The Sensitive Gut Harvard Health

A Harvard Medical School Special Health Report
The Sensitive Gut

A guide to managing common gastrointestinal disorders
In this report:
Calming heartburn
and reflux
Dealing with
constipation and gas
Treating irritable
bowel syndrome
Probiotics and
prebiotics
SPECIAL BONUS SECTION

The stress connection
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Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
THE SENSITIVE GUT
SPECIAL HEALTH REPORT
Contents
Medical Editor
Lawrence S. Friedman, MD Inside the gut . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Professor of Medicine, Harvard Medical School The digestive journey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Professor of Medicine, Tufts University School of
Medicine
The aging GI tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The Anton R. Fried, MD, Chair, Department of
Medicine, Newton-Wellesley Hospital SPECIAL SECTION:
Assistant Chief of Medicine, The stress connection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Massachusetts General Hospital
Executive Editor Gastroesophageal reflux disease . . . . . . . . . . . . . . . . . . . 12
Anne Underwood Causes of GERD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Writers Diagnosing reflux . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Susan Ince, Julie Corliss Complications of reflux . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Copy Editor Self-help for reflux . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Robin Netherton
Antireflux drug therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Creative Director
Judi Crouse Herbal remedies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Production Manager Surgical options for reflux . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Lori Wendin
Functional dyspepsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Illustrators
Harriet Greenfield, Scott Leighton, Diagnosing functional dyspepsia . . . . . . . . . . . . . . . . . . . . . . . . 21
Michael Linkinhoker Tests and medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Published by Harvard Medical School Causes of functional dyspepsia . . . . . . . . . . . . . . . . . . . . . . . . . 23
Gregory D. Curfman, MD, Editor in Chief Treating functional dyspepsia . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Patrick J. Skerrett, Executive Editor
Irritable bowel syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . 25
In association with
What is IBS? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Belvoir Media Group, LLC, 535 Connecticut Avenue, Nor-
walk, CT 06854-1713. Robert Englander, Chairman and Causes of IBS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
CEO; Timothy H. Cole, Executive Vice President, Editorial Diagnosing IBS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Director; Philip L. Penny, Chief Operating Officer; Greg
King, Executive Vice President, Marketing Director; Ron Goldberg, Managing IBS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Chief Financial Officer; Tom Canfield, Vice President, Circulation.
Copyright © 2015 by Harvard University. Permission is required
Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
to reproduce, in any manner, in whole or in part, the material How constipation happens . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
contained herein. Submit reprint requests to: Causes of constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
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Diagnosing constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
hhp_permissions @ hms.harvard.edu Treating constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
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Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
ISBN 978-1-61401-101-9 Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
The goal of materials provided by Harvard Health Publications
is to interpret medical information for the general reader. Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
This report is not intended as a substitute for personal medical
advice, which should be obtained directly from a physician.
Dear Reader,
Out of sight, out of mind, your digestive system is working around the clock delivering the
nutrients in food to your bloodstream. As long as the system is running smoothly, you need
not think about it. Once trouble begins, however, your gut—like a squeaky wheel—suddenly
demands your attention.
For some folks, symptoms such as diarrhea, gas, cramps, heartburn, indigestion, belching,
bloating, and nausea are infrequent and tolerable, but many people experience them far
more often. An estimated one in four people has frequent gastrointestinal problems that
can severely disrupt a normal lifestyle. And the number of prescriptions for gastrointestinal
medications has soared since the late 1990s, according to federal statistics.
Although the misery that such problems inflict is real, these ailments aren’t usually the
product of an illness in the conventional sense. Often, they are functional gastrointestinal
disorders. That means, unlike—for example—ulcers or stomach cancer, they can’t be attrib-
uted to any physical cause, such as a structural abnormality, hormonal changes, or infection.
More than 40% of diagnoses made by gastroenterologists are for functional disorders.
However, just because doctors can’t find a physical cause doesn’t mean you’re imagining
things. The symptoms are quite real, and if they occur frequently or last more than a month,
it’s a good idea to seek help.
You might be relieved to know that even if your doctor can’t pinpoint the cause of your
symptoms, the chances are good that you can get relief. This report focuses on a number
of disorders considered to be functional: reflux, functional dyspepsia, irritable bowel
syndrome, constipation, diarrhea, and excessive gas.
The good news is that our ability to treat gastrointestinal disorders continues to improve.
With proper knowledge—and the support of the right combination of health professionals—
you can make changes in your lifestyle, use specific medications, find other helpful therapies
that will ease your discomfort, and make the right decisions about medical treatments.
Sincerely,
Lawrence S. Friedman, M.D.

Medical Editor
Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
Inside the gut
T he “gut.” It’s an ancient Anglo-Saxon word that

refers to the human digestive system. Think of this
superb accomplishment of nature’s engineering as a
the tongue and teeth help to get the process started by
chewing and chopping the food so it’s small enough
to be swallowed. Salivary glands secrete saliva, releas-
perpetual food processor, constantly mixing, grinding, ing an enzyme that changes some starches into simple
and transforming the meats, vegetables, fruits, and sugars and softens the food for swallowing. The saliva
snacks that you eat into biologically useful molecules. also allows the taste buds of the tongue to sense the
Nearly 30 feet long if stretched out straight, the gut flavors of your foods.
is a series of hollow organs linked to form a long, twist- Swallowing is a complicated, coordinated act that
ing tube that runs from the mouth to the anus (see Fig- begins when your tongue pushes food back into your
ure 1, at right). This string of organs is known variously throat or pharynx. This voluntary action sets off an
as the alimentary canal, gastrointestinal (GI) tract, or
digestive tract. It comprises the esophagus (or gullet),
stomach, small intestine, and colon (which includes Figure 1: A lengthy journey
the rectum). These organs break down food and liq-
uids—carbohydrates, fats, and proteins—into chemical
components that the body can absorb as nutrients and
use for energy or to build or repair cells. What’s left is
expelled by a highly efficient disposal system.
The organs of the gut are almost always moving,
driven by muscles in their walls. These muscles con-
sist of an outer longitudinal layer and an inner circu-
lar layer. The coordinated contractions of these layers
Lower
push food and fluids the length of the canal. If you’ve Esophagus esophageal
ever seen a video of a snake swallowing a mouse, Diaphragm sphincter
you’ve got some idea of what the process is like. This Pyloric
dynamic movement along the gastrointestinal tract is sphincter Stomach
known as peristalsis. Colon
Helping with the job of digestion is the mucosa,
or lining, of the mouth, stomach, and small intes- Small
tine, which harbors glands that produce digestive intestine
enzymes. The salivary glands, liver, and pancreas also
secrete juices that help make food soluble (dissolv-
able in water) so that nutrients can pass easily into the Sigmoid
Rectum
bloodstream. colon
The food you eat travels a winding 30-foot pathway known as

the gastrointestinal tract or the alimentary canal. Along the way,
The digestive journey the mucosa—the surface layer of cells lining the gastrointestinal
Pop a grape, chocolate, or shrimp into your mouth. tract—produces digestive enzymes and juices that help break
Immediately, digestion begins. In the mouth itself, down food to be absorbed into the bloodstream.
2 The Sensitive Gut w w w.h ealt h .ha r va r d.e du
Figure 2: How long does it take? Think of the esophagus (along with the intestine)
as an empty tube surrounded by layers of muscle that
Esophagus
contract in a succession of waves. As the ball of food,
8 seconds called a bolus, travels toward the far end of the 10- to
13-inch-long tube, the lower esophageal sphincter—
one of several cylindrical muscles along the digestive
Stomach tract that function as gates—opens to allow the food
2– 6 hours
to enter the stomach, then closes again. The esopha-
geal tube is quite elastic, stretching to nearly two
Small intestine inches across to accommodate foods of various sizes.
3–5 hours While the esophagus is moving things along, it also
has to keep food from backing up (regurgitating) and
re-entering the throat. That’s where a muscle known as
Colon
the upper esophageal sphincter comes into play. The
4 –72 hours
two esophageal sphincters, upper and lower, make sure
the food doesn’t travel in the wrong direction.
The time it takes for food to pass all the way through the digestive
tract can be anywhere from nine hours to over three days. Stomach
If the esophagus is a conduit with a valve at each end,
involuntary chain of events that transports the food the stomach can be likened to a storage and process-
from the throat into the esophagus and down into the ing facility, where the food is prepared for digestion.
stomach, a journey that typically takes eight seconds This food warehouse can accommodate anything
(see Figure 2, above). from a light afternoon snack to a five-course meal.
Without this large storage capacity, people would have
Esophagus to eat small, frequent meals, and they’d be unable to
Food does not simply drop down the esophagus by drink large quantities of liquids at any given time.
means of gravity. Matter moves through this passage- But the stomach doesn’t just hold food: muscles in
way because it is pushed by contractions of the esoph- the lower stomach also mix that food into a soft mush
ageal muscles. (see Figure 3, below). This process is aided by the liq-
Figure 3: The stomach wall
Lower esophageal Mucosa

Esophagus sphincter
Submucosa
Pyloric sphincter
Muscle
Duodenum
Outside layer (serosa)
The stomach lining (mucosa) is not a smooth, balloon-like surface.

Instead, it has several layers that contain nerve connections to the
brain as well as glands that secrete juices to help digest food.
ww w. h ealt h . h ar v ar d . e du The Sensitive Gut 3

uids we drink and by saliva, hydrochloric acid, and
the enzyme pepsin. Hydrochloric acid and pepsin,
fast fact | While the incidence of ulcers in the
duodenum (the upper part of the small intestine) declines
produced by the glands that line the stomach, help
after middle age, ulcers in the stomach (also called
break down proteins into their constituent amino
gastric ulcers) become more common.
acids. The stomach mucosa has a defense system,
including an overlying layer of mucus and bicarbon-
ate, to protect itself. After mixing, a once-palatable stored in the gallbladder, emulsifies fat, enabling its
meal is reduced to a thick liquid called chyme. absorption. Enzymes secreted by the pancreas, such
The other important function of the stomach is as trypsin, amylase, and lipase, help digest proteins,
delivering the resulting chyme to the small intestine in carbohydrates, and fats. Once reduced to products the
amounts it can handle. The involuntary contractions body can manage, the nutrients from digested food
that push stomach contents along are governed by are absorbed by the intestine’s thin lining and sent to
nerves in the stomach wall, which transmit electrical cells throughout the body by way of the bloodstream
impulses to the brain. The nerves that carry impulses and lymphatic system.
from the GI tract, called visceral nerves, recognize The small intestine is divided into three parts, and
stretching, pulling, or expansion (distension) of the each serves a somewhat different digestive function.
muscles in the walls of the digestive tract. Pain can • First is the foot-long duodenum, located a few
result when these sensations are excessive. inches above the navel. Many minerals, such as
When you haven’t eaten for a while and your stom- iron and calcium, are absorbed into the body
ach is empty, it initiates a series of rhythmic contrac- through the duodenum. This is also where bile and
tions known as hunger pangs. They serve as a signal pancreatic juices join the mix.
to the brain: “Feed me!” These contractions explain • After the duodenum, the next part of the small
stomach noises, which also can be caused when air intestine is the jejunum, which measures eight feet
or fluid is moving around inside. Once you’ve eaten, in length. In the jejunum, fats, starches, and pro-
it takes about two hours for the muscular stomach teins are further broken down and absorbed.
to reduce a typical meal to a liquid and have it ready • The third and lowest portion of the small intestine,
to move along to the small intestine. A high-protein the ileum, is approximately 12 feet long. The ileum
meal can take an extra hour or two. A high-fat meal absorbs water, as well as vitamin B12 and bile salts.
can take up to six hours. That’s why food with healthy
fats (such as those in nuts) help you feel full longer Colon (large intestine)
than high-carbohydrate foods like sugary snacks. Finally, what’s left of the food arrives in the colon, or
large intestine, a four-foot-long muscular tube about
Small intestine the diameter of your fist, where the walls act like a
Through another gate called the pyloric sphincter, the sponge and soak up 80% to 90% of the remaining
stomach empties partially digested food, or chyme, water. In fact, the colon accepts about a quart of liq-
into the small intestine. This hollow tube, which is a uid from the ileum each day. Once inside the colon,
remarkable 21 feet long, is where the main work of food residue travels up the right side (the ascending
digestion takes place. The small intestine breaks down colon), across the transverse colon, down the left side
fats, starches, and proteins into fatty acids, simple sug- (the descending colon), through the sigmoid colon to
ars, and amino acids, which it can then absorb. the rectum, and out of the body. The time required
The food you eat generally takes three to five for food to move through the colon varies widely, but
hours to move through the small intestine. During is generally in the range of four to 72 hours.
this time, the food is bathed in digestive enzymes and Bacteria that reside in the colon help in the diges-
juices that flow into the intestine through ducts from tive process, feeding off whatever remains of your
the liver and pancreas. Bile, produced by the liver and meal. The bacteria produce fatty acids as well as
hydrogen, carbon dioxide, and, in some people, meth-
ane gas. Some of these gases are consumed as nutri- A living colony in your gut—
ents by the cells of the colon, while others are expelled that’s a good thing
as waste. Undigested matter, such as fiber, is propelled
along by contractions of the colon wall and settles as T he GI tract is filled with living microorganisms, collec-
tively called the microbiota or microbiome. It includes
disease-causing organisms as well as health-promoting
solids in the rectum, the final six inches of the colon.
The end of the rectum is guarded by a pair of ones. Under normal circumstances, the “good” bacteria
keep the “bad” bacteria in check. However, an imbalance
sphincter muscles that help control what goes out. of these organisms sometimes causes disease, and there is
The waste accumulates until the rectal wall becomes increasing evidence that a healthy bacterial ecosystem is
so distended that it signals the internal anal sphinc- also important for maintaining robust health in general.
ter to relax, triggering the urge for a bowel movement. Compared with younger adults, older people have fewer
The external anal sphincter, which is under voluntary species of bacteria in the digestive tract, perhaps as an
control, keeps the rectal contents in place until a con- effect of aging itself or the accumulated impact of dietary
changes and the use of antibiotics and other medica-
venient time. tions. A less diverse microbiome may increase constipa-
What comes out is primarily water and colon tion, lower the body’s defense against gastrointestinal
bacteria, plus bile, mucus, and cells normally shed infections, and increase inflammation. However, there is
from the intestinal lining. Undigested food makes up no clear evidence yet on how disturbances in bacterial
balance might result in irritable bowel syndrome and
very little of the average quarter- to half-pound stool.
other disorders.
The exception is fiber: the more fiber you ingest, the
An unbalanced microbiome has also been associated
greater the quantity of your stool.
with several diseases related to aging, such as Parkin-
son’s disease, but the precise relationship is not clear.
The microbiome may even be connected to regulation of
The aging GI tract mood and weight.
Aging takes a toll on the GI tract. Aging muscles,
including the digestive muscles, contract more slowly,
take plenty of time relaxing, and move their contents ously around food after swallowing. Acid reflux is
along at a more leisurely pace. For the most part, that’s often a problem in the elderly, the result of the decline
fine—unless you feel impatient, take drastic measures in esophageal contractions and in the function of the
to hurry things along, or develop a condition that lower esophageal sphincter muscle. However, since
needs a doctor’s attention. Many of the aging GI sys- the esophagus can be less sensitive to acid with age,
tem’s failures can be prevented or corrected. acid reflux might not result in heartburn. Instead,
The mouth. The age-related changes begin at the people complain of nausea or vague chest discomfort.
top of the GI system, in the mouth, where the number Any new onset of difficulty in swallowing should be
of taste buds begins to decline. So does the sensitiv- evaluated by a doctor because the problem could be
ity of those that remain. The muscles responsible for related to cancer of the esophagus or to a motor disor-
chewing also begin to weaken. As a result, some older der (achalasia), more common in those who are older.
people lose interest in food, begin to lose weight, and The stomach and duodenum. As people age, the
develop nutritional deficiencies. Losing teeth can also stomach continues to make acid, but in many older
reduce interest in eating. Good dental care is impor- people, acid production declines because of years of
tant so that eating doesn’t become a problem. carrying Helicobacter pylori infection in the stomach,
The esophagus. Swallowing can also become leading to long-term gastritis (stomach inflammation)
more difficult as you age. Such problems are usually and to atrophy of the stomach lining. While a reduc-
the result of neurological or muscular disorders. Very tion in gastric acid does not usually interfere with
old people sometimes experience a weakening of the digestion, it can lead to two disorders that are com-
muscles of the esophagus, which contract less vigor- mon in the elderly—vitamin B12 deficiency, which can

cause anemia and nerve damage, and excessive bac- with age. In fact, one in three senior citizens has one
terial growth in the small intestine, resulting in mal- or more polyps in the colon. That’s why a screening
absorption and poor digestion. Both problems can be exam called a colonoscopy is recommended on a reg-
treated. ular basis after age 50. Since colon cancer evolves from
The colon. Moving one’s bowels may be the most polyps, removal of polyps will keep colon cancer from
frequent gastrointestinal challenge associated with getting started. In general, people pass less stool after
aging. The problem is usually the result of disease or they reach age 65. In part, this can be the result of a
malfunction of the large intestine. Problems with this change in diet to softer foods, a decreased appetite, or
organ can also result in diarrhea and hemorrhoids. In diminished muscular activity of the colon. Constipa-
addition, the risk for colon cancer and polyps increases tion may also result from a neurological problem.
SPECIAL SECTION
The stress connection

H
ave you ever had a “gut-wrenching” experience? Do
certain people or situations make you “nauseous” (meta-
phorically speaking)? Have you ever felt “butterflies” in
your stomach? We use these expressions to describe emotional
reactions because the gastrointestinal (GI) tract is sensitive to
emotion. Anger, anxiety, sadness, elation: all of these emotions
and many others can trigger symptoms in the gut.
The brain has a direct effect ee’s poor job performance without
Thinkstock
on the stomach: even the thought considering his or her manager The gastrointestinal tract is sensitive to
of eating can release the stomach’s and work environment. emotions. Anger, sadness, and anxiety
can all trigger sympoms in the gut.
juices before food gets there. This
connection goes both ways. A The second brain
troubled intestine can send signals To appreciate the impact of stress motor neurons as well as glial cells,
to the brain, just as a troubled brain on the gut, it is helpful to under- which support and protect the
can send signals to the gut. There- stand the similarities and connec- neurons. And the ENS uses many
fore, a person’s distressed gut can tions between the brain and the of the same neurotransmitters, or
be as much the cause as the prod- digestive system. The gut is con- chemical messengers, as the CNS.
uct of anxiety, stress, or depres- trolled by the enteric nervous sys- The ENS is embedded in the
sion. That’s because the brain and tem (ENS), a complex system of gut wall and participates in a rich
the gastrointestinal system are inti- about 100 million nerves that over- dialogue with the brain during the
mately connected—so intimately sees every aspect of digestion. The entire journey of food through
that they should be viewed as one ENS is heavily influenced by the the 30-foot-long digestive tract.
system, rather than two. central nervous system (CNS), with The ENS cells in the lining of the
This is especially true in cases which it communicates through gut communicate with the brain
when the gut is acting up and pathways of nerves. The “second by way of the autonomic nervous
there’s no obvious physical or brain,” as the ENS is sometimes system, which controls the body’s
infectious cause. For such func- called, arises from the same tissues vital functions. As part of that sys-
tional GI disorders, trying to heal a as the CNS during fetal develop- tem, sympathetic nerves connect
distressed gut without considering ment. It has many structural and the gut to the spinal cord and then
the impact of stress and emotion is chemical counterparts in the cra- to the base of the brain. In addi-
like trying to improve an employ- nial brain, including sensory and tion, parasympathetic nerves pass
www.health.har vard.edu The Sensitive Gut 7

SPECIAL SECTION | The stress connection
to and from the base of the brain activated your “fight or flight” physical cause, such as an infection
via the vagus nerve from the upper response, inhibiting gastrointesti- or structural abnormality.
gut or the sacral nerves from the nal secretion and reducing blood That doesn’t mean, however,
colon. The gut and brain use their flow to the gut). that functional gastrointestinal
shared neurotransmitters, includ- illnesses are imaginary, or “all in
ing acetylcholine and serotonin, Stress and the functional your head.” Psychology combines
to transmit information back and GI disorders with physical factors to cause pain
forth by way of these sympathetic Given how closely the gut and and other bowel symptoms. In
and parasympathetic nerves. brain interact, it might seem obvi- particular, childhood trauma such
This two-way communication ous that the pair often influence as physical or sexual abuse makes
system between the gut and the each other. Some people feel nau- functional GI disorders more likely
brain explains why you stop eating seated before giving a presentation; to occur in adulthood (see “Anti-
when you’re full (sensory neurons others feel intestinal pain during depressants for body and mind,”
in your gut let your brain know times of stress. In any case, emo- page 11). Psychosocial factors in-
that your stomach is distended), or tional and psychosocial factors fluence the actual physiology of
conversely, why anxiety over this play a role in so-called functional the gut, as well as the modulation
morning’s exam has ruined your GI disorders—gut ailments whose of symptoms. In other words, stress
appetite for breakfast (the stress symptoms cannot be linked to any (or depression or other psychologi-
Figure 4: Closing the pain gate

Have you ever noticed that you feel pain
less when you’re doing something that
requires all your attention? That’s because
Inhibitory signal Pain signal pain is not a one-way street. Your brain
from brain to brain
can inhibit the pain signals from the
gut (or elsewhere in your body, for that
Synapse between
matter).
nerve cells
Experts explain this with the “gate con-
Pain gate open Pain to trol” theory. For example, receptors in your
brain
intestines, known as afferent receptors,
Receptors
pick up a pain signal and route it toward
the brain. But certain centers in the spinal
cord can regulate the pain. Fibers in these
“pain gates” may allow the signal to
Pain proceed to the brain, or they may “close
the gate.” This process is sometimes called
Pain gate closed Release of “downregulation” of the pain signal.
neurotransmitters
blocks pain receptors Your brain does this naturally when you
are doing something that requires deep
concentration, such as playing a sport
intensely. Antidepressant medications can
also help close the gate by blocking or
inhibiting the pain signal to the brain.
8 The Sensitive Gut www.health.har vard.edu
The stress connection | SPECIAL SECTION
cal factors) can affect movement

and contractions of the GI tract, Gut reactions
cause inflammation, or make you
more susceptible to infection.
In addition, research sug-
E arly researchers relied on some remarkable yet basic observations to learn
how the digestive tract responds to emotions. In 1833, William Beaumont,
a U.S. Army surgeon, was given an inside view when Alexis St. Martin, a French
gests that some people with func- Canadian traveler, was accidentally shot in the stomach. The wound left a gas-
tional GI disorders perceive pain tric fistula (opening to the skin) that allowed Beaumont not only to observe the
pumping, to-and-fro motion of the stomach, but also to see what happened
more acutely than other people do
when his patient expressed different emotions.
because their brains do not prop-
In his journals, Beaumont wrote that when St. Martin showed fear, anger, or
erly regulate pain signals from the
impatience, his stomach mucosa grew pale and produced less gastric juice.
GI tract (see Figure 4, page 8). In Studies have since found that powerful emotions can evoke both increases and
other words, stress can make the decreases in stomach secretions.
existing pain seem even worse. In another experiment, conducted in the 1950s, a student agreed to let medical
These observations suggest researcher Thomas Almy view his sigmoid colon, the section of the lower colon
that at least some people with func- near the rectum, through a sigmoidoscope. During the exam, someone else
present mentioned cancer of the colon, and the startled student leapt to the
tional GI conditions might find
conclusion that this was his diagnosis. The researchers watched the lining of his
relief with therapy to reduce stress colon blush and contract rapidly, only to relax and regain its normal color when
or treat anxiety or depression. the student was reassured that he did not have cancer.
And sure enough, a 2014 review
of 32 studies showed that people
treated with psychologically based changes in diet or medications. If ful circumstances, stand to benefit
approaches had greater improve- symptoms do not improve, your from psychological treatments such
ment in their symptoms compared clinician may ask you more ques- as cognitive behavioral therapy,
with people who received conven- tions about your medical history relaxation techniques, and hypnosis.
tional medical treatment. and perform some diagnostic tests Some people are reluctant to accept
to rule out a physical abnormal- the role of psychosocial factors in
Treating the whole body ity, infection, or cancer. For some their illness. But it’s important to
Stress-related symptoms in the GI people, symptoms improve as soon know that emotions cause genuine
tract vary greatly from one person as a serious diagnosis, like can- chemical and physical responses
to the next, and treatment can vary cer, has been ruled out (another in the body that can result in pain
as well. For example, one person example of how emotional stress and discomfort. Behavioral therapy
with gastroesophageal reflux dis- affects the gut). Your doctor may and stress reduction treatments do
ease might describe an occasional, also recommend symptom-spe- not directly reduce pain or improve
mild burning sensation in the chest, cific medications. But sometimes symptoms in the way that drugs do.
while another complains of excru- these treatments are not enough. Rather, the goal is to reduce anxiety,
ciating discomfort night after night. As symptoms become more severe, encourage healthy behaviors, and
As the severity of symptoms varies, so does the likelihood that you are help people cope with the pain and
so should the therapies, medica- experiencing some sort of psycho- discomfort of their condition.
tions, self-help strategies, or even logical distress.
surgeries used to relieve them. Often, people with moderate to Cognitive behavioral therapy
Many people have mild symp- severe symptoms, particularly those Cognitive behavioral therapy, or
toms that respond quickly to whose symptoms arise from stress- CBT, involves working with a ther-

SPECIAL SECTION | The stress connection
Is stress causing your symptoms? More likely, you will be taught more
general techniques that you can
When evaluating whether your gastrointestinal symptoms—such as heartburn, apply to your specific situation. To
abdominal cramps, or loose stools—are related to stress, watch for these other
find a trained cognitive behavioral
common symptoms of stress and report them to your clinician as well.
therapist, consult your doctor or
Physical symptoms • Grinding teeth
health plan, or visit the website of
• Stiff or tense muscles, especially • Increased desire to be with or
the Academy of Cognitive Therapy
in the neck and shoulders withdraw from others
at www.academyofct.org
www.academyofct.org. Make
• Headaches • Rumination (frequent talking or
sure your therapist has a license to
• Sleep problems brooding about stressful situations)
practice in your state.
• Shakiness or tremors Emotional symptoms
• Recent loss of interest in sex • Crying
Relaxation therapy
• Weight loss or gain • Overwhelming sense of tension
Relaxation therapy is a technique
• Restlessness or pressure
that helps people to be more relaxed
• Trouble relaxing
Behavioral symptoms when confronted with pain or a
• Nervousness
• Procrastination stressful situation. Therapists use a
• Quick temper
• Difficulty completing work variety of methods, including pro-
• Depression
assignments gressive muscle relaxation, mental
• Poor concentration imaging, music, and even aromas,
• Changes in the amount of alcohol
or food you consume • Trouble remembering things to induce a natural state of relax-
• Taking up smoking, or smoking • Loss of sense of humor ation. During and after relaxation,
more than usual • Indecisiveness thoughts begin to flow slowly and
naturally, muscle tension dimin-
ishes, and breathing slows and
apist to reframe negative ways of and anxiety improve even further. becomes deeper and more regular.
thinking and behaviors that affect In fact, in a study of people with This allows the parasympathetic
a person’s symptoms and quality of irritable bowel syndrome, 77% of branch of the autonomic nervous
life. The goal is to change counter- those who underwent seven weeks system to take over. The result? The
productive thoughts and actions of CBT reported symptom relief body can relax and digest.
and learn new coping skills. This lasting for six months, compared For people with functional or
may be accomplished through a with improvement in 21% of peo- stress-related GI disorders, relax-
number of techniques, including ple receiving usual treatment. ation therapy can help manage
changing negative thought pat- Many mental health profession- the stress associated with physi-
terns, learning stress management als practice CBT, including psychol- cal discomfort. One small study,
and relaxation techniques, mod- ogists, psychiatrists, social workers, for example, found that people
eling healthy behaviors, and role and psychiatric nurses. Most cog- with irritable bowel syndrome
playing. CBT can reduce the stress nitive behavioral therapists are who learned to elicit the relaxation
of dealing with a functional GI not specifically trained in treating response—an approach developed
disorder so that the disorder is no irritable bowel syndrome or other by Dr. Herbert Benson, founder
longer the focal point of a person’s functional GI disorders unless they of the Benson-Henry Institute for
life. As stress decreases, symptoms are associated with a clinic that spe- Mind Body Medicine—enjoyed
often improve, and in turn stress cializes in treating these conditions. significant short- and long-term
10 The Sensitive Gut www.health.har vard.edu
The stress connection | SPECIAL SECTION
reductions in pain, bloating, functional GI disorder, specific perceive GI pain to be more or less
diarrhea, and flatulence. There treatment for anxiety or depres- severe based on how well it regu-
are many relaxation techniques, sion, including referral to a men- lates signals coming from the GI
including yoga, meditation, hyp- tal health professional, may be tract. Tricyclics can turn down the
nosis, and biofeedback. Dr. Benson needed. Moreover, people with level of pain perceived by the brain
is medical editor of the Harvard severe GI symptoms, especially by acting on the neurotransmit-
Special Health Report Stress Man- those with chronic pain, may ters (dopamine, serotonin, norepi-
agement, which explains many benefit from treatment with anti- nephrine, and acetylcholine) that
techniques for tamping down depressants even if they are not are carrying pain impulses between
stress levels. (To order, go to www. depressed. Although these medica- the gut and the brain (see Figure 4,
health.harvard.edu, or call 877- tions are most often prescribed to page 8). They can also act directly
649-9457, toll-free.) Many types of help alleviate depression and anxi- on the gut, reducing the sensitiv-
health care professionals, including ety, in lower doses they also act to ity of the gut to painful stimuli. In
psychologists and behavioral ther- relieve pain. One seven-study anal- addition, they affect motility (con-
apists, teach relaxation skills. Ask ysis of people with irritable bowel stipation is a common side effect,
your doctor for a referral. syndrome found that those treated so they are helpful for individuals
with antidepressants showed an with diarrhea), and they help alle-
Antidepressants for improvement in abdominal pain viate symptoms of depression.
body and mind scores compared with placebo. Selective serotonin reuptake
A small minority of people have Antidepressants also improve inhibitors (SSRIs). These include
severe functional GI symptoms overall well-being in people with citalopram (Celexa), paroxetine
that can be debilitating, signifi- functional GI disorders. And they (Paxil), sertraline (Zoloft), and
cantly affecting their day-to-day can help gut motility (the rhythmic fluoxetine (Prozac). SSRIs are less
lives. It’s important for these peo- contractions of the gut). effective than tricyclics for pain,
ple to be screened for anxiety and Three groups of antidepres- but they have fewer side effects.
depression. People with severe sant medications can be used to They are a good treatment option
symptoms have a high frequency treat functional GI disorders: tri- for people with functional GI dis-
of psychological diagnoses, such cyclic antidepressants, selective orders who also have depression or
as anxiety, depression, or a history serotonin reuptake inhibitors, and anxiety.
of loss, abuse, or trauma. In some serotonin-norepinephrine reup- Serotonin-norepinephrine
studies, high rates of past sexual take inhibitors. reuptake inhibitors (SNRIs).
and physical abuse have been Tricyclic antidepressants Duloxetine (Cymbalta) is one
found in people with functional GI (TCAs). This class of drugs includes example of this class of antide-
disorders—as high as 56% among amitriptyline (Elavil), desipramine pressants. These drugs act on
people with severe symptoms. And (Norpramin), and nortriptyline serotonin and norepinephrine,
among people referred to gastroin- (Pamelor). At full doses, these without the side effects of full-
testinal clinics—usually those with medications have considerable dose tricyclics. Although there are
more severe symptoms—func- side effects. However, when pre- only a few preliminary studies on
tional bowel disorders often started scribed at doses lower than those the effectiveness of SNRIs in fight-
after a time of extreme stress. used to treat depression, they may ing functional GI disorders, they
If either anxiety or depres- relieve pain. Pain is, in part, a mat- are being used by some doctors in
sion appears to be a factor in a ter of perception; the brain may this context.

Gastroesophageal reflux disease
H eartburn, that uncomfortable burning sensation

that radiates up the middle of your chest, is the
most common gastrointestinal malady. Heartburn is
are having a heart attack. Although heartburn can be
extremely painful, it is not generally a serious threat to
your health.
an expression of a condition known as gastroesopha- More people are suffering with the symptoms of
geal reflux disease (GERD), often called “reflux,” in GERD than ever before. About one-third of Ameri-
which acid, pepsin, or both rise from the stomach into cans have heartburn at least once a month, with 10%
the esophagus, much like water bubbling into a sink experiencing it nearly every day. One survey revealed
from a plugged drain. that 65% of people with heartburn have symptoms
Episodes of reflux often go unnoticed, but when both during the day and at night, with 75% of people
reflux is excessive and frequent, the gastric juices irri- with nighttime heartburn saying that the problem
tate the gullet, producing pain, which is experienced keeps them from sleeping, and 40% reporting that
as heartburn. It can hit as you sit in a traffic jam, after nighttime heartburn affects their job performance the
you eat spicy foods, or when you lie down in bed. following day. This epidemic leads people to spend at
Many women experience this sensation during preg- least $2 billion a year on over-the-counter antacids
nancy. Heartburn can be so intense that you think you alone. Clearly, it’s a major problem.
The burning sensation is usually felt in the chest
just behind the breastbone and often extends from the
Figure 5: Reflux lower end of the rib cage to the root of the neck. It
can last for hours and is sometimes accompanied by
the very unpleasant, stinging, sour sensation of highly
Esophagus Diaphragm
acidic fluid rushing into the back of the throat. Some-
Acid reflux times acid regurgitates all the way up to the mouth and
may come up forcefully as vomit or as a “wet burp.”
Inflammation But the heart of heartburn and GERD is burning
behind the sternum. The sensation can be aggravated
by many things, ranging from emotional stress to a
variety of foods and even particular body positions,
Lower esophageal
sphincter like reclining or bending forward. While GERD—and
its symptom, heartburn—can be difficult to cope with,
Stomach many people manage quite well by controlling such
things as stress, diet, or position. However, many oth-
ers spend countless hours and untold sums of money
looking for relief.
Gastroesophageal reflux disease is an often-painful condition that

occurs when the lower esophageal sphincter fails to do its job of
keeping digestive juices in the stomach. When the sphincter relaxes
Causes of GERD
too much, irritating stomach fluids surge up into the esophagus, GERD is a digestive disorder affecting the lower
sometimes causing inflammation and a painful burning sensation esophageal sphincter (LES), the muscle connecting
behind the breastbone known as heartburn. the esophagus and stomach. This muscle acts as a
barrier to protect the esophagus against the backflow
of gastric acid from the stomach. Normally, it works Do you have functional heartburn?
something like a gate, opening to allow food to pass Functional heartburn is heartburn whose symptoms can-
into the stomach and closing to keep food and acidic not be linked to any infection or structural abnormality.
stomach juices from flowing back into the esophagus. A person must have experienced all of the following for
the past three months, with symptoms starting at least
The LES is a complex segment of smooth muscle six months before diagnosis:
under the control of nerves and various hormones. As
✔ burning discomfort or pain behind the breastbone
a result, dietary substances, drugs, and nervous sys-
✔ no evidence that symptoms are caused by acid reflux
tem factors can impair its function. Gastroesophageal from the stomach or esophagus
reflux occurs when the LES weakens or just relaxes ✔ absence of structural disorders that interfere with
when it shouldn’t, allowing contents of the stomach to the movement of food down the esophagus.
rise up into the esophagus (see Figure 5, page 12). Sci- These criteria come from a group of more than 100
entists aren’t sure exactly why this happens, but they international experts and are known as the Rome crite-
have identified some contributing factors, including ria. They cover all functional gastrointestinal disorders,
those listed below. including functional heartburn. As this report went to
press, the most recent version available was Rome III,
When there is no identifiable cause, the problem published in 2006. Rome IV is expected to be published
is called functional heartburn (see “Do you have func- in the spring of 2016.
tional heartburn?” at right).
Delayed stomach emptying. Digestive abnormal-
ities other than malfunction of the LES can contrib- Foods and drinks. Diet can contribute to dysfunc-
ute to reflux. In one study, about half of people with tion of the lower esophageal sphincter. For example,
reflux exhibited impaired motility of the stomach— alcohol can loosen the LES (and irritate the esopha-
the inability of the stomach muscles to contract in a geal lining), as can coffee and other caffeine-contain-
normal fashion. This might delay the emptying of the ing products. Coffee, tea, cocoa, and cola drinks are
stomach, increasing the risk that acid will reflux back all powerful stimulants of gastric acid production.
into the esophagus. A failure of peristaltic contrac- Mints and chocolate, often served to cap off a meal
tions to clear the esophagus of acid that has refluxed, to aid in digestion, can actually make things worse.
a lessening of the esophageal lining’s ability to resist Both relax the LES and can induce heartburn. Some
damage, or a shortage of saliva (which has a neutral- people say that onions and garlic give them heart-
izing effect on acid) can play a part as well. burn. Others have trouble with citrus fruits or tomato
Overweight and obesity. Research has linked products, which are irritating to the esophageal lining.
GERD to excess weight. A study in The New England High-fat and fried foods can also trigger symptoms. If
Journal of Medicine found that weight gain increases you notice that a particular food leads to episodes of
the risk of frequent GERD symptoms—even if the heartburn, by all means, stay away from it.
person’s body mass index (a ratio of weight to height) Eating patterns. How you eat can be as important
remains in the normal range. The additional weight as what you eat. Skipping breakfast or lunch and then
can increase pressure on the stomach, pushing its con- consuming a huge meal at day’s end can increase gas-
tents up. Hormones also play a role, but even modest tric pressure and the possibility of reflux. Lying down
weight gain can induce heartburn, making GERD one right after eating will only make the problem worse. It
more good reason to avoid weight gain. The increase is best to wait three hours after eating before going to
in the prevalence of GERD might be linked to the bed. And stay away from late-night snacks.
growing proportion of obese people in the population. Medications. Some prescription drugs can worsen
Pregnancy. Pregnancy can also promote GERD your heartburn (see Table 1, page 14). Oral contra-
because of hormonal changes and the effects of the ceptives or postmenopausal hormone preparations
enlarging uterus pressing against other organs. containing progesterone are known culprits. Aspi-

risk for heart attacks and strokes, and it causes GI
Table 1: Common medications that can
symptoms in some people. Corticosteroids, used to
cause reflux
treat a variety of medical conditions, are also known
This chart shows examples of each class; not all brands or
versions are listed. to cause heartburn. Other drugs—such as alendronate
(Fosamax), used to prevent and treat osteoporosis—
GENERIC NAME BRAND NAME(S) USE
can irritate the esophagus. And some antidepres-
Bronchodilators
sants, tranquilizers, and calcium-channel blockers can
theophylline Aerolate, Uniphyl, Relieves wheezing contribute to reflux by relaxing the LES. The asthma
others
medication theophylline may initiate or aggravate
Calcium-channel blockers reflux in some people, thereby causing chest pain. In
amlodipine Norvasc Lower blood an interesting twist, however, studies have found that
pressure and
diltiazem Cardizem improve coronary
theophylline can improve chest pain that is not caused
nifedipine Adalat, Procardia artery blood flow by reflux or heart disease.
Smoking. Smoking can irritate the entire GI tract.
verapamil Calan, Isoptin
In addition, frequent sucking on a cigarette can cause
Nonsteroidal anti-inflammatory drugs (NSAIDs)
you to swallow air, increasing stomach pressure and
aspirin Bufferin, Ecotrin, Relieve pain and encouraging reflux. Smoking sometimes also relaxes
others inflammation
the LES.
ibuprofen Advil, Motrin
Hiatal hernia. Hiatal hernia is a common condi-
naproxen Aleve, Anaprox, tion that develops when part of the stomach pushes
Naprosyn
up through the diaphragm—the band of muscle that
Osteoporosis drugs
separates the chest from the abdomen and helps with
alendronate Fosamax Build bone density breathing. The diaphragm has a small opening (hia-
ibandronate Boniva tus), which should be just large enough for the esoph-
risedronate Actonel agus to pass through. However, in a person with hiatal
Progestins hernia, part of the stomach also protrudes through the
diaphragm and into the chest (see Figure 6, page 15).
medroxy- Depo-Provera, Relieve symptoms
progesterone Provera of menopause; This changes the angle at which the esophagus joins
acetate used in oral the stomach, weakening the ligaments that hold these
contraceptives
norethindrone Aygestin, Micronor organs in proper alignment and impairing the LES’s
acetate ability to prevent reflux. Studies indicate that a hiatal
Tricyclic antidepressants hernia, particularly if it is large, allows acid to collect
amitriptyline Elavil, Endep Relieve depression; above the level of the diaphragm and promotes reflux
occasionally used of that acid into the esophagus, causing irritation and
nortriptyline Aventyl, Pamelor for long-term pain
pain.
protriptyline Vivactil
Eosinophilic (allergic) esophagitis. Eosinophilic
esophagitis is a disease characterized by the presence
rin and other nonsteroidal anti-inflammatory drugs of eosinophils, a type of white blood cell, in the wall of
(NSAIDs) such as ibuprofen (Advil, Motrin) and the esophagus. Eosinophils, which are associated with
naproxen (Aleve, Naprosyn) may also pose problems. allergic reactions, stimulate inflammation. One symp-
A prescription NSAID known as a COX-2 inhibitor, tom of the condition is heartburn, although episodes
celecoxib (Celebrex), is widely used to relieve pain of dysphagia, the feeling of food or pills sticking in the
because it is designed to be easier on the stomach than esophagus, are more characteristic. The disease often
standard NSAIDs. Celebrex carries a warning, how- occurs in children and young adults, many of whom
ever, because it has been linked to a slightly increased also have allergies or asthma. Previously, doctors sug-
Diagnosing reflux
Figure 6: Hiatal hernia Many people can manage heartburn through dietary
Hiatal hernia changes, over-the-counter medications, and relax-
Normal stomach ation therapy (see “Self-help for reflux,” page 17). A
doctor can be helpful if your symptoms don’t respond
to self-help techniques and they interfere with sleep
or daily life. If you do seek your physician’s advice, a
Normal diaphragm Weak
diaphragm detailed account of your symptoms will help him or
her make the diagnosis.
The doctor will review your medical history and
ask questions about the nature of the pain and its
pattern of onset. For example, he or she might ask
whether symptoms are worse after you eat a heavy
One possible cause of heartburn is a common condition called meal or known dietary troublemakers such as high-
hiatal hernia, in which a portion of the stomach protrudes through fat foods. Your doctor will want to know if bending
the opening in a weak diaphragm, the band of muscle that sepa- over to tie your shoelaces or lying down aggravates
rates the chest from the abdomen.
the symptoms, and whether the pain seems linked to
anxiety or stress.
gested that people eliminate foods most likely to cause For typical reflux symptoms, doctors usually forgo
allergies one at a time, to see if symptoms improved. diagnostic tests and proceed straight to treatment,
But a study in Gastroenterology suggests a different starting with a proton-pump inhibitor (PPI) such as
strategy. Instead, cut from your diet the six foods most omeprazole (Prilosec, Zegerid) or lansoprazole (Pre-
likely to cause allergies: nuts, fish and shellfish, eggs, vacid). If these acid-suppressing medications provide
wheat, soy, and milk. Then, reintroduce them one at relief, the odds are that the diagnosis of GERD was
a time, one every two weeks, to see which foods cause correct. Once symptoms are under control, you may
symptoms to return. Nearly all of the 50 people with either continue with the PPI or switch to a less power-
eosinophilic esophagitis in the study who tried this ful medication. That might be a histamine2-receptor
approach had fewer symptoms after they cut the six antagonist (H2 blocker) such as cimetidine (Tagamet),
foods from their diets for six weeks. The two foods ranitidine (Zantac), or famotidine (Pepcid), or an ant-
that most often triggered a return of symptoms were acid like Tums. If the medicine doesn’t relieve your
wheat (60%) and milk (50%). symptoms or if other symptoms need investigation,
If your symptoms and the appearance of the the doctor might use diagnostic tests to detect reflux,
esophagus on endoscopy (see “Do you need diagnos- measure pH levels in the esophagus, or rule out other
tic testing?” on page 16) seem to indicate eosinophilic conditions (see “Do you need diagnostic testing?” on
esophagitis, a proton-pump inhibitor such as omepra- page 16).
zole (Prilosec) or lansoprazole (Prevacid) is usually Your doctor will be alert for other symptoms, such
the first recommendation. If that doesn’t help, eosin- as frequent nonburning chest pain, bleeding into the
ophilic esophagitis often responds to a course of the gastrointestinal tract, dysphagia (difficulty in swallow-
steroid fluticasone (Flovent) taken by mouth. ing), hoarseness, or constant coughing and wheezing.
Other medical conditions. As many as 70% of Such symptoms may be associated with GERD, but
people with asthma have reflux. It’s not clear, however, could have other causes and might warrant tests to
whether asthma is a cause or an effect. Still, asthma gain more information.
often improves when GERD is treated. Other illnesses For example, GERD is sometimes accompanied
that sometimes contribute to reflux include diabetes, by respiratory problems such as asthmatic wheezing,
ulcers, and some types of cancer. coughing, or hoarseness. When asthma strikes adult

Do you need diagnostic testing?
D octors ordinarily don’t put people with heartburn through costly diagnostic
evaluations. However, more serious reflux symptoms—such as bleeding from
the esophagus, swallowing problems, or severe symptoms that fail to respond to
eat or sleep and find out how their pH
levels correlate with these activities.
The doctor might ask the person to stop
standard treatment for GERD—might warrant further investigation. People who taking medication during this time to
don’t find relief with medications might also benefit from testing. Common tests see how the pH level responds without
include the following: medication.
Upper GI endoscopy. This is a method smaller than a standard endoscope; it is In another method, the doctor passes
of viewing the inside of the esophagus about the size of a straw. The physi- a thin, acid-sensing probe through the
to look for signs of inflammation or cian inserts the scope through the nose nose and positions it just above the LES.
tissue damage. Upper GI endoscopy is down to the esophagus. No sedation is The probe stays in place for 24 hours to
considered the gold standard for testing needed, and people can see the images assess pH and reflux levels.
for GERD. For this test, the physician and learn the results immediately. This Impedance testing. This is a more
uses a flexible tube that’s about as wide test is not yet widely available, but it sophisticated testing method requiring
as a finger. After giving the person a may gain popularity in the future for specialized training. Impedance testing
sedative and depressing the gag reflex screening people with GERD for Bar- monitors the transport of ions through
with a local anesthetic spray, the doctor rett’s esophagus (see page 17) in the the esophagus and can detect reflux.
passes the tube down the person’s doctor’s office. The doctor passes a flexible catheter
throat. The tube contains a light and Monitoring pH. These tests monitor an through the nose and down into the
camera, which allow the doctor to individual’s reflux episodes over a day esophagus. Sensors at the end of the
inspect the lining of the esophagus, as- or two and measure pH levels in the catheter relay information to a record-
sess injuries such as ulcers or strictures, esophagus. One method involves using ing device. You wear the impedance
and take a biopsy (a tissue sample), if endoscopy to insert a small capsule in device overnight while going about
necessary. the esophagus. The capsule is clipped your normal activity. It is particularly
Transnasal esophagoscopy. This in place for 48 hours, while a radio useful for people who have non-acid
technique, which is available only in transmitter records pH levels. People reflux (when low-acid stomach contents
some facilities, uses a scope that is can keep track of the times when they rise into the esophagus).
nonsmokers with no history of lung disease or aller- of the mucosa, the surface layer of cells that line the
gies, pH-monitoring studies sometimes suggest that esophagus. Besides the burning sensation of simple
GERD is the culprit. As noted earlier, many people heartburn, people with esophagitis may also complain
with asthma experience reflux. of pain behind the breastbone spreading into the back
or up to the neck, jaw, or even the ears. The pain can
be so intense that you have trouble swallowing, and
Complications of reflux you may even think you are having a heart attack.
Although simple reflux is uncomfortable, it doesn’t With esophagitis, food may feel as if it sticks
usually pose a danger to healthy individuals. Half in your throat before going down. Hot drinks are
to three-quarters of people with reflux disease have unpleasant to swallow, and you might have some nau-
mild symptoms that generally clear up in response to sea. You might also regurgitate some acid fluid into
simple measures. Over time, however, serious prob- your throat, resulting in a cough. The inflammation
lems can develop when GERD goes untreated. These of the esophagus can even lead to bleeding. Upper
complications can include narrowing (stricture) of the GI endoscopy (see “Do you need diagnostic testing?”
esophagus, erosion of its lining, precancerous changes above) can confirm the diagnosis of esophagitis and
in its cells, and esophageal ulcers. locate any associated ulcers or strictures. Bleeding
Esophagitis. One complication, known as reflux ulcers in an inflamed esophagus may require aggres-
esophagitis, is inflammation that occurs when acid sive treatment, such as blood transfusions and, to stop
and pepsin, released from the stomach, erode areas the bleeding, a probe passed through an endoscopic
tube to apply electricity or heat, or to inject blood ves- LES and keeping stomach contents where they belong.
sel–constricting agents into the bleeding site. Eat smaller meals. A large meal remains in the
Barrett’s esophagus. Another complication of stomach for several hours, increasing the chances for
chronic esophageal inflammation is Barrett’s esopha- gastroesophageal reflux. Therefore, anyone who suf-
gus, an abnormality in which taller cells resembling fers from this problem should distribute daily food
those that line the small intestine replace the flat intake over three, four, or five smaller meals.
squamous cells that normally line the lower esopha- Relax when you eat. Stress increases the produc-
gus. The condition, a potential consequence of long- tion of stomach acid, so make meals a pleasant, relax-
standing GERD, is caused by long-term and severe ing experience. Sit down. Eat slowly. Chew completely.
exposure to acid from the stomach and bile from the Play soothing music.
small intestine. White men over age 50 who developed Relax between meals. Relaxation therapies such
GERD at an early age and have had it for many years as deep breathing, meditation, massage, tai chi, or
are at the highest risk for getting Barrett’s esophagus yoga may help prevent and relieve heartburn.
and are most likely to be advised to undergo a screen- Remain upright after eating. You should main-
ing endoscopy. tain postures that reduce the risk for reflux for at least
Barrett’s esophagus can, over time, develop into three hours after eating. For example, don’t bend over
cancer, but the risk appears to be very small—between or strain to lift heavy objects.
one-tenth and one-half of 1%, depending on whether Avoid eating within three hours of going to bed.
abnormal cells were detected when the endoscopy was Do not eat bedtime snacks, since lying down after eat-
performed to make the Barrett’s diagnosis. That esti- ing will increase your chances of reflux.
mate comes from findings from a study in The New Lose weight. Excess pounds increase pressure on
England Journal of Medicine that followed more than the stomach and can push acid into the esophagus.
11,000 people with Barrett’s esophagus for an average Loosen up. Avoid tight belts, waistbands, and
of about five years. Currently, people with Barrett’s other clothing that puts pressure on your stomach.
esophagus are typically advised to have regular endo- Avoid foods that burn. Abstain from food or
scopic evaluations with biopsies (called surveillance drink that increases gastric acid secretion, decreases
endoscopies) to identify abnormal cells. Consult your LES pressure, or slows the emptying of the stomach.
physician about your initial test results and how often Known offenders include high-fat foods, spicy dishes,
you should be screened for esophageal cancer. tomatoes and tomato products, citrus fruits, garlic,
Other problems. GERD can also result in dental onions, milk, carbonated drinks, coffee (including
problems, including loss of tooth enamel. And it can decaf), tea, chocolate, mints, and alcohol. The list is
cause spasms of the vocal cords (larynx), blocking the long, but you’re likely to see a substantial improve-
flow of air to the lungs. One study has reported that ment if you cut out or minimize such foods.
such spasms can cause sleep apnea, a condition in which Stop smoking. Nicotine stimulates stomach acid
breathing repeatedly stops and starts during sleep. and impairs LES function.
Chew gum. It can increase saliva production,
soothing the esophagus and washing acid back down
Self-help for reflux to the stomach.
Modifying diet and lifestyle remains the foundation Consult your doctor about your medications.
for treating the symptoms of reflux. In particular, for Drugs that can predispose you to reflux include aspi-
mild GERD symptoms or for symptoms that are not rin and other NSAIDs, oral contraceptives, hormone
relieved by acid-reducing medications like PPIs, life- therapy drugs, narcotics, certain antidepressants, and
style changes are the primary treatment. The following some asthma medications (see Table 1, page 14).
strategies help you prevent pain and other symptoms Raise your bed’s head at night. If you’re bothered
by avoiding foods that reduce the effectiveness of the by nighttime heartburn, elevate the head of your bed

by placing a wedge (available in medical supply stores) rial infections—including a serious diarrheal disease
under your upper body. But don’t elevate your head called Clostridium difficile—and may increase the
with extra pillows. That makes reflux worse by bend- long-term risk of hip fractures. Two PPIs, omepra-
ing you at the waist and compressing your stomach. zole and esomeprazole, should not be taken if you are
Exercise wisely. Wait at least two hours after a taking clopidogrel (Plavix), a drug that helps prevent
meal before engaging in vigorous physical activity, blood clots. Those two PPIs reduce the antiplatelet
giving your stomach time to empty. activity of clopidogrel, potentially placing you at a
higher risk of heart attack or stroke.
Despite these concerns, PPIs are the preferred
Antireflux drug therapy medication for treating GERD. Doctors often recom-
Nonstop advertising has acquainted most people with mend them first for frequent, uncomplicated heart-
antacids, the least expensive treatment for heartburn. burn. But once your symptoms recede, an H2 blocker
These work by reducing the acidity of refluxed material. also can be effective.
But much more effective are the drugs known as pro-
ton-pump inhibitors (PPIs), such as omeprazole (Prilo- H2 blockers
sec, Zegerid), and the H2 blockers, such as cimetidine For chronic reflux, histamine2-receptor antagonists
(Tagamet) and ranitidine (Zantac). Some of these drugs (H2 blockers) are now widely available either by
are available over the counter. PPIs are more effective prescription or, in smaller doses, over the counter.
than either antacids or H2 blockers, but tend to be more They are often effective for GERD symptoms that
costly and cause some unwanted side effects. In severe don’t respond to antacids or changes in eating hab-
cases, physicians combine various antireflux drugs, its. They are also useful for long-term maintenance
such as over-the-counter antacids and H2 blockers, or after a course of PPIs has successfully eliminated
PPIs and prokinetic drugs that increase gastric empty- symptoms.
ing. However, PPIs without additional medications are H2 blockers work by countering the effect of hista-
generally preferable to combinations. mine (which stimulates gastric acid), thereby decreas-
Let’s look at them in the order in which physicians ing the amount of acid that the stomach produces.
typically recommend or prescribe their use. For more They act directly on the stomach’s acid-secreting cells
information on all these drugs, see the Appendix. to stop them from making hydrochloric acid, particu-
larly at night when acid gathers in the stomach and can
Proton-pump inhibitors wash back into the esophagus. Cimetidine (Tagamet)
PPIs are more effective than H2 blockers or antacids was the first H2 blocker on the market. Others avail-
for reducing or neutralizing gastric acid. PPIs work by able in the United States include ranitidine (Zantac),
inactivating a specific enzyme responsible for the final famotidine (Pepcid), and nizatidine (Axid).
step of acid release in the stomach. For people whose heartburn is troublesome only
PPIs available over the counter include esome- at night, a single dose taken in the evening may suf-
prazole (Nexium), lansoprazole (Prevacid), pantopra- fice, but if symptoms occur during the day and night,
zole (Protonix), and omeprazole (Prilosec, Zegerid). more frequent treatments will be needed. All the H2
(Zegerid is an immediate-release medication, in con- blockers are equally effective, so switching to another
trast to other PPIs, which are delayed-release.) PPIs if one fails to work is likely to be fruitless. Increasing
available only by prescription include rabeprazole the dose, however, may be helpful.
(Aciphex) and dexlansoprazole (Dexilant). All these While they are considered relatively safe, H2
medications effectively heal esophagitis and alleviate blockers can have side effects. If you use an over-the-
heartburn. counter H2 blocker for heartburn, be aware that this
In general, PPIs are very safe medicines. But they may mask the symptoms of more serious conditions,
may make the GI tract more susceptible to bacte- so discuss your symptoms with your doctor.
Prokinetic agents
Heartburn or heart attack? Prokinetics—or gastrokinetics, as they’re occasionally
Don’t ignore the possibility that chest pain may mean a called—help empty the stomach of acids and fluids.
heart attack instead of heartburn. Symptoms associated They can also improve LES muscle tone. These medi-
with GERD can mimic the pain of a myocardial infarction
(heart attack) or angina (chest pain caused by diminished
cations are used only for occasional cases of GERD,
blood flow through the coronary arteries), especially either with or in place of H2 blockers, particularly
when the sensation is constricting rather than burning when the stomach appears to empty slowly.
in nature. It can be dangerous to assume that your chest
pain is caused by reflux.
People with known reflux disease should always seek
medical attention if they experience chest discomfort
Herbal remedies
Some people have found herbs and other natural
brought on by exercise, which may signal either angina or
a heart attack. Paying attention to the severity and length remedies to be helpful in the treatment of heartburn
of your chest pain is key. If it’s a severe, pressing, or symptoms.
squeezing discomfort, it may be a heart attack. And heart Chamomile. A cup of chamomile tea may have a
attack pain lasts awhile. If it goes away in five to 10 min-
soothing effect on the digestive tract. People with rag-
utes, it’s probably not a heart attack. It could be angina,
however, which does require a visit to the doctor—and weed allergy should avoid chamomile.
treatment. It’s important not to dismiss chest tightness, Ginger. The root of the ginger plant is another
especially if it follows physical exercise. well-known herbal digestive aid and has been a folk
remedy for heartburn for centuries.
Licorice. This remedy has proved effective in sev-
Antacids eral studies. Licorice is said to increase the mucous
These inexpensive over-the-counter remedies neutral- coating of the esophageal lining, helping it resist the
ize digestive acids in the stomach and esophagus, at irritating effects of stomach acid. Deglycyrrhizinated
least in mild cases of heartburn. While many people licorice, or DGL, is available in pill or liquid form. It is
find tablets more convenient, liquids provide faster considered safe to take indefinitely.
relief. Tablets must be chewed thoroughly in order to be Other natural remedies. A variety of other rem-
effective. The best time to take an antacid is after a meal edies have been used over the centuries, but not enough
or when symptoms occur. The usual recommended scientific studies have been done to confirm their effec-
dosage is 1 to 2 tablespoons (or tablets) each time. tiveness. Catnip, fennel, marshmallow root, and papaya
There are three basic salts used in antacids: mag- tea have all been said to aid in digestion and act as a
nesium, aluminum, and calcium. A major side effect buffer to stop heartburn. Some people eat fresh papaya
of magnesium hydroxide is diarrhea, while the most as a digestive aid. Others swear by raw potato juice,
common side effect of antacids containing alumi- three times a day. However, these remedies have not
num hydroxide is constipation. Those high in calcium been reviewed for safety or effectiveness by the FDA.
(Tums, Rolaids, Titralac, and Alka-2) are probably
the strongest. Calcium carbonate products have been
used for centuries in the form of chalk powder and Surgical options for reflux
ground oyster shell. However, they, too, can be con- Medication and lifestyle changes can successfully
stipating if taken frequently. Sodium bicarbonate, or control 95% of GERD cases, but for a few people, sur-
baking soda, is less powerful than other antacids. It’s gery is the best option. For example, surgery might
the active ingredient in many seltzer antacids (Alka- be preferable for younger people who want to avoid
Seltzer, Bromo-Seltzer) and is found in mineral water. taking PPIs over many years. However, the relief pro-
Because no single agent is perfect, many antacids vided by surgery may not be permanent, and medica-
combine several ingredients that are designed to bal- tions might be necessary again at some point. Other
ance their respective side effects. reasons your doctor might suggest surgery include

ach is wrapped only partway around the esophagus, is
fast fact | About 90% of people are free of heart- another option.
burn in the months following reflux surgery. But a follow- Nissen fundoplication involves grabbing a por-
up study showed that within 10 to 13 years, many such tion of the top of the stomach and looping it around
people need to start taking heartburn medications again. the lower end of the esophagus and LES to create an
artificial sphincter or pinch valve. It prevents stomach
acid from backing up into the esophagus (see Figure 7,
occasional cases of erosive esophagitis that do not below left). The wrap must be tight enough to prevent
improve with drug therapy, strictures that recur the acid from coming back up, but not so tight that
despite treatment, or pneumonia or recurrent respi- food can’t enter and a satisfying belch can’t escape.
ratory problems due to acid reflux that don’t improve Over time, however, the stomach wrap can loosen.
with drug therapy. When that happens, the person may need to resume
The goal of surgery is to tighten the lower esopha- medications and, in a small number of cases, undergo
geal sphincter. The operations are generally effective surgery to redo the procedure.
and can eliminate the need for all GERD medications Today, most surgeons perform fundoplication
for some time. as a laparoscopic procedure, in which special instru-
ments and cameras are inserted into tiny incisions in
Fundoplication the upper abdomen. In 2012, the FDA approved use of
The most common antireflux operation is the Nissen LINX, a ring of magnetic beads that is inserted laparo-
(360-degree) fundoplication. Also known as a stom- scopically and placed around the weak sphincter. The
ach wrap, the operation creates a vacuum effect that magnetic attraction holds the weak sphincter closed
prevents stomach acid from surging upward into the enough to prevent reflux but able to open as needed
esophagus. Partial fundoplication, in which the stom- with the force of a swallow or belch.
A number of newer procedures, known collec-
tively as transoral incisionless fundoplication, rely on
Figure 7: Surgery for GERD an endoscope (a tube that’s placed down the throat) to
Esophagus
reconstruct the lower esophageal sphincter and hold
it tighter with tiny fasteners. A different endoscopic
Top of
approach, called Stretta, delivers radiofrequency
stomach energy to the sphincter muscle. As it heals, the muscle
wrapped thickens and stiffens, reducing reflux. For people with
around LES
to control a large hiatal hernia needing repair, a surgical rather
reflux than endoscopic approach is needed.
The comparative risks, benefits, and long-term
results of surgical and less-invasive endoscopic proce-
dures to treat GERD are not clear. In 2014, the Ameri-
can Gastroenterological Association Center for GI
Most cases of GERD can be managed successfully with medica- Innovation and Technology began a national registry
tions. But in a few cases, a surgical procedure called fundoplication to systematically compare outcomes in people under-
is used to fold the top of the stomach around itself to create a going transoral incisionless fundoplication and those
high-pressure zone that functions as a lower esophageal sphincter. having laparoscopic fundoplication.
Functional dyspepsia
Y ou’re having trouble with your stomach. You feel

uncomfortable. It’s not heartburn, but it seems to
be related to eating. You feel bloated and full or have
Figure 8: Upper GI endoscopy
a burning pain. You complain of nausea, or some-

times you even vomit. You have an “upset stomach” or
“indigestion.” Doctors call it dyspepsia—literally, “bad Endoscope
digestion.” The word is derived from the Greek dys,
which means bad, and peptein, which means “to cook”
Peptic ulcer
or “to digest.”
The term functional dyspepsia is used to describe
persistent upper abdominal pain or discomfort for
which there is no identifiable cause, such as an ulcer.
Symptoms are often triggered by eating, but no physi-
cal or anatomical cause can be found. Because ulcers
produce similar symptoms, functional dyspepsia is An endoscope is a flexible tube with a light and camera at the
end that a doctor uses to view the interior of a person’s esophagus
sometimes called nonulcer dyspepsia.
and stomach. During this procedure, the person lies on his or her
In most cases, the uncomfortable upper abdomi- side as the doctor gently slides the scope through the mouth and
nal symptoms appear after eating, but there’s no diffi- down the esophagus into the stomach, while watching for lesions
culty in swallowing. Sometimes the discomfort begins on a video monitor.
during the meal, sometimes about half an hour later. It
tends to come and go in spurts over a period of about
three months. and women equally. It’s responsible for a significant per-
This condition affects about a quarter of the popu- centage of visits to primary care doctors. Many people
lation—twice as many as have ulcers—and it hits men suspect they’re suffering from ulcers, but are found not
to be. The cause of functional dyspepsia is unknown.
Even more frustrating, there’s no surefire cure.
Do you have functional dyspepsia? The first question on the minds of people with
The Rome III criteria specify functional dyspepsia must functional dyspepsia symptoms is “Do I have an
include one or more of the following for the past three ulcer?” It’s not an unreasonable question, considering
months, with symptoms beginning at least six months
that 10% of Americans develop a peptic ulcer (that is,
before diagnosis:
an ulcer in either the stomach or the duodenum) at
✔ bothersome feeling of fullness after eating
some time in their lives. Ulcers can be treated with
✔ early feeling of fullness
medications, while in most cases medications don’t do
✔ pain in the upper abdomen
much to remedy functional dyspepsia.
✔ burning in the upper abdomen
and
✔ no evidence of structural disease (including any seen
with upper GI endoscopy; see Figure 8, above right) Diagnosing functional dyspepsia
that is likely to explain the symptoms. People with functional dyspepsia have the symptoms
of an ulcer without the ulcer itself. Both conditions

history and about the frequency of the pain, how long
Is it an ulcer? it has persisted, and when it’s most severe. Discomfort
Aside from dyspepsia, other symptoms that may point to that feels worse on an empty stomach and is relieved
an ulcer, rather than to functional dyspepsia, include by eating suggests a duodenal ulcer, although the
✔ evidence of bleeding, such as passing black stools diagnosis isn’t definitive. Ulcer pain often awakens a
or vomiting blood or material that resembles coffee
person during the night. If this pain is relieved by ant-
grounds
acids, H2 blockers, or proton-pump inhibitors taken
✔ repeatedly vomiting large amounts of sour juice and
food, which can signal an obstructing ulcer at bedtime, it might indicate an ulcer. Your physician
✔ sudden, overwhelming pain—a rare but frightening will also address other health habits, such as whether
signal that the ulcer has perforated the stomach or you smoke or drink alcoholic beverages, and will want
duodenal wall. to know if other family members have ever been diag-
nosed with an ulcer.
To confirm the presence of an ulcer, the doctor
seem to be stress-related and affect people of all ages. might order an endoscopy or upper GI series—an
In many cases, the symptoms of both respond to treat- x-ray test to image the esophagus, stomach, and duo-
ment with a placebo pill (which contains no active denum. However, some physicians are hesitant to
ingredient). In both conditions, pressing on the per- order these tests because in most instances of dyspep-
son’s abdomen can produce tenderness. sia, results do not show a problem and are unlikely to
Your doctor’s goal will be to confirm or exclude influence initial treatment strategies. Still, a person
the possibility of an ulcer. During a medical exam, will no doubt take comfort in learning that he or she
your clinician will ask questions about your medical doesn’t have an ulcer.
Lifestyle modifications for Tests and medication

functional dyspepsia As a first step toward both diagnosis and treatment,
Body position, diet, exercise habits, and more can help. your doctor will probably prescribe one or more drugs
Make good eating Reduce stress
that curtail acid secretion to see if the dyspepsia clears.
choices • Use stress reduction
The doctor may also order a fecal, blood, or breath test
• Avoid foods that trigger techniques, including to detect the presence of Helicobacter pylori bacteria,
symptoms. relaxation therapies, or which can cause stomach inflammation and ulcers (see
• Eat small portions, cognitive behavioral “More on ulcers,” page 24). If the test is positive, the
and avoid overeating. therapy. Exercise is also
a proven stress reducer.
doctor will prescribe antibiotics to eradicate the bac-
• Eat smaller, more
teria. In years past, the standard treatment was called
frequent meals. Reduce fatigue
“triple therapy” and included a PPI plus two antibiotics.
• Chew your food slowly • Get enough rest.
and completely.
But in recent years, H. pylori has developed resistance
• Go to bed and get up at
• Avoid activities that
to this treatment in many parts of the world, which
the same times each day.
result in swallowing • Avoid caffeine after noon.
means it is no longer as effective as in the past. As a
excess air, such as smok- result, many doctors are now prescribing alternative
ing, eating quickly, chew- Exercise regimens, including four-drug treatments. If symptoms
ing gum, and drinking • Perform aerobic exercise
carbonated beverages.
have not improved after a few weeks, the next step will
three to five times a
• Don’t lie down within week for 20 to 40 probably be an endoscopy to check for ulcers.
two hours of eating. minutes per session. People over age 55 (some experts say over age 45)
• Keep your weight under • Don’t exercise immedi- with a new onset of dyspepsia and those with a fam-
control. ately after eating. ily history of gastrointestinal cancers should have an
endoscopy right away to look for cancer. Additional
worrisome symptoms, such as weight loss, dysphagia have a lower threshold for pain than their healthy
(difficulty swallowing), gastrointestinal bleeding, or counterparts.
anemia (low red blood cell count), also warrant imme- Motility or sensation problems. The symptoms of
diate attention. Only after tests and drug trials fail to functional dyspepsia may reflect abnormal motility—
pinpoint another cause can the condition be labeled that is, a problem with the movement of the digestive
functional dyspepsia. tract, which might slow the emptying of the stomach,
triggering symptoms.
Stress, anxiety, or other psychological factors.
Causes of functional dyspepsia Anxiety and emotional stress or depression are com-
No one really knows what causes functional dyspep- mon in people with functional dyspepsia. Treating
sia. Many experts doubt that excess gastric acid is to the underlying problem improves symptoms for some
blame. Studies have found no irregularities in acid people.
secretion in people with dyspepsia and no correlation H. pylori infection. While the role of H. pylori
between symptoms and increased acid production. infection as a cause of ulcers and gastritis is well estab-
But the theory remains under consideration, as does lished (see “More on ulcers,” page 24), its involvement
the possibility that the abdominal pain associated with in functional dyspepsia is unclear. H. pylori infection is
functional dyspepsia results from some alteration that only slightly more common in people with functional
increases the sensitivity of the gastric or duodenal dyspepsia than in the general population. Although
mucosa to acid. Following are some other ideas: the organism may contribute to functional dyspepsia
Pain hypersensitivity. Many experts believe that symptoms in some cases, there’s currently no way to
people with functional dyspepsia are more sensi- distinguish these people from those in whom H. pylori
tive to pain than other people are, and that they may is not the source of the problem. In most cases, eradi-
What else could it be, if it’s not functional dyspepsia?

At least some of the distress associated with functional Figure 9: Other causes of pain
dyspepsia reflects the fear that a more serious condition may
be going undetected. This is rarely the case, especially when Gallstone
symptoms persist for months or years without worsening. blocking duct Stomach cancer
Fortunately, more serious ailments have characteristics that set
them apart from functional dyspepsia (see Figure 9, at right).
Gallstones. Stones can dwell silently in the gallbladder or can
produce painful attacks, typically after a large, high-fat meal,
if the gallbladder contracts and a stone lodges in its neck. The
pain is usually located just under the right rib cage or in the
upper middle abdomen and may radiate to the right shoulder
or back. Gallstones
Stomach cancer. Malignancies of the stomach generally
occur later in life, after age 50. Tumors that burrow into the
stomach wall often produce symptoms that resemble those
associated with ulcers. Eating a full meal can become impos- Symptoms similar to functional dyspepsia may come from
sible if growths extrude into the hollow of the organ or spread gallstones, which can cause pain and inflammation if they
through the stomach wall, making it too stiff to expand. Warn- block the neck of the gallbladder or the bile duct (rather than
ing signs include bleeding, persistent vomiting, a constant passing into the small intestine, as shown by the arrow).
sense of nausea or fullness that interferes with normal eating, Another condition producing similar symptoms is cancer of
and weight loss. Stomach cancer usually requires the surgical the lining of the stomach, which can create a sensation of
removal of all or part of the stomach. painful bloating.

More on ulcers
Figure 10: How an ulcer starts
P eptic ulcers are raw, crater-like breaks in the mucosal lining of the
digestive tract. They occur in the stomach or duodenum (the upper
small intestine) and are linked to the erosive action of gastric acid and
sometimes to a reduction in protective mucus. In essence, the stomach,
which is designed to digest foods, is digesting a part of its own lining.
These localized, generally circular craters are rarely more than an inch Helicobacter
pylori
in diameter.
In the early 1980s, researchers made a major discovery. They identified
Helicobacter pylori, a spiral bacterium with an affinity for the stomach,
as a major culprit in ulcer disease. H. pylori is the cause of many ulcers
(see Figure 10, at right). At least 90% of people with duodenal ulcers and
75% to 85% of those with gastric (stomach) ulcers are infected with this
organism. Peptic ulcer
The proportion of ulcers that are not caused by H. pylori has increased,
which could be the result of a lower prevalence of H. pylori among the
general public. Researchers are not yet sure why. Other causes of ulcers Stomach lining
include irritating substances such as aspirin, ibuprofen, and other NSAIDs.
Cigarette smoking impairs the healing of ulcers, and stress appears to
aggravate ulcer symptoms. Studies show there’s also a genetic compo- The corkscrew-shaped bacterium Helicobacter
nent, as ulcers sometimes run in families. They occur more often in peo- pylori attaches to the surface of the stomach by
ple with type O blood than in those with other blood types. Sometimes twisting through the mucus that protects the
there is no known cause (a condition known as an idiopathic ulcer). stomach lining from corrosive gastric juices.
cating H. pylori with antibiotics doesn’t significantly all clinical trials, 25% to 60% of people respond to
improve functional dyspepsia symptoms. medications, and therefore doctors often recom-
Duodenitis. Another condition that might pro- mend them, including over-the-counter antacids and
duce symptoms of functional dyspepsia is duodenitis, omeprazole (Prilosec OTC). In a recent study, people
a long-term inflammation of the lining of the duo- with functional dyspepsia and without depression
denum. However, less than 20% of people with func- were more likely to improve when treated with the
tional dyspepsia have this condition. tricyclic antidepressant amitriptyline (Elavil, Endep)
Diet. Certain fatty foods are often blamed for than when given an SSRI antidepressant or a placebo.
dyspepsia. This connection makes sense because fat Anticholinergic medications that decrease con-
ingestion not only delays gastric emptying, but also tractions in the GI tract, such as hyoscyamine (Levsin),
increases distension of the stomach. Substances like may be used for up to four to six weeks. Simethicone,
alcohol and coffee may also aggravate symptoms. which rids the gut of gas bubbles, is safe and may help
Drugs. Nonsteroidal anti-inflammatory drugs if you have both dyspepsia and flatulence.
(NSAIDs), especially aspirin, can cause dyspepsia, Herbal remedies may also be worth a try. In sev-
ulcers, and gastritis. Other drugs such as opiates, iron eral clinical trials, a combination of enteric-coated
preparations, and digitalis may also cause dyspepsia. capsules of peppermint oil and caraway oil successfully
reduced fullness, bloating, and gastrointestinal spasms
in people with functional dyspepsia. (Enteric-coated
Treating functional dyspepsia means that the preparation is able to pass through the
No truly effective drug exists to treat functional dys- stomach and won’t dissolve until it reaches the small
pepsia. Many people respond no better to drugs than intestine.) Be aware, however, that peppermint oil may
to a placebo. It is noteworthy, however, that in almost trigger reflux in people who are predisposed to it.
Irritable bowel syndrome
A nother common intestinal disorder with a myriad

of unpleasant symptoms is irritable bowel syn-
drome (IBS). IBS affects millions of people, but its
Do you have IBS?
According to the Rome III criteria, you have IBS if you
cause is unclear, and treatment is often a trial-and- have had recurrent abdominal pain or discomfort at least
error process that may or may not be successful. It is three days a month in the past three months, beginning at
least six months ago, and two or more of the following:
the most common diagnosis made by gastroenterolo-
✔ improvement in symptoms after a bowel movement
gists and accounts for as many as 3.5 million physician
✔ a change in the frequency of stool accompanying the
visits and 2.2 million prescriptions per year. Irritable onset of pain or discomfort
bowel syndrome may well be the most challenging ✔ a change in the form (appearance) of stool
functional GI disorder, for doctors and their patients accompanying the onset of pain or discomfort.
alike. Several studies have found that people with IBS
The following additional symptoms are not essential for
have a significantly lower quality of life than people diagnosis, but they support the diagnosis and may also be
without the syndrome and that the illness is seriously used to identify certain types of IBS:
underdiagnosed. ✔ abnormal stool frequency (more than three bowel
Through the years, IBS has been called by many movements per day or less than three per week)
names—spastic colon, spastic bowel, colitis, mucous ✔ abnormal stool form (hard or loose stool) more than
colitis, and functional bowel disease. None of these one in every four times
names is quite accurate. ✔ abnormal stool passage (straining, urgency, or the
feeling of incomplete evacuation) more than one in
four times
✔ passage of mucus in more than one in every four
What is IBS? bowel movements
IBS usually begins in the late teens, 20s, or 30s. You’re ✔ bloating or the sensation of having a distended
a relatively healthy person; then one day you begin to abdomen on more than one out of every four days.
suffer intermittent cramps in the lower abdomen. You
have to move your bowels more often than usual, and
when you have to go, you have to get to a toilet right fort in the abdomen. People with IBS generally feel
away. Your stools are loose and watery, possibly contain- their pain subside after a bowel movement or passing
ing mucus. Sometimes, you feel bloated and full of gas. gas. But they also may feel that they haven’t fully emp-
After a while, the cramps return, but this time tied their rectum after a movement.
when you try to go to the bathroom, nothing hap- A survey of 1,966 adults who met the criteria for
pens. You’re constipated. And back and forth it goes— IBS summarized some of the reasons why this condi-
diarrhea, then constipation, and pain and bloating in tion can be so aggravating. Among other things, the
between. Or instead of alternating between constipa- survey found that
tion and diarrhea, you always have one without the • the diagnosis was typically made 6.6 years after the
other (but always with at least some abdominal pain). start of IBS symptoms
Irritable bowel syndrome is the catchall term for this • 78% of respondents had frequent or constant pain
mixed bag of symptoms. • their activities were restricted, on average, more
It’s a common disorder, with no known cause. The than 73 days a year because of IBS symptoms
most frequently reported symptom is pain or discom- • most respondents used medication, on average two

different drugs, but as many as 13 nosis are abdominal pain and changed bowel habits at
• only 31% were satisfied or very satisfied with their least three times a month, for at least three months.
current medications IBS has no organic basis—that is, there’s no physi-
• 37% had used complementary or alternative cal abnormality or disease at the root of the problem.
treatments. And doctors don’t regard IBS as a forerunner of more
All in all, too many people are suffering from this serious diseases, such as ulcerative colitis, Crohn’s dis-
perplexing condition. If you have some of the symp- ease, colon cancer, or stomach cancer.
toms of IBS, you may want to try some of the life-
style changes in this report to see if they help you feel
better. However, if you are truly miserable or have Causes of IBS
symptoms (such as unexplained weight loss, rectal IBS is probably not a single disease, but rather a set of
bleeding, or abdominal pain during the night) that symptoms that stem from a variety of causes. It may
make you worry about the possibility of more seri- be generally described as a disorder in the functioning
ous illness, don’t wait to seek medical attention (see of the GI tract. Some experts suspect that IBS involves
“What else could it be, if it isn’t IBS?” on page 27). disturbances in the nerves or muscles in the gut. Oth-
While some people have daily episodes or continu- ers believe that abnormal processing of gut sensations
ous symptoms, others experience long symptom-free in the brain may hold the key, at least in some cases.
periods. These patterns make it hard to know whether
someone has IBS or an occasional complaint that’s Infection
part of the bowel’s normal response to stress or diet. Several studies have demonstrated that a bout of infec-
Whether it is IBS usually depends on the frequency and tious gastroenteritis (stomach or bowel inflammation)
duration of symptoms: traditional criteria for this diag- may increase the risk of developing IBS by as much
Table 2: Guidelines for colorectal cancer screening

Symptoms of IBS can be similar to those of colorectal cancer. Follow these guidelines for screening. Some guidelines recommend that people
older than 75 or who are likely to die within 10 years from another health problem and have never had colon cancer or polyps on prior
screening should not undergo further screening for colon cancer. Note that these screening recommendations are for people who have
no symptoms of colorectal cancer. If you have symptoms that suggest colorectal cancer, such as blood in the stool, you should undergo
diagnostic testing.
YOUR RISK CATEGORY SCREENING RECOMMENDATION
Average risk: Age 50 or older without any of the One of the following is recommended:
risk factors noted below • colonoscopy every 10 years
• flexible sigmoidoscopy every five years
• fecal occult blood test with three samples from separate stools every year
• computed tomography (CT) colonography (virtual colonoscopy) every
five years
• fecal DNA test every three years.
Moderate risk: Family history of colorectal cancer Colonoscopy every five years beginning at age 40, or starting 10 years younger than
in a first-degree relative (parent, sibling, or child) the age at diagnosis of the person’s youngest affected relative (whichever is younger).
Moderate risk: Personal history of colorectal cancer Colonoscopy: Consult your doctor for frequency guidelines based on your personal
health risks.
High risk: Certain genetic and disease characteristics; Colonoscopy or flexible sigmoidoscopy beginning in adolescence or early adulthood,
consult your doctor about your specific risk factors depending on your personal and family health history.
Source: Screening for Colorectal Cancer: A Guidance Statement from the American College of Physicians, 2012.
What else could it be, if it isn’t IBS?
A number of gastrointestinal diseases can cause nonspecific symptoms similar to those of IBS.
Diverticular disease. Small sacs or pouches— bowel symptoms may be accompanied by

known as diverticula—may bulge through the fever, weight loss, an elevated white blood cell
colon’s inner lining, where the blood vessels enter count, and a variety of skin lesions and arthritis.
the colon, piercing its walls and causing areas of Ulcerative colitis is easier to diagnose than
weakness. Although this is most common after age Crohn’s disease and is treated with many of the Ulcerative colitis
50, younger people occasionally develop diverticula. The existence same medications.
of such pouches is a condition known as diverticulosis. However, Medications that control inflammation can help relieve
when a diverticulum becomes inflamed or infected, the condition IBD symptoms. The drugs used most commonly are
is called diverticulitis. The symptoms of diverticulitis are much more aminosalicylates (cousins of aspirin); steroids (potent anti-
intense than those of IBS and include severe left lower abdominal inflammatory agents), such as prednisone and budesonide; and
pain, chills, fever, and an elevated white blood cell count. immunosuppressants and antibiotics. Biologic agents, including
Treatment of diverticulitis involves a liquid diet to let the bowel infliximab (Remicade), adalimumab (Humira), and certolizumab
rest and antibiotic therapy to clear the infection. After the immedi- pegol (Cimzia), have also proved effective for selected people
ate inflammation has stabilized, people switch to a steady high- with IBD. Vedolizumab (Entyvio) and natalizumab (Tysabri),
fiber diet to help prevent flare-ups. Although people are often other types of biologic agents, have also been approved,
advised to avoid nuts and seeds, there is no scientific support for although the use of natalizumab is restricted to certain
this recommendation, and people with diverticulosis do not seem patients with Crohn’s disease.
to be predisposed to diverticulitis if they eat nuts. Surgery may be
required for complicated or recurrent diverticulitis. Colorectal cancer. Colorectal cancer is the third
most common form of cancer in both men and
Inflammatory bowel disease (IBD). Inflammatory bowel disease women, with an estimated 154,000 new cases
is characterized by chronic inflammation of a segment or segments diagnosed in the United States each year. Early
of the GI tract. The two main types of IBD are Crohn’s disease and on, colon cancer causes no symptoms. Later, its
ulcerative colitis. The two often have similar symptoms and are symptoms can be similar to those of IBS—ab-
treated in similar ways, yet physicians regard them as distinct. IBD dominal pain, cramping, bloating, gas pains, and a change in
has a wide variety of symptoms, including persistent abdominal bowel patterns. In addition, blood in the stool or rectal bleeding
pain, diarrhea, rectal bleeding, fever, and weight loss. is often present. Advanced cancer is likely to cause bloody bowel
• Crohn’s disease, a type of IBD, can occur movements, severe constipation if the intestine is obstructed, and
anywhere in the gastrointestinal tract, from weight loss. Thus, it’s vital to get checked without delay should
the mouth to the anus, but it’s usually found these symptoms occur.
at the end of the small intestine (ileum), in the The good news is that most cases of colon cancer can be pre-
colon, or both. It involves the full thickness of Crohn’s disease vented through screening (see Table 2, page 26). Almost all pre-
the bowel wall and may burrow into nearby cancerous growths (polyps) can be spotted and removed during
organs. The bowel wall becomes thickened as well as constantly a colonoscopy. Early-stage, localized colon cancers are curable
inflamed, and leakage of intestinal contents from the bowel can by surgery in 90% of cases.
cause internal abscesses. A leak (fistula) that allows intestinal
Celiac disease. Also known as celiac sprue, celiac disease is a ge-
material to pass through the wall of the intestine into another
netically based disorder that damages the small intestine and may
segment of the intestine may require surgery. Severe bleeding is
result in debilitating symptoms. As many as one million Americans
not likely with Crohn's disease.
have the disease, which clusters in families, primarily occurring in
Crohn’s disease usually appears in young people, who whites of European ancestry. It often goes undiagnosed.
develop pain in the right side of the abdomen, a low-grade When people with celiac disease eat foods containing glu-
fever, and perhaps changes in bowel movements. Some people ten—a protein found in wheat, rye, and barley—their immune
develop an abscess or fistula around the anus. systems attack the gluten, but in the process, they also flatten
In some cases, surgery is needed to treat a complication of the tiny finger-like projections lining the small intestine called
the disease, such as bowel obstruction. About 40% to 60% of villi, which help the body absorb nutrients. A simple blood test
those with Crohn’s eventually need surgery to remove dam- for higher-than-normal levels of antibodies is the first step in
aged areas of their small intestine or colon. diagnosing the disease. If the test is positive, a biopsy of the
• Ulcerative colitis, the other principal type of IBD, is small intestine, performed through a standard endoscope, can
characterized by inflammation limited to the lining, or mucosa, confirm the diagnosis. Treatment is straightforward: a gluten-free
of the colon. Like IBS, it can cause lower abdominal pain and diet. Symptoms often improve within days, and the small intes-
diarrhea. Unlike IBS, the stool generally contains blood, and tine gradually returns to normal function.

as seven to 14 times. What’s more, emotional upset awareness of the inner workings of their gut. In sev-
or stress may heighten this risk even further. One eral well-known experiments, balloons were inflated
study reported that among people hospitalized with in the sigmoid colon, rectum, and small intestine of
gastroenteritis, those who had experienced a distress- subjects. Those with IBS generally had a much lower
ing life event (such as divorce or the death of a family threshold for experiencing pain than the healthy vol-
member) during the previous year were significantly unteers. Scientists believe that this lower pain thresh-
more likely to develop IBS than those who’d had an old may be related to the dispatch of nerve signals
uneventful year. from gut to brain.
Overgrowth of intestinal bacteria Hormonal and dietary factors

Another possible explanation for IBS is the over- Hormones produced in the GI tract, such as cho-
growth of bacteria in the small intestine. This over- lecystokinin and motilin, have also been suspected
growth may cause the feeling of bloating and the of triggering IBS symptoms through their effects on
passing of excess gas that are common symptoms of bowel motility, but studies have not been definitive.
IBS. Researchers have found some evidence of bacte- Women with IBS often have more symptoms during
rial overgrowth in the small intestines of people with their menstrual periods, suggesting that changes in
IBS, and it appears that bacterial overgrowth may con- the levels of reproductive hormones can increase IBS
tribute to many common symptoms of IBS, including symptoms.
bloating and distension, diarrhea, constipation, and Certain medicines and foods trigger spasms in
heightened sensitivity to pain. Treatment with anti- some people (see “Foods that may trigger IBS symp-
biotics may improve some of these symptoms (see toms,” below). Sometimes the spasm delays the pas-
“Medications for IBS,” page 33). Treatment with pro- sage of stool, leading to constipation. Chocolate, dairy
biotics, live microbes intended to confer health bene- products, or large amounts of alcohol are frequent
fits (see “Probiotics and prebiotics,” page 34), provides offenders. Some people simply can’t tolerate certain
relief for some people with IBS, but there is currently dietary substances—for example, lactose (a sugar
no way to identify who is most likely to benefit. found in milk), fructose (a sugar found in fruit and
used as a sweetener), or sorbitol (an artificial sweet-
Colon activity ener)—and develop bloating and diarrhea as a result.
Because the spasmodic pain associated with IBS is Lactose intolerance is distinct from IBS, but the symp-
perceived by patients as emanating from the colon, toms can overlap. Caffeine causes loose stools in
researchers have concentrated on this part of the GI many people, but is more likely to affect those with
tract, searching for any irregularities. The findings,
thus far, have been inconsistent.
Some researchers have found that the colon muscle Foods that may trigger IBS symptoms
of a person with IBS begins to spasm after only mild • Apples and other • Chocolate
stimulation. The colon seems to be more sensitive than raw fruits • Dairy products
usual, so it responds strongly to stimuli that wouldn’t • Beans • Fatty foods
affect other people. Sometimes, the spasms lead to diar- • Broccoli • Margarine
rhea; other times, to constipation. But some studies • Cabbage • Nuts
show that most of the time, colonic motor activity is no • Caffeine • Orange and grapefruit
different for people with IBS than for anyone else. • Cauliflower juices
• Chewing gum, beverages, • Wheat products
Heightened sensitivity or foods sweetened with
Another possible explanation for these bothersome fructose or sorbitol
symptoms is that people with IBS have a heightened
IBS. Bran and wheat flour may increase IBS symp-
Are carbohydrates the culprits in IBS?
toms (although sourdough bread might not). On the
other hand, some believe that a lack of dietary fiber
may contribute to IBS. Fat in any form (animal or veg- F or some people, certain sugar-like molecules found in a
myriad of different foods—including milk, some fruits
and vegetables, wheat, rye, high-fructose corn syrup, and
etable) is a strong stimulus of colon contractions after
artificial sweeteners—can be difficult to digest. Gut bac-
a meal and can also contribute to IBS symptoms. teria feed on these sugars, creating the gas and bloating
Poorly digestible sugars such as lactose, sorbitol, that’s a hallmark of IBS. The problematic substances are
and high-concentration fructose might play a role in fermentable oligosaccharides, disaccharides, monosaccha-
rides, and polyols, known collectively as FODMAPs.
bloating. A special diet that avoids these troublesome
sugars has garnered attention in recent years for its In 2001, an Australian dietitian named Sue Shepherd de-
veloped a diet that restricts foods high in FODMAPs. Today,
ability to ease IBS symptoms (see “Are carbohydrates
growing evidence suggests that this low-FODMAP diet may
the culprits in IBS?” at right). Gas-forming vegetables tame IBS symptoms better than standard dietary advice for
such as beans and broccoli may also contribute to IBS. A 2014 study in Gastroenterology compared symptoms
bloating, as can excess fiber. in 30 people with IBS and eight healthy individuals during
It’s often a matter of trial and error to determine three weeks on a typical diet and three weeks following
the low-FODMAP diet. Symptoms of IBS, such as bloat-
which foods trigger your symptoms. Try eliminating ing and pain, were reduced by half in people with IBS
one food at a time to see which ones give you trouble. while they were eating the low-FODMAP diet. In contrast,
Keeping a food diary in which you record the foods the diet made no difference in the few gastrointestinal
that you eat as well as any IBS symptoms can also help. symptoms reported by the healthy participants. In a sepa-
rate 15-month study, 90 people with IBS benefited from
following the low-FODMAP diet, with the most dramatic
Stress and emotion improvements in those shown to have fructose malabsorp-
Stress is known to stimulate colon spasms in people tion on hydrogen breath testing.
with IBS. The process is not completely understood, Although the diet limits some common foods, such as apples
but scientists point out that the intestines are con- and wheat, it does include a variety of choices in every food
trolled partly by the nervous system (see “The stress group. However, FODMAPs are also found in a number of
processed foods. Because the low-FODMAP diet can be
connection,” page 7). Some studies have shown sig-
somewhat tricky to navigate, it’s best to work closely with
nificantly higher stress levels among people with IBS a registered dietitian who is very familiar with the diet.
compared with healthy individuals. And stress reduc- A summary of FODMAP dietary guidelines is available at
tion, relaxation training, and counseling have each www.aboutibs.org.
www.aboutibs.org
helped relieve IBS symptoms in some people.
Despite the influence of emotions, IBS is not an
“imaginary” complaint; the symptoms are real and Like the brain, the gut produces serotonin, which
troublesome enough in many cases to warrant atten- in turn acts on nerves in the digestive tract. Some
tion. But it does appear to have a psychological com- research suggests that people with IBS who suffer
ponent. Studies have found considerably higher rates mainly from diarrhea may have higher levels of sero-
of psychiatric problems among people with IBS who tonin in the gut, while those with constipation-pre-
see a specialist than among healthy people or those dominant IBS have lower levels.
with structural bowel diseases. Some 42% to 61% of
people with functional bowel disorders who are seen
in gastrointestinal clinics also have a current psychiat- Diagnosing IBS
ric diagnosis—usually anxiety or depression, accord- Because there are no specific tests for IBS, the illness
ing to one report. must be diagnosed based on symptoms and by process
One theory related to this connection focuses on of elimination, sometimes with the use of tests to rule
the neurotransmitter serotonin. Neurotransmitters are out other conditions. Fortunately, a diagnosis usually
chemicals that convey messages between nerve cells. can be made with a single visit to a doctor.

Understanding food intolerance
F ood intolerance and allergies often produce similar

symptoms, but they’re not the same. A food allergy is an
immune system reaction to a substance that is not normally
system and can have more serious consequences, including
allergic shock).
The best way to avoid the symptoms of lactose intolerance
dangerous to the body. Food intolerance, on the other hand, is to avoid milk products. But if you don’t wish to make that
is not an allergic response and doesn’t involve the immune concession, you can take a special enzyme preparation, such
system, but rather some other issue, such as inadequate as Lactaid, when eating foods containing lactose. There are
amounts of an enzyme to digest a particular type of food. also now milks, yogurts, and ice creams that already contain
For some people, heartburn, gas, nausea, upper abdominal the enzyme. Others who don’t have as severe a problem may
stomach upset, diarrhea, cramps, and flatulence—all common find that they can eat some milk products as long as they
symptoms of functional disorders—may be caused by a food consume them with other foods. Yogurt (with live cultures)
that simply doesn’t agree with them. The problem isn’t that and aged cheeses may not cause as many problems as other
the food is spoiled, unripe, or contaminated by bacteria, but milk products, probably because some of the lactose breaks
rather that the body is unable to digest a particular sub- down during fermentation. Despite widespread claims that
stance. Two common types of food that cause intolerance are consuming raw (unpasteurized) milk aids lactose intolerance,
dairy products and grain products containing gluten. a 2014 study demonstrated that the practice does not reduce
symptoms or aid lactose absorption. Alternatives to milk
Lactose intolerance is difficulty digesting lactose, the
products include substitutes made from soy, rice, or almonds,
primary sugar found in milk. It’s been estimated that up
which are available in many stores.
to 70% of the world’s people are unable to digest lactose,
although the problem is minor for most. The difficulty oc- But some foods contain hidden lactose. Be sure to check the
curs when a person’s body does not produce enough of the labels on breads, processed breakfast cereals, instant pota-
enzyme lactase, which breaks milk sugar down into simpler toes, soups, margarine, lunch meats, salad dressings, pancake
forms that can be absorbed into the bloodstream. Lactose mixes, and similar products not only for milk, but also for
intolerance is more prevalent in cer- whey. Nondairy kosher foods are
tain ethnic groups, including Jews, a safe choice, since kosher laws
African Americans, Native Ameri- mandate that these foods cannot
cans, and Asians; it is less common contain any milk products.
in Scandinavians and other ethnic Another food intolerance centers
groups that traditionally depended on difficulties in digesting the grain
on dairy foods for a major part of protein called gluten. This protein
their diet. is found in foods containing wheat,
Typically, early symptoms of lactose rye, and barley. In sensitive people,
intolerance appear as soon as 30 ingesting gluten can cause bloating,
minutes after you consume milk gas, abdominal distension, and diar-
Thinkstock
products. You may develop gas, diarrhea. Avoiding gluten-containing
rhea, bloating, cramps, or nausea. foods will eliminate the problem.
The symptoms represent a direct Many people are unable to digest the lactose in Gluten intolerance is distinct from
chemical toxic effect (unlike a food milk. The gluten in wheat can also cause prob- celiac disease, which is an immuno-
allergy, which involves the immune lems, even in those without celiac disease. logical reaction to gluten.
The doctor takes a complete medical history, have developed a set of criteria to help identify people
including a careful description of your symptoms. A with IBS (see “Do you have IBS?” on page 25).
physical exam and some routine laboratory tests are The doctor will also ask whether your symptoms
likely to be part of the exam, and a stool sample is use- started after an episode of gastroenteritis, or if they
ful for evidence of bleeding. Because diagnostic tests seem to be triggered by specific foods or medications,
cannot confirm IBS but are used only to exclude other particularly milk products (to rule out lactose intol-
possible causes of symptoms, the goal is to use as few erance) or foods and beverages that contain fructose
costly, invasive tests as possible. To accomplish this, or sorbitol. You may need to keep a food diary for a
experts in the treatment of gastrointestinal illnesses few weeks to help identify foods that provoke symp-
toms (see “Foods that may trigger IBS symptoms,” (ESR). The ESR, which measures the speed at which
page 28). mature red blood cells settle in a test tube, can be used
It’s especially important to consider emotional and to screen for inflammatory disease. If your blood tests
psychological triggers. The doctor will want to know and your temperature are normal, you’re under age 50,
what prompted the visit and will ask about your life- and your symptoms are typical of IBS, usually no fur-
style and stress level. It’s not unusual for a traumatic ther tests are needed.
life event such as divorce or the loss of a job to wreak For people with persistent diarrhea, stool sam-
havoc on the bowels and the psyche. ples will be examined for infectious agents, includ-
Other symptoms that accompany the pain may ing intestinal parasites. Occasionally, the doctor may
offer clues. If there is pain in the lower abdomen and arrange for a stool collection to check for excess fecal
a change in bowel movements, an abnormality in fat content or weight, which would suggest that IBS is
the large intestine may be present. A combination of not the diagnosis.
abdominal pain and fever can signal inflammation A hydrogen breath test can help the doctor deter-
(for example, diverticulitis), which requires immedi- mine whether IBS symptoms are caused by an inabil-
ate medical attention. ity to properly absorb certain carbohydrates (see “Are
Another major diagnostic clue is bleeding from carbohydrates the culprits in IBS?” on page 29) or an
the digestive tract. People with IBS can have rectal overgrowth of bacteria in the small intestine. For the
bleeding, but IBS does not cause bleeding. Instead, test, the person blows up a balloon to provide a breath
bleeding reflects another cause, such as hemorrhoids. sample before and after consuming a solution contain-
In general, bright red blood comes from the lower
digestive tract, while black, tarry blood comes from
the upper GI tract. If there is bleeding, more tests The “pill camera”
must be performed to determine the cause. If blood is found in the stool and both colonoscopy and
During the physical exam, the physician will look an upper endoscopy fail to detect the source, the doctor
for tenderness in the abdomen. If the tenderness is now has the option of using a wireless video device,
Photo courtesy of Given Imaging Ltd.
located in the lower right part, it may signal ileitis or also known as a “pill
camera.” In this proce-
appendicitis, and in the upper right part, gallstones and
dure, the person swal-
inflammation of the gallbladder. The doctor will also lows a tiny capsule
check for a mass, which might be a tumor, a large cyst, equipped with a cam-
or impacted stool. If the person has IBS, the physical era and a light source.
As the capsule travels
exam will usually not reveal anything other than per-
through the person’s digestive tract, it wirelessly sends
haps a mildly tender abdomen. And lab tests are gener- images to a portable recording instrument strapped to
ally normal in people with IBS. A digital rectal exam is the person’s waist. The person does not feel the progres-
also usually part of the evaluation to check for masses sion of the capsule, experiences no discomfort, and is
in the rectum and, in men, the prostate. If a serious free to go about his or her business. The process takes
about 24 hours.
disorder is suspected, more tests will be ordered.
There is no need to retrieve the capsule, which is passed
out of the body with the stool. The doctor then downloads
Diagnostic tests the images onto a screen and views them as one would a
An experienced gastroenterologist will probably movie in fast motion, but rolling back to study individual
be able to make a preliminary determination as to frames if anything suspicious is encountered. Often, but
whether IBS is the problem after hearing the person’s not always, a source of bleeding will be identified. The
main use of the pill camera is to evaluate the small intes-
initial story, even before ordering any tests. If tests are
tine for bleeding when endoscopy and colonoscopy fail
necessary to rule out other causes of symptoms, they to reveal a source; the pill camera is not used to diagnose
may include a complete blood count, thyroid tests, IBS (or any functional GI disease).
and a measurement of erythrocyte sedimentation rate

ing a specific carbohydrate. The lab then measures the
hydrogen levels (which are usually minimal) in the fast fact | When introducing fiber to your diet,
samples. The results can suggest whether antibiotics do so gradually. Too much, too fast can cause excessive
or specific food restrictions may ease the symptoms. gas, cramping, and bloating. Drink lots of water or other
A person’s age or atypical symptoms may per- liquids to avoid constipation.
suade the doctor to conduct additional—and some-
times more invasive and expensive—diagnostic
procedures. A colonoscopy or flexible sigmoidoscopy Eliminate triggers. What we know is that some-
(procedures that involve viewing the inside of the thing has disrupted the automatic functioning of the
colon with a scope inserted through the anus) enable bowel in people with IBS. The trigger could be emo-
the doctor to check for tumors or inflammatory tional stress, for example, or it could be a dietary irri-
bowel disease (see “What else could it be, if it isn’t tant. One place to start the search is with something
IBS?” on page 27). Sigmoidoscopy can be performed consumed—foods, beverages, or drugs, for example.
in the doctor’s office with no sedation. The doctor Food allergy testing has not proved to be useful in
views the rectum and sigmoid colon through a view- identifying triggers.
ing tube and may also take a tissue sample. To rule Eat fiber. Adding fiber to the diet may help to
out colon cancer, or to screen for it in someone over increase the stool’s bulk and speed its movement
age 50, the doctor may order a colonoscopy, a more through the GI tract. A high-fiber diet doesn’t always
involved procedure in which a lighted tube is used to improve bowel symptoms, and for a few people, it
view the full length of the colon. Alternatively, a com- may increase bloating or gas. But many clinical tri-
puted tomography (CT) colonography, also known als have shown that it does seem to relieve constipa-
as a virtual colonoscopy, may be used, although this tion and may ease abdominal pain, and sometimes it
test might not be covered by insurance when used to even improves diarrhea. You can increase the fiber in
screen for colon cancer. your diet by eating plenty of fresh fruits and vegeta-
Not every person with a gut problem will need bles. A 2014 analysis of 14 studies found that supple-
every test. On the other hand, everyone age 50 and ments containing soluble fiber, which attracts water
over should be screened for colon cancer (see Table 2, and forms a gel that slows down digestion, reduces
page 26). Besides flexible sigmoidoscopy, colonoscopy, IBS symptoms, while insoluble fiber (such as bran) is
and CT colonography, options for screening in people of little value for many people with IBS. Soluble fiber
at average risk for colon cancer include testing of stool supplements containing psyllium or methylcellulose
for occult (hidden) blood. are available in many products found in supermarkets
or drugstores and can be highly effective. For some
people, these measures may be all that are needed to
Managing IBS reduce symptoms.
Because there is no cure for IBS, treatment aims to Try heat. For people who experience IBS inter-
control individual symptoms. As a result, the manage- mittently, a home heating pad can be a simple and
ment of IBS requires a great amount of understanding inexpensive way of soothing abdominal pain. Heat
between doctor and patient. People need to educate can help relax cramping muscles. Similarly, drinking a
themselves about IBS and receive adequate informa- warm, noncaffeinated tea such as chamomile may help
tion from their physicians so they can learn to manage reduce discomfort.
the syndrome and regain control over their lives.
Psychotherapy
Self-help Because IBS symptoms are sometimes related to anxi-
You can play an active role in managing your own ety or stress, cognitive behavioral therapy to reframe
condition. Begin with these measures. negative thoughts into more positive, productive ways
of thinking can improve some people’s symptoms be used only by people who have diarrhea- or pain-
and quality of life. One study found that people with related IBS symptoms.
moderate to severe IBS who participated in cognitive Selective serotonin reuptake inhibitors (SSRIs),
behavioral therapy enjoyed considerable improve- such as fluoxetine (Prozac), do not control pain as
ments in symptom severity after six months, com- effectively as the tricyclics, but they have become
pared with people who did not have therapy. more popular for treatment of IBS because they tend
to cause fewer side effects. SSRIs help to relieve the
Medications for IBS anxiety and depression that is sometimes associated
If you have symptoms that are troublesome enough to with moderate or severe IBS, so they may be a good
stop you from participating in normal activities, talk treatment option for people with IBS who also have
with your doctor about drug therapy. While medi- those psychological diagnoses.
cations can’t cure IBS, they may ease the symptoms. Antidiarrheals. Loperamide (Imodium) and
Depending on your particular symptoms, your doctor diphenoxylate with atropine (Lomotil) are gener-
might select from the following classes of drugs. ally recommended for people whose main complaint
Antispasmodics. These medications, including is diarrhea. Loperamide, available over the coun-
enteric-coated peppermint oil, dicyclomine (Bentyl), ter, reduces the secretion of fluid by the intestine.
or hyoscyamine (Levsin), may provide some tempo- Diphenoxylate, which is related to codeine and avail-
rary relief of mild abdominal pain by reducing bowel able by prescription only, helps to slow down intes-
spasm. People who often experience cramps after eat- tinal contractions. Because diphenoxylate can be
ing may reduce symptoms if they take one of these habit-forming, atropine is added to the formula to
medications before meals. cause unpleasant side effects if you take it in larger-
Antibiotics. A substantial percentage of people than-prescribed quantities.
with IBS who don’t have constipation have an over- Laxatives. Many clinicians think that some laxa-
growth of bacteria in their small intestines. Research tives, including the polyethylene glycol preparation
shows treatment with antibiotics to eliminate this (Miralax) used for colon cleansing prior to colonos-
overgrowth may help improve symptoms. Two large copy, are safe and effective for IBS when used judi-
studies compared the gut-specific, broad-spectrum ciously. However, laxatives with stimulant properties
antibiotic rifaximin (Xifaxan) against placebo in peo- like bisacodyl (Dulcolax, Correctol) or senna (Ex-Lax)
ple who had IBS without constipation. Combined, may cause cramping.
1,258 study participants took either rifaximin or pla- Other medications. In 2012, the FDA approved
cebo for two weeks. Over the three months of fol- linaclotide (Linzess), which is used to treat constipa-
low-up, people who had taken the antibiotic enjoyed
significant improvement in overall symptoms and in
bloating in particular compared with those taking pla- A new treatment for IBS?
cebo, with no notable side effects. A disordered balance of bacteria within the small intes-
Antidepressants. Antidepressants are sometimes tine is thought to be a factor in creating IBS symptoms.
Transplanting the fecal microbiota from a healthy donor
prescribed to treat IBS pain. It’s not entirely clear has been suggested as a means to restore balance and
whether the ability of antidepressants to relieve pain relieve IBS symptoms. The first randomized controlled trial
works independently of their ability to treat depres- of this approach is now under way to determine whether
sion, or if the mechanism of action in IBS is related to people with diarrhea-prominent IBS improve after swal-
lowing fecal microbiota capsules. In addition to testing
the drugs’ effects on mood. Medications such as ami-
the treatment approach, bacterial tests may help deter-
triptyline (Elavil, Endep) and desipramine (Norpra- mine which of the thousands of microbes in a healthy
min) may be prescribed at low doses for people who person’s gut are responsible for the improvement, if any,
have pain-predominant IBS. Because these tricyclic so future therapy can be targeted more specifically.
antidepressants can cause constipation, they should

tion in people with IBS. It relieves intestinal pain and on probiotics, the researchers found that the products
helps stool move more quickly through the colon. The reduced IBS symptoms for some people, with those
most common side effects include diarrhea, flatulence, consuming probiotics having a 21% greater chance of
and abdominal pain and distension. improvement compared with those taking a placebo.
Lubiprostone (Amitiza) is a prescription medica- In general, products that contained combinations
tion first approved to treat adults who have persis- of bacteria seemed most effective, but there was not
tent severe constipation without an identifiable cause enough evidence to identify specific strains of bacteria
and who have not responded to traditional thera- as most beneficial.
pies. The FDA extended approval of this drug for Since there is currently no way to predict which
the treatment of women ages 18 and older who have people with IBS may benefit from probiotics, or how
constipation-predominant IBS. Known as a chloride- much, some gastroenterologists suggest regular con-
channel agonist, it enhances production of chloride- sumption of fermented foods, such as sauerkraut and
rich fluid in the gut. The most common side effects of yogurt, along with a trial of products that contain Lac-
lubiprostone are nausea, diarrhea, abdominal pain, tobacillus or Bifidobacterium to see how symptoms
and headache. respond.
Research is also focusing on the gut-brain con- Although safe for most healthy people, probiotics
nection, which appears to play a role in IBS. Among are live microorganisms that pose concerns for people
the medications being investigated are serotonin-like with certain medical conditions, including people at
drugs known as 5-hydroxytryptamine receptor ago- risk of invasive infection, people with an abnormal
nists. The first of these to be approved for diarrhea- gastrointestinal mucosa barrier, those with central
predominant IBS was alosetron (Lotronex), which venous catheters, people who are immunocompro-
works on the serotonin type 3 receptor. However, mised, children with short gut syndrome, and all criti-
Lotronex was temporarily taken off the market in 2000 cally ill patients in intensive care units.
because of colitis and severe constipation that resulted
in 44 hospitalizations and five deaths. Lotronex is now Alternative and complementary treatments
available for women with severe IBS with diarrhea for IBS
and bowel urgency, but only under a tightly controlled People with IBS frequently turn to alternative or com-
prescribing program. plementary therapies ranging from herbal remedies to
Probiotics and prebiotics. Probiotics are live meditation. Research shows that some people expe-
microorganisms used to benefit health. Prebiotics are rience improvement through any of several stress-
nonliving substances intended to promote the growth reduction techniques taught by psychologists or other
of the beneficial microorganisms. The promise of pro- medical professionals. However, evidence of beneficial
biotic and prebiotic treatments for gastrointestinal and effects is lacking for most of the herbal therapies or
other ailments is growing as scientists understand more other supplements.
about the important role that the microbes living in and Relaxation response training and meditation.
on the human body have on health. Simple and easy to learn, these techniques help reduce
People with GI disorders, including IBS, are nervous system activity and relax muscles. Therapies
prime targets for the many popular yogurts, supple- that induce a similar response include progressive
ments, fruit juices, and other products marketed as muscle relaxation and guided imagery.
having probiotic or prebiotic ingredients. However, Yoga. Yoga, the ancient Indian discipline that
the quality of the scientific studies is too poor to pro- seeks to bring body and mind into balance, has proved
vide meaningful evidence on the use of prebiotics in valuable to some IBS sufferers. Yoga, like meditation,
IBS, according to researchers at several institutions, can serve as a form of self-relaxation.
including Beth Israel Deaconess Medical Center. In a Hypnosis. Increasing evidence suggests that this
2014 analysis combining data from 35 controlled trials mind-relaxation technique calms the autonomic
nervous system and might contribute to
improvement in symptoms. Stress-reduction
techniques, such as
Biofeedback. Biofeedback is a mind-
meditation or yoga,
body technique in which participants use seem to help some
a machine to see and learn to control their people with IBS
body’s responses to stimuli such as pain. symptoms.
Some people who periodically lose control
of their bowels, for example, have been able
to improve their control using biofeedback
techniques. In a 2013 study, women with
difficult-to-control IBS had less anxiety and
depression and fewer digestive symptoms
after three sessions of biofeedback.
Thinkstock
Acupuncture. This system of applying

small needles to prescribed points on the
body has been used for treatment of IBS symptoms. from nine placebo-controlled studies and found
However, a 2012 review by the international Cochrane that peppermint oil capsules or softgels significantly
Collaboration found that studies using sham acu- improved abdominal pain and overall IBS symp-
puncture as a control did not reveal any added benefit toms. The most common side effect was heartburn.
to real acupuncture in improving symptoms or quality Peppermint oil may work by blocking calcium chan-
of life. nels, thereby relaxing smooth muscles in the walls of
Herbal remedies. A growing number of people the intestine.
are turning to herbal remedies for the relief of IBS Some evidence has emerged for the use of Chinese
symptoms, including St. John’s wort, fish oils, flax- herbal preparations, but once again, the quality of the
seed oil, aloe vera juice, chamomile tea, and a variety studies is not sufficient to recommend these therapies.
of Chinese herbs. However, the number and quality Because most herbal preparations do not undergo
of studies to support the safety and effectiveness of rigorous scientific study, be alert to the possibility of
such remedies is limited. One possible exception is unexpected side effects or drug interactions if you
peppermint oil. In 2014, investigators analyzed data take an herbal remedy.

Constipation
C onstipation is the slow movement of feces through

the large intestine, resulting in the difficult passage
of dry, hard stool. It’s one of the most common gastro-
ological problems or diseases. The following are the
more common causes of constipation:
Lack of exercise. People who exercise regularly
intestinal complaints in the United States, responsible seldom complain about constipation. Basically, the colon
for more than 2.5 million visits to health care providers responds to activity. Good muscle tone in general is
each year. The National Institutes of Health says that important to regular bowel movements. The abdominal
more than four million Americans have frequent con- wall muscles and the diaphragm all play a crucial role
stipation. The complaint is more common in women in the process of defecation. If these muscles are weak,
than men, and more common among older people. they’re not going to be able to do the job as well. But
exercise is not a cure-all. Increasing exercise to improve
constipation may be more effective in older people, who
How constipation happens tend to be more sedentary, than in younger people.
The hard, dry stool that defines constipation develops Medications. Constipation is a side effect of
when the colon absorbs too much water. This may many prescription and over-the-counter drugs. These
happen because the muscle contractions of the colon include pain medications (especially narcotics), ant-
are too slow, so the stool moves along sluggishly. Or it acids that contain aluminum, antispasmodics, antide-
can occur when the anal sphincter fails to relax when
it should, causing an excessive amount of stool to be
stored in the rectum. Constipation can also occur Do you have functional constipation?
when you deliberately hold back bowel movements. The Rome III criteria for a diagnosis of functional con-
If you routinely override the urge to defecate by constipation state that people must have experienced two
sciously constricting the external sphincter muscles or more of the following symptoms for the past three
months, and that symptoms must have begun at least six
that surround the anus, your reflex to defecate may months before diagnosis:
be blunted, and accumulated stool may harden as a ✔ straining during at least one out of four bowel
result, becoming even more difficult to pass. movements
Eventually, the colon tries to move the stool by ✔ having lumpy or hard stools during at least one out of
squeezing down to push it along. This causes an four bowel movements
uncomfortable pressure and cramping. If the stool ✔ having a sensation of incomplete evacuation in at
is not eliminated, more hard stool accumulates. least one out of four bowel movements
When the stool finally passes, it can cause extreme ✔ having a sensation that your rectum or anus is blocked
during at least one out of four bowel movements
discomfort.
✔ resorting to manual maneuvers such as using a finger
to help facilitate movement during at least one out of
four bowel movements
Causes of constipation ✔ fewer than three defecations a week.
There are many factors that predispose someone to
The diagnosis also requires these two conditions:
constipation. Some can easily be prevented by chang-
✔ loose stools rarely present without the use of a laxative
ing habits and lifestyle (although the role of lifestyle
✔ no diagnosis of irritable bowel syndrome.
factors in constipation may not be as important as
once thought). Often, the cause has to do with physi-
pressants, tranquilizers and sedatives, bismuth salts, kidney disease; bowel cancer; and diverticulitis (see
iron supplements, diuretics, anticholinergics, calcium- “Diverticular disease,” page 27). A number of systemic
channel blockers, and anticonvulsants. conditions, like scleroderma, can also cause constipa-
Irritable bowel syndrome (IBS). Some people tion. In addition, intestinal obstructions, caused by
who suffer from IBS (see “Irritable bowel syndrome,” scar tissue (adhesions) from an operation or strictures
page 25) have sluggish bowel movements, straining of the colon or rectum, can compress, squeeze, or nar-
during bowel movements, and abdominal discomfort. row the intestine and rectum, causing constipation.
Constipation may be the predominant symptom, or it
may alternate with diarrhea; cramping, gas, and bloat- Functional constipation
ing are also common. Some people experience constipation that persists for
Abuse of laxatives. Laxatives are sometimes years or decades, even though they have no physical
used inappropriately, for example, by people suffer- abnormality of the bowel on x-ray studies (such as
ing from anorexia nervosa or bulimia. But for people barium enema examinations) or colonoscopy. This
with long-term constipation, the extended use of lax- condition—known as chronic severe constipation,
atives may be a reasonable solution. In the past, long- functional constipation, or chronic idiopathic consti-
term use of some laxatives was thought to damage pation—is rare, but is more common in women.
nerve cells in the colon and interfere with the colon’s
innate ability to contract. However, newer formula-
tions of laxatives have made this outcome rare (see Diagnosing constipation
“Oral laxatives,” page 39). Diagnosing constipation might sound simple, but in
Changes in life or routine. Traveling can give some order to determine what’s causing the problem—par-
people problems because it changes normal diet and
daily routines. Aging often affects regularity because a
slower metabolism can reduce intestinal activity and Frequency of bowel movements:
muscle tone. Pregnancy may cause women to become What’s normal?
constipated because of hormonal changes or because What is regularity? The idea that you’ve got to move your
the heavy uterus pushes on the intestine. bowels each day to be healthy is a myth, not a medical
Ignoring the urge. If you have to go, go. If you fact. In fact, as far back as 1909, the British physiologist
hold in a bowel movement, for whatever reason, you Sir Arthur Hurst said it wasn’t unusual to find healthy peo-
ple who had a bowel movement three times a day or once
may be inviting a bout of constipation. People who every three days. Today, that’s still the range that’s consid-
repeatedly ignore the urge to move their bowels may ered “normal.” But many perfectly healthy people don’t
eventually stop feeling the urge. even fall within this broad range. In 1813, the British phy-
Not enough fiber and liquid in the diet. A diet too sician William Heberden described a patient who “never
went but once a month.” He also described a patient who
low in fiber and liquid and too high in fats can con-
relieved himself 12 times a day. Both patients seemed per-
tribute to constipation. Fiber absorbs water and causes fectly content with their bowel habits.
stools to be larger, softer, and easier to pass. Increasing The truth is that everyone experiences variations in how
fiber intake helps cure constipation in many people, often they move their bowels. Menstruation, vigorous
but those with more severe constipation sometimes physical exercise, diet, travel, and stress can all cause
find that increasing fiber makes their constipation temporary changes in bowel habits. Going a day without
a bowel movement certainly shouldn’t be considered
worse and leads to gassiness and discomfort.
constipation. And three movements in a day isn’t neces-
Other causes of constipation. Diseases that can sarily diarrhea. More important than the number of bowel
cause constipation include neurological disorders, movements is the consistency of the stools as they pass,
such as Parkinson’s disease, spinal cord injury, stroke, the effort needed to expel them, any associated symp-
or multiple sclerosis; metabolic and endocrine disor- toms, and changes in frequency.
ders, such as hypothyroidism, diabetes, or long-term

Dietary fiber and supplements
fast fact | On average, Americans eat about 5 to For many people, adding fiber to the diet is a highly
20 grams of fiber a day, well below the daily 21 to 38 effective way to prevent or treat constipation. The
grams recommended by the Institute of Medicine. Food and Nutrition Board of the Institute of Medicine
recommends 38 grams of fiber per day for men and
25 grams per day for women ages 50 and younger; for
ticularly if it persists—your doctor will need to ask men and women over 50, they recommend 30 and 21
questions about your health and symptoms and per- grams per day, respectively. Most Americans ingest
form a physical exam. He or she will ask what medi- much less fiber than these amounts.
cations you are taking, in case one of them could be Whole-grain foods, brans, fruits, and vegetables
contributing to the problem. are good sources of fiber. Fiber will generally improve
The physical exam may involve a visual and hands- symptoms of mild constipation in people whose diet
on examination of your abdomen for any masses or does not include adequate amounts. At least 20 grams
tenderness. Your doctor may also perform a digital per day of unprocessed bran and plenty of liquid are
rectal exam (insertion of a gloved finger into the rec- necessary to provide these benefits. Depending on
tum) to feel for polyps or other abnormalities and to the brand, a bowl of high-fiber bran cereal delivers
assess the strength of the anal sphincter muscle. He approximately 4 to 12 grams of fiber.
or she may perform one of several tests to help deter- Fiber supplements and other products containing
mine if there’s a blockage in the colon or an underly- psyllium seed or methylcellulose are quite effective.
ing condition such as hypothyroidism. Follow the directions on the label carefully as you mix
Evaluating constipation may require special tests, the powder with a large glass of water or juice. Drink-
including a colonic transit study (to measure how ing plenty of liquid is most important when using
quickly stool passes through the colon), defecography these products. Some people find that drinking a sec-
(an imaging study of the rectum during attempted ond glass of water or juice after drinking the mixture
defecation), and anorectal manometry (to measure boosts effectiveness.
the pressure of anal contraction). If liquid formulations are difficult for you to
ingest, psyllium and methylcellulose are also available
in capsule and tablet forms.
Treating constipation
People suffering from constipation should start by Laxatives
boosting fiber and fluid intake and increasing physi- For thousands of years, people have been using vari-
cal exercise. Drinking more fluids may reduce the ous substances to help ease the passage of stool
need for the colon to rehydrate stools and is, in any through the bowel. Under most circumstances, laxa-
case, harmless. Exercise, which is widely believed to tives should be used only when dietary and behavioral
promote regularity (although few studies have inves- measures fail.
tigated this), has many other health benefits as well. Most of the time, oral laxatives will be sufficient
Bowel training is another option. In order to (see “Oral laxatives,” page 39), but sometimes different
retrain your bowel, you attempt to defecate at a regu- approaches may be needed.
lar time each day, when bowel movements are most Suppositories. Suppositories have been used to
likely to occur (first thing in the morning, following aid evacuation since the days of ancient Egypt, Greece,
exercise, or after a meal). The idea is to repeat the and Rome. Glycerin suppositories are made of about
routine until the body adopts the bowel movement 70% glycerin, sometimes with sodium stearate (a fatty
as part of its daily rhythm. Although bowel training is acid) added. After insertion, a glycerin suppository
harmless and does help some people, it has not been stimulates the reflex to defecate, in part because of its
widely tested. lubricating action. Suppositories with bisacodyl (Dul-
Oral laxatives
Depending on the type, oral laxatives work in a variety of ways to ease the passage of stool through the rectum.
Bulk-forming agents. These fiber-based products take a Stimulant laxatives act directly on the intestinal lining
day or so to work but are very effective and safe to take to elicit more vigorous contractions of the colon and to
indefinitely on a daily basis. Take with plenty of liquid. alter water and electrolyte secretion. They’re best used for
They include occasional constipation. They include
• bran (in food and supplements) • bisacodyl (Correctol, Dulcolax, Ex-Lax Ultra, others)
• calcium polycarbophil (FiberCon and others) • casanthranol (included in Dialose Plus, Peri-Colace)
• methylcellulose (Citrucel and others) • cascara (included in Naturalax)
• psyllium (Metamucil and others). • castor oil (Purge)
• senna (Ex-Lax, Fletcher’s Castoria, Senokot, others).
Stool softeners merge with stool and soften its consistency.
• Docusate (Colace, Surfak, others) is generally safe for A unique side effect of some stimulant laxatives, those in
long-term use. the class known as anthraquinones (casanthranol, cascara,
• Mineral oil should not be used daily because it reduces senna), is pseudomelanosis coli—a darkening of the lining
absorption of fat-soluble vitamins. Also, it can cause lung of the colon seen on colonoscopy. However, pseudomelano-
damage if it is accidentally inhaled. sis coli is not associated with altered colon function and ap-
pears to be a harmless consequence of long-term stimulant
Osmotic agents are salts or carbohydrates that promote laxative use.
secretion of water into the colon. They are reasonably safe,
even with prolonged use. They include A chloride-channel agonist called lubiprostone (Amitiza)
• polyethylene glycol (Miralax)—shown to be helpful in received FDA approval in January 2006. The drug causes
additional fluid to be secreted into the intestine, making it
children with functional constipation
easier to pass stool. Lubiprostone may be a good option for
• lactulose (Constulose, Cholac, others).
people who are not helped by standard treatments. However,
Saline laxatives attract and retain water in the side effects such as nausea are frequent, and its long-term
intestines, increasing pressure and release of stool. effects are unknown.
They include A guanylate cyclase 2c agonist called linaclotide (Linzess) was
• magnesium hydroxide (milk of magnesia) approved in 2012 for chronic idiopathic constipation (func-
• magnesium sulfate (Epsom salt). tional constipation). It increases intestinal fluid secretion.
colax) are more potent and usually produce a bowel Biofeedback

movement within 20 minutes. Biofeedback can be helpful for severe constipation that
Enemas. The simple tap water enema distends results from an inability to relax the necessary muscles
the rectum, mimicking its natural distension by the and adequately straighten the angle of the rectum
stool, and prompts the reflex that opens the sphinc- enough to pass stool effectively. With this method, you
ters to empty the rectum. While it isn’t ideal to rely can be trained to relax the pelvic floor muscles dur-
on artificial stimulation to kick off evacuation, occa- ing straining and coordinate this action with abdomi-
sional use can be safe and effective. Sodium phos- nal wall muscle contractions to enable the passing of
phate (Fleet) enemas are available in single-dose stool. About two-thirds of people with anorectal dys-
plastic containers. These salts draw fluid into the function report improvement.
bowel, prompting contraction. Oil-containing ene-
mas are sometimes prescribed as softeners for feces Probiotics and prebiotics
that have become hardened within the rectum. They Probiotics are live microorganisms used to benefit
are generally recommended for short-term use only. health. Prebiotics are nonliving substances intended
Avoid soapsuds enemas, which can irritate the lining to promote the growth of the beneficial microorgan-
of the colon. isms. A variety of probiotic and prebiotic agents have

been tested for treatment of constipation, with vary- intestine directly to the rectum. But at least half of
ing results. In a 2014 analysis of 14 studies, probiot- those undergoing the procedure have had to endure
ics (particularly Bifidobacterium lactis) sped up stool further surgery because of leaking at the junction of
transit and frequency. However, high-quality studies the small intestine and rectum, obstructions of the
establishing the efficacy of specific probiotic microbes small intestine, or other complications.
at specific dosages are lacking. Studies have not shown
prebiotics to help more than placebo in relieving con- Alternative approaches
stipation, perhaps because it takes time to build up a A variety of alternative, herbal, and other approaches
colony of microflora in the gut. are available for constipation. Solid scientific evidence
is limited, but some people find flaxseed or sesame
Surgery seed useful. In a 2014 study, people who used peri-
Surgical intervention as a means of treating severe neal self-acupressure just before defecating—pressing
constipation is necessary for only a limited number of on the area between the anus and vaginal opening in
people with very severe constipation caused by a lack women and between the anus and scrotum in men—
of colonic motility that has not responded to other reported improved bowel function over those using
treatments. The operation most commonly performed standard treatments alone. Others have reported suc-
involves removing the colon and connecting the small cess using abdominal massage.
Diarrhea
A lmost everyone has had a bout of “the runs” from

eating tainted food or drinking unclean water.
But some people experience the frequent, runny
Do you have functional diarrhea?
According to the Rome III criteria, for a diagnosis of func-
tional diarrhea, a person must have experienced the fol-
bowel movements of diarrhea for no apparent rea-
lowing for the past three months, with symptoms starting
son. Although diarrhea can accompany a number of at least six months before diagnosis:
GI disorders, it may occur on its own, intermittently ✔ loose (mushy) or watery stools without pain, occurring
or constantly, for reasons that are not always identifi- in at least three-quarters of stools
able. Diarrhea is described as acute when it lasts less ✔ no identifiable cause.
than four weeks, as in viral gastroenteritis. It is consid-
ered chronic when it lasts four weeks or longer. When
diarrhea occurs more than three-quarters of the time fluid from the diet every day and pushes about 1 liter
and lasts at least three months without an identifiable of that to the colon. (The rest is absorbed into the body
cause, the diarrhea is said to be functional. before it reaches the colon.) The colon absorbs most of
this fluid and moves the compacted residue, which con-
tains a few ounces of water, to the rectum. The rectum
What is diarrhea? can store up to 200 grams of stool before defecation is
Diarrhea is sometimes defined as having more than triggered. However, any interference with this process
three bowel movements a day. But a more widely can cause the colon to be overwhelmed by the fluid
accepted definition of diarrhea is liquid or watery load, resulting in diarrhea. In fact, any disturbance in
stools. the colon that interferes with the packing, storage, or
Diarrhea is the body’s response to something that dehydrating of the stool can result in diarrhea.
upsets the intestines; it’s the body’s way of clearing out While functional diarrhea has no known cause, it
whatever is causing the upset. Sometimes you know is important to investigate possible causes before con-
exactly what caused the intestinal distress—for exam- cluding that the diarrhea is functional.
ple, bacterial contamination in food. Other times, it
remains a mystery. Causes of acute diarrhea
In most cases, the problem will clear on its own, Acute diarrhea may be caused by viruses, bacteria, or
and you may not need to call a doctor. Diarrhea usu- parasites, as well as by various foods and drugs. It can
ally isn’t serious, but it can lead to dehydration and also be a symptom of other medical conditions.
weight loss. And while everybody experiences diar- Viruses. A wide variety of viruses can cause diar-
rhea sometimes, for a significant percentage of the rhea, which is usually short-term and resolves on its
population, the condition is persistent. Cases that own. Among them are rhinovirus or adenovirus, rota-
don’t clear up in a few days require a doctor’s care. virus (the most common cause of diarrhea in infants),
influenza, and norovirus (the most common cause
in adults). Most diarrhea is not caused by viruses,
Causes of diarrhea although many of the most severe cases are.
Normal defecation depends on the small intestine, Bacteria. A number of bacteria are associated
colon, rectum, and anal sphincter working normally. with acute diarrhea. Shigella, Vibrio cholerae, Esch-
The small intestine usually handles about 8 liters of erichia coli, and Clostridium difficile produce toxins

that cause diarrhea, while Salmonella and Campylo- syndrome. Chronic diarrhea may also be caused by
bacter invade the stomach lining and produce inflam- disorders such as celiac disease that lead to the malab-
mation and diarrhea. Food poisoning is usually due to sorption of nutrients.
bacterial contamination of food. Some forms of chronic diarrhea have nothing to
Parasites. Intestinal parasites, such as Giardia do with food but are the result of fluids secreted by the
intestinalis, Cryptosporidium parvum, and roundworms intestine. These are called secretory diarrheas and may
or tapeworms, may cause diarrhea. These parasites are rarely be caused by hidden tumors, sometimes in the
often found in untreated or contaminated water. Drink- pancreas, that release chemical messengers telling the
ing untreated water from a lake or stream while camp- bowel to release large amounts of liquid. Microscopic
ing is a common way to pick up Giardia parasites. colitis is a more common cause of secretory diarrhea.
Inflammatory bowel disease. Crohn’s disease and In this case, the colon looks normal during a colonos-
ulcerative colitis, two forms of inflammatory bowel copy, but biopsies show intense inflammation of the
disease, can cause diarrhea (see “What else could it be, colon lining.
if it isn’t IBS?” on page 27). In rare cases, genetic mutations can cause people
Immune deficiency. People suffering from dis- to have chronic diarrhea. A 2012 report in The New
eases such as AIDS or those who are undergoing treat- England Journal of Medicine described 32 members
ments that weaken the immune system and damage of a Norwegian family who all had a gene that caused
the lining of the intestine, such as chemotherapy, may mild, chronic diarrhea. The gene appears to lead to
also suffer from severe diarrhea. the production of a substance that increases salt and
Stress. Emotions are known to wreak havoc on water excretion from cells in the small intestine, caus-
the bowels in a number of ways. Diarrhea is a coming loose stools.
mon complaint of people under severe stress or emo-
tional upset.
Foods. Certain foods, even if perfectly fresh, can When to call the doctor
cause diarrhea in some people. Among them are fruits, If your diarrhea lasts three days or more, it’s time to call
beans, and coffee. For most people, unripe fruits or the doctor. However, call immediately if there is blood
any type of spoiled food will cause diarrhea, as will the in the stool or if the stool looks like black tar. The same
particular foods that a person cannot tolerate, such as goes for diarrhea accompanied by a fever over 101° F,
milk products for those who are lactose intolerant. severe abdominal or rectal pain, and severe dehydra-
Medications. A number of prescription and over- tion (symptoms of which include dry mouth, wrinkled
the-counter drugs can cause diarrhea as a side effect. skin, and lack of urination). Weight loss of more than 5
The most common culprits include antibiotics, ant- pounds is also a reason to see a doctor.
acids containing magnesium, and some blood pres-
sure and heart medications. Because antibiotics kill
some of the naturally occurring GI bacteria, the gut Diagnosing diarrhea
becomes more vulnerable to attack by Clostridium dif- The doctor will ask questions about your symptoms
ficile, a bacterium that produces toxins that can cause and try to determine whether the diarrhea is chronic,
diarrhea. In 2005, the Centers for Disease Control and or whether it’s the result of a virus or bacterium and
Prevention reported the emergence of a new, more thus likely to be short-lived. If it’s chronic, the doc-
virulent strain of C. difficile that causes more serious— tor will want to probe further to establish whether the
and more often deadly—disease. diarrhea is due to an identifiable physical problem
or whether it’s functional. You may be asked ques-
Causes of chronic diarrhea tions about your habits, including drug or alcohol use.
There are numerous causes of chronic diarrhea. The Alcohol abuse commonly causes diarrhea, as does use
condition may be an indication of irritable bowel of certain drugs, including cocaine.
The doctor will probably ask questions such as For more severe cases, sports drinks like Gatorade
these: can replace sugars and electrolytes, but too much may
• When did the diarrhea start? cause further diarrhea. Rehydration solutions such as
• Have any other family members been sick? Pedialyte are probably best, particularly for children
• Have you recently traveled out of the country? with diarrhea.
• Are you having abdominal pain? Fever? Chills? Products such as kaolin and pectin (Kaopectate)
• Is there blood in the stool? give the stool a firmer consistency. Medications that
• Is it worse when you are under stress? work to slow the bowel include paregoric, opiates, and
• Do any specific foods make it worse? diphenoxylate with atropine (Lomotil), all of which
• Do you drink coffee? Alcohol? are available by prescription only, as well as loper-
• What medications are you taking or have you amide (Imodium), which is available over the counter.
taken recently? These provide quick but temporary relief by reducing
If blood or pus in the stool accompanies diarrhea, muscle spasm in the GI tract. They should be used
or if there is fever, anemia, profound loss of appetite, only for a few days, however. Bismuth subsalicylate
or severe vomiting, it’s not functional diarrhea. (Pepto-Bismol) also seems to work fairly well; it may
For most people and for most mild episodes of temporarily turn the stool and tongue black, so don’t
diarrhea, no specific lab tests are required. But for be alarmed if that happens.
more severe cases, or when symptoms of inflamma- Be aware, however, that using these remedies
tion are present, the doctor will order stool tests to for symptomatic relief can prolong diarrheal illness
look for the presence of certain bacteria. caused by infection with certain bacteria, including
Your doctor may recommend a blood test to Salmonella and possibly Campylobacter. While the
check for anemia, as well as testing your white blood medicines may make you more comfortable, they sup-
cell count and sedimentation rate to check for signs of press the diarrhea that helps cast the offending bacte-
inflammation (see “Diagnostic tests,” page 31). A sig- ria out of your system. If you slow down the process,
moidoscopy may also be performed. For people over the bugs stay in your system longer.
40, a colonoscopy may be ordered to check for dis- After the first 24 hours, a little food is probably
eases. Doctors must exclude the possibility of Crohn’s permissible. But it may be best to try to go without
disease, ulcerative colitis, or other serious illness, solid food as long as possible. If you are really hun-
such as colon cancer. These are often accompanied by gry, try going on a BRAT diet: bananas, rice, apple-
blood in the stool, fever, or weight loss. The evaluation sauce, and white toast. The bananas bind the stool,
is likely to be more extensive if the diarrhea is chronic slowing the movement a little. White rice, apple-
rather than acute and if “alarm” symptoms, such as sauce, and dry, white-bread toast are low in fiber
bleeding or weight loss, are present. and easily digested.
A wide range of probiotic and prebiotic prod-
ucts have been proposed as treatment for diarrhea.
Treating diarrhea The most commonly tested probiotic ingredient for
Most people with acute diarrhea will recover on their diarrhea is Lactobacillus rhamnosus GG. Some trials
own; it generally runs its course in a few days. In partic- have shown that this probiotic shortens the duration
ularly severe or prolonged episodes, replacement of lost of diarrhea. However, dose and duration of treat-
fluids and electrolytes (such as sodium and potassium) ment varied so much among the studies that no firm
is essential to combat dehydration. Clear liquids are the conclusions can be drawn. Although some probiot-
first choice. For mild cases of dehydration, juices, soft ics may benefit people with diarrhea, the research
drinks, clear broth, and safe water are recommended. remains too inconclusive to support specific recom-
Apple juice and sodas are also a good choice. Citrus mendations. For more, see “Probiotics and prebiot-
juices are not. Neither are alcoholic beverages. ics,” page 34.

Preventing diarrhea them. If you are traveling in an area where the water
Preventing diarrhea is largely a matter of luck and com- purity is questionable, drink and brush your teeth
mon sense. If certain foods give your intestinal tract a only with bottled water, and don’t eat any uncooked
hard time, stay away from them. Many cases of diarrhea fruit or vegetables. At home, rinse chicken before you
are caused by intestinal bugs, but if yours seems to be cook it, and cook chicken and other meats thoroughly.
functional and not connected with bacterial infection, Clean all food preparation areas such as countertops
try to assess what conditions seem to trigger it and, in and cutting boards with soap and warm water. Wash
particular, whether stressful situations seem connected. your hands thoroughly before and after handling food.
Take steps to reduce stress (see “The stress connection,” Be careful about eating foods left outside for long
page 7) and ask your doctor about medications that periods of time—at barbecues or picnics, for example.
might treat functional diarrhea. Bacteria can grow easily in the warm air. And don’t
General rules for avoiding diarrhea caused by bac- take leftovers home from these events. Even inside,
terial infections include washing all fruits and vegeta- leftovers should be refrigerated quickly after the meal
bles well and making sure they’re ripe when you eat has been served.
Excessive gas
A side from causing embarrassment, too much gas

in the digestive system can result in considerable
pain and discomfort—symptoms that may appear on
Frequent supragastric belching is considered to be a
learned behavior that can be changed.
Aerophagia—excessive swallowing of air—is a dis-
their own or in conjunction with functional dyspepsia tinct condition that produces supragastric belching or
(see page 21) or irritable bowel syndrome (see page burping. People with GERD and functional dyspepsia
25). Sometimes you even hear and feel air and liquid often swallow excess air in response to their uncom-
swirling around inside. But there are practical steps fortable GI symptoms, leading to excess supragastric
you can take to control this problem. burping.
Flatus
Where does gas come from? Also known as flatulence, this term describes gas that
There are only two ways for gas to get into the GI tract. escapes from the rectum. The gas is mostly the byprod-
Either you swallow it (aerophagia), or it’s manufac- uct of the fermentation of undigested food by bacteria
tured in the gut (often producing flatulence). in the colon. It contains carbon dioxide, hydrogen,
and, in some people, methane. Tiny amounts of vol-
Swallowed air atile chemicals produced by bacterial metabolism of
With every swallow, a little air enters the digestive residual fats and proteins are responsible for the dis-
tract and is transported to the stomach. To relieve tinctive foul odor of flatus.
pressure in the stomach and keep excess air from Although passing gas is a natural, normal func-
entering the intestines, about 25 to 30 times each day a tion, the resulting sounds and smells are unwelcome
normal reflex causes the lower esophageal sphincter to in social situations. The average human intestine holds
relax and release the air in what’s called a gastric belch. 0.1 to 0.2 liters of gas, but researchers have found that
People with GERD can experience frequent gastric in 24 hours, production of flatus averages 2 liters.
belches, and treatment to reduce acid may help. This gas originates in the intestine, and its quantity
In contrast, a supragastric belch expels air that has and composition depend largely on the foods you eat.
just been swallowed and not reached the stomach. The Studies using hydrogen breath testing have found that
upper gastrointestinal gas that erupts from the mouth up to one-fifth of the complex carbohydrates eaten by
comes from swallowed air that forces itself back up. average, healthy individuals is turned into gas.
Do you have aerophagia? A gas primer

According to the Rome III criteria, for a diagnosis of aero- The air we breathe is made up mostly of nitrogen (N2)
phagia, people must have experienced both of the follow- and oxygen (O2), the gas the human body needs to
ing for the past three months, with symptoms starting at sustain life. Air that’s swallowed enters the GI tract.
least six months before diagnosis:
As it moves along, its makeup changes as oxygen
✔ troublesome repetitive belching at least several times
passes into the blood and nitrogen is removed from
a week
the blood. Another intestinal gas is carbon dioxide
✔ air swallowing that is objectively observed or
measured. (CO2), a byproduct of a chemical reaction with acid
in the stomach. Hydrogen (H2) is released in the colon

when undigested carbohydrates undergo bacterial
fermentation. Foods that may cause gas
Bacteria in the gut produce foul-smelling gases There is great variation in the foods that cause gas in
when they ferment undigested foods that have not different people. Some of the more common offenders are
listed below.
been absorbed in the small intestine. These foods
• Apples • Grapes
consist mostly of carbohydrates, sugars, and fats.
• Bananas • Milk and other dairy
The carbohydrates found in high-fiber foods, such as
• Beans, peas, and products
beans, broccoli, cauliflower, and Brussels sprouts, are
lentils • Nuts
the worst culprits. These foods release gases such as
• Broccoli • Oats and other high-
methane and hydrogen sulfide, which smells like rot-
• Brussels sprouts fiber foods
ten eggs. The worst odor is related to strong-smelling
• Cabbage • Onions
sulfurs that make up just 1% of flatus.
• Carbonated beverages • Raisins
Methane is detected in about one-third of adults.
• Cauliflower • Sorbitol
Studies show that Americans and Europeans are more
• Corn • Turnips
likely to produce methane than Asians are, possibly
• Cucumbers • Wine
because of diet. Women also produce more than men
do. Genes may play a role in methane production, as
the trait is passed along in families.
Additional carbon dioxide is produced in the Borborygmi is an onomatopoeic word that refers
colon as the byproduct of bacterial fermentation of to sounds created by peristaltic activity. Although dis-
unabsorbed sugars and starches. Eating beans sub- concerting to the person whose insides are grumbling,
stantially increases CO2 production, as does taking it often goes unnoticed by anyone else.
sodium bicarbonate for heartburn. Thus, it doesn’t
make sense to use bicarbonate-containing seltzers Eating habits and gas
for gas. Throughout history, certain foods have been notori-
ous for producing gas (see “Foods that may cause gas,”
Gas in the intestine above). Beans are the most obvious example. Beans
You hardly notice gas when it enters your digestive contain the complex carbohydrates stachyose and raf-
system, but once it’s there, the discomfort can be finose, which the intestine can’t absorb but the bac-
intense. People who suffer the symptoms of gas pain teria in the colon love. The problem is most serious
usually have the same volume of gas as anyone else, or in people who have been eating a low-fiber diet and
just a little bit more. But it affects them more because switch to a diet rich in beans and other high-fiber
they are more sensitive. Some people with chronic gas foods. Their digestive tracts don’t have enough of the
pain have impaired peristalsis and significant reflux of enzymes needed to digest bean sugars, which pass
gas from the small intestine into the stomach. undigested into the lower intestine, where the bacteria
Although gas pain is not usually a sign of signifi- metabolize them and generate gas. If people eat beans
cant health problems, it is important to see a doctor if on a regular basis, the problem usually lessens as the
the symptoms persist because they are occasionally a body begins to produce the enzymes it needs.
sign of some more serious condition. Severe disten- People who are lactose intolerant often describe
sion immediately following a meal is called magen- distressing flatulence if they consume milk products
blase (or stomach bubble) syndrome and may be (see “Understanding food intolerance,” page 30).
mistaken for heart pain. Splenic flexure syndrome is Other factors, such as disturbances in motility or
a painful spasm in the left upper abdomen below the metabolism, also influence how often and how much
rib cage, produced by localized areas of trapped gas in flatus is passed. For instance, people with slowed intes-
the colon. tinal motility may produce more gas simply because
bacteria have more time to work their magic on com- excessive air swallowing may be the culprit. The doc-
plex carbohydrates. Gas production may also increase tor will ask about possible lactose intolerance as well
when people take antibiotics, which lead to changes in as habits such as gulping down meals, drinking car-
the types of bacteria in the colon, or when the acidity bonated beverages, sipping through a straw, chewing
level in the bowel goes down. gum, smoking cigarettes, or chewing tobacco.
The doctor will also want to know about anxiety
and psychological problems that may contribute to
Diagnosing and treating air air swallowing and predispose people to symptoms,
swallowing and flatus including gas and cramping. Likewise, he or she will
The important thing for a doctor to consider in diag- want to review the medications you are taking, since
nosing a belching or flatulence problem is whether it’s some—especially drugs that are encapsulated with a
occurring alone or in conjunction with one or more of sorbitol filler—can induce gas, bloating, and diarrhea.
the various functional GI disorders or a more serious A distended abdomen can be detected by listen-
GI illness. He or she should be alert to problems that ing for a hollow sound when tapped. Causes of intes-
may suggest disease, such as weight loss or anemia. Of tinal distension include obstruction of the bowel or
course, a physician may be able to determine quickly fluid or a mass in the abdomen. But other signs usu-
that the problem is the result of eating too many beans ally accompany these more serious problems, and they
or swallowing too much air. In most cases, evaluat- usually can be readily confirmed by an imaging study
ing complaints of gassiness will not require extensive such as a CT scan. Some, such as gastric distension,
diagnostic testing. can be identified with a simple abdominal x-ray. In
To assess your gassiness, your doctor will first many cases, an imaging test is not necessary. Some
question you about your symptoms and dietary pat- doctors may want to run a lactose absorption test or
terns. If upper GI symptoms are the major problems, hydrogen breath test to check for lactose intolerance.
Bloating and distension: It’s not excess gas
Y our abdomen feels uncomfortably full and actually looks

a bit larger than usual. Is it excess gas? Probably not.
That feeling of fullness and tightness in the abdomen is
relaxation of the muscles of the abdomen and diaphragm
(the muscle that separates the abdomen from the chest).
Scientists have measured gas content and abdominal size
called bloating, while distension is the actual increased size in people who have bloating and distension and have not
of the abdomen. The two conditions usually occur together, found that people with these symptoms have more gas than
but it is possible to have bloating without distension. Bloat- people who don’t.
ing with distension, however, is much more bothersome than
Abdominal wall strength or function seems to play a role.
bloating alone.
Abdominal muscles relax during meals to accommodate
Bloating affects 10% to 30% of the general population, with large volumes of food. In people who experience distension,
women twice as likely to experience it as men. Functional the abdominal wall may relax to an abnormal degree, and
bloating is an independent diagnosis, but it is also frequently the diaphragm may drop, causing further distension. Think
associated with other functional GI disorders. For example, of the opposite of the typical upright military posture, which
75% of people with irritable bowel syndrome (see page 25) requires sucking in abdominal muscles and the diaphragm
complain of bloating; in fact, people with IBS often rank to pull in the stomach and thrust out the chest. In people
bloating as their most bothersome symptom. Bloating is also with distension, the diaphragm drops, abdominal muscles
often accompanied by excessive flatulence and frequent sag, and waist circumference grows. Excessive descent of the
belching. diaphragm may also be a factor.
You might think that bloating and distension come from There are no surefire treatments for bloating and distension,
excess gas. But more likely the discomfort is due to ir- but because they often go hand in hand with IBS, they are
ritable bowel syndrome, and the distension is the result of treated the same way (see “Managing IBS,” page 32).

Treating belching Beano, which contains the enzyme alpha-galactosi-
The key is to reduce the amount of air you swallow. dase, might help metabolize difficult-to-digest com-
If you chew gum or smoke, quitting should cut down plex carbohydrates when taken before meals. And
on air gulping. Dentures that are too loose can also preparations containing the pancreatic enzymes
cause you to swallow air. Avoid carbonated drinks and lipase, trypsin, and amylase may reduce gassy emis-
whipped desserts, which trigger burping. Some people sions by helping to digest proteins, starches, and fats
swear by including certain foods in the diet, such as when taken with meals. These enzymes are sold over
brown rice or barley broth. Papaya and pineapple are the counter in capsule form (a product called Super
also said to help. Digestive Enzymes is one example) at stores that sell
Make sure to chew foods slowly, and avoid wash- nutritional supplements.
ing food down with liquids. Try to eat smaller meals, Some people find it helps to drastically reduce
and don’t eat when you are anxious, upset, or over- dietary sugars and cut back on refined starches and
tired. If you have aerophagia, antidepressants and wheat flour. Activated charcoal, a tasteless black pow-
tranquilizers may help by calming the nerves or less- der, absorbs gas and for some people reduces gassi-
ening anxiety, but they must be used carefully and ness, particularly after a high-carbohydrate meal.
only under a doctor’s close supervision. Occasional use is not harmful. Additionally, Pepto-
Taking a brisk stroll after eating, rather than tak- Bismol may reduce the odor of flatus.
ing a nap, is a good idea. It promotes gastric emptying Some people have had success with anticholin-
and helps relieve the bloated feeling. When it’s time to ergic drugs such as dicyclomine (Bentyl) and hyo-
go to bed, try sleeping on your stomach or right side scyamine (Levsin). These agents block nerves that
to aid in the escape of gas and alleviate fullness. stimulate the digestive tract. A course of the broad-
In cases of supragastric belching, behavioral ther- spectrum antibiotic rifaximin (Xifaxan) may also help
apy may be effective. reduce flatulence, usually without side effects.
A variety of probiotics have been tried for treating
flatulence, with some success, but the size and quality
Treating flatulence of studies have not been sufficient to support specific
The first step is to stop eating the foods that cause recommendations.
gas: beans, fruits, and other complex carbohydrates, When all else fails, wearing a deodorizing and
as well as the artificial sweetener sorbitol. But don’t absorbing pad containing activated charcoal beneath
eliminate all fruits and vegetables, because these one’s undergarments doesn’t stop flatulence, but it
foods are the basis of a healthy diet. A product called may prevent others from noticing it.
Appendix: Drugs used to treat functional gastrointestinal disorders
Pregnant or nursing women should not take these drugs, except on the specific advice of a physician.
Antacids (for acid reflux)
ACTIVE INGREDIENTS* BRAND NAME USE SIDE EFFECTS COMMENTS

alumina, aluminum Amphojel, Relieve heartburn Constipation, diarrhea. Excessive Side effects more likely for
carbonate, aluminum Gaviscon, Maalox, and functional and prolonged doses may cause people with kidney disease.
hydroxide Mylanta dyspepsia pain. bone pain, discomfort, appetite loss, Aluminum-containing antacids
Promote ulcer mood changes, muscle weakness. not advised for elderly people
healing by with bone disease or Alzheimer’s
neutralizing disease. Do not use within
stomach acid. three to four hours of taking
tetracycline-type antibiotics.
calcium carbonate Alka-Mints, Constipation. Excessive and Chalky taste. Side effects
Caltrate, Rolaids, prolonged doses may cause upset more likely for people with
Tums stomach, vomiting, stomach pain, kidney disease.
belching, constipation, dry mouth,
increased urination, loss of appetite,
metallic taste.
magnesia, magnesium Gaviscon, Gelusil, Excessive and prolonged doses Chalky taste. Side effects
carbonate, magnesium Maalox, Mylanta, may cause difficult or painful more likely for people with
hydroxide, magnesium Phillips’ Milk of urination, dizziness, irregular kidney disease. Do not use within
trisilicate Magnesia heartbeat, loss of appetite, mood three to four hours of taking
changes, muscle weakness. tetracycline-type antibiotics.
sodium bicarbonate Alka-Seltzer, Abdominal fullness, belching. Not advisable for people on
baking soda Excessive and prolonged doses may low-sodium diets. Side effects
cause additional side effects. more likely for people with
kidney disease.
* Most over-the-counter antacids contain two or more of these active ingredients.
Anticholinergics/antispasmodics (for intestinal pain)
GENERIC NAME BRAND NAME USE SIDE EFFECTS COMMENTS

atropine with Donnatal Relieve Dry mouth, difficulty urinating Should not be used by people
hyoscyamine, gastrointestinal or urinary retention, blurred vision, with glaucoma. Consult
phenobarbital, and cramps and spasms. rapid heartbeat, increased ocular your doctor if you take other
scopolamine pressure, headache, nervousness, medications, because these
drowsiness. Antispasmodics that drugs block or boost the actions
dicyclomine Bentyl
contain phenobarbital may cause of many other medications.
hyoscyamine Levsin sedation, drowsiness, or, rarely, Phenobarbital may decrease the
agitation. effect of anticoagulants and may
be habit-forming.
Antidiarrheal agents (for diarrhea)

diphenoxylate and Logen, Lomotil Stops diarrhea Abdominal discomfort, constipation. Drink plenty of fluids. May
atropine by slowing down Less frequently, may cause blurred be habit-forming. Not to be
intestinal movement. vision, urinary discomfort, dry mouth used with alcohol or other
or skin, rapid heartbeat, restlessness, depressants.
or warm, flushed skin.
loperamide Imodium, Reduces secretion of Abdominal discomfort, constipation. Drink plenty of fluids. Should be
Imodium A-D fluid by the intestine. Less frequently, may cause used with caution by people with
drowsiness, dizziness, dry mouth, liver disease.
nausea, vomiting, rash.
continued on page 50
Chloride-channel agonist (for constipation)

lubiprostone Amitiza Relieves constipation- Nausea, diarrhea, abdominal pain. FDA-approved for chronic
dominated IBS. Rarely, may cause urinary tract constipation in both men and
infections, dry mouth, fainting, women, but only in women for
swelling, difficulty breathing, and constipation-dominated IBS.
heart palpitations.
H2 blockers (for acid reflux)

cimetidine Tagamet Relieve heartburn and Rarely, may cause diarrhea, May interfere with the absorption
functional dyspepsia constipation, dizziness, anxiety, of anticoagulants, antidepressants,
pain and promote ulcer depression, drowsiness, and hypertension medications.
healing by decreasing sleeplessness, headache, irregular
famotidine Pepcid No serious drug interactions
stomach acid. May heartbeat, sweating, itching, redness
known.
nizatidine Axid be used long-term of skin, fever, confusion in ill or
following a course of elderly people.
ranitidine Zantac PPIs. May interact with anticoagulants.
Laxatives (for constipation)

bisacodyl Correctol, Increases the motility Stomach cramps, upset stomach, May cause a blackening of the
Dulcolax, Fleet, of the bowel. diarrhea, stomach and intestinal lining of the colon seen on
others irritation, faintness, irritation colonoscopy (pseudomelanosis
or burning in the rectum (from coli), which appears to be
suppositories). harmless.
castor oil Purge Causes fluid to Diarrhea, upset stomach, vomiting,
accumulate in the small irritation, cramping.
intestine.
docusate Colace, Surfak Softens stool by merging Stomach or intestinal cramps, Generally considered safe for
with feces and softening stomach upset, throat irritation. long-term use.
consistency.
lactulose Cholac, Synthetic sugar softens Diarrhea, gas, nausea. Also used to draw ammonia
Constulose, stool by pulling water from blood in people with liver
others into the intestine. disease.
linaclotide Linzess Relieves constipation- Diarrhea, flatulence, abdominal
dominated IBS. pain and distension.
lubiprostone Amitiza Increases the amount Nausea, diarrhea, bloating, May be a good option for
of fluid secreted into the stomach pain, gas, vomiting, those not helped by standard
bowel, allowing stool to heartburn, dry mouth, headache. treatments.
pass more easily.
mineral oil various Softens stool by merging May cause deficiencies of fat-soluble
with feces and softening vitamins if used regularly. Can cause
consistency. lung damage if inhaled.
polyethylene glycol Miralax Softens stool and Upset stomach, bloating, cramping,
increases the number gas.
of bowel movements by
flushing the intestine.
senna Ex-Lax, Fletcher’s Increases motility of Diarrhea, upset stomach, vomiting, May cause a blackening of the
Castoria, the bowel. irritation, cramping. lining of the colon seen on
Senokot, others colonoscopy (pseudomelanosis
coli), which appears to be harmless.
Prokinetic agents (for stomach discomfort)

metoclopramide Reglan Enhances gastric Diarrhea. Less frequently, may cause Increases the effects of alcohol
emptying. restlessness, drowsiness, muscle and other depressants.
tremor, spasms, breast discharge. Caution advised for people with
Potentially irreversible involuntary type 1 diabetes or Parkinson’s
movement of limbs may occur with disease.
longer (more than 12 weeks) or
higher-dose treatment.
Proton-pump inhibitors (for acid reflux)

dexlansoprazole Dexilant First-line treatment Rarely, may cause constipation, PPIs increase the risk of diarrhea
for reflux chest pain, headache, gas, rash, associated with C. difﬁcile
esomeprazole Nexium esophagitis. Promote drowsiness. infection. Long-term use may
lansoprazole Prevacid ulcer healing increase the risk of vitamin B12
by suppressing deficiency, hip fracture, and other
omeprazole Prilosec, Zegerid secretion of stomach complications. May increase
acid. risk of bacterial infection in
pantoprazole Protonix
people with liver disease. May
rabeprazole Aciphex prolong the effect of other
prescription drugs. Rabeprazole,
pantoprazole, and esomeprazole
are available as intravenous
formulations.
Selective serotonin reuptake inhibitors (for a variety of functional disorders)

citalopram Celexa Relieve chronic Upset stomach, diarrhea, vomiting, Limited experience in functional
abdominal pain. stomach pain, drowsiness, excessive bowel disorders. May help
tiredness, tremor, excitement, reduce sensitivity to pain in
nervousness, difficulty falling or some people.
staying asleep, muscle or joint pain,
dry mouth, excessive sweating,
changes in sex drive or ability, loss of
appetite.
fluoxetine Prozac Rash, headache, dizziness, insomnia,
anxiety, drowsiness, excessive
sweating, nausea, diarrhea, bronchitis,
weight loss, painful menstruation,
sexual dysfunction, urinary tract
infection, chills, muscle or joint pain,
back pain.
paroxetine Paxil Pain, bodily discomfort, hypertension,
sudden loss of strength, rapid
heartbeat, itching, nausea, vomiting,
weight gain or loss, central nervous
system stimulation, depression,
vertigo, cough.
sertraline Zoloft Nausea, trouble sleeping, diarrhea,
dry mouth, sexual dysfunction,
drowsiness, tremor, indigestion,
increased sweating, increased irritability
or anxiety, decreased appetite.
continued on page 52

Serotonin antagonist (for diarrhea-predominant irritable bowel syndrome)
alosetron Lotronex Reduces cramping, Constipation. In rare cases, may Available only under a tightly
abdominal pain, cause diarrhea and intestinal controlled program. Only proven
urgency, and bleeding. effective in women.
diarrhea caused by
IBS.
Tricyclic antidepressants (for pain relief)
amitriptyline Elavil, Endep Relieve chronic Dizziness, dry mouth, blurred vision, Should not be used with alcohol,
abdominal pain. drowsiness, constipation, urinary other antidepressants, or
retention, low blood pressure, immediately following a heart
desipramine Norpramin irregular heart rhythm. attack. Side effects may be
worse when cimetidine is used
nortriptyline Pamelor simultaneously. Caution advised
for people with glaucoma.
Other agents (for a variety of gastrointestinal disorders)
activated charcoal Actidose-Aqua, Relieves intestinal Black stools, abdominal pain. Effectiveness uncertain.
CharcoCaps gas. Do not take at exactly the same
time as other medications.
alpha-galactosidase Beano Reduces intestinal No known side effects. Effectiveness uncertain.

gas by breaking
down indigestible
carbohydrates.
bismuth subsalicylate Pepto-Bismol Relieves heartburn, Dark tongue, grayish-black stools. Avoid if allergic to aspirin or
indigestion, nausea, Excessive doses may cause other salicylates.
and diarrhea. additional side effects.
Occasionally used
with antibiotics to
cure ulcers.
lactase Lactaid Prevents gas, No known side effects. Effectiveness uncertain. Available
abdominal bloating, as pills or prepared food
and diarrhea by products.
breaking down milk
sugar into simpler
forms.
rifaximin Xifaxan Prevents traveler’s Headache, constipation, hives and Should not be used by people
diarrhea caused by itchiness. with fever or blood in stool.
E. coli. Treats small
intestinal bacterial
overgrowth in IBS.
Reduces flatulence
and discomfort of
bloating.
simethicone Gas Relief, Gas-X, Relieves pain from No known side effects. Effectiveness uncertain.
Mylanta Gas excess gas.
Resources
American College of Gastroenterology Offers detailed practical information on gastrointestinal
6400 Goldsboro Rd., Suite 200 disorders; publishes a monthly online newsletter.
Bethesda, MD 20817
301-263-9000 Irritable Bowel Syndrome Self Help and
www.patients.gi.org Support Group
Provides information on digestive health topics and diagnostic 24 Dixwell Ave., #118
tests; offers an online locator for gastroenterologists. New Haven, CT 06511
203-424-0660
American Gastroenterological Association www.ibsgroup.org
4930 Del Ray Ave. Provides educational resources and support for people
Bethesda, MD 20814 with IBS and other functional GI disorders; publishes a
301-654-2055 newsletter.
www.gastro.org/patient-care/patient-center
Provides information on various digestive disorders and National Institute of Diabetes and Digestive and
treatments; offers an online locator for gastroenterologists. Kidney Diseases
2 Information Way
International Foundation for Functional Bethesda, MD 20892
Gastrointestinal Disorders 800-891-5389 (toll-free)
P.O. Box 170864 www.digestive.niddk.nih.gov
Milwaukee, WI 53217
888-964-2001 (toll-free) Provides information on gastrointestinal disorders and
www.iffgd.org procedures.
Glossary
aerophagia: Excessive swallowing of air. gastritis: Inflammation of the stomach.
alimentary canal: Another term for the gastrointestinal tract gastrointestinal (GI) tract: The string of hollow organs
or the digestive tract. running from the mouth to the anus, including the esophagus,
stomach, small intestine, and colon.
bile: Fluid secreted by the liver that helps break down fats in
the small intestine. ileum: The section of the small intestine between the jejunum
and the beginning of the colon.
chyme: A nearly liquid mass of partly digested food and secre-
tions in the stomach and intestine. jejunum: The section of the small intestine between the
duodenum and the ileum.
colon: The large intestine.
lactose intolerance: The inability of the body to break down
colonoscopy: Examination of the interior of the colon using a lactose; causes gastrointestinal distress.
flexible viewing instrument.
microbiota: The community of microorganisms living in the
diverticula: Finger-shaped pouches protruding off the colon digestive tract. Also called microbiome.
that often develop with age.
motility: The ability of the digestive tract to propel its contents.
diverticulitis: Inflammation of one or more diverticula.
pepsin: A name for several enzymes secreted by the stomach
duodenitis: Inflammation of the duodenum. to break down protein.
duodenum: The first part of the small intestine, extending peptic ulcer: A raw, crater-like break in the mucosal lining of
from the stomach to the jejunum. the stomach or duodenum.
dysphagia: Difficulty swallowing. peristalsis: Wavelike movement of intestinal muscles that
propels food along the digestive tract.
endoscopy: A diagnostic test that allows a physician to view
the upper gastrointestinal tract via a flexible tube inserted peritonitis: Inflammation of the membrane lining the abdomi-
down the person’s throat. nal cavity.
functional gastrointestinal disorders: Gut ailments whose sigmoidoscopy: Internal examination of the rectum and
symptoms cannot be linked to any physical cause, such as an sigmoid colon by means of a flexible viewing tube inserted
infection, hormonal changes, or a structural abnormality. through the anus.

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A Harvard Medical School Special Health Report

The Sensitive Gut

SPECIAL BONUS SECTION

Here’s what you CAN do Here’s what you CAN’T do

Licensing, Bulk, and Corporate Sales

Harvard Health Publications

Lawrence S. Friedman, M.D.

T he “gut.” It’s an ancient Anglo-Saxon word that

The food you eat travels a winding 30-foot pathway known as

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Figure 3: The stomach wall

Lower esophageal Mucosa

Outside layer (serosa)

The stomach lining (mucosa) is not a smooth, balloon-like surface.

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The stress connection

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Figure 4: Closing the pain gate

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cal factors) can affect movement

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H eartburn, that uncomfortable burning sensation

Gastroesophageal reflux disease is an often-painful condition that

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Y ou’re having trouble with your stomach. You feel

a burning pain. You complain of nausea, or some-

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Lifestyle modifications for Tests and medication

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What else could it be, if it’s not functional dyspepsia?

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A nother common intestinal disorder with a myriad

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Table 2: Guidelines for colorectal cancer screening

YOUR RISK CATEGORY SCREENING RECOMMENDATION

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Diverticular disease. Small sacs or pouches— bowel symptoms may be accompanied by

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Overgrowth of intestinal bacteria Hormonal and dietary factors

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F ood intolerance and allergies often produce similar

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Acupuncture. This system of applying

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C onstipation is the slow movement of feces through