Bloating and its accompanying pain, cramping, and abdominal distention is one of the most common complaints in my practice.
Believe it or not, there are many different underlying causes for one simple yet confusing symptom. This post will walk you through some of the most commonly overlooked causes of bloating and offer some potential approaches. Let’s dive in!
Weakened Upper Digestion
The body is wildly intelligent, and during periods of stress, it will conserve energy by reducing circulation to the digestive tract, limiting enzymatic secretions, and slowing digestive activity. Everyone’s stress response looks a little bit different, but for some people, prolonged stress can especially suppress the activity in the upper digestive tract and reduce the production of stomach acid.
In the short term, this type of energy efficiency in the body can be helpful: quieting the digestion while the attention needs to be diverted to more immediate needs. However, over prolonged periods of time, weakening of the upper digestion can start to erode balance in the entire digestive tract.
Over time, the stomach and upper digestive tract secrete less of the enzymes responsible for digesting our food. The lining of the inside of the stomach and upper digestive tract can become thinner, inviting susceptibility to ulceration, certain pathogenic or opportunistic bacterial species, and causing incomplete digestion.
Eventually, when external stressors are resolved, there can be a lag time between when the appetite and desire for regular nourishment returns and when the digestive system is strong enough to handle eating normally again. A weak, thinned stomach lining, with no stomach acid secretions, a habitually strong stress response, and a big appetite = recipe for indigestion and downstream bloating. Depending on how out of balance the system is allowed to get, it can take a while to get things back on track.
Solutions:
The first few recommendations here are about prevention: you have to manage the impact of stress on your digestive system. Notice when your stress levels are affecting your appetite and/or impinging on meal times.
Learn about the brain-gut axis and learn to take care of your vagus nerve tone.
Create boundaries around meal times. Stop and allow yourself to focus on a balanced, nutritious meal in a calm space. If you are still stressed when you sit down to eat, take a moment to place your feet flat on the floor, take several deep breaths, and pause for a several minutes of gratitude before you pick up your fork and take your first few bites.
Next, after prolonged periods of stress, your digestion may benefit from using either apple cider vinegar or digestive bitters to help stimulate your digestive secretions and get things back on track.
In more pronounced cases, the judicious use of digestive enzymes as a supplement can help prevent further imbalances in the digestive system. Recommend working with a healthcare practitioner to help determine which kind of digestive enzymes may be right for you.
Expanding the diet after excessive food restrictions – whether due to stress, a bout of gastroenteritis, or due to dietary changes like moving from something like a fast or a vegan diet to a more omnivorous palette – may go a lot more smoothly with the recommendations above.
Dysbiosis: An Imbalanced Microbiome
Over long periods of time, poor digestion can contribute to imbalances in the populations of gut bacteria. The term for these imbalances in the populations of gut bacteria is called dysbiosis (dys meaning out of balance and biosis referring to the organic species present).
Dysbiosis is a huge topic and can take many forms including:
Loss of beneficial bacteria the protect the immune system, gut lining, and metabolic milieu in the digestive tract.
Overgrowth of potentially pathogenic bacteria or parasites that contribute to local inflammation, gut permeability issues, increased sensitivity to specific food allergies, constipation, sluggish movement through the digestive tract, and/or gas production.
Loss of overall bacterial diversity that can contribute to susceptibility to further imbalances.
Solutions:
Test don’t guess. Is it SIBO? Citrobacter? H. Pylori? Parasitic infection? Get to the bottom of it with comprehensive digestive panels. Check out: ‘Gut Microbiome Testing: When Is It Worth It?’
Recent research has shown that improving ‘upper gate digestion’ (e.g with thorough chewing and release of salivary amylase, appropriate digestive secretions from the stomach, pancreas, and gallbladder, and encouraging healthy peristaltic waves between meals) has significant impacts on preventing dysbiosis. See notes above.
Unless you have a specific health condition that prevents it, try to eat abundantly and to satisfaction every 4.5-5 hours. Avoid excessive grazing and snacking between meals, which can interrupt the cleansing peristaltic wave that passes through the digestive tract. Many people who try to overly restrict their eating or undereat end up grazing and picking at small bits of food throughout the day which can interrupt this peristaltic wave, called the migrating motor complex.
If you think that your digestion is significantly imbalanced, it may be helpful to have specialty digestive testing completed to analyze your microbiome. You may benefit from Diagnostic Solutions’ GI MAP, Genova GI Effects Panel, or a SIBO Breath Test to gain better clarity on the treatment that may be helpful for you. Learn more about the benefits of functional digestive testing here. From there, therapeutic recommendations can be made with efficiency so that you can start feeling better sooner.
Heightened Sensory Experience of Bloating: Visceral Hypersensitivity
Gut-brain interaction disorders associated with bloating and distension include IBS, chronic idiopathic constipation, pelvic floor dysfunction, functional dyspepsia and functional bloating. Some individuals with these types of conditions also have a disorder in how their nervous systems experience sensations coming from the internal organs (the viscera). They perceive excessive amounts of pain and discomfort in relationship to their symptoms. For these people, even mild amounts of distention related to normal food intake can feel painful and distracting.
The complexity and sophistication of the brain-gut neural pathways, amplified by factors such as anxiety, depression, somatization and hypervigilance that may be related to trauma can also contribute to the perception of bloating.
Solutions:
Research shows that hands-on manual therapy such as osteopathic visceral manipulation, biofeedback, and somatic processing may be helpful for reducing the symptoms of visceral hypersensitivity and comprise an important component of treatment (Attali, 2013).
Look for a practitioner who offers hands-on abdominal work such as osteopathic visceral manipulation.
Eating When Rushed, Angry, or Upset
East Asian medicine has a specific and unique way of recognizing the constellation of symptoms that can arise from eating too quickly, eating when rushed, or eating when angry. In the body, the echo of these habits can be detected in the pulse, abdomen, and acupuncture channels by a trained acupuncturist. Even when meal composition is balanced and consciously, our intentions around eating are positive, if the body is experiencing excessive urgency and irritability while eating, the acupuncture channels related with digestion can respond with a host of rebellious symptoms. For what it’s worth, this pattern is referred to as Chai Hu pattern or ribside distress in some lineages.
Common symptoms that might arise from eating while stressed often include: indigestion, tightness in the diaphragm/ribcage, burping, bloating, food stagnation after meals, irregular bowel movements, nausea, pain, irritability, constant restlessness, and fullness sensations.
Solutions:
Rushing, feeling a constant sense of urgency and restlessness, and internalized anger and irritability are very strong tendencies in western modern culture. These pressures impact our bodies. However, many people are simply not in touch with their emotional state or the changes that are happening inside the body while keeping up with a rushed schedule. It sounds basic to say it, but it’s important to take time every day to set a baseline of calm; that way you can notice the difference when traffic, schedules, deadlines, or the ambient pace of modern life takes its toll.
Take moments throughout the day to greet yourself, acknowledge your emotional body, and make time and space for how you are doing.
If you’ve been trying many different approaches to help heal your digestive symptoms, consider working with East Asian medicine and acupuncture. There are specific patterns that can be uniquely addressed with acupuncture that western and functional medicine treatments simply cannot quite treat in the same way.
If you want to learn more about this pattern affecting digestion, check on this post ‘Patterns of Liver Imbalance’.
Food Sensitivities, Food Allergens, Food Intolerances
If there is a specific food ingredient that is causing a type of inflammatory reaction in your body and you continue to eat it, it can contribute to a host of health issues including increased gut permeability issues, which can lead to immune inflammation, further food sensitivities, bloating, and digestive symptoms (Vita 2022).
Technically food allergies and food sensitivities are different types of immune reactivities and should be distinguished from one another:
Food allergies tend to cause more immediate, anaphylactic-type symptoms such as swelling, redness, hives, welts, itching, throat swelling, nausea, vomiting, shortness of breath, and sometimes hot/cold sensations. Food allergies are mediated by a specific immune protein called immunoglobulin E (IgE) and often occur within seconds to minutes after exposure to a food or environmental trigger. Common instigators of food allergies include shellfish, peanuts, soy, wheat, and dairy products.
Food sensitivities tend to cause a slower, more diffuse inflammatory response with a wide range of chronic symptoms including: gut permeability issues, a myriad of digestive symptoms (bloating, constipation, diarrhea, abdominal pain, irregular bowel movements) long-standing skin conditions such as eczema, psoriasis, chronic acne, and rosacea, weight gain, worsening autoimmune issues such as in rheumatoid arthritis, Crohn’s disease, and Hashimoto’s Thyroiditis, respiratory congestion such as bronchitis and sinus pressure, joint pain, brain fog, depression, mood swings. Food sensitivities are mediated by specific immune proteins called immunoglobulin A (IgA) and immunoglobulin G (IgG) and occur over a course of days to weeks following exposure to food or environmental trigger. Because of this time delay between exposure and symptom onset, food sensitivities can be harder to pinpoint. In addition, since the gut microbiome is constantly changing, food sensitivities sometimes change over time whereas food allergies generally remain static. Food sensitivities are commonly associated with other GI-related conditions such as leaky gut, irritable bowel syndrome (IBS) and more.
The ingredients most known to cause inflammatory food sensitivities are broad and might include: milk/dairy, eggs, nuts, fish, crustaceans, shellfish, gluten/wheat, soy, sesame, nightshades, and citrus.
Solutions:
If you can identify specific food ingredients that seem to worsen your symptoms, eliminating or reducing consumption will be the best approach. Depending on the type of immune reaction you are having (allergy, sensitivity, or intolerance), you may need to temporarily avoid it until your gut lining and immune system can heal, or you may need to eliminate it more permanently. Follow guidelines around how to do an elimination diet successfully or work with a naturopathic doctor to get individualized recommendations.
IgE Food Allergy Testing is typically done via skin prick tests in an Allergist’s office.
IgA/IgG Food Sensitivity Testing is done using an at-home finger prick-based test and can assess you for up to 240 different food ingredients. This can be an extremely helpful way to narrow down dietary changes that may be helpful for you.
Maintaining a healthy gut lining – the layer of cells lining the inside of the digestive tract—is very important for reducing your susceptibility and inflammatory responses to foods.
Eating Highly Processed and Packaged Foods
Another overlooked cause of bloating may be due to packaging and processing agents used in foods. Food additives, like emulsifiers, colors, thickeners, and preservatives have been proven to cause hypersensitivity reactions, which are more pronounced in people with symptoms of IBS, such as bloating (Fiolet, 2018).
We finally have research-backed evidence to show that the added sugar, salt, trans fat, hydrogenated oils, food additives, and chemicals that go into processed food and food packaging have a negative impact on everyone’s health. Studies show proportionally increased risks of cancer, inflammatory bowel disease, and cardiometabolic diseases with the increased increments of consumption (Narula,2021). But for those with IBS, impacts can be even more pronounced.
Solution:
A good way to avoid ultra-processed foods is to stay away from foods with long ingredient lists that have words you don’t recognize.
Gastroparesis
Gastroparesis is the medical term for when the stomach can’t empty food at a normal pace, and bloating and abdominal distention are a common symptoms. Gastroparesis occurs when the nerves responsible for coordinating movement of the stomach are damaged in some way. This is common in people with diabetes and pre-diabetes, connective tissue disorders like scleroderma, autoimmune conditions, eating disorders, or those who have undergone surgery of the upper intestinal tract resulting in vagal nerve damage. Regardless of the underlying cause, gastroparesis can strongly impact how you feel after you eat and significantly contribute to chronic downstream bloating.
Solutions:
If you suspect you have gastroparesis, thoroughly investigate and treat your blood sugar regulation (e.g. fasting glucose, insulin, HgbA1c) with your provider. There are many different interventions that can help better regulate your blood sugar and improve the innervation of the digestive tract.
You may need to pursue specialized testing to assess gastric emptying with a gastroenterologist. Gastric emptying studies help determine how long it takes food to move through your stomach.
People with gastroparesis may need to prioritize eating smaller meals and engineer most of their nourishment habits around foods that are easy to digest.
Cyclical Bloating that Increases During Luteal Phase or During Period
In some cases, increased bloating symptoms are not stemming from the digestive system, but from the reproductive organs and the pelvis.
In women, the presence of endometrial lesions such as fibroids, polyps, cysts, increased endometrial lining thickening, or endometriosis can increase pelvic pressure and in some cases, impede digestion and elimination and contribute to bloating.
If you tend to experience bloating that comes and goes in a cyclical nature coordinated with your menstrual cycle, pursue further work up and treatment.
Solutions:
A transvaginal ultrasound (TVUS) can assess the presence of structures present in the uterine lining. Fibroids and polyps can be very common, especially in women in their 40s and 50s and there are many possible treatments available to help reduce their size and impact on hormone balance as well as digestive health.
In some conditions such as endometriosis, it is diagnostically challenging to confirm certain lesions via ultrasound only and further imaging such as MRI or laparoscopic approaches are necessary.
Seek naturopathic care to help reduce the underlying causes of hormonal imbalances and detoxification routes that are contributing to your bloating in the first place. There are many potential interventions that can help treat the problem at its root.
Conditions like IBS, IBD, SIBO, Celiac disease, pancreatic insufficiency, liver cirrhosis, non-alcoholic fatty liver disease, biliary congestion or biliary disease
Given the broad range of possible causes of bloating and distension, identifying the most effective treatment can be a complex process. If none of the above explanations seem to fit the pattern of your symptoms, or if you have other recurring symptoms along with bloating, there are many other potential conditions that could be contributing.
Therapeutic options might include dietary changes, probiotics, antibiotics, prokinetic agents to help with gut motility, herbs or medications that help reduce intestinal spasm, liver decongestion support with antioxidants and choleretics, neuromodulators and/or biofeedback.
If you are at your wits end, or tired of trying to navigate your health journey alone, do not hesitate to reach out to a local, accredited naturopathic doctor to help you treat the root cause of your symptoms and feel better sooner.
REFERENCES
o Attali TV, Bouchoucha M, Benamouzig R. Treatment of refractory irritable bowel syndrome with visceral osteopathy: short-term and long-term results of a randomized trial. J Dig Dis. 2013 Dec;14(12):654-61. doi: 10.1111/1751-2980.12098. PMID: 23981319.
o Vita AA, Zwickey H, Bradley R. Associations between food-specific IgG antibodies and intestinal permeability biomarkers. Front Nutr. 2022 Sep 6;9:962093. doi: 10.3389/fnut.2022.962093. PMID: 36147305; PMCID: PMC9485556.
o Fiolet T, Srour B, Sellem L, Kesse-Guyot E, Allès B, Méjean C et al. Consumption of ultra-processed foods and cancer risk: results from NutriNet-Santé prospective cohort BMJ 2018; 360 :k322 doi:10.1136/bmj.k322
o Lacy BE et al. Management of chronic abdominal distension and bloating. Clinical Gastroenterology and Hepatology. 2021;19:219.
o Narula N, Wong E C L, Dehghan M, Mente A, Rangarajan S, Lanas F et al. Association of ultra-processed food intake with risk of inflammatory bowel disease: prospective cohort study BMJ 2021; 374 :n1554 doi:10.1136/bmj.n1554