Episode 14: Why are you bloated?

As part 2 of our bloat series (go back to episode 13 for part 1), let’s talk about the reasons you may be bloated…

While this episode is full of valuable information that may help you learn more about your body, remember that is simply information. Take this to your trusted healthcare provider to determine what’s going on in your body and what your plan of action will be.

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Welcome back to The Gut Show! I'm Erin, your host, and I'm thrilled for today's episode, because this is something I get asked about almost every single day, and that is, why am I bloated? So we're going to uncover what happens to cause bloat, so different reasons why you could be bloated, and then some of the different causes of that type of bloat. And then whenever we break those down, we'll talk a little bit about what's going on with those different conditions or situations so that you can decide if that is something that you want to explore with your healthcare provider or not.

We're not going to go into specific tips for bloating, because it is going to be personalized depending on what is actually going on. If you're looking for actual care, personalized care for your bloating, know that we can help you in our practice or help find the right referral for you. You can schedule a consult call and be able to chat with us about what's going on to see if we would be a good fit.

For today's episode, let's go dig into what bloating truly is, what could be going on, and then how to determine what might be the cause for you to begin to explore. So when we're thinking about bloating, it's a very generic term that can be hard to define. So there's no clear definition for what bloating technically is, so it can be a little bit subjective to the person that's describing it. Typically, when we're thinking about bloating, we're thinking about that feeling to the feeling of fullness plus distension.

Distension is when the stomach is actually out, when there has been a stretch of the stomach, there's actually an increase in size, if you will, it's called distended. You do not have to be distended in order to have bloat, you can also be distended and not really be bloated. So there's a lot of different pieces to this puzzle that we want to think about as we dig deep. Some of the things that are causing bloat, or the reasons for bloat is fullness, gas or water. So whenever you eat a large amount of food, and you are full, that food has to go somewhere, so it starts in the stomach, and the stomach lining begins to stretch.

The stomach churns, produces acid, breaks foods down, and then sends it into the small intestine. This may not happen super fast and so when you're eating a large amount of food in a short amount of time, that stretch of the stomach can get really intense and that can cause that feeling of fullness and even actual distension and bloat. Whenever that food thing then goes into the small intestine, the same thing could happen as well as the large intestine. And so it's important to know that large amounts of food and excessive fullness could be a major reason for bloat, it's typically going to be one of the most common reasons for bloat. And some situations, which we'll dive into in a little bit, that fullness can happen more quickly, and so it might not actually seem like you're eating a large amount of food like Thanksgiving dinner or you know, getting takeout late at night or something like that, but you still might experience that fullness because some of the mechanisms of the digestive tract in the stomach might not be working properly like they need to.

The next reason for bloat is gas, so excess gas production. So our bacteria in our large intestine, they ferment foods, ferment carbohydrates, and they produce some really beneficial byproducts like short chain fatty acids, they also produce gas. So that is where our gas comes from whenever we're passing it. That gas can also stay isolated in the intestines, and so whenever the gas is produced, the large intestine that's going to stretch, right? So if you fill a container with gas and it’s going to have to stretch, think about like a balloon. And so with that stretching, that can lead to actually distension, it can also lead to that feeling of fullness, especially in conditions where we have an increased hypersensitivity, or those sensations of the gut stretching can be pretty significant, and can be perceived, as you know, painful, uncomfortable, more distended than you truly are, right. So that would be gas production, and there are certain reasons why there might be excess gas production that we'll dive into.

The third one is water, so water in the gut. So this can either be from drinking a large amount of water at once, which really goes more into our fullness category. Whenever we're looking at water, we're thinking about water being pulled into the intestines, and causing the intestinal wall to stretch. So we see this a lot with IBS and fodmaps, where fodmaps can pull water and it's supposed to slowly small carbohydrate molecules, and that could be one reason why, there could also be some other reasons why there may be excess water coming into the gut.

So whenever we're thinking about bloating, we're thinking about the intestinal walls somewhere along the GI tract expanding either due to fullness, gas, and or water. So then going a little bit deeper into what can actually be driving some of these things to happen, and what are the characteristics that we're looking for? So let's think about the placement of the bloat first, and then as we break down the different causes we'll talk about whether that is a fullness, a gas, or water situation. So let’s first thing about upper abdominal bloat. So think about kind of above the belly button, usually between the rib cage and the belly button. So when you're feeling fullness or noticing distension in the upper abdominal area, and there are a few different causes that typically will overlap.

The first one is called gastroparesis, this means that the stomach empties slowly. So remember, the food goes down the esophagus into the stomach, and the stomach churns like a washing machine and produces stomach acid, gastric acid, that breaks down food, and then the mechanical breakdown from the churning gets it you know, all mushed together and forms what we call bolus and it goes down into the small intestine. So whenever the stomach either isn't churning, or acid isn't being produced, this can lead to slow stomach emptying. So if we think about a little like thought funnel, like a cone funnel, the ones that you would put on top of maybe like a bottle that you're filling, right, so we got a little funnel, if let's say that funnel opening is very small, or for some reason, maybe it's blocked up, and it's not ending very fast, it's not going to take long before the thing that you're pouring in to start to overflow, right, you're going to fill your funnel more quickly, and you're probably gonna have to stop, wait for it to empty and then refill it. So with gastroparesis, it's a similar thing where the stomach isn't emptying enough, so the food coming in is going to fill the stomach more quickly and either overflow, so come back up, or just feel so full that there's nothing else that you can put in so you have to stop. So this is a fullness issue, and typically it's going to happen with small portions of food and even drinks, where you feel excessively full quickly. And then maybe within you know, an hour or when the stomach finally empties, you may feel extremely hungry, because all of that stretch that was present that was telling you you're full, now it's completely gone away, and now you're hungry again. Sometimes this is going to be accompanied by constipation because food is moving slower through the GI tract. Typically it will also be accompanied by upper GI symptoms like reflux, or even vomiting in severe cases.

Another reason for this upper abdominal bloat, can you what we call dyssynergia. So this is abnormal coordination of the muscles of the abdominal wall and cavity that are going to be involved in the flow of food as well as with the diaphragm and how it moves and nerve responses. So typically, this is going to be accompanied by constipation, and may actually be accompanied by, again that upper abdominal symptom, like maybe some reflux or GERD. With this one, there may be a pelvic floor physical therapist involved in the treatment, there's going to be some overlap with the treatment of gastroparesis, and so it's really important to be able to identify and kind of monitor your symptoms to make sure that the pieces of the puzzle are coming through, but you could get a muscle assessment done by a pelvic floor physical therapist that specializes in this area to see if this could be one of the problems in play. And there also maybe kind of nerve modulators that could be used for this and then, you know, the food side really does overlap with gastroparesis.

If you're having upper abdominal bloating that's accompanied by a lot of belching or like burping, then that could be indigestion or aerophagia. So indigestion is, you know, reflux, GERD, all those kind of go in there, it's where things come up, and so there could be a reason why things are coming up. And it could be accompanied by the bloat, you know, that could overlap with gastroparesis as well. Aerophagia, which is really common is swallowing of air. So indigestion is most likely going to be an issue of like the fullness more so or specific trigger foods, which is a little bit different. Aerophagia is going to be a gas issue, it's where you're swallowing air, so a different style of gas, it's not gas production, necessarily, but it is air. And so if you're swallowing air, and you're more sensitive to that, then you might be dealing with upper abdominal bloat that also is accompanied by belching and burping. One way that you can note this is having kind of an assessment done to see how you are eating and drinking, and then monitor and kind of adjust some of those different things, and that can help a lot.

If you have bloating without dissension, so upper abdominal bloating that's not distended, so there's no significant change in the size of the gut, the size of your body, right, this could actually be due to functional dyspepsia, and so this is something that has an unknown cause. So it's kind of like an upper abdominal bloat without known cause, and it really is that feeling of fullness without the change in like bowel movements, without the change in the size of the stomach and without acid production. So indigestion is usually going to be accompanied by acid, whereas functional dyspepsia is typically not going to be accompanied by acid production. And, you know, this one could be caused by H. pylori, which is a sort of bacterial kind of infection, if you will, or low stomach acid, or even excess serotonin, so kind of getting to the root of what might be causing it, like what could be going on, and then tailoring the treatment to that can be extremely beneficial.

So that that kind of covers some of our upper abdominal bloating and that you may be dealing with. So now let's shift to lower abdominal bloating or full belly bloating, so not just in the upper abdominal region, but the lower abdominal region plus the upper abdominal region in some cases. One of the most common causes of lower abdominal bloating is constipation or stool burden. So the constipation, the colon, which is the kind of the bottom of the GI tract is full. And so it's either full because it's not emptying properly, things are moving too slowly, maybe some diet and lifestyle behaviors going on, there could be pelvic floor issues. So whenever you have constipation, or what we call stool burden syndrome, which means you are just full of stool, that stool is gonna actually cause pressure up. And so what can happen is the stool sitting there might over ferment, and that's gas production, that pressure might cause a feeling of fullness, and so with this, you could get more of the feeling, you could also get the distension. The thing that you would want to check on is just monitoring bowel habits and making sure that the constipation is resolved and typically that will also resolve the bloat. Usually what we're going to see here is we're going to see worsen bloat with worsen constipation. And so whenever a good bowel movement happens, and it seems like the bowels clear out, and there's less stool burden, then there's going to typically be less bloat and if there is more stool burden, less bowel movements and there might be more bloat.

Another reason for this would be SIBO, which is small intestinal bacterial overgrowth. So this is where we have lower abdominal bloating, and we have significant distension that looks almost like the pregnant belly. So remember our dyssynergia, which kind of originates in the upper abdominal region, it can also cause this pregnant belly bloat. So these can be a little bit hard to differentiate from, but thankfully, we can actually test for SIBO so it's something that we can rule out. Usually, it's going to start lower and then it's going to increase upper and be kind of more full, full pregnant belly looking bloat. With SIBO, the bacteria from the large intestine have made their way to the small intestine. So remember, remember I mentioned earlier that bacteria ferment carbohydrates and they produce byproducts and gas. So these bacteria are doing their job, they are just doing it in the wrong place, so they're producing gas earlier on in the GI tract. And so we're going to have excess gas production and have gas produced in the place it typically is not, which is why that bloat might be higher up as well.

And so this one, it's going to be related to the gas production, and with that bacterial overgrowth, you have to eradicate the overgrowth, and then be able to get to the root cause of what caused that overgrowth in the first place to really get the bloat under control. Usually, we're going to see this worse at the end of the day, and we're typically going to see some change in bowel habits. So the most common type of overgrowth is going to contribute to diarrhea, and some less common types might contribute to constipation or kind of a mixed type, but you're usually going to see some sort of altered bowel movements, and then you're usually going to see the symptoms worsen throughout the day versus start at the beginning of the day, or be very up and down. This could be different depending on the diet and like changes that are being made either consciously or subconsciously, so you would want to be evaluated for this. You can get tested through a breath test, which is really helpful. Another reason for lower abdominal bloat would be excess gas production through carbohydrate intolerance, which would be like lactose intolerance or other specific carbohydrate intolerances, and that's usually where the enzymes that break those carbohydrates down, either aren't being produced or we don't have enough of them.

With the carbohydrate intolerance, may see excess gas, and usually we're also going to see a change in bowel movements, we might see pain, and then usually the bloating is going to be related directly to that food that is not being properly broken down. So this is where we might see kind of a random bloat occurrence, we're seeing it most often with those specific foods, versus it feeling like something that's every single day or happening no matter what you eat. And with the carbohydrate intolerance, IBS kind of goes in there, so we get throw IBS in next, which is irritable bowel syndrome. This is where we have that change in motility, we also are going to have some gut brain issues. Typically what we see is those with IBS, might have a little bit more gas production, they may have some carbohydrate intolerances or sensitivities and things going on. And so we might see those overlap together, and that could be a reason for that bloat. With IBS, the bloating can happen really anytime. So you might wake up with bloat that then resolves and it can change, and the characteristics may be all across the board, which is why good data is important for getting the right diagnosis to figure out exactly what is going on.

Another reason for some lower abdominal bloat will be celiac disease or pancreatic insufficiency, and this is usually going to be accompanied by malabsorption. So you may see undigested food in the stool, that could be a sign. Also, if you have some nutrient deficiencies, or something like that keeps coming on, weight loss, that could be a sign that there's a malabsorption issue, and that could also be with bloat. And that can be water pulling into the gut can also be some gas production or even inflammation, so that's something that you definitely want to look into and make sure that we're dealing with this on an ongoing basis, if you know that you're dealing with signs of malnutrition, or malabsorption, then making sure that we're ruling out some of these conditions. Celiac disease, it's an inflammatory disease, and gluten is removed from the diet completely and that can usually resolve the symptoms that are accompanied by that. And then with pancreatic insufficiency, that's where enzymes aren't being produced well, so pancreas isn't doing what it needs to be doing so enzymes are typically supplemented. You can get tested for both of those and get those ruled out.

There are other reasons why bloat could happen, these are the most common reasons why and things that we kind of want to lay out and look at whenever we're assessing a patient that is dealing with bloating, and so some things that you can start to do and kind of look for and log to then be able to understand and communicate your bloat well to your healthcare provider to see what might be causing it would be the area that the bloating is happening. Is it happening in the upper abdominal area, that lower abdominal area? Does it start in one area and then worsen? What are you noticing with the area?

The time of day that it typically occurs. Is there a clear pattern where it's every single night? Is it every day after lunch? Is it first thing in the morning? Is it no one specific part of the day but, all over the place? And being able to kind of know is there any sort of pattern or complete lack of pattern in terms of the time of day?

Is it soft or hard to the touch? So if you touch is it soft, more like a balloon or is it hard like a rock? Noting that being able to kind of keep up with that can be really helpful. Are you producing gas or not? And then what's the smell of the gas? And where does it come out? Right? So are you producing gas through belching? Through flatulence like, Is there a smell, like what's happening? And so being able to kind of navigate that and note whenever there's gas or not.

Changes in bowel movements and consistency of bowel movements, so are you noticing constipation or diarrhea or any of those changes that accompany your bloat either to start, you know, at the end of the bloat, like what comes first? Do you notice any patterns there? How quickly does the bloat happen after meals? So is it something that you feel after every single meal? Is it immediate? Is it a few hours later? Like when do you typically notice it coming on? So keeping a pretty detailed log, like a food and symptom log can be really helpful for navigating you know that piece.

And then, distension. Is there actual distension present, or is it more of a feeling of fullness? So you could take pictures, this can be helpful, and you want to make sure that you're doing this with some wisdom, because the body dysmorphia that we see with bloating, and that altered vision of yourself, poor body image, like that can be tied closely with bloat. So if you're taking pictures, you really want to make sure that you are either getting under care with a professional like a dietician or your doctor, whoever it might be, or you already are under care with them and you're sharing that with them and also really checking in with yourself to make sure that your mental and emotional health is still protected while you are taking the pictures. But taking pictures can be helpful just to show like, okay, this is the start of the day versus the end of the day, or this is whenever I am bloated, this is a day where I am not, that can help a lot of times get the right diagnosis, or just help you be able to explain the bloat more clearly and accurately to your providers so that they can dig where they need to.

So a great way to do this is through a food and symptom log because you can keep up with all of these different details over time, and then be able to break them down and share that data with your provider. Within our practice, we actually have a My Gut Journal, which is a 90 day food and symptom journal that you can use to track all of these symptoms, as well as some mental health pieces. There are also some amazing apps out there that you can use if you want to kind of look and see if there's something that is easy for you to use and connects with you. Just make sure that as you're collecting that data that you're linking up with the right healthcare professionals, like a dietician, pelvic floor physical therapist, a doctor, whoever it might be that you want on your team, to be able to help you navigate that data you are collecting, and make the right choices to get you to where you want to be.

So I hope that's helpful. Please, please, please go over to The Gut Community on Facebook and make sure to tell us what you thought about this episode or ask questions that you have specifically around bloating. I know there's a lot that you might want to break down so join us there for more conversation, and I'll see you on our next episode!