Got irritable bowel?  As many as 40 percent of people who go to the doctor with gastrointestinal problems suffer from irritable bowel syndrome (alternating diarrhea and constipation); dyspepsia (uncomfortable fullness or pain in the upper abdomen, heartburn, or other digestive problems); or gastroparesis (the stomach muscles or the nerves that drive them stop working, and food doesn’t move out of the stomach the way it should).

These conditions are motility disorders, and they involve the enteric nervous system, the massive highway of nerve cells lining the muscular walls of your esophagus, stomach, intestines, and rectum.  The enteric nerves control peristalis, the conveyor-belt series of muscle contractions — think of toothpaste being squeezed through a tube — essential for swallowing, for digestion, absorption of food, and for pooping (literally, movement of the bowels).

The treatment of motility disorders really requires the art as well as the science of medicine, because every patient responds differently,” says Pankaj Jay Pasricha, M.D., gastroenterologist and neuroscientist, director of the Center for Digestive Diseases at Johns Hopkins Bayview.  Pasricha created the Johns Hopkins Center for Neurogastroenterology and Gastrointestinal Motility Disorders to explore this gut-brain axis, which I wrote about here.

Diagnosing and treating these disorders can take time, dedication, creativity, and patience.  My husband, Mark, an excellent gastroenterologist, was on the faculty at Johns Hopkins and the University of Virginia before he went into private practice here in his home state of Arizona.  Many of his patients have difficult diseases, and he works with them – sometimes for months or even years – to find the right treatment to improve their lives.  By the time they get to him, these patients may be feeling frustration or even despair because they haven’t gotten the help they need.  For years, irritable bowel was the fibromyalgia of GI disorders, misunderstood and misdiagnosed.  If you are suffering from irritable bowel symptoms, you probably already know this.  Maybe you’ve also had a doctor get frustrated or impatient with you when you didn’t get better – like it’s your fault, or it is all in your head!  Or maybe the doctor has done a colonoscopy or endoscopy and, not finding anything striking, has seemed to lose interest in your care.  You’re not alone.

Successful treatment starts with a meticulous history and careful physical exam.  “About 80 percent of the time,” says Mark, “the key to the diagnosis is right there in the history.”  But just knowing the underlying cause of a motility disorder doesn’t necessarily mean the problem can be fixed right away.  Everybody’s different, and there is no cookie-cutter approach to making this better; treatment that helps one person won’t necessarily help someone else with the same diagnosis.  “If we’re trying a new medicine, it can take four weeks, or longer, to see if it works,” says Mark. “And if it doesn’t, then it’s another several weeks with the next medicine, and the next.  There’s a lot of trial and error, but if the doctor and patient are determined, and if they have patience to keep trying, we can often make it better.  The art is managing the symptoms, such as diarrhea, without simply converting it to chronic constipation, which is just as miserable in its own way.”

Not all treatment requires a prescription:  There are some very good over-the-counter products that can help reduce symptoms.  (Note: Heartburn and gastro-esophageal reflux disease (GERD), and acid reducers and proton pump inhibitors, are discussed here.)  Here are four:  For dyspepsia, Mark often recommends FDgard, whose ingredients include peppermint oil and caraway oil.  For irritable bowel, IBgard is a similar product — except it works in the gut, instead of the stomach.  Iberogast, an herbal medicine from Germany, works on both the stomach and gut: just put 20 drops into a glass of water or tea.  Equalactin helps ease irritable bowel by evening things out:  it treats constipation by adding bulk and also increasing the amount of water in your poop, making it easier to pass; at the same time, the bulking agent treats diarrhea by making it less runny and more solid.

What else?  You may need to take a good, close look at your diet. “Foods can be a major issue,” says Mark. “Many people have food allergies and don’t know it, and the way we figure this out is to remove one type of food (like dairy products) from the diet at a time and see if it makes a difference.  Celiac disease is not an allergy but an immune reaction to gluten, and the treatment is a gluten-free diet, which is harder than you may think,” because many products, from soy sauce to shampoo, have wheat.  Shampoo??  Yes, and to people with celiac, or people who are very sensitive to gluten, even absorbing it through the skin can cause cramping, bloating, and diarrhea.  If you have a food allergy or celiac disease, “you need to change the diet permanently to get lasting relief.  This requires a commitment,” and vigilance to check every single label of every packaged food you buy.  It also requires discussions with the server at every single restaurant you go to.  This can get old – trust me; in my family, in addition to GERD and irritable bowel, we’ve got celiac disease, lactose intolerance, and an allergy to milk and butter (from cows, but not from goats; go figure!).  It’s a pain, but the consequence of not being vigilant about what my family members eat is sickness.  In the case of celiac disease, prolonged exposure can actually lead to cancer in the small bowel — but prolonged avoidance of gluten means a healthy life!  It’s a no-brainer.

“Many patients have a sensitivity to FODMAPs, which are fermentable things in foods we eat.”  Every time I hear the word, “FODMAP,” I think of the old song, “RaggMopp,” by the Treniers.  Just putting that out there.  FODMAP is an acronym for Fermentable Oligo-, Di-, Mono-saccharides And Polyols.  And what are these fine fellows, you may be wondering?  Basically, they’re carbs.  Notorious carbs that may not do villainous things to other people, but if you are sensitive to them, they trigger bloating, gas and stomach pain.

The key word here is fermentable: Sugars, sugar alcohols, high-fructose corn syrup, lactose, sugars in fruits, especially stone fruits (pears, plums, peaches, prunes, and probably some others that don’t start with the letter p). “All these foods tend to make everyone produce gas, but the effect is greater on people who have irritable bowel,” says Mark.  Basically, if you have irritable bowel, these foods are a fermentable toot fest.

So that’s the F in FODMAP; what about the other letters?  Oligosaccharides are foods including wheat, rye, legumes, garlic, onions, and some other fruits and vegetables.  Disaccharides are milk, yogurt, and soft cheese.  The sugar they contain is lactose.  Monosaccharides have a different type of sugar, fructose, and include fruits such as figs and mangoes, agave nectar and honey.  Polyols are found in other fruits and vegetables, including blackberries.  They’re also found in sugar-free gum.

The bottom line here, no pun intended, is this:  If you find that you have a lot of gas and discomfort after eating, if you are prone to diarrhea, constipation, or both, if you are feeling like food is not moving through your GI tract the way it ought to, well, it’s quite possible that you have a motility disorder such as irritable bowel.  The good news is that there is help out there — prescription medicine, over-the-counter treatment, and dietary changes.

©Janet Farrar Worthington



Soothing heartburnEarlier I wrote about the causes of heartburn, also called GERD (gastro-esophageal reflux disease). Now, let’s talk about how to make it better.

First scenario: You’re minding your own business, it’s late at night, you have an attack of heartburn, and you don’t have any medicine. What can you do? Well, you can go to the pantry, and make your own antacid by mixing up 1/2 teaspoon of baking soda in half a glass of water. It will neutralize the acid. But as with any antacid (see below), the effect won’t last forever. Some foods are soothing for the acid-inflamed stomach, as well. Soda crackers (like Saltines) have baking soda, and can help soak up the acid. Also, apples are your friend. Just eating a plain old apple can help disarm the stomach acid. Some people swear by apple cider vinegar:  A tablespoon, mixed with a tablespoon of honey in a cup of warm water can provide temporary relief, as well.

But this is just emergency stuff, best for the occasional flare-up.

The next scenario:  It’s not your first rodeo. You have noticed that you’ve been having heartburn lately, so you’ve bought some Tums. Well, okay. The problem here is that Tums contain calcium carbonate. They will buffer the acid and give you immediate relief. But the calcium actually causes the acid level to bounce back — higher than it was before you took the Tums. This is called rebound hyperacidity. “So an hour later, you are making more acid than you did before, and you’re taking another Tums,” says Prescott, Arizona, gastroenterologist Mark Worthington, M.D. (Disclaimer: I happen to be married to Mark, an excellent, caring physician who was on the faculty at the University of Virginia for 10 years and then on the faculty at Johns Hopkins for five. He’s in private practice now.)

You probably don’t want to live this way, with one surge of stomach acid following another in big, unpleasant waves. Tums are not a good long-term solution for chronic reflux, so let’s move on to drugs.

The next level up from Tums is other antacids:  Rolaids, Maalox, Mylanta, and Gaviscon. These are different from Tums in the chemicals they contain (the names for these compounds end in oxide and ate): Rolaids have calcium carbonate magnesium hydroxide. Maalox and Mylanta contain aluminum hydroxide and magnesium hydroxide, and Gaivscon has aluminum hydroxide and magnesium carbonate. You can get these kinds of antacids as chewable tablets, dissolving tablets, as chewing gum, and in a liquid form. Some of them have a bonus ingredient, like simethicone, which can subdue the gas bubbles percolating in your stomach; Gaviscon’s bonus ingredient is alginic acid, which foams and helps keep what’s in your stomach from creeping back up the esophagus.

“These work for people with heartburn that is occasional and not too severe,” says Worthington, “although the magnesium can cause loose stools (diarrhea).”

However, if you have more frequent bouts of heartburn, you need to move on to the next room in the acid-resisting bunker:  Acid Reducers, also called H2 Receptor Antagonists, or H2 Blockers. These drugs end in “idine.” Pepcid (famotidine), Zantac (ranitidine), Tagamet (cimetidine), Axid (nizatidine). Pepcid Complete combines an acid reducer with an antacid, so it gives immediate relief and then keeps the acid down. Interestingly, although they’re high on the ladder of heartburn remedies, doctors don’t even think of them as particularly high-powered. “These are okay reflux drugs,” says Worthington. “They don’t suppress acid as much as proton pump inhibitors do,” (see below), “which some people see as a benefit.” Why a benefit? Well, if you can get away with taking this level of drugs and having your symptoms controlled, you can still get some of the good out of stomach acid. Long-term lack of stomach acid can lead to bacterial overgrowth (an excess of bacteria) in the small intestine, and a deficiency of magnesium, iron, calcium, and other trace minerals — because it turns out that you need some acid to absorb them.

And that brings us to the big guns:  Proton Pump Inhibitors. These drugs are the “prazoles.” Prevacid (lansoprazole; note: this is different from the less powerful version of Pepcid discussed above), Prilosec (omeprazole), Protonix (pantoprazole), Nexium (esomeprazole), Dexilant (dexlansoprazole), Aciphex (rabeprazole). Some of these require a prescription. The good thing is, because they pretty much dry up all the acid in your stomach, they give your poor inflamed esophagus a chance to heal.

And this is really important because your esophagus can only take so much. So if your doctor thinks you need a proton pump inhibitor, you should take it. Because if you don’t treat GERD, it can damage your esophagus. Inflammation in the esophagus, called esophagitis, hurts, and makes it difficult to eat, because you’re in discomfort. Worse, long-term esophagitis can lead to a condition called Barrett’s esophagus — which, in turn, can lead to cancer. This is diagnosed with an upper endoscopy, and the good news is that there is treatment for it, called radiofrequency ablation. “We basically zap the lining of the esophagus with radio waves,” says Worthington. “This causes a very defined, superficial burn, and the Barrett’s tissue sloughs off. It’s like getting a sunburn in the esophagus, but it can save your life.”

There is also a condition called a Schatzki ring. “This is a shelf of scar tissue between the stomach and esophagus,” says Worthington, “and food can get hung up on that when you swallow. It’s called ‘steakhouse syndrome,’ because it’s usually a big piece of steak that gets stuck in there. You feel like you’re having a heart attack, but it’s really just the esophagus having a spasm around the food.” Long-term damage to the esophagus can also lead to development of a stricture — more scar tissue, but instead of a ring, it’s a progressive narrowing, so that food can’t go down very easily. This can be opened up during upper endoscopy, as a gastroenterologist makes tiny cuts in the scar tissue to relax its stranglehold on the esophagus.

Finally, there is surgery, a procedure called fundoplication:  taking the top of the stomach and wrapping it around the esophagus to create an artificial valve — so that what happens in the stomach stays in the stomach. “It works pretty well,” says Worthington, although with this procedure in place, “you can’t burp and you can’t vomit, because if you do, you could rip the stitches.” The fundoplication may not last forever. “They do tend to stretch a little over time, but for people with the most severe reflux, it is not an unreasonable thing to do.”

If you keep having heartburn more than twice a week, what should you do? Well, you can try the lifestyle and diet changes written about in the previous post. If those don’t make your symptoms better, you can start on the remedies here, but the best thing you could do would be to get an upper endoscopy (done by a gastroenterologist, so you’ll need a referral from your primary care doctor), to make sure you don’t have any damage to the esophagus that needs more serious treatment.


©Janet Farrar Worthington

soft drinks and chilisYou asked for it, and you got it!  A nice lady at church told me, “My husband has heartburn and keeps hoping it will go away. He won’t go to the doctor, and he doesn’t know anything about what he should do.  He needs very basic information.” 

So, this is part of an occasional series of very basic stuff that you should know about your body.  We’ll start with heartburn.  A lot of men have frequent heartburn, and either take something for the symptoms or tough it out, and neither approach is ideal.  If you are having a lot of heartburn, you should talk to a doctor, ideally a gastroenterologist, a doctor who specializes in the digestive tract.  You may be treating it the wrong way.  If you’re ignoring it, you should know that untreated heartburn can lead to a very bad situation called Barrett’s esophagus — which is treatable, but which can lead to cancer if it’s not addressed.

Heartburn 101

I hate heartburn.  It’s a burning in your esophagus, a fire in the chest, pain that, if it’s really bad, can make you think you’re having a heart attack.  It can affect the throat, too.  This is called throatburn (the medical name is “laryngopharyngeal reflux”), and it can make you cough and need to clear your throat a lot, can make your voice hoarse, even make it harder to swallow. 

Just about everybody gets heartburn sometimes.  But if you have it more than twice a week, then what you call this miserable condition should probably change to GERD — gastroesophageal reflux disease. 

What is it?

Basically, the problem is a leaky valve.  When you eat, food goes down your esophagus and into the stomach.  There is a stopper — a muscle that’s supposed to clench like a fist after food gets into the stomach — called the Lower Esophageal Sphincter (LES).  In a lot of us, it doesn’t always work right.  This is bad because stomach acid, also called gastric acid, is very powerful.  It’s made up of hydrochloric acid, potassium chloride, and sodium chloride, and its job is to activate digestive enzymes, so they can start breaking down the proteins in what you just ate.  Think of Coke taking the tarnish off a penny:  stomach acid just works away, breaking down hamburgers and pizza and biscuits and gravy and apples and beer and cereal and salad.  That’s usually not a problem in the stomach, because the stomach is equipped to handle all that acid.  But the esophagus and throat are not protected from that spillover — so it’s like holding a hot pan without an oven mitt.  Not pleasant.

Why doesn’t my dang valve work? 

“There are three major reasons why people reflux,” says Prescott gastroenterologist Mark Worthington, M.D.  (Disclaimer: I happen to be married to Mark, an excellent, caring physician who was on the faculty at the University of Virginia for 10 years and then on the faculty at Johns Hopkins for five.  He’s in private practice now.) 

One reason:  Transient (temporary) lower esophageal relaxations, “where the lower esophageal sphincter winks open,” just like it does when you burp, “and it bathes the lower esophagus in acid.”  The acid may never go all the way up to the throat; in fact, “some people don’t think they have reflux because they don’t taste acid,” Worthington says.  People with this problem have a normal valve; it just doesn’t function properly. 

Two: Hiatal hernia.  That’s where the junction between the stomach and esophagus is stretched, so that it no longer functions properly.  The valve itself is abnormal.  Have you ever heard of a dunlop?  As in, “my gut dunlopped over my belt?”  Well, in this case, there’s a tiny “dunlop” in which a little piece of your stomach pokes upward into the chest.  By itself, a hiatal hernia is not a worrisome thing; a lot of us have it.  But it can contribute to GERD.

The last big reason: Extra poundage:  Speaking of dunlops, if you want your heartburn to get better and you don’t want to take medicine forever, lose a few pounds.  It’s that darn belly fat again.  Using a few thousand patients from the Nurses’ Health Study, a massive long-term study of more than 238,000 nurses, Harvard physicians studied the link between Body Mass Index and symptoms of GERD; their work was published in the New England Journal of Medicine in 2006.  They found that women who gained just a few pounds had more frequent and severe symptoms of GERD.  The problem with excess weight around the gut — as opposed to extra weight elsewhere, as in thunder thighs or junk in the trunk — is that it pushes on the stomach, causing more pressure in there.  Very simply, this is a mechanical problem.  More pressure on the LES forces some of that stomach acid out and upward.  Now, there’s a flip side to every statistic, and the good news here is that even losing a little bit of weight is going to take some of that pressure off and make your symptoms better.  “You can make reflux better by losing weight, often as little as 10 pounds,” Worthington says.

Here are some other factors:

The luck of the genetic draw:  GERD has a genetic component.  It is known to run in families.  Now, you may say that in a lot of families, everybody eats the same food, so no wonder they all have it, and that’s a good point.  But there still seems to be an inherited tendency to GERD, so if a parent or sibling has it, you might have it, too.  A hiatal hernia can also be hereditary.

Tobacco: In addition to everything else bad that smoking does, it makes GERD worse.  When you smoke, your mouth produces less spit — and saliva helps buffer that awful acid from your stomach. Nicotine also seems to relax the Lower Esophageal Sphincter — it causes that fist to unclench.  And, if you cough a lot from smoking, that can cause acid to shoot upward, as well.  Chewing tobacco, because it has nicotine, is going to have that same effect of relaxing the LES.

 Stress:  Stress makes heartburn worse.  It’s not clear why; it may be that it makes you more sensitive to stomach acid, so even a little goes a long way to making you feel bad.  Also, when you’re stressed, you make fewer prostaglandins, chemicals that help protect against stomach acid.

Eating like a pig:  Yes, I could have put it more delicately.  But I don’t judge; we’ve all done it.  Two things here:  One, when you pig out, it causes more pressure on the stomach, which puts more pressure on that valve, which can open and send acid into the esophagus and throat.  Two, you know it, I know it: Chances are, when you’re scarfing down food, it’s not broccoli and kale. The kind of foods that people tend to overeat — comfort foods, high in fat or oils — are known to relax the valve.  Chili, cheesesteaks, pizza, burgers, lasagna, fried chicken, cheese puffs, onion rings, etc.  Also, garlic, chocolate, alcohol, coffee, citrus fruit, and tomatoes can trigger GERD.

 Tight clothing:  Loosen your belt, and you may feel better.  It takes the pressure off the belly — which, in turn, takes pressure off that pesky valve.

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©Janet Farrar Worthington