Gut microbiome connection to bloating

Photo Cred: Polina Zimmerman/Pexels

By Kellie Blake, RDN, LD, IFNCP

Many patients experience abdominal bloating and distention at some point. However, up to 30 percent of American adults report suffering these symptoms on a consistent basis. In patients with irritable bowel syndrome (IBS), 83 percent deal with bloating and rank it as one of their most troubling symptoms, second only to abdominal pain.

While bloating can be the result of serious illnesses such as gastric, bowel, and ovarian cancers and liver disease, in my practice, it is most often related to small intestinal bacterial overgrowth (SIBO), carbohydrate intolerance, an altered gut microbiome, pancreatic insufficiency, and altered gastrointestinal motility. Bloating can also be the result of pelvic floor dysfunction, abdominophrenic dyssenergia, and visceral hypersensitivity.

My patients with bloating often say their abdomen seems to expand as the day progresses. Quality of life is typically significantly decreased, and patients may report feeling “normal” only when they avoid eating.

It’s easy to assume bloating is simply related to an increase in intestinal gas, but increased gas production is only found in 25 percent of cases. Bloating and abdominal distention often exist as components of other functional intestinal disorders such as dyspepsia, IBS, and constipation where the gut microbiome is known to be altered. According to a study published in the American Journal of Physiology. Gastrointestinal and Liver Physiology, IBS patients with bloating and without bloating have different intestinal microbiota. Both groups have higher levels of Lactobacillus and Streptococcus, but lower levels of Lachnospiraceae.

In patients with bloating, there seem to be higher levels of Ruminococcaceae, but there is also a significant decrease in the Subdoligranulum variable. The elevated Lactobacillus and Streptococcus with the depletion of specific varieties of Ruminococcaceae could partially be responsible for bloating in IBS.

Investigating the gut microbiome and overall gut health is important for pin-pointing the root cause or causes of symptoms. Bringing the gut microbiome back into balance with nutrition and lifestyle-related strategies can provide significant relieve and improve quality of life.

Case Study

Linda, a 70-year-old female with no diagnosed medical problems and an active lifestyle, was concerned about her bloating, gas, and discomfort with food intake. Pre-pandemic, she was going to the gym four to five days per week to participate in a variety of exercise classes. She is five feet tall and initially weighed 143 pounds.

By the time she came to see me, Linda had already made some changes to her diet to address her digestive distress, including eliminating gluten, corn, soy, genetically modified foods, garbanzo beans, and peanuts. Her food recall indicated very limited vegetable intake, she was skipping breakfast on most days, and eating snacks from the vending machine at work in the afternoon. She did not eat her evening meal until between 8 p.m. and 10 p.m., and she reported having a chocolate candy drawer in her desk at work.

The patient was taking no prescription medications, but did take vitamins C, vitamin D3, a multivitamin, a probiotic, and an omega-3 fatty acid supplement daily. Her initial symptom score of 50 indicated severe symptoms.

Aside from the digestive symptoms, she was frustrated with her inability to lose weight despite exercise and she was concerned about an increase in belly fat over the past year and the associated health consequences. Linda said she wanted to feel great again and have a flat stomach.

The initial plan for Linda included:

1. An anti-inflammatory, low-glycemic meal plan moderate in high-quality fats and free of refined-grains, gluten, soy, and dairy. The patient was to eat earlier in the day and avoid eating after seven p.m. Additionally, she was to aim for nine servings of vegetables each day.
2. At home stomach acid testing, which revealed hypochlorhydria.
3. Labs to include a full thyroid panel with antibodies, fasting insulin, complete blood count (CBC), complete metabolic panel (CMP), folate, and homocysteine. Patient declined to have labwork completed.
4. GI Map stool testing, which patient completed.
5. SIBO breath testing, which patient declined.
6. Continue current supplement regimen and add a digestive enzyme with betaine hydrochloride with each meal and snack.

After five weeks, Linda’s symptom score was down to 23, indicating significant improvement. She reported not getting bloated as often, her clothes were fitting better, and her hair was less dry.

Linda did well with the anti-inflammatory meal plan. She was eating at least seven servings of vegetables each day, her craving for sweets had disappeared, but she reported missing dairy products. She said her exercise had declined due to the pandemic, but she was walking with an eight-pound weighted vest and practicing yoga at home.

Linda’s GI Map results revealed Helicobacter pylori (H.pylori) infection, elevated numbers of commensal bacteria, and high levels of opportunistic bacteria, specifically Bacillus spp, Morganella spp, and Streptococcus spp. There was no inflammation, but pancreatic enzyme function was inadequate.

The follow-up plan included:

1. Continuing the anti-inflammatory meal plan and previous goals but add in goat’s milk or cheese if tolerated.
2. Continuing the current supplements, but add in a daily probiotic.
3. H. pylori treatment for eight weeks to including heracurmin 600 milligrams three times per day, mastic gum with deglycerrhizinated licorice two twice per day, oregano oil soft gel three times per day, 100 percent cranberry juice one cup per day, and plain green tea three cups per day.
4. Continue with exercise and get outside in nature.
5. Recheck H. pylori after eight-week protocol completed, which patient declined.

After four more weeks, Linda reported her bloating was 90 percent improved and she had lost a total of eight pounds. She had more energy and attributed this to the anti-inflammatory meal plan with increased vegetable intake, but also felt the digestive enzymes were very helpful. She reported being able to get back to her previous wardrobe and she was no longer worried about hiding her stomach.

References

Mari, A. (2019) Bloating and Abdominal Distension: Clinical Approach and Management. Advances in therapy. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/30879252/

Ringel-Kulka, T. (2016) Molecular characterization of the intestinal microbiota in patients with and without abdominal bloating. American journal of physiology. Gastrointestinal and liver physiology. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/26702134/

Lacy, B. (2021) Management of Chronic Abdominal Distension and Bloating. Clinical Gastroenterology and Hepatology. Retrieved from: https://www.cghjournal.org/article/S1542-3565(20)30433-X/fulltext