Bloating seems to be among the most common symptoms experienced by people who have Celiac Disease. While this can absolutely be a symptom of gluten exposure, if you have already confirmed that there is no gluten getting in through your diet, personal care products, medications or supplements, or other environmental factors (like drywall or baking), there are a few other possibilities that can be considered as potential underlying causes. Some can be eliminated with common sense, and others will require the help of your medical practitioners to look into. Let’s explore some of the possibilities.
Celiac Disease
Just in case this is the first article that you’re reading on this subject, it feels important to acknowledge that bloating is notoriously associated with celiac disease. Briefly explained, celiac disease is an autoimmune condition in which the body attacks itself following the ingestion of gluten (the proteins found in wheat, rye, barley, and to a lesser degree, in other grains). There is most definitely a genetic component, but significant infection, stress, or trauma can all serve as additional epigenetic factors that affect the timing of onset/progression of the disease. Common symptoms include: bloating, constipation, diarrhea, gas, belching, abdominal pain or cramping, vomiting, migraines, acne, eczema, dermatitis (especially herpetiformis), brain fog, poor memory, poor nutrient absorption, failure to thrive (in children), chronic iron or vitamin B12 deficiency, and so on. There are also strong ties to neurological conditions like anxiety, depression, ADD/ADHD, and OCD. There are countless great resources for this condition, many of which are highlighted throughout www.downwiththepastryarchy.com.
Additional Food Sensitivities
As we begin to change our diets post diagnosis, many Celiacs discover additional food sensitivities or allergies. As the inflammation caused by gluten begins to cool, different triggers become more obvious. Some of the most common foods to cause additional issues are: other grains like corn,quinoa, or oats, dairy products, soy, and eggs. For other individuals, it might be potatoes, tomatoes, peppers, and eggplant (the nightshade family). For others it might be nuts and seeds, or legumes. The autoimmune paleo template was particularly helpful when I was trying to identify mine, as well as the Loving Diet, which incorporates some further insights about FODMAPs. These elimination diets are designed to help you remove the most likely sources of inflammation, allow the inflammation to cool, infuse your diet with nutrient dense, healing foods, and tune in and listen to the feedback from your body as you reintroduce foods mindfully, one at a time, so as to be able to identify clearly which are working or not working for you.
Some of these sensitivities or allergies are easy to identify with allergy testing, and others seem more elusive and are better recognized through elimination and reintroduction. If you start noticing patterns, like starchy foods, or those eliminated in a low FODMAP diet are consistently the problem, you may want to consider the possibility of Small Intestinal Bacterial Overgrowth (aka SIBO). If you notice a more consistent pattern among the higher histamine foods, it might be useful to look into the possibility of Mast Cell Activation Syndrome (more on both of these below).
SIBO
SIBO or Small Intestinal Bacterial Overgrowth is a condition in which bacteria that are meant to remain in the large intestine/colon migrate into the small intestine and grow out of control. In some cases, it may also be an overgrowth of (unhelpful) bacteria native to the small intestine. There are different bacterial cultures that are meant to live in each section of the gut, with specific roles to play in digestion and absorption. SIBO can happen for a number of reasons, including things like poor motility, dysfunction of the ileocecal valve, long standing damage caused by Celiac disease, IBS, low stomach acid, Crohn’s disease, Diabetes (types 1 and 2), prior bowel surgery, repeated antibiotic use, or dysfunction in other organs like the liver, kidneys, gallbladder, or pancreas. Heavy alcohol use and taking oral contraceptives also increases your risks for developing SIBO. Additional symptoms that might suggest SIBO is the culprit behind your bloating include: gas and belching, bloating/abdominal distension, abdominal pain or discomfort, diarrhea, constipation, and weight issues associated with nutrient deficiency.
There are several treatment options, including targeted antibiotics, or a combination of herbal medicines. Unfortunately, only around half of the people treated for SIBO find that it goes away after one round of treatment. In the other half of the cases, it appears to be necessary to do more than one round of treatment, and/or to address other underlying causes, such as in the case of valve dysfunction, or another under managed condition. Improving transit time (how long it takes food to be digested and move through your body) is one of the factors noted to improve the chances of remission. To learn more about SIBO, visit https://kresserinstitute.com.
Crohn’s Disease
Crohn’s disease is an autoimmune condition which can affect any part of the digestive tract from the mouth to the anus. Symptoms will vary depending on which part is most affected, but some of the most common symptoms to watch for are blood or mucus in the stool, bloating, abdominal cramping, diarrhea, fatigue/lack of energy, and unexplained weight loss. In children, it can appear as failure to thrive. There can be serious complications as a result of Crohn’s disease. Some symptoms may be affected by dietary choices, stress, or additional infections. This diagnosis is definitely a case where you would want to work closely with a skilled gastroenterologist. In some cases, medications like low dose Naltrexone have been found helpful in reducing the severity of symptoms, reducing pain, and cooling inflammation. In severe cases, surgery to remove sections of the intestine or the use of an ostomy bag may be necessary. Diets designed to be low inflammatory like SCD, autoimmune paleo, and low FODMAP may be helpful, as well as noting that cooked foods may be better tolerated than raw.
Ulcerative Colitis
Ulcerative Colitis can present in several different forms, named for the area of the bowel impacted: Ulcerative Proctitis, Proctosigmoiditis, Left-sided Colitis, Pancolitis, and acute severe Ulcerative Colitis. Common symptoms include, diarrhea, blood or pus in stool, feeling the need to go #2 (but sometimes being unable to go despite the sense of urgency), failure to thrive (in children), abdominal pain and cramping, rectal pain or bleeding, weight loss, fatigue, and fever. There is still some debate as to the mechanism underlying this condition. It was thought that diet and lifestyle factors were the sole cause, but it is now clear that while they can bring on a flare, they are not the true cause. There seems to be a hereditary factor, possibly autoimmune involvement, and a common pattern of onset following a serious gastrointestinal infection. This condition is complex, and it is best to work with a skilled physician to ensure that symptoms and the advancement of the disease are well controlled.
Diverticulitis
Diverticulitis seems to be a disease of modern life. It is caused by the formation of weakened spots in the wall of the large intestine (most often the descending colon), which balloon out to form a small pouch where bacteria, bits of mostly digested food, etc, can pool and fester and cause inflammation. These symptoms can lead to serious complications and appropriate treatment is necessary. It is possible to have diverticula (the little pouches) that aren’t inflamed or infected, in which case no treatment would be necessary. It is also possible to have Symptomatic Uncomplicated Diverticular Disease (SUDD) which is associated with symptoms like bloating and abdominal pain, not unlike IBD (Irritable Bowel Disease). The good news is that the disease progresses slowly, and very few people develop the most serious/advanced forms, particularly where efforts are made to manage symptoms well.
Patients can reduce their risk of advancing the disease by ensuring healthy gut motility (fiber, adequate hydration, and pao d’arco tea can help here), being physically active, maintaining healthy body weight, not smoking, avoiding excessive use of NSAIDs, steroids, and opiates (particularly if they have hereditary factors suggesting they’re at risk of developing diverticulitis), and ensuring that they get adequate amounts of vitamin D (supplementing with vitamin D3 + K2 is ideal, and generally necessary unless you live in the tropics). Men are at slightly higher risk than women, and generally speaking, this condition is more common in adults over the age of 60. Those who develop it at a younger age do seem to be at slightly higher risk of the disease advancing, but it’s not fully clear why yet. Personally, I suspect a link to connective tissue disorders like Ehlers-Danlos Syndrome, but I don’t have the research on hand to back that up (just knowledge of how that condition affects connective tissues). Symptoms that might suggest you have diverticulitis include: abdominal pain (especially of the lower left side), bloating, fever, nausea, vomiting, increase in urgency, frequency, or pain with urination, constipation, or diarrhea. If these sorts of symptoms persist longer than a few days (or the point at which it is clearly not just the flu), please follow up with your medical care team.
Parasites/Chronic Infection
There are so many possibilities in this category that could be causing bloating. There could be a parasite (of the worm/tapeworm sort) gobbling up your food, swelling, and releasing inflammatory markers into the gut. There could be bacterial dysbiosis or SIBO, as discussed previously. There could be infections of various sorts, notably H.Pylori would be one requiring medical treatment. There could even be an overgrowth of bacteria like saccharomyces cerevisiae which ferments gluten and carbohydrates to effectively create alcohol in the gut, rendering it’s host drunk without consciously consuming alcohol. Ultimately, a comprehensive stool test checking for parasites should be part of the detective work done in getting to the bottom of troubling symptoms like persistent bloating, and a medical practitioner should be involved in the treatment of anything discovered there. In some cases, blood work or an endoscopy may also be necessary for accurate diagnosis. Interestingly, part of what may be happening in these situations, is that the virus, bacteria, or parasites release histamine and other inflammatory markers into their host’s body in their excrement, and as their dead bodies break down. These inflammatory markers can cause symptoms similar to those we will discuss next regarding MCAS and IBS. Generally speaking, symptoms caused by an infection or parasite should resolve once that has been treated and cleared from the body. In some cases it may be necessary to address nutrient deficiencies that were caused by the uninvited guest(s), and to ensure effective hydration and motility as they are cleared from the body.
Mast Cell Activation Syndrome and Irritable Bowel Syndrome
Mast cells are one of the types of immune cells in our bodies, and they play a significant role in allergic inflammatory reactions. They tend to congregate in areas that interact with the outside world, like the respiratory system, digestive system, mucous membranes, genitourinary system, and skin. They contain many different inflammatory markers, which are released to signal to the body that something in that part of the body requires attention, or that trigger a cascade reaction – some are linked with various hormonal functions. Either overproduction (too many) or overactivation (too sensitive) of mast cells can cause significant issues, as can a deficiency of the enzymes (eg. DAO and HNMT) which help the body to degrade the inflammatory markers released by mast cells, once they have served their purpose.
The role that these cells play in gastrointestinal conditions is still a matter of emergent research, but there are potentially exciting implications for treatment options as we learn more, as suggested in this medical journal article, notably in the form of mast cell stabilizing medications and antihistamines. There is also indication that many cases of IBS may in fact be a case of mast cells in the gastrointestinal system causing trouble. They are specifically noted to be associated with diarrhea, abdominal pain, and bloating. Where acute or chronic stress or anxiety seems to be a trigger of such symptoms, suspect mast cells as the underlying cause (the journal article linked above explains more of the mechanism behind this).
Intestinal biopsy and special staining can be used to assess and diagnose this condition (details for this are also in the journal article), but no specific diagnostic criteria have been established yet, which in some cases means ruling out other potential diagnoses and testing treatment options. In some ways, MCAS is still a diagnosis of exclusion (identified by process of elimination). While medications like Nalcrom aka Cromolyn Sodium, Ketotifen, and antihistamines are the most likely suspects, there is also emergent research looking at the benefits of supplements like NeuroProtek, quercetin, high dose vitamin C, 5-HTP, and low dose Naltrexone. While it is not yet understood fully, there appears to also be a connection with Ehlers-Danlos Syndrome and the impact it has on connective tissues in the gut. It is possible that EDS causes weakening of the tight junctions in the intestinal wall; these sites normally produce DAO enzymes which the body uses to manage histamine, one of the mediators released by mast cells. Without enough DAO, there can be excessive build up of histamine, resulting in elevated symptoms. This is just a theory at this point, but an interesting theory nonetheless. While there is no clear or easy road to diagnosis of MCAS yet, it is still worth pursuing because of the implications for other areas of medical care (such as being wary of some form of anesthetic), and treatment options.
Gastritis/Gastroparesis
Gastritis quite literally means inflammation of the stomach. It may be associated with an H.Pylori infection, overuse of NSAIDs, ulcers, or the over consumption of alcohol. Symptoms include bloating, nausea, vomiting, abdominal pain, gas, belching, fatigue, or burning in the throat (acid reflux). Some celiacs experience these symptoms if they consume gluten and the condition resolves on a gluten free diet. There may be other food/drink triggers that contribute, such as corn, soy, grains, caffeine, processed foods, trans fats, and alcohol. Medications, stress, smoking, and obesity may also contribute. Increasing your intake of antioxidant rich and alkalizing foods and beverages can be a significant help, in addition to avoiding the above triggers and treating any underlying causes.
Gastroparesis is a condition in which the stomach does not empty into the small intestine in a timely manner, and may not empty completely. This is due to poor function of the peristaltic muscle action which typically moves food through the digestive system. This reduced muscle function has been linked with damage to the vagus nerve, connective tissue disorders like Ehlers-Danlos Syndrome, diabetes, serious gastrointestinal infection (typically viral), scleroderma, multiple sclerosis, Parkinson’s, hypothyroidism, and medications like opiates, antidepressants, high blood pressure medications, and allergy medications. While many people with this condition experience no signs or symptoms, some of the most common ones among symptomatic patients are abdominal bloating, vomiting (particularly of undigested food they ate hours earlier), changes in blood sugar levels, nausea, acid reflux, abdominal pain, lack of appetite, and weight loss and malnutrition. There are potentially significant implications, so please follow up with your medical care team if you suspect this is the cause of your symptoms.
Third Spacing
As explained in this article, there are three places the body of a healthy adult holds water: the intracellular, intravascular, or interstitial spaces, more recently referred to as the interstitium. Generally, two thirds is held within the intracellular space, as in inside of your cells. When an excessive amount of the fluid is held in the interstitium, we can develop edema or swelling, including what can look like bloating of the abdomen. In some cases, receiving IV saline, or consuming more salt and electrolytes can help to reduce these symptoms. Far more research is needed to understand this complex “new organ” we are just beginning to understand.
Gallbladder dysfunction and low stomach acid
Both of these issues contribute to bloating due to their importance in the digestive process. If there isn’t enough stomach acid (aka hypochlorhydria), unwelcome bacteria can make their way into the intestine, as well as improperly digested food which can create extra gas and bloating when bacteria in the small intestine go to work on it. Some of the most common causes for low stomach acid include: age (being over 65), vitamin deficiency (notably zinc and b vitamins), stress, H.Pylori and gastric ulcers, medications (particularly those that reduce stomach acid), and surgery. This condition can be diagnosed with a physical exam, and testing the level of acidity in stomach secretions. Please refer to this link for further details about symptoms, other risk factors, and treatment options. The most common treatment option is to take a betaine HCl supplement with meals. Some folks also report benefit from consuming diluted unfiltered apple cider vinegar (with live cultures). I’m curious whether well-fermented kombucha might also have a similar effect, but again, more research is needed to better understand these things.
The gallbladder is responsible for releasing bile, which is designed to help breakdown fats into their useable parts. When this isn’t working well, we can experience bloating and gastrointestinal upset. Other common symptoms may include pain in the upper right abdomen, nausea, vomiting, fever, or jaundice. There are a number of things that can come up here ranging from poor function of the valve which is meant to strategically release bile, to gallstones (which can obstruct ducts), to more serious conditions. You can read more here. If it seems to be more along the lines of poor function (rather than serious disease), it may be helpful to consider a supplement which contains ox bile, bitter herbs, and/or other things that a functional medicine naturopath would be well equipped to help you explore. Where there are acute, scary levels of pain, vomiting, and fever, please seek out medical care as soon as possible.
Conclusion
So, as you can see, there are many different, complex conditions that can contribute to symptoms like bloating. Because of this, there can be no one solution that works for everyone, but I hope that this has provided you with some potential areas to explore further as you seek greater health and wellness for yourself (or your loved ones). Please be kind and patient with your body and your emotions as you try to find better answers. You will get there, one step at a time.
Until you find those answers, allow me to share a few of my favourite tools for soothing a grumpy, bloated belly:
- Snuggling with a heating pad or hot water bottle
- Sipping warm tea in soothing flavours like mint and ginger. Pao d’Arco tea can be a big help in improving motility (at a comfortable speed). Kombucha, Jun, and Kefir may also help to reduce bloating by improving the balance of good microbes living in your gut.
- Soaking in a warm bath with magnesium bath soak.
- Stretching – there are strategic yoga and pilates poses and movements that can help, particularly when gas is the cause of the pain. This funny video might give you a few ideas; others I’ve found effective are rocking in a “happy baby” position, child’s pose, or bringing my head down, and my bum up while in a hands and knees position. This handy device can also make elimination easier. You’re welcome 😉
If I’ve missed something that you have discovered is contributing to these symptoms for you, or if there is a treatment strategy that should be added to this resource, please do let me know. You can reach me at support@downwiththepastryarchy.com.