Overcoming Digestive Disorders

There’s almost nothing worse than a stomach ache. Joe’s mother used to complain that if her belly was hurting, she couldn’t think about anything else. Like many of us, she tended to sometimes abuse her digestive system—overeating, skipping the occasional meal, snacking late at night, and eating all the wrong foods. 

Lots of us do things we know our stomachs might not like: guzzling coffee by the gallon, overdoing it on spicy foods, indulging in rich, chocolatey confections, reaching for just one more bottle of beer after eating one last piece of pepperoni pizza. And even though we know on a gut level, as it were, what foods, beverages, and behaviors can exacerbate a bad belly, we sometimes can’t help ourselves. Then we moan about it later. (They don‘t call it bellyaching for nothing.) 

Pills And Abdominal Pain:

But it's not just what we eat that can cause digestive woes. Lots of things can cause a stomach ache. Medications can lead to abdominal pain. Think aspirin or NSAIDs (nonsteroidal anti-inflammatory drugs) like celecoxib (Celebrex), diclofenac (Voltaren), ibuprofen (Advil, Motrin), meloxicam (Mobic) or naproxen (Aleve, Anaprox, Naprosyn). Such drugs can not only cause stomach pain, they can also irritate the lining of the stomach to the point of ulceration. Hundreds of other medications can also lead to digestive distress. They include the stop-smoking drug varenicline (Chantix), the diabetes drug metformin, the corticosteroid prednisone and the osteoporosis medication alendronate (Fosamax), to name just a few. 

Other Causes of Bellyaches:

Gas and bloating can make you quite uncomfortable. So can gallstones! Actually, gallstones represent a level of pain way beyond discomfort. Irritable bowel syndrome (IBS) is another potential problem along with nasties like diverticulitis or appendicitis. Any pain that persists, is out of the ordinary or worse than usual, requires a medical workup.

We consider it strange that indigestion is so often referred to as "heartburn." It actually has nothing to do with the heart. However, the symptom of burning and pain in the esophagus usually manifests high under the sternum (or breastbone). That means it's chest pain. Sometimes the symptoms of heart attacks masquerade as upper gastrointestinal (GI) tract discomfort, especially for women, who don’t always have the same onset symptoms as men. If you think there’s any chance that what you may be experiencing is a heart attack instead of a terrible attack of heartburn, chew an aspirin, call 911, and get to the ER.

A Brief Historical Perspective

Humans have suffered from heartburn for all of history. Hunters and gatherers consumed just about anything that was edible and some things that probably weren't. Hippocrates warned in 400 BC that eating cheese after a full meal could cause indigestion, especially if accompanied by wine. Your gastroenterologist is likely to give similar advice today. Centuries ago, doctors called heartburn dyspepsia, from the Greek words meaning difficult to digest. Some doctors still like to use that term for reasons that mystify us. 

Whether you call it indigestion, reflux, sour stomach, acid stomach or dyspepsia, heartburn is unpleasant. It can quickly wipe out the memory of a fabulous dinner. Trying to sleep with a burning sensation in the middle of your chest is difficult at best and impossible at worst. 

Complications of GERD

Of course, even though gastroesophageal reflux disease (GERD) is not life threatening, it should be treated seriously. Recurrent reflux can lead to health complications. The longer that corrosive stomach acid remains in contact with the fragile tissues of the esophagus, the more damage it can do.

Symptoms may include chronic cough, laryngitis and asthma. Over time, reflux can cause scarring, narrowing (stricture), abnormal cell growth (Barrett's esophagus), and, potentially, esophageal cancer. If you are experiencing frequent or prolonged heartburn, you absolutely must see a gastroenterologist for a full examination and tests. Taking care of chronic heartburn isn’t for us amateurs!

What Causes Indigestion? Is It All Due to Excess Acid?

The cause of heartburn is not  as obvious as you might think. While it’s true that stomach acid is partly to blame, ads for acid-reducers would have us believe that stomach acid is the sole culprit behind indigestion. Was stomach acid a huge evolutionary mistake stretching back hundreds of millions of years? Almost all animals have complex digestive systems that create powerful stomach acid, including dogs, cats, chickens, cows, rhinos, elephants, beavers, vultures, penguins and wombats. 

Drug companies may have figured out highly effective ways to shut down acid production in our stomachs, but there are good reasons our bodies make it: acid is essential for digestion and for facilitating the absorption of specific nutrients. Stomach acid also creates an inhospitable environment in our upper digestive tracts. That makes it harder for germs we may swallow with our food to set up housekeeping and create infection. You will shortly learn that long-term acid suppression may have some negative consequences. 

What's In Your Belly?

Stomach contents are corrosive. There is hydrochloric acid. It's nasty stuff. If you were to get it on your skin it would burn. Consider this: battery acid has a pH of around 1.0. Stomach acid ranges from about a pH of 1 to 3. For comparison, tap water in New York City is about 6.7 and the pH of an average cup of coffee is around 4.5.

You might not think the change from a pH of 1 to a pH of 2 is that big a deal. Remember, though, the pH scale is logarithmic. If you go from pH 4 to pH 5, that is a ten fold decrease. If you go from a pH 2 to a pH 4 that is 100 times less acidic. Consider that acid-suppressing drugs like esomeprazole (Nexium) can change the pH of the stomach from around 2 to at least 6. That is a 10,000 fold difference in stomach acidity. Not exactly what mother nature intended, eh?

The stomach has lots of other stuff besides acid. There's gastrin for starters. This hormone stimulates the production of hydrochloric acid. Gastrin also gets the muscles in the stomach moving as part of the digestive process. More about gastrin shortly. There are other hormones in the stomach along with bile acids and enzymes such as pepsin. This gemish of chemicals helps us digest our food properly.

If you have ever thrown up you know how nasty stomach contents can be. Ever wonder why that corrosive hydrochloric acid doesn't regularly eat holes in your stomach lining? It's complicated, but a key factor is mucus. Specialized "goblet" cells in the lining of your stomach protect your delicate tissues from caustic acid and enzymes. Your esophagus is not as well protected as your stomach.

Lazy LES: The Real Culprit Behind Heartburn?

Heartburn is not so much caused by acid as by a lazy muscle that lies just above the stomach at the end of the esophagus. Usually, when food is chewed and swallowed, it’s pushed into the stomach past a one-way valve called the lower esophageal sphincter (LES). The LES is supposed to keep food and gastric juices from getting back up into the esophagus. If it functioned perfectly, the corrosive chemicals in your stomach would not work their way back up into your food tube.

Sometimes, though, this muscle loses its contractility, which leads to reflux. Scientists aren’t entirely sure why this happens. A surprising number of medications, including benzodiazepines (benzos for short) can make LES laziness worse. Benzos include alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium) and lorazepam (Ativan). Blood pressure pills such as verapamil (Calan, Verelan), nitrate-type heart medicines such as nitroglycerin, progesterone and anticholinergic drugs (see list here) can also relax the lower esophageal sphincter. Bronchodilators for asthma or COPD can also do it. We suspect that many health professionals do not always mention that a medicine they have prescribed can potentially increase the risk for heartburn because they alter LES function.

Zolpidem (Ambien) and Heartburn

Visitors to our website alerted us to a surprising side effect of the sleeping pill zolpidem (Ambien) over a decade ago. The unexpected complication is heartburn (acid reflux). We don't know if it is because the drug relaxes the LES. That seems as plausible as any other mechanism. 

Although the official prescribing information for zolpidem now includes “dyspepsia” as a frequent adverse event, we suspect that many patients do not realize that is the medical term for heartburn. And we doubt that many health professionals warn patients about this problem.

We think this is a serious adverse drug reaction that deserves attention as this reader describes:

"Why is it that doctors (even my gastroenterologist) are not aware of the severe heartburn side effects of zolpidem (Ambien)? It seems that in some people, this drug causes a malfunction of the esophageal sphincter.

"I took Ambien daily for several years before the heartburn symptoms started. I was put on strong proton pump inhibitors to control my symptoms for over a year. I also had lots of diagnostic tests — an upper GI endoscopy and esophageal manometry — all unnecessary. I finally discovered the connection of GERD [gastroesophageal reflux disease] to Ambien on my own.

"How can we make the side effects of Ambien more well known?"

A study published in BMJ Open (Feb. 27, 2012) confirmed this adverse reaction is real, but there is hardly any mention of this side effect in the medical literature. Nevertheless, we have heard from a surprising number of people that it is real. Here are just a few more reports from readers:

"I was prescribed Ambien for insomnia, then began experiencing reflux and heartburn nightly. After a few weeks, it occurred to me that the heartburn began about the same time I started the Ambien.

“As I was only instructed to take the Ambien ‘as needed’, I stopped immediately and went online to research this. I found many, many instances of people who’d experienced the same thing. Of course, my doctor was surprised, as she had never heard of this before…..”

R.M. was dismissed by his doctor:

“After taking zolpidem for 20 days I started having stomach cramps, bloating, acid reflux, heartburn and a nervous feeling. Finally, after 4 days of not taking it, I’m feeling better. The doctor that prescribed zolpidem didn’t agree that these side effects were due to the medicine.”

No one should stop zolpidem cold turkey. Doing so can cause rebound insomnia. Should you need to discontinue this sleeping pill to overcome reflux, please discuss a gradual tapering process that might last several weeks or months. 

Everybody passes gas. Most people do so 14 times per day on average. Michael Levitt, MD, one of the world’s leading flatologists, has said that 22 or fewer flatus events per day is normal, and doesn’t require any special action.

As in all areas of life, however, there are always some overachievers. We once heard about a man whose output was so impressive— and so distressing, to him, and no doubt to others—that Dr. Levitt encouraged him to keep a “flatulographic record” (aka a fart chart) in order to figure out which items in his diet might be triggering his problem. By making note of every time he had a “flatus event,” he soon found out that milk was the culprit. When he went on a plain milk diet, he passed gas 141 times in a single day! In fact, he farted 70 times in a single four-hour period—in other words, once every 3.4 minutes.

One maddening thing about flatulence (besides the obvious) is that everyone’s triggers are different. There’s no easy way to know what might be causing your discomfort without keeping a careful record of what you consume (and thus create). There are, of course, some common offenders. Perhaps you have heard the grade-school verse that goes, “Beans, beans, good for the heart, the more you eat, the more you fart.” But what about wheat, barley, and rye? Or, more surprising still, the drugs paroxetine (Paxil) or atorvastatin (Lipitor)?

Digestive discomforts can come from the unlikeliest places. But luckily, there are also some unlikely-sounding remedies that may ameliorate the problem, or at least help trap the odor. Have you ever considered sipping fennel seed tea for gas? Or experimenting with carbonized underclothes to keep bad smells at bay? Cutting back on the foods that cause you trouble seems sensible. But which ones are they? 

A good place to start is with the aforementioned fart chart. It’s a diary of everything you eat—and the medications you take—and every time you fart. Creating this kind of record can help gas-prone people determine which things are triggering their flatulence. You might think the answer is just to hold it in. Not everyone can do this—some people’s sphincters are stronger than others. But even if you can hold it like a pro, we don’t recommend it. As most practitioners have no doubt noticed, holding gas in can lead to painful cramping, pressure, bloating, and even colic.

We know there’s a social stigma attached to farting in public, but we say: let ’em rip. It will keep the pain away. Of course excuse yourself to the bathroom when you can, and sometimes you may feel it’s necessary to hold it in. We agree that a board meeting is not necessarily the time to let out a loud, smelly fart. But try not to get in the habit of squeezing farts away. Instead, figure out your triggers.

Drug-Induced Flatulence

When was the last time your physician warned you that one of the drugs she was prescribing could give you gas? And yet there are hundreds of medications that can cause flatulence. Part of the reason for this is that lactose is a filler in some drugs. For those who are lactose intolerant, this could certainly cause a problem. 

Below, you’ll find a list of some of the medications that have commonly been linked to flatulence, but it’s by no means exhaustive. You may want to check with your physician if you’re still having trouble after keeping a fart chart, watching your diet, and taking other measures. It could be that the problems you’re having are linked to your medications.

Sometimes, gas can be the symptom of something more serious. One possible cause is celiac disease, which affects far more people than once thought. It used to be that doctors believed only 1 in 5,000 people were likely to have the illness, whereas now they think that it may be as common as 1 in 100, or even as high as 1 in 22 in families prone to the condition.

People with celiac disease can’t tolerate gluten, which is found in the grains wheat, rye, and barley. When they eat gluten, they experience an immune reaction that kills off cells in their small intestines. Not surprisingly, this can lead to all sorts of uncomfortable abdominal symptoms (listed below), and it also makes it difficult to absorb calcium, magnesium, iron, and other nutrients that the body needs. 

Lots of doctors practicing today were never taught about the wide array of problems that celiac disease can cause, like migraines or peripheral neuropathy. With new evidence of its ubiquity, we think more patients should be tested for this condition. 

If you have several of the symptoms on the list below, ask your doctor for EMA (endomysial antibody) and tTG (tissue transglutaminase) blood tests. People with celiac disease MUST avoid all foods and beverages containing gluten (like wheat-based pizza, bread, bagels, pretzels, pasta, and beer), which should help clear up a lot of digestive problems. 

Some Signs and Symptoms of Celiac Disease:

• Anemia (iron deficiency)
• Bloating
• Bruising
• Dementia
• Diarrhea or runny stools (They may float and smell terrible)
• Fatigue
• Gas and flatulence
• Headaches and migraines (frequent)
• Heartburn
• Itchy skin rash
• Numbness or tingling (hands and feet)
• Osteopenia (weakened bones), osteoporosis
• Reflux

Many doctors believe that celiac disease mostly affects children, but more recent research shows that people past middle age can be diagnosed for the first time with celiac disease (BMC Gastroenterology, June 29, 2009; Gastroenterology Clinics of North America, Sep. 2009). 

Following a Gluten-Free Diet:

Food labels have gotten better at identifying gluten as an ingredient than they were decades ago. Still, US manufacturers are not as good about this as European manufacturers. People who must follow a gluten-free diet need to make sure they are getting proper nutrition from a range of vegetables and fruits as well as protein such as eggs, fish, chicken or meat (European Journal of Nutrition, March 2017). None of those foods in their natural state contain any gluten, but vegetarians need to read the labels carefully if they use meat substitutes. Many contain gluten.

People around the world are concerned about regularity, and have been so for a very long time. The ancient Egyptians used aloe vera as a laxative, while Arab healers in the ninth century used senna for that purpose. The lasting power of laxatives can be seen by the fact that more than a thousand years later, the popular laxative Ex-Lax contains senna-derived compounds.

When constipation is defined in terms of regularity, no single standard determines what is normal. Some people do well with two or three bowel movements a week, while others may visit the bathroom three times a day. Effort counts, too, and so does the consistency of stool. Passing “bricks” can be distressing.

If bowel movements suddenly become infrequent or difficult, or if increased fluid and fiber don't help, it is appropriate to check with a doctor. An underlying medical problem, such as Parkinson's disease or an underactive thyroid gland, requires treatment. When there is no apparent medical cause, physicians may dismiss constipation as a minor complaint. Patients don't see it that way. One man suffering from heart disease, failing vision, and prostate enlargement still rated constipation as one of his most troublesome health problems.

Medicines That Cause Constipation

Physicians may sometimes contribute to constipation unintentionally and without informing their patients. Quite a few medications may cause constipation as a side effect. Narcotic pain medicines and older antidepressants are especially notorious in this regard, and some anti-cancer medicines and AIDS drugs can also be constipating. If this happens to you, don’t stop taking your medicine. It may be a lifesaver. But do discuss the situation with your doctor. In some cases there may be an alternative that is less likely to produce this complication. Here is a short list of constipating drugs. It represents just the tip of the figurative iceberg.

As mentioned above, this is just the proverbial tip of the iceberg. If you are taking older-generation antihistamines (such as diphenhydramine or chlorpheniramine, medicines for overactive bladder like oxybutynin, older antidepressants (amitriptyline, doxepin, etc) blood pressure meds such as beta blockers like metoprolol or calcium channel blockers such as amlodipine, the cholesterol-lowering med cholestyramine or prescription pain relievers like tramadol, constipation could be your companion. Please check with the prescriber if any of your medications are be causing you digestive difficulties. 

Many readers have shared their practical wisdom with us. One woman in Seattle, Washington, reminds us that some people experience difficulties with constipation after eating specific foods. Mango has this effect for one person in her family, and many people know that cheese has this reputation. She warns that peanut butter can also slow the system down. Other readers, keeping in mind that coconut macaroons seem to be a helpful antidote for diarrhea, avoid coconut when they are troubled with constipation.

People have special favorites when it comes to foods for fighting constipation. One reader proclaims, “The VERY BEST fibers are leafy green vegetables, like SPINACH.” Another swears by prune juice with pulp, a traditional stand-by. Prunes have a well-deserved reputation for combatting constipation. In additional to the natural fiber in this fruit, scientists have found a compound in prunes that is similar to a laxative used in the 1950s. This drug, oxyphenisatin, was taken off the market because it was associated with liver problems. It seems unclear whether prunes really contain this compound, but if they do, it would be smart to follow the advice of the Harvard Health Letter: “It is unlikely that moderate consumption would cause any problems, but prune use, like everything else, should be prudent.”

Another old-fashioned approach to constipation is “hot lemonade”— hot water with a big squeeze of lemon juice first thing in the morning. If you prefer coffee, there is evidence that about three cups of your favorite brew can get things going (Diseases of the Colon and Rectum, Aug. 2019). Dates and apples are popular, too. Another is blackstrap molasses. According to a reader, “I take 3 spoonfuls 4 every other day and I no longer need laxatives. It is not a laxative but it works. When I need extra help, I eat some black licorice.”

Flax seed can be beneficial in avoiding constipation. We like this reader's description of how she uses it:

"Some time ago you had a question from a person who wanted to know how to use flax seed to relieve constipation. I purchase it in bulk at a health food store for about $1.50 per pound. I put three quarts of water on to boil, add two tablespoons of flax seed and simmer for fifteen minutes. Then I cool it and strain it into containers. (It makes just over two quarts.) With two ounces in my orange juice every morning, I am more than satisfied."

Several herbs may be useful, though we don't recommend regular use of the usual laxative herbs like senna. Ginger, on the other hand, can stimulate digestive tract action. It is not habit forming and is said to ease flatulence as well. Milk thistle, an herb used to protect the liver, has given one reader relief: “I'm 75 and I've had trouble all my life. A few months ago, a doctor told me about milk thistle. His wife takes it so I tried it. Milk thistle works wonders.” Dong quai also has laxative action.

Dietary supplements sometimes cause diarrhea as a side effect. At high doses, vitamin C can cause diarrhea, and some readers have used this to fight constipation. Others utilize the mineral magnesium. After all, milk of magnesia, a magnesium salt, is a time-honored laxative. Taking magnesium with calcium can ease the constipation sometimes associated with calcium supplements.

If these remedies don't help, and constipation is a persistent problem, please get medical attention. Constipation could be a symptom of something more serious that requires prompt treatment.

Joe & Terry's Ten Tips to Combat Constipation

• Lots of fiber & fluid
• Bran-apple-prune mix
• Flax seed
• Sugarless gum
• Psyllium
• MOM (milk of magnesia)
• Unifiber (cellulose)
• Pumpkin bran muffins
• Vitamin C
• Ginger

Gastroenterologists often refer to irritable bowel syndrome (IBS) as a "functional digestive disorder." That's because they can't blame any specific germ or immune system problem for the difficulties that sufferers experience. Symptoms like severe abdominal pain, flatulence, bloating and either diarrhea or constipation can be debilitating. Sometimes they seem to come from nowhere, although at other times the trouble is triggered by stress or even particular foods.

Evidence is growing that these symptoms may actually be caused by disruptions in the balance of bacteria in the digestive tract (Pimentel & Lembo, "Microbiome and Its Role in Irritable Bowel Syndrome," Digestive Diseases and Sciences, March 2020). Sometimes an intestinal infection is the first sign of IBS, with changes in the gut microbiota later. Scientists have identified overgrowth of the small intestine with bacteria causing diarrhea (IBS-D). A different type of microbial imbalance results in the predominance of constipation among the symptoms (IBS-C).  

Simple Remedies for IBS

Psyllium

Surprisingly, there is one remedy that appears to be helpful for both forms of irritable bowel syndrome. You may think of psyllium (eg, Metamucil) as a laxative. Indeed, it can help people who are constipated, but it is also quite useful in calming diarrhea (Surdea-Blaga et al, "Dietary interventions and irritable bowel syndrome - what really works?" Current Opinion in Gastroenterology, online Dec. 16, 2020). 

Probiotics

If the main cause of IBS is a disruption of the gut microbes, wouldn't probiotics be an obvious therapy? Some investigators have put them to the test. In a review of 15 randomized, placebo-controlled trials of probiotics (Didari et al, "Effectiveness of probiotics in irritable bowel syndrome: Updated systematic review with meta-analysis," World Journal of Gastroenterology, March 14, 2015), the authors concluded:

"Probiotics reduce pain and symptom severity scores. The results demonstrate the beneficial effects of probiotics in IBS patients in comparison with placebo."

The hitch in this review is that we don't learn which specific strains of probiotic are most beneficial. A Chinese trial is currently underway testing a combination of four strains of Bifidobacterium for treating IBS-D (Bai et al, "The efficacy of Bifidobacterium quadruple viable tablet in the treatment of diarrhea predominant irritable bowel syndrome: protocol for a randomized, double-blind, placebo-controlled, multicenter trial," Trials, June 30, 2020). We will be very interested in reading the published results when this study is completed.