Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change.  (Search our archives for her posts, calling on the expertise of medical specialists, on topics ranging from angiography to vulvar melanoma.)

This month—National Nutrition Month—Dr. Pat asks  gastroenterologist Brain Landzberg, who is affiliated with the Weill Medical College of Cornell University, New York–Presbyterian Hospital, and Hospital for Special Surgery, to address the concerns of a woman with “worsening bowel issues” who has five specific questions.

 

irritable-bowel-syndromeImage via

Dear Dr. Pat:

I am a 52-year-old woman with some significant and worsening bowel issues. Unfortunately, I have had chronic sinus infections and have needed antibiotics about six times a year for the past decade.  I have developed significant abdominal bloating with gas on top of lifelong mild irritable bowel syndrome.  I had a normal colonoscopy last year and have had no new change in my bowel function in the past five years. Here’s what I’d like to know:

  1. What causes this gas bloat?
  2. Does something happen to our gut as we get older to cause this gas bloat?
  3. Are antibiotics responsible for killing all the good bacteria in the gut?
  4. My sister takes a probiotic and she swears it has helped with her symptoms, which are similar to mine.
  5. I read that not all probiotics are the same. How do I know what to take? I read that the types that are refrigerated are the most effective.

Emily

 

Dr. Pat Responds:

Dear Emily:

Your questions are common ones; those of us who are primary care physicians hear them frequently.  The symptoms of “irritable bowel syndrome” may include constipation alternating with diarrhea along with bloating and gas. Also, as the lining of the colon ages, the process of digestion may be altered for some people. Dietary modification is helpful for many patients working with a nutritionist who has an interest in helping patients learn if they have become gluten- or lactose sensitive over time. These nutritionists suggest an elimination diet so patients can understand what foods seem to increase these distressing symptoms.

Antibiotic overuse is an epidemic problem. Antibiotics can destroy the healthy bacteria in the gut and produce bacterial strains that are now resistant to many—sometimes all—antibiotics. As part of your plan to address your GI issues, I would encourage you to see a sinus specialist to determine if your frequent sinus episodes are caused by an anatomic problem that can be corrected.  Often, sinus pressure from environmental allergies can mimic the symptoms of an infection, and the knee-jerk use of an antibiotic for symptoms that may not be caused by an infection is not good medicine.  Doctors and patients need to be much more cautious about the overuse of antibiotics for sinus symptoms.

The use of probiotics makes sense to patients (“replacing the good bacteria in the gut that have been destroyed by antibiotics or age”).  However, we often do not know about the quality of these poorly regulated products, and there is a dearth of strong medical evidence to support the effectiveness of probiotic use.

I have asked Dr. Brian Landzberg, a member of Women’s Voices’ Medical Advisory Board, to address your timely and important questions.

Dr. Pat

 

Dr. Landzberg Responds:

Dear Emily:

Your questions are particularly timely, since March is not only National Nutrition Month but National Colorectal Cancer Awareness Month as well.

We’ll include probiotics under the domain of nutrition. As physicians, we try to offer medical treatments that have been proven to be effective, usually in large, placebo-controlled, randomized trials.  Some specific disease entities, such as antibiotic-associated diarrhea from C. difficile, as well as  inflammatory bowel disease, such as ulcerative colitis, do demonstrate clear evidence, in good studies, for the beneficial effects of probiotics. The data surrounding probiotics and functional bowel disorders, however, are a morass of small, poorly controlled trials, and proprietary, industry-based studies.  Couple this with a 40 percent placebo response of conditions such as irritable bowel syndrome to any intervention, and the medical literature doesn’t give us much to go on.  So the physician is left with personal experience, careful history as to patient symptoms, and empiricism—the latter essentially a fancy way of saying “trial-and-error.”  The good news is that probiotics are extremely unlikely to cause harm, so serially trying a few which have been effective in the practitioner’s experience is worthwhile.  I find for diarrhea-predominant IBS patients, Culturelle tends to be quite helpful. In patients with primarily gas-bloat symptoms, I find the combination of Culturelle and Align useful.

Now to the problem of gas in general.  A wise, venerable gastroenterologist once said that when he hears that the chief complaint is gas, his heart sinks. This is not because it is an ominous complaint—the vast majority of cases are completely benign—but we have much less ability to alleviate symptoms than we do with other common gastrointestinal complaints like diarrhea or constipation.  Many conditions may predispose to this, including increasing age, or loss of intestinal motility due to conditions like scleroderma, operative adhesions, or narcotic drug use.  Usually, bacteria that live in the bowel and ferment carbohydrates that have not been digested or absorbed well produce gas.  Lactose, artificial sweeteners, and other carbohydrates present in beans and  cruciferous vegetables—including  cabbage, Brussels sprouts, broccoli, and cauliflower—are frequent culprits.

Avoidance of these carbohydrates, or the use of supplements such as Lactaid (lactase) and Beano, is a good place to start. In some patients, we take an elimination-diet approach—even taking the diet down to water and adding back food classes one by one.   Another helpful approach is directed at reducing small-bowel bacterial load with a non-absorbed antibiotic such as Xifaxan.  Other patients experience gas because of prolonged stool dwelling in the colon, and laxatives such as Miralax often relieve symptoms.

Although abdominal gas–bloat is usually not serious, treatment can be very challenging.  It requires time and thought by the treating physician, and often a multidisciplinary approach. Hope that helps.

Brian Landzberg, M.D. 

 

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