in younger and otherwise healthy patients without “red flag” symptoms like melena, hematochezia or weight loss. High FODMAP foods include other shortchain carbohydrates that are poorly absorbed in the intestine as well, leading to rapid formation with gas production and often with resultant symptoms of bloating. Some examples of these are foods that contain fructose like honey, high-fructose corn syrup, apples, pears, mangoes, cherries and wheat. The FODMAP diet involves elimination of these foods for 6-8 weeks and then, upon symptom improvement, slow categorical reintroduction of foods helps to identify intolerances or triggers contributing to symptoms.

Belching, bloating and flatulence are incredibly common. In the absence of red flag symptoms, initial management may involve avoidance of carbonated beverages, chewing gum and poorly digested carbohydrates. Constipation should not be overlooked, as it can be simple to treat in many cases. Diets like the Low FODMAP diet or elimination diets with consultation of a registered dietitian, especially in young and otherwise healthy patients, may be a reasonable next step. Otherwise, additional workup and medical management with a gastroenterologist can be helpful to diagnose and treat alternate etiologies like GERD, Helicobacter pylori, peptic ulcer disease, gastroparesis, bacterial overgrowth and more.

Chirag Patel, MD is a Gastroenterologist in Bexar County and a member of the Bexar County Medical Society.