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Listen to your gut

Gastrointestinal complaints like constipation, gas and reflux disease can be managed
Guardian Lifestyles Editor

Published: Jul 23, 2013

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Everyone has experienced gastrointestinal troubles at some point in their life whether it be constipation, gas, reflux disease — complaints that plague the community, but which are issues that can be managed, according to gastroenterologist Dr. Gemma Rolle.

Speaking at the most recent Doctors Hospital Distinguished Lecture Series, Dr. Rolle broke down the wide range of digestive problems that a person could have, how they present and how they can be managed.

High on her list of gastrointestinal troubles was constipation. According to the doctor, if you have less than three bowel movements per week, along with two or more of the following — straining to pass stool, passing lumpy or hard stools, having to use manual maneuvers to facilitate evacuation, having a sensation of incomplete evacuation, as well as sensing that there is something blocking the rectum, or blocking stool from coming out, a person can consider that they have constipation.

She said constipation is so common that it affects one in five adults and that one-third of senior citizens complain of it. She said the female to male ratio stands a 1.5 to one because pregnant women often complain of constipation.

According to the gastroenterologist, constipation is an incompletely understood process, but she said there are a combination of things that need to take place for people to have bowel movements — the nervous system has to play its role with neurotransmitters; muscle function plays a role because the colon is lined by muscle. So with the movement of these muscles, stool moves around the colon until it reaches to the rectum and evacuation takes place.

Common causes of constipation

A person’s diet and lifestyle she said plays an important part in whether a person becomes constipated or not, like indulging in low-fiber diets and ignoring the call (some people just don’t want to have a bowel movement outside of their house). According to Dr. Rolle, the best time to have a bowel movement is first thing in the morning.

She said that endocrine/metabolic disorders (uncontrolled diabetes affects the nervous system which plays a role in how a person’s bowel moves; hypothyroidism and high calcium levels — whether a person is taking in too much calcium or a person’s body is not getting rid of or not using the calcium appropriately) also play a part.

Neurologic disorders like Parkinson’s disease, multiple sclerosis, stroke patients and those with spinal cord injury also play a part in moving the bowel.

The gastroenterologist said psychological conditions (anorexia, severe depression), mechanical obstruction (masses, stricture, prior surgery) and medications also affect a person’s bowel movement.

To ensure a healthy bowel movement, Dr. Rolle said a person should take note of their medications, such as certain pain killers, blood pressure meds, aluminum and antacids, anticholinergics and iron supplements can be constipating and that stool softeners should be taken in conjunction with the medications.


Soluble versus insoluble fiber

She encouraged people to improve their fiber intake and to look to consume between 25-30 grams daily. Insoluble fiber is found on the walls of plant cells and is what gives a person bulk in their stool that will draw water back into the stool, lubricate it and allow for good bowel movement. The soluble fiber also found in the same fiber-rich foods is what’s important in lowering a person’s cholesterol to avoid heart disease.

Breaking down the fiber in foods most people consume, she said one cup of lettuce provides one gram of fiber. A cup of kidney beans and lima beans provides six to eight grams of fiber. A cup of prunes provides 10 to 12 grams of fiber per cup. Granola (and bran cereal) gives seven to 15 grams per cup.

Dr. Rolle encourages people to read labels in the grocery store to ensure that they purchase high-fiber foods to get their daily intake.

“You can take fiber supplements, and if you look at the serving size as to how much grams of fiber you’re getting it’s very small, about three grams or so, and I always tell patients they can take them, but they would be getting more out of eating fiber-rich foods, than having to remember to take fiber pills,” she said.

And there is truth to the saying that you should drink eight glasses of water per day to avoid dehydration and for a person’s overall health.

“The purpose of the colon is to reabsorb water so if you’re not taking in enough, by the time that stool gets to the colon and you’re dehydrated, it will take all of the water out of that stool to get back into your system to hydrate you. So you want to make sure that you hydrate yourself and hydrate your stool. And avoid caffeine — because caffeine is a diuretic naturally, so that’s why we say to avoid coffee if you have to, or take in more water.”

If you do become constipated, the doctor says there are four main types of laxatives — fiber bulk forming, osmotic/saline, stimulant and stool softeners/lubricants that can help alleviate the problem.

Fiber bulk forming laxatives, she said, ensure larger stools, which help with the contraction of the colon to move the bowels along. The side affects though she said are a problem for many people. Fiber tends to be gas forming and can cause bloating and discomfort.

“It doesn’t happen with everyone and if it does, it’s just a catch 22,” said Dr. Rolle.

Osmotic or saline laxatives take about one to two hours to take effect. They help to bring water into the stool or coat the stool as a lubricant, but a person has to take lots of water with it.

Stimulant laxatives or irritants cause increased contractions. They work in about six to eight hours. Dr. Rolle cautioned overuse of these type of laxatives, which she said can give a person lazy bowels.

The doctor said stool softeners or lubricants take a few days to take effect and that it doesn’t really allow the stool that’s already there to pass, but softens newly formed stools.

After drinking all your water, taking in as much fiber as possible and if a patient still receives no relief from constipation, the doctor said a medical professional will consider doing a colonoscopy to rule out a structural lesion that may be prohibiting bowel movement.


Dealing with stomach problems

The most common complaint of the upper digestive tract, according to Dr. Rolle would be Gastro-Esophageal Reflux Disease (GERD) or heartburn, for which the definition is any complication that arises from the reflux of stomach contents or acid into the esophagus or beyond, into the oral cavity or lung.

Complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity or lung include a weak muscular ring which allows fluids to reflux back into the esophagus or a stomach bulging through hiatus in the diaphragm.

The most common symptoms of GERD include a sensation of burning or discomfort which usually occurs after eating, lying supine or bending over; regurgitation, actually feeling that their stomach juices coming into the mouth and trouble swallowing.

Atypical symptoms she said included coughing or wheezing, hoarseness, chest pain, otitis media (ear infection) and enamel decay.

Consuming spicy foods, chocolate, fatty foods, citrus, acidic foods, peppermint, caffeine, alcohol and soda are all common triggers of GERD, according to Dr. Rolle.


Diagnosis and management

A diagnosis, she said, is made through history and, the majority of times, by what a patient says to their doctor.

To manage GERD, Dr. Rolle says diet and lifestyle modification are most important, as well as knowing your triggers and avoiding them.

Weight loss, she said, would also help. The extra weight she said increases abdominal pressure, which causes the stomach to come up towards the diaphragm, increasing a person’s risk of acid going back into the esophagus. Dr. Rolle said sleeping on a wedge, and avoiding eating within two to three hours of lying down also helps.

If everything else fails to give relief, she said medication (Proton Pump Inhibitors or PPI), which are taken 30 to 60 minutes prior to the first meal, and surgery are options.

But with the medications she said there are possible complications from being on them for a long time – infections, pneumonia, C diff infection (an overgrowth of bad bacteria in the colon); malabsorption of vitamins and minerals, acute interstitial nephritis (something that affects the kidneys, but which is very uncommon) and other drug interactions, decreasing the efficacy of other drugs.

Dr. Rolle said medical professionals opt to do endoscopy when persons have trouble swallowing, have an inadequate response to PPI therapy and a classification of the disease. And if the PPI’s don’t work and the endoscopy appears normal, she said they then do a pH monitoring to check the acidity of the esophagus.

Complications of GERD include erosive esophagitis, Barrett’s esophagus (essentially a pre-malignant condition, rare in The Bahamas) and peptic stricture, where after having so much inflammation the esophagus can scar and tend to close up.

When meds don’t work, a surgery called the Nissen fundoplication, which involves the tightening of the sphincter is used.


The elephant in the room — gas

Gas is another tummy issue that many people complain about. And according to Dr. Rolle, everyone has gas that is essentially air in the digestive tract, and everyone burps/belches, but some of the gas remains inside. She said the remaining gas is partially absorbed into the small intestine and is breathed out. The air that does not get absorbed in the small bowel passes on to the colon and a person gets flatus and farts.

Excess gas is caused by the breakdown of certain foods in the large intestine by bacteria, usually undigested complex carbohydrates.

She said swallowing too much air when you eat and drink too fast, smoking, drinking carbonated beverages, sucking hard candy, chewing gum and eating certain foods like beans, broccoli, cauliflower, brussel sprouts, cabbage, onion, wheat breads, juices with artificial sweeteners and complex sugars, milk and dairy products, apples, pears and peaches can cause excess gas.

Other symptoms include bloating and abdominal pain or discomfort from the abdominal distention, but she cautioned that not every abdominal pain is caused by gas, and could be the result of ulcers, pancreatitis, gallstones, cancer, diverticulitis, appendicitis, inflammatory bowel disease or even irritable bowel syndrome.

And that people should seek medical advice if the onset of abdominal pain is after 40 years of age, or if they have a change in symptoms (increased frequency and/or severity), associated symptoms like changes in the bowel habit, blood in the stool, nausea, vomiting, loss of appetite, weight loss, early satiety, these are things you should mention to your doctor.

To manage gas, Dr. Rolle said people should reduce the amount of air they swallow by drinking from straws, avoiding hard candy, stop smoking, changing their diet and taking medications that break down the air bubbles in the stomach.

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