Acknowledgments Gutbliss started out as a book about food. I was alarmed by what I was seeing in people's digestive tracts and the growing prevalence of bloating and other gastrointestinal complaints. To me, food was the obvious but frequently overlooked connection. So I set out to write a book about how our food was making us sick. Along the way, I had the incredible good fortune to meet Howard Yoon, my literary agent, who helped me mold my passion about food and the gut into a broader conversation that included the obstacles to digestive wellness and how to go about removing them. Whether you like this book or not (and I hope you do!), it is undoubtedly a much better one because of Howard's wisdom, patience, and belief that I had something important to say. And for the opportunity to say it, I am eternally grateful to Lucia Watson and Bill Shinker at Gotham/Avery, to Gabrielle Campo, who guided me through the entire process, and to Toni Sciarra Poynter, who provided invaluable editorial assistance. To my husband, Eric, who at this point knows far more than he ever imagined he would about bowel movements and gut bacteria, and whose support never wavered as I abandoned my post for several months at a time to focus on completing this book. Without his encouragement and overall picking up of the slack at home this book would never have been possible. And to my amazing daughter, Sydney, who loves to talk about bowel movements and gut bacteria, and who spent so many hours keeping me company in my study while this manuscript was being written. You are a constant source of inspiration. Bette Greenhause and I have been keeping company since my first day on the job at Georgetown in 1997. Without her, the Digestive Center for Women would never have come to fruition. I do not think I could practice medicine without her. To the late Dr. Henry Janowitz and Dr. Jerry Waye, who taught me much about both the art and the science of gastroenterology. To Gena Hamshaw, whose journey from editor to doctor I am honored to be a part of. To all my friends who put up with canceled dinners and no-shows while I wrote this book and cheered me on toward the finish line. A special thank-you to Dr. Ida Bergstrom, Alicia Sokol, Jill Hudson, and Elise Museles. Vernon Jordan, Doug Heater, and Robert Raben are my three wise men. I am grateful to them for always pointing me in the right direction. To my parents, for teaching me the invaluable lesson that with good living comes mostly good health. A huge thank-you to Dr. Mehmet Oz, for giving me the opportunity to share my passion for digestive wellness with America. And most of all, to the many patients along the way, who have taught me so much. It has been an honor and a privilege. Introduction "Why am I so bloated?" That's a question I hear nearly every day in my gastroenterology practice. Over the course of my medical career, I've gone from helping a handful of women a week with bloating, sluggish fullness, and constipation to feeling like I'm dealing with a full-on epidemic. For many, the symptoms are daily, relentless, and life altering, but even when they're not that severe, they're always annoying. The causes of bloating vary tremendously, from common benign conditions to rare, life-threatening illnesses. Some may be connected to behaviors you don't even think about. (Do you talk with your mouth full? You could be swallowing enough air to go up a dress size!) Some you may have heard of but need more information and aren't quite sure whether you should be worried. (Is celiac disease the same as gluten intolerance?) Some may surprise you. (Taking antacids to settle your stomach can make your jeans un-zippable!) In this book you'll learn about these issues and many more, including how to tell if your bloating is serious . . . or if you're just seriously bloated. Your Inner Doctor The information in this book incorporates aspects of both conventional and alternative medicine to create an intuitive, commonsense approach to digestive wellness. The goal is not to scare you into having an unnecessary procedure or taking a pill you don't need, but to encourage you to explore the cause of your symptoms and to implement some useful basic strategies, many of which are already in your toolbox. I believe that buried deep beneath the information overload we all receive from consumer marketing is our own innate sense of what we need to make ourselves well. I like to call it our "inner doctor." This book will help you access that deep inner sense, building your understanding by providing reliable information on what helps and what hinders when it comes to your digestive health. Many digestive problems that a decade ago we thought were "all in people's heads" we now know are caused by very real gastrointestinal disturbances--conditions like bacterial overgrowth and gluten intolerance. I refuse to believe that millions of women who suffer from bloating but don't have a diagnosis are "crazy" or "just stressed out." I've seen how often, by thinking outside the box, we're able to find both the problem and the remedy. I want to help you trust your inner doctor. If you think there's something going on, there probably is, and you need to keep searching till you find the right person who can help you figure it out. They may not always have a white coat on and an MD behind their name. Much of what I know I've learned from patients, nutritionists, biofeedback practitioners, holistic health coaches, naturopathic doctors, acupuncturists, farmers, and even my yoga instructor. I hope the information in this book will serve as a guide to help you understand what's going on in your body and offer you some real solutions. My Promise to You I've spent a lot of time inside the digestive tract, observing what's gone wrong and why. This book contains the information I think is most important to share, in short, digestible (pardon the pun) chapters. When I don't know something, I'll tell you I don't know. When I think a particular practice is shady or suspect, I'll tell you that, too. I'll give you the information that has been helping my patients make real improvements in their digestive health--including a comprehensive 10-Day Gutbliss Plan to heal yourself from the inside out, based on twenty years of experience. It's helped thousands of women tighten their tummies and end their discomfort. Many have reported a surge in energy and mood, too! This easy-to-follow integrative approach to digestive wellness will help you banish bloat, flush toxins, and dump your digestive baggage--the healthy way. The world these days can be an intimidating place. We worry about environmental toxins, drugs can be dangerous, and Mother Nature would hardly recognize much of what's available at the grocery store. But left to its own devices, the human body is still a marvel, with an amazing capacity to recover and heal itself, particularly when injurious practices are identified and stopped. My sincere hope is that you're able to use the information in this book to find your own gutbliss and that when you and I meet, it'll be at the farmer's market or on the yoga mat, and not in my office. Finding My Gutbliss In 2004 I decided to leave the hallowed halls of academia and set up my own practice. Georgetown Hospital had been my first job when I finished my training in New York in 1997, but after almost eight years, hospital-based medicine no longer seemed to have the answers my patients and I were looking for. I owed a lot to the institution--my career had flourished there: I had a sixteen-page résumé of published articles, book chapters, and speaking engagements throughout the United States and Europe; I had helped to train over thirty gastroenterologists; I had colleagues I respected and admired; and I enjoyed the teaching opportunities. My salary was more than generous. My professional life was bountiful and I should have been happy, but I wasn't. I had lost my faith. Over the years my priorities had gradually shifted from high-tech procedures that diagnose and treat disease to no-tech lifestyle modifications that prevent them. It was becoming difficult for me to emphasize the industry message in my speaking and teaching that colonoscopy saves lives (which it does) without giving equal billing to what I had come to believe: that diet and lifestyle were more important in achieving and maintaining digestive health than any procedure I could recommend. Philosophically, I felt a lack of alignment. I was interested in an integrative and more holistic approach to digestive diseases and I wanted that to be part of my message. My colleagues seemed more interested in technical innovation. Their mission and approach hadn't changed, but mine had. The practice of gastroenterology had also changed and was feeling more and more like a business venture, with the patients as the consumers and endoscopy as the product. Many gastroenterologists now owned their own endoscopy units, as well as the pathology services used to process their biopsy specimens. While this allowed for better quality control and closer collaboration, it also greatly incentivized doctors to do more procedures and biopsies. The gastroenterologists I knew were people who cared deeply about their patients, but many of them struck me as overly committed to doing procedures. I wanted to provide patients with equally relevant lifesaving information--like the fact that switching to a plant-based diet can cut your risk for colon cancer in half; or that exercise and a low-fat diet can prevent gallstones--not just perform procedures. A screening colonoscopy takes from fifteen to thirty minutes to perform. The reimbursement to the physician when done in an outpatient facility that they own can be several times what they make for an office visit of the same length. It's not hard to do the math and see why the nature of my specialty was changing. The economics simply don't encourage problem solving and exploration beyond the endoscope. At the same time that gastroenterologists are being incentivized to do more procedures and spend less time talking to patients, the nature of digestive illnesses is changing, too. We're seeing more conditions related to diet, lifestyle, and environmental factors, and diagnosing and treating those conditions requires more than just a quick endoscopy. Not all gastroenterologists are singularly focused on the revenue stream that endoscopic procedures like colonoscopies provide. Many have the kind of medical practices that embrace more integrative solutions, educating their patients about the importance of dietary intervention and other preventive measures, and exploring alternative diagnoses, while performing endoscopy in a responsible manner. But providing comprehensive digestive care is not always easy or straightforward. It requires extra time for us to sit down and talk with patients about what they're eating and how they're living. It requires research into things we're unfamiliar with, and consideration of the possibility that maybe our colleagues in the alternative medicine world know a thing or two. That kind of care means a lot of additional education in things we learned nothing about in medical school and that we can't touch and see with our endoscopes. Thanks to the Internet, some patients know more about their digestive disorder than their gastroenterologist, although they may not have the tools and context that allow them to manage it. So they're turning to their yoga instructors, massage therapists, life coaches, and social network for medical advice. Visits to alternative practitioners outnumber visits to conventional doctors four to one, even though they usually aren't covered by insurance. Conventional gastroenterology, while flourishing in the realm of advanced procedures and screening of healthy populations, is falling short in providing people with what they really need: reliable information on how to achieve and maintain digestive wellness. I knew these were vitally important issues that needed to be addressed with patients. But I was still spending most of my time doing procedures and prescribing complicated drugs with lots of side effects. My philosophy had changed; now my practice needed to change, too. An Integrative Solution In 2004, while pregnant with my first child and renovating a house down to the studs, I decided to open a practice that was more in line with my philosophy of an integrative approach to digestive disease. In addition to providing patients with resources in nutrition, stress reduction, and exercise, there were three basic principles I wanted to adhere to: * Ensure sufficient time with my patients to explore problems in detail. * Abide by my belief that most people aren't crazy, even if their symptoms don't always make sense. * Make and keep a commitment to think outside the box. I gave notice at Georgetown, found an ideal location, applied for a tax ID number, and opened my doors. I called the practice the Digestive Center for Women, although it turns out women aren't the only ones interested in more integrative solutions to their digestive troubles, and men constitute about 20 percent of our patients. I remained a voluntary faculty member at Georgetown and continued to perform procedures at the hospital, although the number of procedures was much lower than what I had previously been doing. Slowly but surely, patients came. Many of them had already been evaluated and diagnosed by very competent gastroenterologists. They didn't come because I was smarter than their last doctor; they came to have a dialogue and to get ideas and feedback on what they could do to improve their digestive health. We talked in detail about symptoms, test results, nutrition, and stress and the possible relationship among them. I didn't always have the answers, but I usually knew where to look. I built an integrative practice that relied a great deal on the excellent skills of my collaborators: a biofeedback practitioner, integrative nutritionists, exercise physiologists, and referrals to practitioners in counseling, acupuncture, and massage. I continued to see patients with complex problems related to Crohn's disease and ulcerative colitis, which had been my area of expertise at Georgetown. I found that these patients, too, benefited greatly from an integrative approach that included nutritional intervention and stress reduction. My focus shifted from scientific papers in medical journals on the role of endoscopy to articles in yoga, health, and women's magazines on the role of diet and lifestyle in preventing and treating digestive diseases. My talks at national gastroenterology meetings were now about obesity and the gastroenterology practice of the future, which would incorporate cooking classes, biofeedback, meditation workshops, and exercise sessions, not just endoscopy facilities. I was grateful for the opportunity to merge my personal beliefs with my professional practice and engage a larger audience with what I believed to be the truth about digestive health. I decided to write a book to share what I had learned over the years about how to achieve a blissful gut, and I enthusiastically began work on the outline and manuscript. On the last day of my tenure on the governing board of the American Society for Gastrointestinal Endoscopy (ASGE), I pitched an idea for a nonprofit called Gutrunners, which would focus on improving digestive health through educating the public about the benefits of nutrition and exercise. I was delighted when the ASGE agreed to be the founding sponsor and provided a loan as seed money. Gutrunners incorporated as a nonprofit in the state of Maryland and I dove into my new role as executive director, race director, and fund-raiser, arranging races at national gastroenterology conferences and meeting with potential sponsors and participants. Life was very busy but filled with meaningful work that I loved. Bliss less I had witnessed firsthand with many of my patients what happened when work-life balance was disrupted, but, ironically, I failed to see the warning signs in my own life. Although my practice was incredibly rewarding, the decrease in the number of lucrative procedures relative to what I'd been doing at Georgetown and the fact that I was in solo practice (i.e., there was no one with whom to share expenses) meant a drop in income. My days at the office were long and I spent my nights working on the book, writing articles, and trying to get Gutrunners off the ground. It was thrilling to have founded an organization dedicated to the principles I believed in, but now I was responsible for running it, and in the hole personally for the loan amount, which was to be repaid to the ASGE within five years. My schedule was a brutal six a.m.-to-midnight routine that was difficult to maintain. My leisurely daily runs and regular yoga practice fell by the wayside. I now only had time for occasional weekend warrior workouts that left me sore the next day and did little to improve my fitness level. My daughter was the joy of my life, but there was never enough time with her. I had grown up eating fresh produce from my grandfather's farm and home-cooked meals every day and had continued those traditions in our household. But now dinner was frequently takeout and not always healthy. I didn't have time for lunch most days and was eating way too much sugary and starchy food for quick energy. Some days half my calories came from cookies. The more sugar I ate, the more of it I craved, and my consumption increased dramatically. I'm not a coffee drinker so sugar became my caffeine, causing wide swings in my mood and blood sugar, which left me feeling even more tired. I also started drinking champagne at night while I worked. I'd not been much of a drinker in college, medical school, or the years since, but as life got busier and more stressful, it became part of my routine to have a glass or two after dinner. The sugar in the champagne was what attracted me. It opened the floodgates for more cravings, so there was often a sweet dessert happening along with the champagne. The late nights and excessive sugar gave me a terrible headache the next day and left me bleary-eyed and exhausted. Here I was, preaching attention to proper nutrition, leisure, stress reduction, and exercise to my patients--and I was having a hard time practicing what I preached. Out of Balance I'd never had any serious medical problems, and my only experience as a patient had been with labor and delivery, so I was unprepared for poor health when it finally arrived. And because I still thought of myself as a healthy person with good habits, it took me a while to recognize what was going on. For the first time in my life, I was bloated. And constipated. It gets worse: I had persistent rectal itching at night that drove me absolutely crazy. At first I thought the itching was from a hemorrhoid, but close inspection proved that diagnosis to be incorrect. Then I was sure it must be pinworms, since night itching is a characteristic symptom, but that wasn't what I had, either. Other symptoms that I developed included rosacea (misdiagnosed as acne), chronic sinus infections, fatigue, brain fog, dark circles under my eyes, thinning hair, a ten-pound weight gain, food intolerances (especially to dairy and nuts), and body odor. I know this last one is somewhat subjective, but even after running ten miles or doing ninety minutes of hot yoga, my sweat had previously been profuse but odorless. I looked and felt terrible. And despite all my knowledge, or maybe because of it (a subconscious belief that sickness happens to other people, not to us, can be a common trait among physicians), it took me several months to figure out the diagnosis. I had severe bacterial imbalance, also known as dysbiosis. My starchy, sugary diet, excessive dessert, after-dinner champagne, lack of exercise, and skyrocketing stress had altered the delicate balance of "good" and "bad" bacteria in my gut, and I was experiencing the fallout. My less-than-healthy diet and lifestyle had changed my entire body chemistry, and the results were manifest both internally (bloating and constipation) and externally (rosacea and hair thinning). After a sugar binge I could feel my face burning as the rosacea flared and the rectal itching became intense as my gut bacteria shifted. Clumps of hair filled the shower drain, and I was exhausted all the time. As varied and disparate as they seemed, my symptoms were all a result of dysbiosis, except for the brain fog and episodes of extreme fatigue, which turned out to be manifestations of gluten sensitivity. How I Found My Gutbliss As disconcerting as it was to lose control of my own health, the experience was valuable and meaningful. It affirmed some of the difficult choices I'd made about the kind of medical practice I believed in and highlighted a lot of the shortcomings of gastroenterology as it's practiced today. Dysbiosis can't be detected or treated with an endoscopic procedure. It's the sort of diagnosis that can only be made through a careful evaluation of someone's history, as well as the ability to recognize the relationship among a number of ostensibly unrelated symptoms. It's a condition that might easily escape conventional detection and be written off as stress or anxiety. In this book, you'll learn a lot more about dysbiosis and how to recognize and address it. Having firsthand experience with a condition like this has given me a renewed sense of purpose. It has made me more confident than ever that the future of medicine depends on doctors' willingness to listen, to use food and fitness as tools in the pursuit of health, and to think outside the proverbial prescription and procedure box. Lifestyle-related conditions such as dysbiosis significantly disrupt your quality of life yet can't be detected through a standard procedure. They represent the new kind of digestive illness so prevalent today. Dysbiosis and conditions such as food allergies, leaky gut, parasitic infections, candida overgrowth, gluten intolerance, and many others can lead to frustration and self-doubt for undiagnosed patients stumbling around in the dark looking for answers. Even after I realized the cause of my symptoms, it took me a while to implement the changes I needed to feel better. Despite my good dietary foundation of fruits and vegetables, the addictive nature of some of the not-so-healthy food I was eating had taken hold, and it was hard to let go. I continued to experiment with gluten, avoiding it for several days and then eating a bagel to see what would happen. Invariably the symptoms of brain fog and intense fatigue would return. I'd do well avoiding dessert and alcohol during the week but continued to indulge on the weekends, paying the price with an increase in symptoms and the slow burn of suboptimal health. The strategy that ultimately worked for me was to finally completely eliminate the foods I knew were causing my symptoms and affecting my health. It was easy to identify what those foods were: I felt awful after consuming them, and they were the same culprits responsible for many of my patients' digestive problems. Incremental change may seem like less of a challenge, but it can be hard to maintain because it takes a while before you experience a tangible difference in your symptoms, and so people frequently give up. I knew from experience with my patients that it took about ten days for a dietary change to be experienced physically and also for it to become psychologically easier to maintain. Withdrawal symptoms from sugar and other carbohydrates are the most prominent in the first week and then tend to become less intense. Going through the process of habit change myself helped me better understand and help my patients as they did the same. I found my gutbliss by getting rid of GAS: gluten, alcohol, and sugary treats. I also slowed things down a little at work and at home and rediscovered the healthful habits that had previously sustained me. Green juices instead of champagne kept me company at night, and a few pieces of dark chocolate became my new splurge. I had more energy in the mornings to start running and practicing yoga again, and my daughter took on the role of sous-chef as we spent time together in the kitchen whipping up healthy meals. With the help of a good probiotic, more kale than I ever thought I could eat, regular exercise, and eliminating GAS, the dysbiosis and all its symptoms gradually improved and I got back to looking and feeling healthy and strong. These days I enjoy the occasional dessert, croissant, or glass of champagne, but I pay attention to how I nourish myself, and my diet, as well as my digestive tract, feels balanced and joyful. The Journey Continues . . . Together Gutbliss is truly a journey, not a destination, and I continue to explore what feels best and is the right path for me. There's still lots on my to-do list, including deepening my yoga practice, completing a full Ironman Triathlon, experimenting with veganism, moving my gastroenterology practice to a farm, and learning to play the guitar, but I appreciate where I am and the good health that I have right now. We live differently but we suffer similarly. My sincere hope is that if you're suffering from bloating or any form of digestive distress, you'll find your gutbliss within the pages of this book. PART 1 Digestion 101 1 What's Happening in There? Your gastrointestinal (GI) tract is the engine for your entire body. Your cells depend on the nutrients extracted there from the food you eat for energy and on other essential ingredients like oxygen and minerals they need to survive. It's an incredibly complex and specialized system, and every part plays a crucial role. There are multiple points along this thirty-foot digestive superhighway where things can go awry. Bloating is one of the earliest and most common indications that there may be a problem. In this chapter I'll give you a quick overview of the digestive system and some of the things that can go wrong along the route. The more familiar you are with your GI tract, the easier it is to determine whether you've taken a wrong turn somewhere along the way. A Trip Down Your Digestive Superhighway GI discomfort can start at any point in the digestive tract, from the mouth to the anus and everywhere in between. The upper GI tract includes the mouth, esophagus, stomach, and the first part of the small intestine called the duodenum. Digestion actually begins in the mouth, where enzymes in saliva start to break down food. Gravity and muscular contractions help propel things down the long tubular esophagus into the stomach, where hydrochloric acid provides the optimum pH for digestive enzymes such as pepsin to break down protein and other food molecules. Alcohol, caffeine, nicotine, fatty foods, and a too-full stomach can all send acid back up into the esophagus where it doesn't belong and leave you reaching for antacids--which, it turns out, may not be such a great idea. Stomach acid is a crucial part of the digestive process. Decreasing acid production with medications can lead to major problems, including poor absorption of nutrients and overgrowth of harmful bacteria, which is a major cause of bloating. Delayed emptying of the stomach, called gastroparesis, can bloat you, too. It's an underdiagnosed condition associated with nausea and abdominal pain that can lead to vomiting and weight loss in severe cases. Once semi-digested food known as chyme has passed through the stomach, digestion continues in the small intestine. This is where our bodies start to extract the nutrients from food. Coming out of the stomach, chyme is very acidic, but the small intestine secretes a hormone called cholecystokinin (CCK), which stimulates the gallbladder to release alkali bile into the intestines, changing the acid content. Bile helps with the digestion of fats by providing a detergent-like effect, which emulsifies the fats so that they can dissolve in liquid and be more easily absorbed through the lining of the GI tract. Too much fat in the diet can cause gallstones, a problem that's frequently blamed on the gallbladder and leads to surgery. Although we can live without our gallbladder, digestion is never the same without it. As the food breaks down into smaller and smaller molecules, it's absorbed across the surface area of the small intestine by tiny fingerlike projections called villi. Conditions like celiac disease flatten your villi and can lead to bloating, malabsorption, and lots of other problems. The absorbed nutrients are transported via the bloodstream to the liver, the main detoxification organ in the body. In addition to removing toxins from the blood, the liver synthesizes hormones, proteins, and bile. Your pancreas is a gland that also makes and secretes important hormones like insulin and pancreatic juice that contains enzymes crucial to the digestive process. Insulin helps glucose get from the bloodstream into the cells of your body to be used for energy. Insufficient amounts of insulin lead to diabetes, a serious illness characterized by high levels of glucose in the blood and not enough in the cells. The main digestive enzymes are proteases, amylases, and lipases; they digest protein, carbohydrates, and fat, respectively. Enzyme levels decrease with age, and chemicals in the food we eat and medications can decrease them even further, leading to maldigestion and bloating. Bloating: Getting the Story Behind the Symptom Symptoms like bloating are very nonspecific, and that can pose a real problem in pinning down a diagnosis. Any number of conditions can cause it, from garden-variety constipation to cancer. Look up "bloating" on the Internet and you're as likely to come up with a worrisome but unlikely diagnosis like pancreatic cancer as you are to find a probable explanation like lactose intolerance, leaving you confused and scared as to what might really be going on. With bloating, the symptom itself may not be as helpful as the story behind the symptom. That's why you have to make sure that the information you give your doctor is complete, with all the details, and that it's heard, that key questions are asked, and, most of all, that the person you're telling your story to believes that you know when something is not quite right with your body, even if you don't know exactly what it is. That's ultimately what will help you turn your bloating into a meaningful diagnosis that you can do something about. Wavelike contractions called peristalsis transport the products of digestion through the small intestine into the colon. One of the main functions of the colon is to absorb water from the stool into the bloodstream as it transports things to the finish line. When it's working well, water is extracted as the products of digestion move through the colon in a clockwise direction from right to left, and as a result the stool that comes out of the anus is solid. The colon is also the site of bacterial fermentation of unabsorbed materials. Lots of factors can affect the transit time and consistency of the stool and result in bloating and a change in bowel habits. The things you can't see in the digestive tract may be more important than those you can. The trillions of bacteria and other organisms that live there play a crucial role in digestive health, as do the levels of digestive enzymes and hormones. That's why knowing which foods and habits upset the ratio of helpful to undesirable species and how to boost enzyme activity and optimize hormonal secretion is essential information. Mechanical blockages, out-of-control hormones, bacterial imbalance, low enzyme levels, active inflammation, structural abnormalities, and a host of other issues can disrupt the smooth functioning of your digestive engine and lead to bloating and abdominal distress. It's vitally important to pay attention to the feedback your GI system gives you--what makes it feel good and what aggravates it. You'll be learning about this in later chapters. Over time, as you're able to read your digestive road map, you'll be able to figure out the changes and adjustments you need to keep your GI tract functioning like the miraculously efficient system it's meant to be. 2 The Voluptuous Venus Colon Anne is a wisp of a woman who's been terribly bloated and constipated for as long as she can remember. Two tablespoons of psyllium husk (soluble plant fiber that adds bulk to the stool) and one tablespoon of ground flax seed in the morning, followed by two capfuls of a polyethylene glycol osmotic cathartic (a powerful laxative), plus three stool softeners and six prunes at night--and she still has difficulty having a bowel movement. She's had several visits to the emergency room after nearly passing out from abdominal pain. Each time, the main finding on X-ray was a colon full to the brim with stool. We take a dietary history. Impeccable: she's quasi-vegetarian and her standard lunch is brown rice, lentils, and kale. She's two years shy of being the age for a colon cancer screening, and given the findings on X-ray, I recommend a colonoscopy to make sure there's no obstructing lesion inside her colon. On the day of the procedure, the anesthesiologist gets Anne nice and comfortable, and within a few minutes she's asleep and I begin my journey through her colon. I find this procedure fascinating, even after performing thousands of them, because just as every patient is unique, so every colon is unique in its own way. Anne's colon is an impressive maze of twists and turns and switchbacks and loops that are very difficult to navigate. After more than three times the amount of time it usually takes me to complete a colonoscopy, we are finally finished. The diagnosis: a voluptuous Venus colon. Physiology, Not Psychology Women may be from Venus and men from Mars, but are our colons really that different? It turns out that they are. As science in recent years has proven repeatedly, women aren't just smaller versions of men, and that means in the GI tract, too. There are significant anatomical differences in the female digestive tract that explain why bloating is such a problem for us. In the medical literature there are lots of articles about colonoscopy being more difficult in women, requiring more sedation, and the procedure overall taking longer. The differences have been attributed to a lower pain threshold in women--something I find hard to believe, given the fact that most women go through labor without any anesthesia and the world's population is still growing. Anatomical variances between the female colon and her male counterpart are the real explanation for these differences, and for the significantly higher prevalence of constipation and bloating in women compared to men. The Link Between Women and Bloating Women tend to have longer colons than men, on average four to five inches longer. The difference is probably to allow for more absorption of fluids during pregnancy. Most of the extra female colon, which is sometimes referred to as a redundant, tortuous, or spastic colon, is in the transverse segment or low down in the sigmoid colon. Not only does the extra length predispose to loop formation during colonoscopy, making the procedure more challenging, but it's also prone to loop formation at other times, too, particularly when the colon is filled with gas or stool. When the products of digestion get stuck in these sharp angulations, there's a lot of gas buildup behind the blockage, leading to tremendous discomfort and bloating. It was episodes like this that had landed Anne in the emergency room. The pain from the stretching of a full segment of colon led to what's called a vasovagal reaction in which her heart rate dropped and she felt sweaty, nauseated, and dizzy. It's a reaction I've seen in lots of people with extreme constipation and bloating when the colon gets too full of stool or gas, or after colonoscopy if too much air is left in the colon. In addition to a longer colon, women have a more rounded, deeper pelvis than men. The combination of the shape of the pelvis and the added length of the colon causes the colon to drop deep into a woman's pelvis, where it competes for space with her ovaries, Fallopian tubes, uterus, and bladder. This can lead to a lot of looping, crowding, constipation, and bloating. By contrast, men's reproductive organs take up much less space, and their narrower pelvis doesn't usually lead to the bowel taking up residence there. A visual representation of the male colon would be a gentle horseshoe shape, while the female visual would be a Six Flags roller coaster. Hormonal differences play a role, too. Higher levels of testosterone in men result in an abdominal wall that's generally more muscular and defined, which buttresses the colon, preventing it from forming redundant loops and keeping things moving through more efficiently. Even men with a beer belly often have a relatively tight abdominal wall underneath, which is why they'll complain about being fat but not bloated. In addition to less testosterone, women sometimes have too much estrogen on board, a condition called estrogen dominance that's associated with the growth of uterine fibroids and endometriosis, both of which can press on the bowel and be a major source of bloating. (Surgical removal of the uterus, a common treatment for fibroids and endometriosis, is also a risk factor for bloating because of the scar tissue that can develop afterward in the abdominal cavity, hampering the colon's freedom of movement and creating additional angulations and kinks.) Anne was thrilled to hear she didn't have colon cancer or any other worrisome condition inside her colon. As it turned out, some of the positive things she was doing needed some tweaks to help maximize their benefits. She was eating large amounts of fiber, but she was doing it at one sitting. This was contributing to her bloating as the bulky stools were getting stuck in the hairpin turns of her colon, causing a lot of discomfort. She modified her diet to keep her total intake of fiber the same, but she spread it out throughout the day. She also doubled up her water consumption to help move the fiber through her digestive tract more efficiently. As a result, she was able to stop taking the stool softener and osmotic cathartic at night. Just knowing the diagnosis was tremendously helpful to Anne in managing her symptoms. When she felt her bowels getting backed up and started to become really bloated, she'd do a liquid diet for a day, drinking primarily green veggie juices and broth, sometimes with a couple of doses of the cathartic to help clean things out. Her colon still required a lot of attention, but there were no more near-fainting spells or trips to the emergency room. On occasion I've had to prescribe a full bowel prep for patients with a voluptuous Venus colon filled with stool, but I always recommend not letting things get to that point by doing a day or two of liquids, instead of blasting your bowels with osmotic cathartics. A longer colon, a deeper pelvis, a less defined abdominal wall, and hormonal influences--all of these factors can conspire to constipate and bloat us. But knowing what's going on inside can help you manage your bloat--including figuring out when to lighten up your diet to give your curvy colon a chance to decompress. 3 Traffic Jams on the GI Superhighway? As mentioned in Chapter 1, the gastrointestinal tract is one long road, from the mouth to the anus. There are no shortcuts, bypasses, or alternate routes--and unfortunately, there can be plenty of obstacles along the way, both structural and functional. In this chapter we'll look at some of the conditions that slow things down en route and can be a major source of bloating. I'll also provide you with some useful information on what to do if your digestive contents are stuck in transit. Expect Delays Deborah had been complaining of severe bloating, abdominal pain, and heartburn for a few months, which was worse after meals. She had tried over-the-counter antacids and prescription acid suppressors to no avail. She didn't have any of the common risk factors associated with acid reflux that cause heartburn: she was a nonsmoker, didn't drink caffeine, and wasn't overweight. Her job with a large international bank meant lots of time sitting in meetings, but she went running every evening after work and did yoga on the weekends. Dinner at around nine p.m. was her main meal, since breakfast was light and lunch nonexistent. Her husband did most of the cooking, and dinner was meat, chicken, or fish with a starch and a vegetable, and sometimes a glass of wine and a piece of chocolate for dessert. Deborah was worried about an ulcer and so was I, since she took a lot of nonsteroidal anti-inflammatory drugs (NSAIDs) for aches and pains from running. These medications are notorious for causing ulcers and inflammation in the GI tract, so I scheduled her for an endoscopy to take a look. When I sedated Deborah and inserted the endoscope through her esophagus into her stomach, I was very surprised by what I saw: no ulcers and a normal stomach, but a large mound of what looked like cheese and tomato sauce sitting right in the middle of everything. The first thing I asked Deborah when she woke up was whether she had forgotten to fast before the procedure and had eaten breakfast by mistake. No, she had dutifully followed the written instructions. Her last meal had been cheese pizza the night before at nine p.m. The fact that I could still see it sitting in her stomach eleven hours later was definitely not normal. To confirm my suspicions, I sent Deborah for a test called a gastric emptying study that measures how long your stomach takes to empty after eating. You're given food containing a small amount of radioactive material, and your stomach is scanned from the outside to see how long it takes for the food to pass through. Less than half of it should be in the stomach at the completion of the test. Deborah's results were very abnormal: at the end of the test, 80 percent of the food was still in her stomach! The gastric emptying study confirmed Deborah's diagnosis: delayed emptying of the stomach, a condition called gastroparesis, which means partial paralysis of the stomach. The stomach isn't really paralyzed in gastroparesis, but its function is slowed down to varying degrees and bloating is one of the most common symptoms. We don't know the reason behind gastroparesis in most people. The vagus nerve, which controls stomach emptying, can be damaged or affected by illness, causing the muscles to not work properly. Diabetes, intestinal surgery, narcotic medications, some antidepressants, and neurological conditions like Parkinson's disease and multiple sclerosis are causes. It can also occur after certain viral illnesses. Fatty Foods, Too Full of Fiber, and Sleepy Stomachs: Lifestyle Causes of Gastroparesis Gastroparesis can be severe in some people, especially in diabetics, whose stomach emptying can completely shut down when their blood sugar is poorly controlled, leading to pain, bloating, and recurrent episodes of vomiting after eating. In most people, the symptoms are much less severe and usually fluctuate, with flare-ups that can be precipitated by a large fatty meal or by eating too much fiber in one sitting. Excerpted from Gutbliss: A 10-Day Plan to Ban Bloat, Flush Toxins, and Dump Your Digestive Baggage by Robynne Chutkan All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
